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The Impact of Fear, Stress and Anxiety during Pregnancy and Birth on Women and Infants

Sally Dear Healy, Ph.D.

by Sally Dear-Healey, Ph.D., PPNE, CCE (BWI), CD (BWI), TICP

Research shows that “both psychosocial stress and pregnancy-specific stresses can have marked effects on pregnancy, maternal health, and human development across the lifespan.”  Moreover, both animal and human studies suggest that activation of what is referred to as the “maternal stress response” and resulting changes in endocrine and inflammatory activity can span generations.  This is considered an epigenetic influence (Coussons-Read, 2013).[1]  Additionally, fear of childbirth can increase the number of unnecessary cesarean births, especially those which are elective (Aksoy et al., 2014).[2] Perhaps even more concerning is the fact that moms with clinical anxiety are at increased risk for postpartum depression and postpartum anxiety.

It is not unusual, nor is it always unhealthy, to fear something we have no experience with or know little to nothing about.  In fact, Carleton (2016)[3] argues that “fear of the unknown may be a, or possibly the, fundamental fear.” While the term xenophobia is often correlated with fear and hatred of strangers, it also is correlated with the fear of anything that is strange or foreign.  For many women, and men, birth, and especially birth in a hospital is a ‘strange and foreign’ land for which there is no travel guidebook, and often no designated and/or reliable guide.  Moreover, the “us” and “them” aspects of xenophobia clearly play out as beliefs and prejudices develop around certain birth practices, including but not limited to place of birth, type of care provider, the mode of birth, and beliefs and behaviors around early infant care. These beliefs can be embodied by women, their partners, as well as their care givers and differences are often a source of anxiety, stress, or fear- which can be counterintuitive in pregnancy and birth.

Tokophobia, a term first identified by Dr. Kristina Hofberg in 2000, is defined as “A pathological fear of pregnancy (which) can lead to avoidance of childbirth.  It can be classified as primary or secondary.  Primary is morbid fear of childbirth in a woman, who has no previous experience of pregnancy.  Secondary is morbid fear of childbirth developing after a traumatic obstetric event in a previous pregnancy” (Bhatia and Jhanjee, 2012).[4]  Fear and anxiety are inextricably linked, and both can produce a stress response in both the mother and her baby.  Let’s unpack what this means for birthing women today.

Many women today fear pregnancy or birth, or both.  An article in the Journal of Perinatal Education suggests that one of the reasons women today are so fearful of birth has to do with its negative portrayal in the mainstream media.  The author provides examples of how these influences, as well as the way hospital births today are “managed” with technology and ‘fear-based’ attitudes can single-handedly convince most women that their bodies are incapable of birthing without major medical intervention and that they would be crazy not to want all the technology they can get their hands on.”[5]   In other words, their fears are often generated by what they have seen, heard, or experienced.  They may also be generational in the sense that they are “old” memories of the experiences of our mothers and grandmothers.[6 ]  The fear itself may be conscious or unconscious.  Either way, as we have already acknowledged, fear not only impacts the woman/mother, it impacts the yet-to-be-born and newborn infant.

While some stress is normal and considered to be healthy, and most people return to balance after a stressful experience, constant or chronic stress and the inability to regulate can have both short- and long-term negative impacts, sometimes referred to as fetal programming.[7]  For example, among other things, constant stress alters the body’s stress management system, causing it to overreact and trigger an inflammatory response.  According to Ann Borders, MD, MPH, MSc, “There are some data to show that higher chronic stressors in women and poorer coping skills to deal with those stressors may be associated with lower birth weight and with delivering earlier.”  She adds that “Chronic stress may also contribute to subtle differences in brain development that might lead to behavioral issues as the baby grows.”[8] Additional research by Myatt (2006) shows that “Untreated, significant, and ongoing antenatal anxiety exposes the fetus to excess glucocorticoids, which may influence the fetus’s susceptibility to enduring neuroendocrine changes.”[9] This is especially troubling as research by Bhatia and Jhanjee (2012) shows that between 20% and 78% of pregnant women report fears associated with pregnancy and childbirth.

