gms | German Medical Science

One of today’s top priorities for midwifery worldwide is to examine the provision of intrapartum care and how that care is organised with the aim of supporting physiological processes, preventing complications and ensuring the safety and wellbeing of the recipients of this care [37]. For some pregnant women, the imminent birth of their child is a terrifying event. These women are afraid of their bodies being inadequate, of the unbearable pain, and, given the uncertainty about the process of labour and birth, also of potentially losing self-control. They are also worried that they will not receive adequate support and will experience complications requiring medical intervention. For some women this fear is so severe that it can only be described as a morbid dread of childbirth [46], [54], [68], [71]. These mothers-to-be believe there are no courses of action they can take that will contribute to making childbirth a positive experience and that will enable them to cope with the process [41], [54], [82]. They suffer from real and even distorted or incomprehensible fears, which can be seen as learned dysfunction (formerly called ‘neurotic’) [73].

Fear is a basic emotion which manifests itself as tension, anxiety, nervousness and an inner turmoil in situations perceived by an individual as threatening; at the physical level, fear results in increased activity of the autonomic nervous system [6]. From the perspective of the cognitive theories of emotions, following Magda Arnold and Richard Lazarus, fear is a partly subconscious, changeable response to an individual’s appraisal of circumstances that are important for their personal wellbeing. In an ongoing process comprising interactions between a person and their environment, the individual constantly re-evaluates the situation [49], [67]. Fears that are not universal or innate are acquired through conditioning or observation and can also be changed through learning processes; there is empirical evidence of the effectiveness of cognitive behavioural therapy, which for instance helps individuals to develop new skills and reduce ways of thinking that trigger fear [6].

In the case of fear of childbirth (FOC), typical effects are negative cognitions in the form of rumination or recurring fearful thoughts even going as far as catastrophising, for example during periods of night-time wakefulness. In the worst cases, women suffering from FOC experience symptoms of panic such as difficulty breathing, palpitations and sweats [54], [61]. Severe fear of childbirth, also known as tocophobia, and generally operationalised as = 85/165 points in the Wijma Delivery Expectancy Questionnaire (W-DEQ A) [56], is a major psychological stress for a pregnant woman and significantly diminishes her quality of life [54].

For women who had FOC during pregnancy, the progress of labour and childbirth is often slowed [1] and is more frequently accompanied by intense and even unbearable labour pain [35], [51]. These women are also more likely to be afraid during labour even if they are given regional anaesthesia [3]. FOC is the most common reason for women requesting an elective caesarean section [28], [60], [61], [79], something which also holds true for Germany [58], as well as a significant risk factor for a negative or traumatic birth experience [20], [37], [55], [69], for symptoms of post-traumatic stress syndrome (PTSD) [71] and postnatal depression [4]. It can also have a negative impact on bonding and attachment with the baby [5].

FOC is strongly influenced by socio-cultural factors [68]. The prevalence of FOC/ tocophobia is between 6.3 percent and 14.8 percent of all pregnancies in the West, including Europe, Australia, Canada and the USA [53]. Any significant regional differences can be explained by heterogeneous survey methods and timing and probably also maternity care structures. A regional study of the phenomenon would therefore seem expedient.

Women wish for a positive pregnancy experience and birth preparation that takes their values, beliefs and needs into account; alongside clinical care, this also includes timely and appropriate explanations and information about the most important aspects of labour and childbirth as well as social, cultural, emotional and psychological support [18]. Midwives¹ need specific knowledge to facilitate a positive birth experience for mothers-to-be suffering from tocophobia [8]. This particularly applies to cases where the women request an elective caesarean section [17], [19], [29], [31]. Various studies have highlighted interventions in this area that can contribute to an enhanced sense of self-efficacy and help diminish fears [75]. Before any kind of intervention is undertaken in a specific care context — in Germany, for instance — preparatory research is needed to identify the experiences and needs of the care recipients [57], [80]. The present paper therefore seeks to explore the following research questions: How does FOC develop? What experiences and social interactions, both in their private environment and the clinical care context, are significant for pregnant women with FOC?

An interpretative or hermeneutic research methodology is well suited to address these research questions. Ralf Bohnsack's documentary method [13], [12], in particular, reconstructs collective frames of orientation of social groups and patterns of their orientation of action/behaviour. Pregnant women with FOC represent such a social group of persons who share a so-called “conjunctive space of experience” [13], [50], implicating shared milieu-specific orientations of behaviour. From a cognitive sociology perspective, these collective patterns of orientation are based not only on explicit but specifically also on implicit knowledge and can therefore not easily be explored through simple questioning.

