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Health, obstetric outcomes and reproduction in women with vulvar pain or primary fear of childbirth
Linköping University, Department of Clinical and Experimental Medicine, Division of Children's and Women's health. Linköping University, Faculty of Medicine and Health Sciences.
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Fear of childbirth (FOC) is common and affects approximately 5-20 % of all pregnant women. FOC is associated with giving birth by caesarean section on maternal request (CSMR). The rate of caesarean sections (CS) and CSMR has increased during the last decades. To decrease these women’s fear, the rate of CSMR and to promote a more positive birth experience, many treatments for FOC have been evaluated. In Sweden, the treatment is individualized and given by obstetricians, midwives, psychologists or psychotherapists in the specialist care.

Women with FOC suffer more often from psychiatric illness and rate their general health as less good, which is important to consider when counselling these women and deciding on mode of delivery. Little is known about the long term obstetric and reproductive outcomes for women with FOC. Therefore, the aim of the studies on which this thesis is based was to compare psychiatric care before and after childbirth in women giving birth by CSMR to women giving birth by other modes of delivery and to follow the subsequent obstetric and reproductive outcomes in women receiving counselling for FOC in their first childbirth. Furthermore, we hypothesized that women with localized provoked vulvodynia (LPV) and/or vaginismus might fear vaginal childbirth and little is known about their reproduction and obstetric outcomes which is why we investigated the parity and obstetric outcomes in women diagnosed with LPV/vaginismus before first childbirth.

Based on data linked from several Swedish National registers, the prevalence of psychiatric in- and outpatient care before (paper I) and after first childbirth (paper II) was compared in primiparae giving birth by CSMR to primiparae giving birth by other modes of delivery. The prevalence of psychiatric disorders was found to be significantly higher in women giving birth by CSMR, indicating a severe burden of psychiatric illness in these women.

In paper III, also based on data from several Swedish National registers, a diagnosis of LPV/vaginismus before childbirth was shown to decrease the odds of giving birth. When giving birth these women had an increased risk of CS, especially CSMR. This could possibly indicate FOC in these women. Further, women with vaginismus had an increased risk of pelvic floor injuries.

Paper IV was a follow-up study of women who received counselling for FOC in their first pregnancy leading to parturition. It was based on data from medical records and a questionnaire. The women were followed 7-14 years after their first childbirth. Women treated for FOC more often gave birth by CS, rated their first birth experience as less positive and more often required counselling for FOC in their subsequent pregnancies compared to women without FOC in their first pregnancy. There were no significant differences in the rate of complications during pregnancy and childbirth compared to the other women. Women treated for FOC less often gave birth more than twice. Despite being given counselling and being exposed to childbirth almost one in five women felt fearful towards childbirth 7-14 years after the first childbirth.

In conclusion, women with FOC are a vulnerable group suffering from a significant burden of psychiatric illness. FOC is not easily treated; many women require counselling in subsequent pregnancies and many still fear childbirth after the childbearing years. Furthermore, LPV/vaginismus is a risk factor for giving birth by CSMR, possibly indicating FOC, and these women are less likely to give birth. Our study shows it is important not only to address sexual function in these women but reproductive function as well. Further studies are needed to establish how to optimize their care regarding fertility, antenatal, obstetric and post-partum care.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2019. , p. 72
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1681
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
URN: urn:nbn:se:liu:diva-156622DOI: 10.3384/diss.diva-156622ISBN: 9789176850770 (print)OAI: oai:DiVA.org:liu-156622DiVA, id: diva2:1307998
Public defence
2019-05-24, Berzeliussalen, Campus US, Linköping, 09:00 (English)
Opponent
Supervisors
Available from: 2019-04-30 Created: 2019-04-30 Last updated: 2019-08-06Bibliographically approved
List of papers
1. Psychiatric illness in women requesting caesarean section
Open this publication in new window or tab >>Psychiatric illness in women requesting caesarean section
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2015 (English)In: British Journal of Obstetrics and Gynecology, ISSN 1470-0328, E-ISSN 1471-0528, Vol. 122, no 3, p. 351-358Article in journal (Refereed) Published
Abstract [en]

