DoWomen with Epilepsy Have More Fearof Childbirth During Pregnancy

ComparedwithWomenwithout Epilepsy?A Case-Control Study

Katherine Turner, PhD, Ada Piazzini, PhD, Albertina Franza, MD, Raffaele Canger, MD,Maria Paola Canevini, MD, and Anna Maria Marconi, MD

ABSTRACT: Background: Although anxiety and depression in populations with epilepsy havebeen studied, no research on fear of childbirth in women with epilepsy have been conducted. Thepurposes of this study were to examine whether a significant difference occurred in fear of childbirthbetween pregnant women with epilepsy and pregnant healthy controls and to evaluate the mostcommon fears. Methods: Fifty pregnant women with epilepsy and 50 pregnant women withoutepilepsy were assessed at a gestational age between 32 and 36 weeks of pregnancy, using twoquestionnaires for the measurement of fear of childbirth, an open question, and a clinical interview.Results: We found that during pregnancy, women with epilepsy experienced a significantly higherrate of fear of childbirth when compared with healthy controls, whereas after delivery, the experiencesand feelings about childbirth are almost the same as those of women without epilepsy. Conclusions:Our findings signify the importance of the assessment of the fear of childbirth, especially in womenwith epilepsy, and the need to offer professional and ad hoc support to those who suffer from it.(BIRTH 35:2 June 2008)

Key words: fear of childbirth, epilepsy, pregnancy, postpartum

Pregnancy represents a transition period in a woman’slife, characterized by biological, psychological, andsocial changes (1). During pregnancy, a woman pre-pares herself for permanent changes in her life andnew responsibilities after childbirth (2). Ambivalent

feelings intensify, which can lead to fear of childbirthand pregnancy-related anxiety (3).

Most common fears during pregnancy are those ofpain, losing control, incapacity to give birth, becom-ing a parent, obstetric injuries, concerns about thehealth and life of the baby, and concern for prematurechildbirth (4).

The prevalence of antenatal fear of childbirth mayvary from one study to another and may depend onthe definition of the concept, the timing of measure-ment, and the woman’s cultural background. In moststudies, 1 of 5 pregnant women experiences moderatefear of childbirth, and 6 to 13 percent experienceintense, disabling fear of childbirth (5,6).

Adverse childbirth experiences related to unexpec-ted medical intervention, severe pain, and emergencycesarean section may evoke fear and anxiety for somewomen and precipitate post-traumatic stress disorder.Converging evidence that 1 to 2 percent of women

Katherine Turner and Ada Piazzini are Clinical Psychologists,Albertina Franza is a Neurologist, Raffaele Canger is an AssociateProfessor and Head, and Maria Paola Canevini is an AssociateProfessor at the Epilepsy Center; and Anna Maria Marconi is anAssociate Professor in the Department of Obstetrics and Gynecology,DMSD, St. Paolo Hospital, University of Milan, Milan, Italy.

Address correspondence to Katherine Turner, PhD, Epilepsy Center, St.Paolo Hospital, University of Milan, Via A. Di Rudinı, 8, 20142 Milan,Italy.

Accepted October 5, 2007

� 2008, Copyright the AuthorsJournal compilation � 2008, Wiley Periodicals, Inc.

BIRTH 35:2 June 2008 147

develop post-traumatic stress disorder as a result ofchildbirth exists (7).

Fear of childbirth often implies a maternal requestfor elective cesarean section, despite the known risksof this procedure (8). For some women about to givebirth for the first time, the event appears to be unfa-miliar, uncontrollable, and intimidating. Thus, toreduce fear and anxiety, as well as the morbidity bothof women and of infants due to obstetric complica-tions and unnecessary cesarean sections, treatment forfear and anxiety should be established in antenataloutpatient clinics (5).

Pregnancy in women with epilepsy is considered tobe a risk because several factors can complicate its cou-rse and outcome. The teratogenicity of antiepilepticdrugs is a major concern. The incidence of both minorand major malformations is reported to be higher ininfants of mothers with epilepsy who are taking anti-epileptic drugs (9).

It is important for a woman tomaintain good seizurecontrol during pregnancy. Furthermore, not all seizureshave the same risks. Although generalized convulsiveseizures are reported to produce hypoxia in the fetus,other types such as focal or absence seizures may nothave adverse effects. Most women with epilepsy havea normal pregnancy and delivery and an unchangedseizure frequency, and more than 90 percent havea chance of giving birth to a normal baby (10,11).