While screening for fear, anxiety, and stress – as well as depression – should be incorporated into every woman’s prenatal care, or as those in the field of prenatal and perinatal psychology suggest even prior to conception, obstetricians don’t regularly, or adequately screen for them.  This may be because it is assumed that pregnant women must be happy or because women feel ashamed to bring it up.[10]  And, while treatments such as Cognitive Behavioral Therapy (CBT) or psychopharmacology can be very effective for the treatment of anxiety disorders, we can also effectively argue that practices such as conscious conception, pregnancy, and birth – as well as having a positive mental attitude – can have a positive influence.[11]  Additional benefits can be realized through relaxed breathing, progressive muscle relaxation, meditation, and changing over from less healthy thinking patterns to healthier ones that focus on strengths-building and positive states of mind.  In turn, mothers and babies can have a more positive and less fearful and anxious experience of pregnancy and birth, which sets the stage for bonding, attachment, and greater physical and emotional health for mothers and babies.

[1] Coussons-Read, M.E. (2013). Effects of prenatal stress on pregnancy and human development: mechanisms and pathways. Obstetric Medicine. 6(2): 52-57.

[2] Aksoy, M, Aksoy, A., Dostbil, A., Celik, M. and Ince I. (2014). The relationship between fear of childbirth and women’s knowledge about painless childbirth. Obstetrics and Gynecology International. 274303. doi: 10.1155/2014/274303.

[3] Carleton, R.N. (2016). Into the unknown: A review and synthesis of contemporary models involving uncertainty. Review. Journal of Anxiety Disorders.  Vol. 39: 30-43.

[4] Bhatia, M. S. & Jhanjee, A. (2012). Tokophobia: A dread of pregnancy.  Industrial Psychiatry Journal. Jul-Dec; 21(2):158-159.

[5] Lothian, J.A. and Grauer, A. (2003). “Reality” Birth: Marketing Fear to Childbearing Women.  The Journal of Perinatal Education. 12(2): 6-8.

[6] Those who have given birth at home often experience a model of birth that has been shown to reduce the incidence of birth injury, trauma, and medical interventions which in turn decreases the fear and subsequent stress response(s).

[7] “Fetal programming occurs when the normal pattern of fetal development is disrupted by an abnormal stimulus or ‘insult’ applied at a critical point in in utero development.  This then leads to an effect, which manifests itself in adult life” (https://physoc.onlinelibrary.wiley.com/doi/full/10.1113/jphysiol.2006.104968).

[8] https://www.webmd.com/baby/features/stress-marks#1

[9] Myatt, L. Placental adaptive responses and fetal programming.  The Journal of Physiology. Vol. 572: 25-30.

[10] Rope, K. (2019). How to Cope with Anxiety and Depression During Pregnancy.  Parents.com. https://www.parents.com/pregnancy/my-life/emotions/coping-with-anxiety-and-depression-during-pregnancy/

[11] It should be acknowledged that in some cases women need to take medication, however it is currently unclear whether and to what extent these medications impact the infant while still in the womb and during breastfeeding.  In addition, “Information of mixed quality in lay media, stigma, and fear may lead women to decline effective pharmacological treatment, take less than the recommended dose; or stop treatment prematurely, which may lead to discontinuation symptoms, relapse of underlying anxiety, and even suicidal ideation” (See Einarson, A. and Selby, P. (2001). Abrupt discontinuation of psychotropic drugs during pregnancy: Fear of teratogenic risk and impact of counseling. Journal of Psychiatry and Neuroscience. Vol. 26: 44-48 and Gawley, L. and Bowne, A. (2011). Stigma  and attitudes towards antenatal depression and antidepressant use during pregnancy in healthcare students. Advances in Health Science Education. 16(5): 669-679).