During the preparatory and implementation phase of the study, the lead author reflected on her own professional role as an experienced midwife and researcher. Her prior knowledge of FOC, acquired through her own clinical experience caring for pregnant women, was the basis for the “sensitising concepts” ([48], p. 141), which facilitated her access to the research field and also supported the dialogue during the interviews. Besides her experience of applying the documentary method, she was also able to switch between an internal and external perspective and develop a more in-depth understanding of the respondents’ experiences and frames of orientation as well as to see things from the angle of a professional providing intrapartum care.

The participants of the study were fully informed that participation was voluntary and received comprehensive information about data protection. They were asked to provide their written consent to participate. To cover the eventuality of an interview seriously exacerbating a respondent’s fear, six psychotherapists working in the region were pre-emptively requested to facilitate a therapy session, should the need arise. The relevant ethics committee of the university voted positively on the study.

Recruitment

For the purpose of ensuring a diverse recruitment process, the study used the access to users via registration consultation sessions at six maternity hospitals, independent midwives and psychologists, relevant professional associations and societies, as well as regional Internet portals and social networks for pregnant women.

Inclusion criteria were mothers-to-be in either their first or subsequent pregnancies who self-reported as suffering from FOC. Exclusion criteria were existing pregnancy complications and insufficient knowledge of German. A total of 28 women contacted the lead author by email or phone. The reasons for an interview not being conducted were non-fulfilment of inclusion criteria (n=4), premature contractions or birth (n=3), or personal or organisational reasons (n=7). Ultimately, interviews were carried out with 12 women, and, with three of the women, two interviews were conducted. Table 1 [Tab. 1] shows the characteristics of the participants.

Problem-centred interviews were conducted, which, on the one hand, enabled interviewees to talk freely about their experiences and their own frame of relevance in a protected environment and, on the other hand, also enabled the researchers to pose more in-depth follow-up questions based on their prior knowledge [82]. The interviews generally took place in the woman’s home (one interview was conducted by telephone) and lasted for between 43 and 278 minutes. As a stimulus to encourage the narrative, interviewers opened the discussion by asking the women to describe their experiences in as much detail as possible, as though they were talking to someone who was not a midwife. The interviews were digitally recorded, saved, password protected and protected from access by unauthorised persons. They were transcribed in full and pseudonymised. Participants were entitled to withdraw their consent up until the completion of recruitment. Once the analysis was concluded, the audio files were deleted.

Data evaluation

The analysis was conducted on a continuous basis, parallel to data collection, and was initiated with the introductory narrative in each transcript. For data evaluation, the lead author selected those passages from the transcript which were thematically linked to the research question. Narratives, descriptions and passages comprising particularly focused argumentation were specifically identified as these are known to best illustrate the frames of orientation and patterns of orientation of action/behaviour [12]. In the first analysing step ("formulating interpretation"), statements on the overarching themes and subtopics were summarised. The objective of the subsequent "reflective interpretation" was then to explicate the frames of orientation in which these topics were discussed. Finally, in the "comparative analysis", internal and cross-case comparisons were conducted with the aim to arrive at homologous patterns, which means the generic principle or the modus operandi of habitus.

In order to illustrate the lifeworld experience shared by the women interviewed, a minimal contrasting pairs approach was used to identify “a habitus or frame of orientation common to all interlocutors” ([11], p. 194. This included understanding the “incorporated coherent modes of perception, evaluation, and action” ([9], p. 201), which emerged as a ‘basic type’ ([11], p. 194). In the present study, this basic type was entitled “pregnant women with FOC”.

Repeated reflections in a research workshop, a doctoral study course and with experienced researchers facilitated the communicative validation of key interpretations. To ensure transparency of the research process, the lead author kept a research journal and documented the methodology-specific steps of interpretation in a manner that could be objectively verified. Once the analysis of the 12^th interview revealed no new aspects, it could be assumed that the theoretical saturation point had been reached; therefore, data collection was concluded (January 2017).

First of all, the ‘basic type’ is presented based on the genesis and subjective experience of FOC during pregnancy. This is followed by the description of the women’s characteristic lifeworld experiences and collective frames of orientation regarding antenatal care as well as birth preparation. The respondents’ frames of orientation focussing specifically on labour and birth as well as three types of coping strategies is published elsewhere (Journal of Psychosomatic Obstetrics and Gynaecology).