Objective To compare psychiatric in-and outpatient care during the 5 years before first delivery in primiparae delivered by caesarean section on maternal request with all other primiparae women who had given birth during the same time period. Design Prospective, population-based register study. Setting Sweden. Sample Women giving birth for the first time between 2002 and 2004 (n = 64 834). Methods Women giving birth by caesarean section on maternal request (n = 1009) were compared with all other women giving birth (n = 63 825). The exposure of interest was any psychiatric diagnosis according to the International Statistical Classification of Diseases and Related Health Problems (ninth revision, ICD-9, 290-319; tenth revision, ICD-10, F00-F99) in The Swedish national patient register during the 5 years before first delivery. Main outcome measures Psychiatric diagnoses and delivery data. Results The burden of psychiatric illnesses was significantly higher in women giving birth by caesarean section on maternal request (10 versus 3.5%, P less than 0.001). The most common diagnoses were ` Neurotic disorders, stress-related disorders and somatoform disorders (5.9%, aOR 3.1, 95% CI 1.1-2.9), and ` Mood disorders (3.4%, aOR 2.4, 95% CI 1.7-3.6). The adjusted odds ratio for caesarean section on maternal request was 2.5 (95% CI 2.0-3.2) for any psychiatric disorder. Women giving birth by caesarean section on maternal request were older, used tobacco more often, had a lower educational level, higher body mass index, were more often married, unemployed, and their parents were more often born outside of Scandinavia (P less than 0.05). Conclusions Women giving birth by caesarean section on maternal request more often have a severe psychiatric disease burden. This finding points to the need for psychological support for these women as well as the need to screen and treat psychiatric illness in pregnant women.

Place, publisher, year, edition, pages
Wiley: 12 months, 2015
Keywords
Caesarean section; maternal request; mental health; psychiatric diagnoses
National Category
Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-115326 (URN)10.1111/1471-0528.12714 (DOI)000348866600015 ()24628766 (PubMedID)
Note

Funding Agencies|County Council of Ostergotland, Sweden

Available from: 2015-03-13 Created: 2015-03-13 Last updated: 2019-06-28
2. Mental health after first childbirth in women requesting a caesarean section; a retrospective register-based study
Open this publication in new window or tab >>Mental health after first childbirth in women requesting a caesarean section; a retrospective register-based study
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2017 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 17, article id 326Article in journal (Refereed) Published
Abstract [en]

Background: Psychiatric illness before delivery increases the risk of giving birth by caesarean section on maternal request (CSMR) but little is known about these womens mental health after childbirth. In this study we aimed to compare the prevalence of psychiatric disorders five years before and after delivery in primiparae giving birth by CS on maternal request to all other primiparae giving birth, indifferent on their mode of delivery. Methods: The study population comprised all women born in Sweden 1973-1983 giving birth for the first time in 2002-2004. Psychiatric diagnoses, in- and outpatient care were retrieved from the National Patient Register in Sweden. The risk of psychiatric care after childbirth was estimated using CSMR, previous mental health and sociodemographic variables as covariates. Results: Psychiatric disorders after childbirth were more common in women giving birth by CSMR compared to the other women (11.2% vs 5.5%, p amp;lt; 0.001). CSMR increased the risk of psychiatric disorders after childbirth (aOR 1. 5, 95% CI 1.2-1.9). The prevalence of psychiatric disorders had increased after compared to before childbirth (mean difference 0.02 +/- 0.25, 95% CI 0.018-0.022, p amp;lt; 0.001). Women giving birth by CSMR tended to be diagnosed in the inpatient care more often (54.9% vs. 45.8%, p = 0.056) and were more likely to have been diagnosed before childbirth as well (39.8% vs. 24.2%, p amp;lt; 0.001). Conclusions: Women giving birth by CSMR more often suffer from psychiatric disorders both before and after delivery. This indicates that these women are a vulnerable group requiring special attention from obstetric-and general health-care providers. This vulnerability should be taken into account when deciding on mode of delivery.

Place, publisher, year, edition, pages
BIOMED CENTRAL LTD, 2017
Keywords
Psychiatric disorders; Caesarean section; Maternal request
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:liu:diva-142173 (URN)10.1186/s12884-017-1514-2 (DOI)000412205800001 ()28969603 (PubMedID)
Note

Funding Agencies|Research Council in the southeast of Sweden, FORSS

Available from: 2017-10-23 Created: 2017-10-23 Last updated: 2019-06-28
3. Reproduction and mode of delivery in women with vaginismus or localised provoked vestibulodynia: a Swedish register-based study
Open this publication in new window or tab >>Reproduction and mode of delivery in women with vaginismus or localised provoked vestibulodynia: a Swedish register-based study
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2015 (English)In: British Journal of Obstetrics and Gynecology, ISSN 1470-0328, E-ISSN 1471-0528, Vol. 122, no 3, p. 329-334Article in journal (Refereed) Published
Abstract [en]