The Impact of Fear, Stress and Anxiety during Pregnancy and Birth on Women and Infants

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The Importance of Why

One of the beauties of a strong and vibrant community of birth workers is that our conversations quickly delve into conceptual yet crucial topics such as human rights in birth, the effects of language and persona on confidence, power dynamics in the laboring room.  This talk brings us, as birth professionals, to a higher plane in understanding advocacy and the metaphysical aspects of labor.  However, when we share information with expecting clients, particularly in a group setting, it’s important that we are able to seamlessly shift from our hive minds, as birth workers, into the realm of creating a foundation of knowledge with our clients.

Offering too much all at once, although helpful for some who have researched a lot on their own, may feel overwhelming to expectant parents taking their first birth class.  When people experience information overload, they have a greater tendency to tune out, picking up and processing only bits and pieces, and ultimately feeling excluded from the greater conversation.  As childbirth educators, in order to successfully create a foundation of knowledge, we must understand the information our clients are bringing to the class space and we must assume nothing until we have reason to do so.  When we effectively and collectively have formed a knowledge baseline, we meet the parents where they are and have the ability to elevate them to a place of confidence and a space of safety in exploring their own priorities.  This will eventually help them utilize their rights to informed consent OR refusal, and communicate those preferences to their providers.

A simple online search for a birth plan will turn up all sorts of templates with prompts such as “I would like to…” and options including “walk and sit up during labor,” “avoid an epidural,” “have skin to skin right after birth,” and more.  Knowledge of these options are important and parents have the right to request these things.  However, what I have noticed in teaching birth classes, is that often parents are accepting that these are helpful things to do without having any understanding as to why.  Without knowing why, for example, movement in labor is important, clients are left without the confidence to back these preferences and without the ability to assert that these choices are honored.

As educators, we need to be ready to answer the question, from a research based standpoint as to why epidurals may not be the recommended first option against labor discomfort (and, on the flip side, why in some cases they may be beneficial), why movement and the use of gravity in labor is beneficial, why skin to skin has benefits for both the new parent(s) and the baby.  The greatest service we can provide our clients is in helping them understand why certain preferences have benefit so that they can make a conscious choice as to their priorities.  When we simply relay information and lay out techniques, we have merely bombarded expectant parents with more information – information they can often get from a simple google search.  By helping them understand the physiological process and how certain preferences may support or detract from that and how they can affect labor and birth, we are truly creating an environment of empowerment and learning.  The art of childbirth education is in the why.

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What is Birthpedia and How is it Changing the World of Birth?

A qualified resource where the worlds of hospital, birth center, and homebirth co-exist? A place
where parents’ choices are respected, where information isn’t condemning, but enlightening? A
resource like that simply didn’t exist… until now.

In this post, you will learn how Birthpedia is changing the way information about birth is being
presented and why future parents and birth professionals should know about it.
What a wonderful world it would be if every mother felt empowered during her pregnancy and
believed in her ability to give birth. But information for pregnancy and birth are now found in a
world of excessive data, obsession with social media, and self-diagnosis thanks to Google. The
upcoming generations of parents are found here, and they are lost. Between horror stories of their
mothers and the latest forum board on BabyCenter, parents are feeling anything but educated,
empowered, and prepared for the journey of parenthood. Confusion, debate, opinion, and fear
dominate their circles of influence. There has to be a better way. A midwife/OB can only stretch
themselves so thin. A doula can only have so many clients. And childbirth educators can only
reach those who take their classes.

Birthpedia is a subscription-based app and website that provides quick, current, and
qualified information to expectant families, delivered in short videos by birth professionals.
Birthpedia’s mission is to provide this information in a judgment-free space, helping expectant
families and parents of newborns make educated and informed decisions.
We believe that providing information in a collaborative way helps families feel supported and
equips them with essential knowledge—which empowers them to make informed decisions
within their experiences.
The app and website are organized into three main sections: ASK, SHARE, and DO.