The findings presented below are based on statements taken from the interviews with all 12 respondents. Therefore, no further reference will be made regarding the sample. Particularly insightful quotes² illustrate the reconstruction of content (“P” is the abbreviation for participant).

During the first half of pregnancy, the participants repeatedly think about labour and birth but they have very little opportunity to compare their preconceptions with others? experiences because, for instance, their own mother is deceased or their sisters do not have any children. If other women are reluctant to describe their experiences, this discourages them from asking any further questions as they assume that the experiences of these other women must be unfavourable, and they want to protect themselves from hearing negative accounts of childbirth.

If family members, friends or colleagues recount traumatic birth stories, this leaves a lasting impression: the mothers-to-be develop a fear that something similar could happen to them:

The women cannot get these images out of their heads and they repeatedly come to the surface:

Particularly terrifying for the participants are descriptions of unbearable pain during childbirth, especially if it is experienced and recounted by their own mother or grandmother:

This results in fundamental doubts about the capabilities of their own bodies:

Because the respondents had only limited opportunities for discussions, their unsettling thoughts, perceived by them as threatening, are put aside (“suppressed” P 2.1, 33) and negative feelings are avoided as a form of self-preservation (“otherwise I will go crazy” P 2.1, 94-5). At this early stage, they see no way of dealing with their fear. The further the pregnancy progresses, the more cognitive effort they have to make to calm themselves inwardly. Here we can identify a form of rational optimism, a belief that everything will turn out for the best:

As the pregnancy progresses, the fact that the birth is inevitably approaching persistently comes to the fore and is experienced like a countdown:

During the day, when the mothers-to-be are on their own and able to relax, or at night in bed, their thoughts centre on the birth. They feel as though they cannot escape them. In the daytime, the respondents feel irritable and inwardly nervous or even in a state of panic. They look for distraction to avoid these thoughts. Multiparous women perceive their fear as being very closely linked to their previous experiences and they describe their first birth as an event, the intensity of which surprised and overwhelmed them. In retrospect, they consider the preparation they had for their first labour as inadequate, for instance, if they had not participated in a birth preparation course:

In hindsight, the women recall the complete loss of control over their own bodies during strong contractions as a particular source of fear:

Trying to talk about their fear of childbirth with their own partners does not really help the pregnant women. Discussions of their fears are put off until later:

this discussion is still by no means helpful to her.

The participants become part of a clinical care system where the gynaecologist’s office is their first port of call. Midwives are not chosen based on the range of services they offer, but rather according to subjective criteria (“What she looks like. And whether she comes across as friendly.” P 11, 125-5). However, the women know very little about how obstetric and midwifery care complement one another:

Pregnant women attach great hopes to the prospect of being cared for by a midwife who provides continual-care (“that would be a dream” P 8, 896). This is based on the desire to get to know the person who is going to be present at birth already during pregnancy and to have the opportunity to develop trust in her: that

The respondents felt helpless to do anything about the poor availability of midwives providing continuity-of-care:

During the antenatal check-ups in the obstetrician’s office, the women feel they have very little opportunity to talk about their fear and to receive help:

They consider it the doctor’s role to carry out an overall and impersonal risk assessment:

The impending birth is not really a subject of discussion, but neither do the respondents raise the issue with the doctor on their own initiative:

The respondents do feel that they can broach the subject with a midwife but even then, this rarely results in any kind of in-depth discussion:

In contrast, regular discussions with a familiar and trusted midwife have the potential to provide the respondent with a sense of relief and to ease her fear, because she has:

If the midwife is able to create a relaxed atmosphere, this can have a positive impact on the mother-to-be:

The fact that the midwife takes the initiative and proactively makes suggestions is seen as something positive:

Because the respondents often see themselves as inadequate and weak, negative feelings arise if they feel that they have not fulfilled the demands placed on them:

Pregnant women with FOC pay great attention to what the doctors and midwives tell them. They find it very reassuring when they receive confirmation during their antenatal appointment that everything is going well, such as when they hear words like

When there are no apparent anomalies and the mother-to-be asks whether everything is fine and does not receive a response that is unambiguously positive, such as:

this can worry the women unnecessarily. Even just a slightly deviant lab result during a routine antenatal check, such as a raised blood glucose level, for example, is interpreted by the respondent as a sign of personal weakness:

Comments on test results during pregnancy are often remembered word for word. The mother-to-be then extrapolates a prediction for the forthcoming birth from these results, for instance when the doctor comments during an ultrasound examination that the baby must have inherited its big head from the father, or it is really big in comparison with the mother’s height:

A statement like this can remain engraved on the woman’s mind and exacerbate her fear:

The respondents are all highly motivated to follow the obstetricians’ advice:

In the case that pregnant women pose their questions to different professionals and receive differing information, for instance in answer to whether an epidural is possible despite being on anticoagulants or whether an epidural is generally recommended during childbirth, this results in great uncertainty and helplessness.

