Support for pregnant women identified with fear of childbirth (FOC)/tokophobia - A systematic review of approaches and interventions

Background: providing appropriate care for pregnant women with high or severe fear of childbirth (FOC) is a challenge in midwifery care today. FOC is associated with predisposing anamnestic factors, various socio-demographic and psychosocial characteristics, and may result in serious healthrelated consequences. It is therefore important to establish which interventions may increase a woman's faith in her own ability to cope with labour and birth. Aim: to systematically identify and review studies examining interventions for relief of severe fear of childbirth in pregnancy and their underlying conceptual foundation. Methods: a systematic literature search was performed following Cochrane Collaboration and PRISMA Statement recommendations. Inclusion criteria were: studies including pregnant women diagnosed with high or severe FOC or who requested a caesarean section due to severe FOC, studies (regardless of design) observing the effect of an intervention addressing FOC, and studies published in English. Publications addressing anxiety or stress were excluded. 377 references were screened by title and abstract. The risk of bias was assessed. Findings: 19 articles referring to 15 research projects were included in the analysis. The studies show heterogeneity regarding assessment methods, type, conceptualisation and application of interventions. There is evidence that both cognitive therapy sessions and a theory-based group psychoeducation with relaxation are effective interventions. Key conclusions: despite methodological limitations, single or group psychoeducation sessions for nulliparous women or therapeutic conversation during pregnancy (in group or individual sessions) have the potential to strengthen women's self-efficacy and decrease the number of caesarean sections due to FOC. The theoretical validation of an intervention deepens the understanding of psychological processes in women coping with severe FOC.