The ASK Area:
Consists of five color-coded categories: Conception, Pregnancy, Labor & Delivery, Postpartum,
and Newborn Care. A search bar allows for search on any topic or question, or by category. Each
question will be answered in a 1–3 minute video by a birth professional. The database of
questions will hold over 1000 videos from over 100 birth professionals called “contributors.”
Contributors include midwives, obstetricians, doulas, childbirth educators, massage therapists,
chiropractors, fertility specialists, anesthesiologists, aroma therapists, herbalists, and more.
Answers to questions are based on the most current information in each category and speak to
the pregnant family—regardless of where they choose to give birth.

The SHARE Area:

Users will find a variety of shared stories. These stories are inspirational: stories of birth,
fertility, and adoption. The videos share positive and redemptive real-life experiences. Sharing
these stories will inspire new parents to believe in themselves and their natural, instinctual, and
God-given abilities. They will encourage couples struggling with infertility, going through a
grueling adoption process, or preparing for a VBAC.

The DO Area:
Users will find a wide variety of instructional videos, such as prenatal and postpartum exercises,
prenatal yoga, labor positions, breastfeeding, babywearing, changing a diaper, nutritional food
prep, and more! These videos will encourage users to be more active and provide up-to-date
visuals to help guide them.

WHO is Birthpedia for?
First and foremost, future and expecting parents. Birthpedia offers three different subscriptions;
24 hours, monthly, or six months.
Birthpedia also serves to be an excellent reference resource for current birth professionals. Birth
Professionals can sign up for a Lifetime Membership and grow with this incredible resource for
the lifetime of their career!
Birthpedia aims to be a socially responsible company that strives to invest in improving the
global birth landscape for better birth outcomes.
At Birthpedia, we believe…
● every newborn baby deserves the right to their best birth.
● informed parents create better birth experiences for all involved.
● birth is a primal human function and should not be treated like a disease
● every woman giving birth has a right to respectful maternal care
● every woman has the freedom to choose how she wants to give birth without
condemnation.

You are invited to join the journey toward better birth with Birthpedia! Birthpedia can be found
online at www.birthpedia.net, Instagram @Birthpedia, and Facebook/Birthpedia. For a limited
time up until January 2020, all of the content is FREE as the Birthpedia database continues to
grow!

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Accepting Fully Who We Are

Our Birth Doula training is very comprehensive and includes not only Optimal Pelvic Positioning and “The Four Principles,” but also ways in which to enhance character development.  One of the ways we do this is by having our students complete the BirthWorks Doula Journal Workbook in which one of the exercises is to write responses to insightful quotations.  Here is an inspiring one we would like to share with you that is pertinent not only to doula work but to life itself.

 Quotation:

“The more we become ourselves, the more we change”. – Carl Rogers

This quotation speaks of accepting fully who we are.  In a society that tells us how to act, think, look and feel this can be incredibly difficult.  Many seemingly subtle experiences create a culture of how and who we should think, feel and be – a parent reassuring a child that, “That didn’t hurt” when they fell off their bike (it might not have hurt the parent but the child sure is hurt).  An Aunt insisting, “Come on and give me a hug, you’re not shy” – though the child is feeling shy in that moment. Teenagers are told who they should “like”; until recently this person must have been a member of the opposite sex.  If someone likes long floral skirts they may be seen as old fashioned, or hippy – everyone seems to have forgotten that floral skirts have gone in and out of fashion many times over the years.  As adults society has all sorts of messages – you should own your own home; you may only have one sexual partner – a dog and two kids is a complete family unit; you should be saving for retirement etc etc.

 

In this barrage of repression many people find it hard to find themselves.  It takes a lot of work to dig through perceived ideas and false personalities to find their true self.  It may even take decades of work through therapy, meditation, restorative practice and life crises.  It’s worth the journey though  for once we have found this true self we have found real freedom and real liberation.  Unshackled we are able to live in movement, flowing with the tide of life, able to shift and change with our current situation or environment.  We are free to live completely in the “Now” because we understand that we are merely consciousness flowing through a series of present moments.