During a birth preparation course, the women expect to receive important information about childbirth, for example about methods of pain relief, and to be able to try out different birthing positions. However, they only have a vague idea about what such a course will entail:

The women interviewed wanted the course to give them a realistic impression of what they could expect during childbirth:

They want to know what they can do for themselves during labour:

A particularly important aspect is that there won’t be continual pain throughout the entire duration of childbirth but that there are breaks between contractions during which women can rest and that they can use their breath to help them get through their contractions:

The respondents worry that discussing birth complications during an antenatal class will increase their FOC. They were particularly keen not to be told anything about severe complications, unless a woman herself could actively do something for their prevention these complications (P 2.2, 664-74). However, the respondents did want to be well informed about the measures routinely taken during childbirth so that they are prepared, for instance if, during the birth, a blood sample is taken from the baby’s head:

The fact that childbirth preparation courses have a group format is a positive aspect for the respondents because it gives them the opportunity to exchange information and experiences with like-minded women and they realise: “OK, so others have the same problems as I do” (P 2.2, 62). To be able to really put themselves in the position of the other women participating in the course can be “liberating” (P11, 535). When confronted with normative behavioural expectations in an exchange with others, the desire to free themselves from the idealistic images and to find their own independent path becomes apparent:

Moreover, a woman’s sense of her own inadequacy can put her under pressure to choose the best method of preparing for birth and can also trigger a fear of failure:

Regardless of any possible pressure to succeed, or of competition, an antenatal course can potentially alleviate FOC:

Respondents want their partners to accompany them to the course so that they can find out exactly how to support them during childbirth. They expect the course to give their partners an opportunity to discuss their own fears and correct any misinformation they may have. They place a lot of hope in their partner’s presence during birth: they expect their partners to have a calming effect on them when they themselves become anxious or scared:

In their quest to be well prepared for birth, the mothers-to-be who were interviewed were highly motivated to make use of other available options such as yoga or breathing exercises over and above the standard birth preparation courses — but they were very uncertain about their ability to assess the usefulness of such courses and services. In this context, the wide range of services on offer in a city can be confusing and the mother-to-be may see herself as “easy prey” (P 5, 1100) for service-providers offering courses of dubious quality. In order to be able to make a confident and informed decision, they are keen to seek professional advice.

The strength of this study is that the respondents were very willing to talk about their fears and, moreover, were also reporting on a situation that they were currently directly experiencing; in other words, the risk of recall bias is low. Before starting the interview, the level of FOC could not be reliably obtained due to the absence of a valid assessment tool in German language. Using self-reported FOC as an inclusion criterion, on the one hand, could be criticised as being too subjective, on the other hand, it may have contributed to creating a heterogeneous sample. The development, validation and use of a German assessment tool would help to identify FOC in pregnant women more reliably in future and could also be useful for interdisciplinary communication and referrals, as for example to a psychotherapist.

The participants differed in terms of parity, country of origin, income, as well as the level of support they received from their partners, and the planned mode of delivery. This meant that the sample provided data that were sufficiently conceptually representative and gave a valid and detailed insight into typical experiences of pregnant women with FOC. However, it was not possible to include any less educated women in the study (lower level than secondary education [Hauptschule] or those leaving school without qualification). It is generally difficult to attract persons living in less privileged conditions to participate in studies [26]. As we were unable to reach these women for the current study, it is unknown how their experiences might differ.

The original concern of the researcher that the in-depth interview might be perceived by the participants as a stressful experience proved to be unfounded. None of the respondents expressed the wish, at the end of the interview, to be put in touch with a psychotherapist.

The results of this study corroborate the findings of a Swedish study (n=20) [21], indicating that mothers-to-be with FOC, on the one hand, attempt to avoid the subject of childbirth and thus their fear but, on the other hand, also have the need to process and overcome their fear. Moreover, it is difficult for them to talk to other people about FOC; they therefore hope that the midwife will ask them about experience of fear thus signalling an openness to the subject. Important actions taken by mothers-to-be with FOC in order to deal with their fear include developing constructive thought strategies, such as hope, confidence or belief in a positive outcome, but particularly conversations in their social environment and discussions with professionals, as well as their own independent search for knowledge (in books, for instance) [47]. These insights could be starting points for the provision of compassionate care for women with FOC.

