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Therapy can help fearful mothers avoid C-sections

By Trevor Stokes

NEW YORK (Reuters Health) - Group therapy can help women avoid risky and costly cesarean sections, especially first-time mothers fearful of childbirth, according to a new study from Finland.

While nearly half of first-time mothers with an extreme fear of childbirth opted for C-sections before counseling, researchers found, only about a third ended up choosing C-sections after attending therapy sessions.

"Our study showed that group counseling is a very effective way to treat first-time mothers with intense fears of childbirth, in order to decrease the number of C-sections and to have more satisfactory delivery," lead study author Dr. Hanna Rouhe, clinical researcher at the Helsinki University Centralö Hospital, told Reuters Health.

"Many of these women with severe fear of childbirth don't come to any maternity clinic for consultation, they just come to deliver with all the anxiety and fear, so there will be problems in delivery," Rouhe said.

Previous research has shown that giving expectant mothers a forum to voice their fears reduced C-sections, but the Finnish researchers said their randomized clinical trial of a formal intervention to address those fears was a first.

C-section is the most common surgery in the U.S., and accounted for a third of deliveries in 2010, according to the Department of Health and Human Services.

The C-section rate in Finland is half that of the U.S. Still, several medical groups have expressed alarm at the generally high number of C-sections performed in western countries, because the procedure both increases a woman's risk of bleeding, infection and infertility, and incurs higher medical costs.

It's been estimated that between six percent and 10 percent of C-sections may be scheduled by women with extreme fear of childbirth, according to the Finnish team.

"This study raises the issue that maybe we should pay more attention to why women are opting for primary cesarean sections," said Dr. Laura Riley, an obstetrician who specializes in high-risk pregnancies at Massachusetts General Hospital in Boston and was not involved in the new study.

A number of initiatives aim to reduce the first cesarean section by waiting longer to induce labor and by allowing longer delivery times before C-sections are offered, she noted. But, Riley wrote in an email, "I am not aware of initiatives surrounding childbirth fear - maybe there should be."

Most hospitals include childbirth counseling in standard prenatal care, but when obstetricians discuss the C-section option, they give unsatisfactory treatment by not addressing any underlying fears, the Finnish researchers conclude.

For their study, which is published in the British obstetrics and gynecology journal BJOG, the team used a standard psychological questionnaire to screen a total of 4,575 first-time expecting mothers for fear of childbirth or a strong desire for C-section, and identified 371 with a severe fear of vaginal birth.

Symptoms of the intense fear included panic that affected daily life, nightmares about delivery and a strong desire for a C-section.

The researchers then randomly divided the fearful expectant mothers into two groups: 90 women received six two-hour sessions of group therapy led by a trained psychologist and 240 received standard prenatal care.

When it came time to deliver their babies, 66 percent of the women in the therapy group chose to have vaginal delivery, while just 47 percent of the women in the control group chose vaginal birth. More than a third of women in the therapy group also reported afterwards that they had had a "positive" delivery experience, versus 23 percent in the control group.

Still, one expert questioned the study's design and said its results offer nothing new for doctors or pregnant women.

"Education and support of pregnant women works; it decreases C-sections, we already know that," George Saade, chief of the division of maternal-fetal medicine at the University of Texas Medical Branch, told Reuters Health. "That study doesn't prove much because the design is flawed."

Nearly half (106 out of 240) women not assigned to therapy in the study sought out their own support and therapy - including Lamaze classes and consultations with doulas and midwives - Saade pointed out, making the effect of the therapy intervention difficult to distinguish.

During the therapy sessions for the intervention group, would-be mothers underwent imaginary deliveries in calm settings and equated childbirth with peaceful images such as a flower opening.

"I really do not see the value of the screening test or the intervention described in the study," Saade added.

The total therapy cost about 600 euros ($762) per mother, Rouhe countered. Vaginal birth plus the therapy cost 17 percent less than a 2,500-euro ($3,176) planned C-section, according to Rouhe, but the cost did not factor in the initial psychological test.

To date, three hospitals in Finland have adopted the screening system, which researchers aim to introduce across Finland. Most hospitals in Finland offer counseling, but don't screen and target fearful mothers for specific interventions.

Fearful pregnant women have alternatives, Saade said, including talking with their doctors, childbirth classes that usually include a tour of the delivery room or using a midwife or doula who can help address the issue.

This month, professional medical associations and federal funding agencies published new guidelines for obstetricians intended to decrease C-sections.

Rouhe and colleagues plan to break down the cost effectiveness and longer-term impacts of the group therapy in future studies.

"We have to look at the larger problems in these women's lives," Rouhe said. Women with little social support and histories of abuse or mental health problems have increased childbirth fears, according to previous research.

"It's not only a problem of delivery," Rouhe said.

SOURCE: http://bit.ly/STFxHM BJOG An International Journal of Obstetrics and Gynaecology, online November 2, 2012.

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