 

Such acceptance is of huge benefit to us in our practice of being a doula as it allows one to be flexible and resilient.  It let’s us accept that other people are complete individuals and we are able to differentiate ourselves from them (differentiation being the ability to hold on to ourselves, our values and our opinions while accepting that there is room for more than one valid opinion and remaining connected whilst dealing with the anxiety that comes from these differences in opinion). We realize that though we may be doing things we may not be comfortable with for our own selves, it may be the best way to meet the birthing mother’s needs at that time.  It allows us to lend ourselves to our clients though they may not always heed our advice and may make decisions that we personally would not make.  It allows us to be gentle and compassionate in all our dealings with our birthing couple and with the entire birthing team.

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“The Baby Comes Out the Back” – Birth Story

by Krista Haggerty, BWI Trainee

I was 40 weeks and 6 days pregnant when I woke at 6am to my waters breaking.  It was a small trickle, but I knew today would be the day we would meet our third child.  I woke my husband, text my doula, and called my midwife.  Since this would be a VBAC, I had to deliver at a different hospital than where most women delivered at my practice, and it was almost a 40 minute drive.  My last labor was under 4 hours, so we wanted to be ready to go as soon as the contractions picked up.

I started having irregular contractions, but since they weren’t painful I figured we had some time.  We called my mother-in-law to come stay with our other two children.  Around 7am, I felt like contractions were becoming regular.  I called out when they began and ended and my husband timed them as I showered and got dressed, then helped my mother-in-law get settled with the kids.  When I asked him what the interval was, he said close to 3 minutes apart!  I called the midwife to let her know, and we left the house just after 8.

I played my birth playlist in the car to help me relax, and my husband and I smiled and chatted during the drive.  It was a beautiful morning, and we were happy to finally have our baby!  The contractions were getting more intense to the point that I was vocalizing through them.  They were coming closer together, but since they still were not too painful I thought we had plenty of time before things would “get serious”.

When we were about ten minutes from the hospital, I had a contraction that ended with me feeling the first twinges of pushing.  I text my doula quickly before another contraction hit me, telling her to leave ASAP.  I also told my husband, “it’s not an emergency yet, but maybe you should probably drive a little faster.”  He was very calm as he started passing cars, reminding me to breathe and telling me we were almost there.

We reached the hospital around 8:40.  By this time I was having contractions right on top of each other, and could barely move to get out of the car and into a wheelchair.  The urge to push was becoming much more intense.  My husband left the car right in front of the main entrance and jogged me through the front doors.  We flew through the hallways (with me yelling quite loudly most of the way!) until we reached the maternity door, and waited to be buzzed in.  I may have yelled “let me in!” in between contractions.  Once the doors opened, my midwife and nurses were rushing towards us, directing my husband to our delivery room.  As the birth team helped me get up from the chair, my husband jokingly said “she’s your problem now!”

I got on the bed and lay on my side, still vocalizing loudly and pushing with the contractions.  I asked for the lights to be turned off and welcomed the soothing dusk of the darkened room after our ride through the bright hallways.  My midwife checked me and told me I was only at 8 cm, so I needed to stop pushing.  I was annoyed, this made me 3 for 3 births where I was pushing too soon and risking a swollen cervix.  My doula wasn’t there yet, so the midwife and nurse talked me through the contractions, reminding me to slow my breathing and cheering me on.  My husband caught on and joined in, letting me know he was nearby.

After what felt like a long time (is there any time longer than trying not to push when everything inside you is screaming to push?), I suddenly felt the baby’s head drop down and I said “is that the head?  My midwife helped me get to a hands and knees position, and raised the top of the bed so I could be upright and lean against the bed.  My husband stood near me at the top of the bed and let me grip his hands, and I stabilized myself against him as I followed my body’s cues to push.  I wasn’t really hearing anyone in the room, but in my head I heard something I had learned last year:  “the baby comes out the back”.