One new finding delivered by the current study is that birth experiences are a taboo subject in the respondents’ immediate social context. This highlights the lack of communication and knowledge about childbirth [47], even in a familiar environment. Bearing this in mind, we can understand why the “horror stories” told by others can be a source of particular stress and result in misconceptions about childbirth. Also, in television programmes, births are usually portrayed as excessively risky, dramatic and painful experiences [42]. Studies from Canada and England prove that this — combined with accounts of complications and emergencies — can contribute even in young non-pregnant women and men to increased fear of a future birth [75], [77]. Midwives are therefore called upon to develop educational and didactic concepts to facilitate access to positive experiences of the physiological process of childbirth and to appropriately reflect statements about risks of childbirth with the mothers-to-be in their care. Whether the “story-telling café” [59] method known from biographical studies and established in many German cities would be suited for ameliorating FOC would have to be assessed.

In terms of searching for information on the Internet which has become common practice for pregnant women these days [39], [64], it is problematic that users do not receive any assistance in appraising the quality of the information provided [9]. In order that mothers-to-be with FOC can satisfy their need for education and information, it is essential that health policy measures are taken to initiate the planning, provision and quality assurance of evidence-based and easily accessible health education and information about childbirth and the services provided by maternity hospitals. Pregnant women should be involved in developing the kind and manner of information provided. Midwives should point out recommended sources of information to counter the women’s sense that the sheer amount of information is overwhelming.

It is recognised that pregnant women develop confidence regarding the impending birth primarily when they feel informed and involved in decision-making processes and when the professionals caring for them convey trust in the women’s abilities [7]. This is reflected in concepts for psychosomatic-oriented maternity care [36], [52], [73].

Mothers-to-be with FOC require information on how the antenatal care provided by midwives and doctors is organised, on the physiology of childbirth and pain including explanations about the importance of position, movement, breathing and relaxation for the progress of birth, on routine measures that will be taken in hospital, on medicated and non-medicated methods of pain management and relief (and the advantages and disadvantages of these) as well as information on elective caesarean sections including decision-making support. These are essential prerequisites for them to be able to exercise their right to self-determination [32]. The experience of uterine contractions and the loss of control that occurs during childbirth are also important pieces of information for pregnant women with FOC. Midwives should plan sufficient time, right from the beginning and routinely, for their consultation sessions with mothers-to-be to ensure that there is enough time for a discussion about the woman’s fears regarding the impending birth. According to a Finnish survey of mothers conducted shortly after childbirth (n=20) [45], the act of women writing down their fears for their hospital files antepartum, for instance, proved to be a very helpful exercise.

The respondents of this study would prefer a midwife’s care in keeping with the midwife-led model of continuity, which is associated with greater satisfaction, fewer interventions during childbirth and better obstetric outcomes [14], [63], also for women with FOC [33], [76]. However, it is not solely the presence of the midwife during birth that makes the difference but rather her competency to manage a pregnant woman’s fear [30] as well as to provide the appropriate style of care and to guide her supportively during labour [44]. One challenge for midwives is that there is a possibility, especially with women suffering from tocophobia, that a discussion about fear might lead to a greater awareness of their fear, or an increase in their perceived level of fear. This was reported by a Swedish study for 11 percent of retrospectively surveyed women (n=10/94) and 26 percent of men (n=11/43) [23].

Conducting a risk assessment as part of the process of birth planning presents a particular challenge in case of FOC. One new finding from the present study is that women take prognostic statements, such as about the size of the baby, very much to heart and that such statements can increase their fear. In the event of even minor discrepancies, for example of lab results, a mother-to-be with FOC can also develop a lasting sense of guilt about the potential negative consequences of her body’s malfunction for her unborn child. In this regard, there is a link to feminist criticism that the focus on risk and the economisation of obstetric medicine prevailing in Germany today have the potential to lead to a problematic shift of the responsibility for a successful pregnancy to the pregnant woman herself [34]. It would therefore be advisable to implement structural changes which aim at achieving a birth culture characterised by a respectful care relationship between midwives and doctors, on the one hand, and with pregnant/labouring women, on the other.