Objective To compare sociodemographics, parity and mode of delivery between women diagnosed with vaginismus or localised provoked vestibulodynia (LPV) to women without a diagnosis before first pregnancy. Design Retrospective, population-based register study. Setting Sweden. Sample All women born in Sweden 1973-83 who gave birth for the first time or remained nulliparous during the years 2001-09. Methods Nationally linked registries were used to identify the study population. Women diagnosed with vaginismus or LPV were compared to all other women. Odds ratios for parity and mode of delivery were calculated using multinominal regression analysis and logistic regression. Main outcome measures Parity and mode of delivery. Results Women with vaginismus/LPV were more likely to be unmarried (P = 0.001), unemployed (P = 0.012), have a higher educational level (P less than 0.001), a lower body mass index (P less than 0.001) and use nicotine during pregnancy (P = 0.008). They were less likely to give birth (adjusted odds ratio [OR] 0.61, 95% confidence interval [95% CI] 0.56-0.67). Women with vaginismus/LPV more often delivered by caesarean section (P less than 0.001) especially for maternal request (adjusted OR 3.48, 95% CI 2.45-4.39). In women having vaginal delivery, those with vaginismus/LPV were more likely to suffer a perineal laceration (adjusted OR 1.87, 95% CI 1.56-2.25). Conclusions Women with vaginismus/LPV are less likely to give birth and those that do are more likely to deliver by caesarean section and have a caesarean section based upon maternal request. Those women delivering vaginally are more likely to suffer perineal laceration. These findings point to the importance of not only addressing sexual function in women with vaginismus/LPV but reproductive function as well.

Place, publisher, year, edition, pages
Wiley: 12 months, 2015
Keywords
Caesarean section; localised provoked vestibulodynia; reproduction; vaginismus
National Category
Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-115325 (URN)10.1111/1471-0528.12946 (DOI)000348866600011 ()24990073 (PubMedID)
Note

Funding Agencies|Medical Research Council of Southeast Sweden

Available from: 2015-03-13 Created: 2015-03-13 Last updated: 2019-06-28
4. Reproduction, fear of childbirth and obstetric outcomes in women treated for fear of childbirth in their first pregnancy: A historical cohort
Open this publication in new window or tab >>Reproduction, fear of childbirth and obstetric outcomes in women treated for fear of childbirth in their first pregnancy: A historical cohort
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2019 (English)In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 98, no 3, p. 374-381Article in journal (Refereed) Published
Abstract [en]

Introduction About 8% of the pregnant women in Sweden receive counseling for fear of childbirth (FOC) during pregnancy. Little is known about the long-term reproductive and obstetric outcomes after counseling for FOC: Therefore, the objective of this historical cohort study was to compare the long-term reproductive and obstetric outcomes in women treated for FOC in their first pregnancy to women without FOC. Material and methods All nulliparas consecutively referred for treatment of severe FOC between 2001 and 2007 (n = 608) were compared with all other nulliparas giving birth on the same day (n = 431). Women who were not fluent in Swedish, missing a postal address, had moved out of the area, given birth at another hospital or had a late spontaneous abortion were excluded (n = 555). A total of 235 women agreed to participate in the study, 63 (39%) women in the index group and 172 (53%) in the reference group. The women were contacted by letter in 2015, ie 7-14 years after first childbirth, and asked to permit access to their medical charts from pregnancies and childbirths and to fill out a study specific questionnaire. Based on data from the medical charts and questionnaire, the mode of delivery, birth experience, obstetric complications, FOC, counseling for FOC and number of childbirths were compared in the two groups. Results Women in the index group less often gave birth more than twice compared with the reference group (8.2% vs 22.0%, P = 0.012). We found no significant differences in complications during subsequent pregnancies and deliveries. Women in the index group more often gave birth by CS in their first (P = 0.002) and second childbirth (P = 0.001), more often had a less positive birth experience (index group NRS: median 6.0, interquartile range 6 vs reference group NRS: 7.0, interquartile range 5, P = 0.004) in their first delivery and more often received counseling for FOC (58.7% vs 12.5%, P amp;lt; 0.001) in subsequent pregnancies. Women in the index group more often experienced FOC (18% vs 5.3%, P = 0.001) 7-14 years after first childbirth. Conclusions FOC is not easily treated. Despite treatment and exposure to childbirth many women received treatment in their next pregnancy and still suffered from FOC 7-14 years after the first childbirth.

Place, publisher, year, edition, pages
WILEY, 2019
Keywords
birth experience; cesarean section on maternal request; counseling; fear of childbirth
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:liu:diva-154981 (URN)10.1111/aogs.13503 (DOI)000459481000013 ()30431149 (PubMedID)
Note

Funding Agencies|Medical Research Council of Southeast Sweden, FORSS

Available from: 2019-03-20 Created: 2019-03-20 Last updated: 2019-06-28

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