Last August, I attended a BirthWorks Childbirth Educator Workshop.  The phrase “the baby comes out the back” was new to me, and was used several times over the weekend.  I had a difficult time understanding exactly what it meant.  It wasn’t until I saw a visual of a 9 month pregnant woman with a view into her womb; the baby was angled not straight down or slightly towards the front as I’d always imagined, but towards the back of her body.  It suddenly clicked!  The baby comes out the BACK!

Fast forward to a little more than a year later, and that was the mantra running through my head as I worked with my baby.  I rested in between contractions, knowing I was close to the end.  I pushed and breathed towards the back, and then felt baby’s head:  the ring of fire!  I slowed down and took a moment to breathe.  When I pushed in the next contraction, my baby was born!  It was only 30 minutes since we had arrived at the hospital, and I pushed for less than ten minutes.  It was my fastest birth, and my first that was intervention free.  I waited impatiently as they got ready to move me so I could hold my baby, and for my husband to tell me the gender since I was facing away.

It took a moment for my husband to announce in shock, “It’s a GIRL!”  There was a wonderful feeling of joy in the room, everyone was smiling and laughing.  It was a beautiful way to welcome our daughter to the world.

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Accepting Fully Who We Are

Our Birth Doula training is very comprehensive and includes not only Optimal Pelvic
Positioning and “The Four Principles,” but also ways in which to enhance character
development. One of the ways we do this is by having our students complete the
BirthWorks Doula Journal Workbook in which one of the exercises is to write responses
to insightful quotations. Here is an inspiring one we would like to share with you that is
pertinent not only to doula work but to life itself.

Quotation:
“The more we become ourselves, the more we change”. – Carl Rogers

This quotation speaks of accepting fully who we are. In a society that tells us how to
act, think, look and feel this can be incredibly difficult. Many seemingly subtle
experiences create a culture of how and who we should think, feel and be – a parent
reassuring a child that, “That didn’t hurt” when they fell off their bike (it might not have
hurt the parent but the child sure is hurt). An Aunt insisting, “Come on and give me a
hug, you’re not shy” – though the child is feeling shy in that moment. Teenagers are told
who they should “like”; until recently this person must have been a member of the
opposite sex. If someone likes long floral skirts they may be seen as old fashioned, or
hippy – everyone seems to have forgotten that floral skirts have gone in and out of
fashion many times over the years. As adults society has all sorts of messages – you
should own your own home; you may only have one sexual partner – a dog and two kids
is a complete family unit; you should be saving for retirement etc etc.

In this barrage of repression many people find it hard to find themselves. It takes a lot
of work to dig through perceived ideas and false personalities to find their true self. It
may even take decades of work through therapy, meditation, restorative practice and life
crises. It’s worth the journey though for once we have found this true self we have
found real freedom and real liberation. Unshackled we are able to live in movement,
flowing with the tide of life, able to shift and change with our current situation or environment. We are free to live completely in the “Now” because we understand that
we are merely consciousness flowing through a series of present moments.

Such acceptance is of huge benefit to us in our practice of being a doula as it allows
one to be flexible and resilient. It let’s us accept that other people are complete
individuals and we are able to differentiate ourselves from them (differentiation being the
ability to hold on to ourselves, our values and our opinions while accepting that there is
room for more than one valid opinion and remaining connected whilst dealing with the
anxiety that comes from these differences in opinion). We realize that though we may
be doing things we may not be comfortable with for our own selves, it may be the best
way to meet the birthing mother’s needs at that time. It allows us to lend ourselves to
our clients though they may not always heed our advice and may make decisions that
we personally would not make. It allows us to be gentle and compassionate in all our
dealings with our birthing couple and with the entire birthing team.