For the participants of this study the subject of pain – alongside the unpredictable nature of childbirth – is particularly important since they lack confidence in their body’s capabilities, as has also been described in other studies [61], [68]. Yet, when FOC results in women declining to attend any form of antenatal course[27], [70] the consequence is that these women then also lack knowledge about both the medicated and non-medicated methods of pain relief available, which could, in fact, help to reduce their FOC [2]. Here, individual one-to-one support during pregnancy would be helpful for women with FOC which could acknowledge the woman’s personal fears and, moreover, impart information about the range of healthcare services provided by midwives.

The question also arises as to how we can meet the need of women with FOC for an exchange with peers and for social support in order to help them tackle their situation, without persuading them to come to specific decisions [40]. Moreover, midwives also need to respond adequately to the participants’ subjective feelings of inadequacy and, in some cases, also a detrimental competitive pressure within the group attending a birth preparation course. The partner or accompanying person and their own fears [22] also have to be taken into account. Antenatal courses must therefore have a sound basis from both a psychological [25], [24] and learning theory [15], [62] perspective and need to be carefully planned in terms of their didactic approach in order for them to have a positive and empowering effect.

An extensive care concept should be developed for pregnant women with FOC covering both outpatient and inpatient care. Out-patient care for women with FOC should be expanded to include theory-based individual and group psychoeducation with components of relaxation provided by midwives as well as therapeutic cognitive-therapy-based consultations with a psychotherapist. In studies both approaches have proven to be effective [75] and would provide mothers-to-be suffering from FOC with the opportunity to access individualised support in tackling their fear.

As the respondents’ desired form of support during childbirth from a midwife known to them cannot for various reasons, including structural conditions and a lack of resources in Germany, always and everywhere be realised, it remains an open question as to how the hospital’s care provision can be organised in such a way that the needs of women with FOC are taken into account. It is recognised that a pregnant woman develops confidence regarding the impending birth primarily when she feels informed and involved in decision-making and when the professionals caring for her convey trust in her abilities [7]. Rather than a birth plan, an in-depth assessment conducted at the maternity hospital about the wishes, values and options of the mother-to-be would seem to be a more suitable way of developing trust [16]. In inpatient care, it is important that all professionals involved in looking after mothers-to-be with FOC are aware of their additional care needs. Establishing multidisciplinary standards of respectful care for pregnant women can contribute to the prevention of FOC as a consequence of inappropriate, insensitive care in hospital which is disrespectful of their subjective experience [43]. Swedish reports refer to multidisciplinary units which they call “Aurora Teams” [81]; unfortunately, a description of this approach is not available in German. A communication concept that has already been successfully implemented in an English hospital might also be plausible [45]. According to this method, a prominent sticker is placed on the front of a vulnerable pregnant woman’s hospital file, supplemented by file notes on her emotional state. In addition, the personnel attend several days of further training. According to the author of the concept, 53 women whose care followed this approach did not have a traumatic birth experience as a consequence of poor and inappropriate care. Moreover, greater emphasis was generally placed on the psychological welfare of pregnant women and women in childbirth [45]. However, since the overall evaluation was not published and possible undesirable effects of labelling must also be considered, as is the case with all interventions for women with FOC, a feasibility study and on-going evaluation would have to be planned in future.

Midwives caring for pregnant women with FOC require specialised knowledge in order to appropriately design their care process, also in terms of its educational-didactical and targeted approach [44]. It is therefore important that as part of their primary training, midwives acquire a basic psychological knowledge of the specific needs of pregnant women with tocophobia as well as the educational and didactic skills to advise, and care for, these women. However, midwives need further qualifications to stimulate and support learning processes for coping with FOC in conducting individual or group psychoeducation and consultations [75].

To capture the birth experience, an assessment tool is required which does not yet exist in German language. The translation and validation of the English Pregnancy and Childbirth Questionnaire (PCQ) [78] is therefore recommended.

Future research studies could explore the inter-relationship between history of experiences, such as lower levels of education, geographic origin, and coping with FOC (socio-genetic typification) and thus diversify the current knowledge base.

¹ The term “midwife” refers to both male and female practitioners.

² In the quotations, the pauses in speech are indicated with a point/points in brackets.

³ Putting an “@” either side of a word indicates that the respondent is laughing whilst speaking.

The authors declare that they have no competing interests.

The author received 300 Euros from the Hebammengemeinschaftshilfe (HGH e.V.) and was awarded a grant of 1,500 Euros from the German Society of Psychosomatic Obstetrics and Gynecology (DGPFG e.V.) to conduct this study. This does not result in a conflict of interest as the sponsors had no influence whatsoever on the planning of the study, data collection and analysis.