Although anxiety and depression in the popula-tion with epilepsy have been studied, no reports areavailable on fear of childbirth in women with epilepsy(12–14). In this study, we have administered two self-reported scales to assess the rate of fear of child-birth in women with epilepsy compared with healthycontrols. The goals of our study were twofold: (a)to investigate the prevalence of fear of childbirth inwomen with epilepsy and the presence of any differ-ence with healthy controls and (b) to point out demo-graphic, clinical, and other factors associated withfear of childbirth in pregnant women with epilepsy.

Methods

The study was performed at the University of Milan,St. Paolo Hospital, Milan, Italy. Fifty pregnantwomen, who were consecutively followed up at theEpilepsy Center between April 1, 2004, and December31, 2006, were enrolled.

The following inclusioncriteriawereused: (a) diagno-sis of idiopathic, cryptogenic, or symptomatic epilepsyaccording to the International League Against Epi-lepsy syndromic classification (15); (b) maternal agegreater than or equal to 18 years; (c) gestational agebetween 32 and 36 weeks of pregnancy; (d) education

level greater than or equal to 8 years; and (e) ability toread, understand, and speak Italian. Women receivingmedications other than antiepileptic drugs and thosewith a psychiatric background or who had previouslyexperienced mood or anxiety disorders were excluded.Similarly, women who had one or more previous cesar-ean sections were excluded because the psychologicalinstrument was not adjusted to surgical delivery.

Women with epilepsy are not discouraged frombecoming pregnant since the chances of having ahealthy baby are very high and can even be improvedwith good planning and supervision of the pregnancy.For women who plan a pregnancy, monotherapy at thelowest possible dose to achieve satisfactory seizure con-trol is always considered the optimal treatment regimen(16,17). Research on the relative teratogenic risk asso-ciated with different antiepileptic drugs is still ongoing.However, it is generally accepted that the risk of mater-nal and neonatal harm, as a result of seizures duringpregnancy, is greater than the risk of teratogenicitywith antiepileptic drugs (18–20).

Fifty consecutively matched pregnant healthy con-trol women were recruited from the outpatientDepartment of Obstetrics and Gynecology. The fol-lowing inclusion criteria were used: (a) maternal agegreater than or equal to 18 years; (b) gestational agebetween 32 and 36 weeks of pregnancy; (c) educationlevel greater than or equal to 8 years; and (d) ability toread, understand, and speak Italian. Women witha psychiatric background or who had previously expe-rienced mood or anxiety disorders were excluded.

Table 1. Clinical Characteristics of Women with Epilepsy

CharacteristicResults(n = 50)

Type of epilepsy, No. (%)Generalized 19 (38)Focal 31 (62)

Etiology, No. (%)Probably symptomatic 11 (36)Symptomatic 20 (64)

Seizure frequency (monthly), mean ± SD 1.5 ± 4.7Minimum-maximum 0–30

Duration of epilepsy (yr), mean ± SD 18.3 ± 9.3Onset of epilepsy (yr), mean ± SD 14.7 ± 8.5Antiepileptic drug therapy, No. (%)Monotherapy 42 (84)Carbamazepine 20 (48)Valproate 13 (31)Phenobarbital 3 (7)Phenytoin 3 (7)Topiramate 2 (5)Clobazam 1 (2)

Polytherapy 7 (14)No therapy 1 (2)

148 BIRTH 35:2 June 2008

Data were collected at two stages: between 32 and 36weeks of gestation (stage I) and at 5 weeks postpartum(stage II). The Wijma Delivery Expectancy/ExperienceQuestionnaire version A (W-DEQ A) (21), an openquestion, and a clinical interview were administeredat stage I. The Wijma Delivery Expectancy/ExperienceQuestionnaire version B (W-DEQ B) was assessed atstage II (21).All women with epilepsy and control women had

given their written informed consent before answeringthe questionnaires. The University of Milan Institu-tional Review Board reviewed and approved the studyprotocol.

Instruments

The W-DEQ A and W-DEQ B have been developedto measure prenatal and postpartum fear of child-birth. In this study, Wijma Delivery Expectancy/Ex-perience Questionnaire (W-DEQ) was elaborated tomeasure the pattern of childbirth-related fear duringpregnancy and after delivery by asking the womanabout her expectations before (version A) and herexperiences after (version B) childbirth.The W-DEQ is a 33-item self-administered question-

naire. Women were instructed to rate their personal

feelings and cognitions on a 6-point Likert scale from0= ‘‘not at all . . .’’ to 5= ‘‘extremely . . ..’’ The overallW-DEQ score, obtained by summing the scores ofeach item, ranged between 0 and 165. The higherthe score, the greater the fear of childbirth. Womenwho scored above 84 were considered to be suffer-ing from fear of childbirth, following the author’sprocedure (21).

A semistructured clinical interview was used toenroll women. It was administered by a trained clini-cian and included the major axes I and II diagnosticclasses on the basis of Diagnostic and Statistical Manualof Mental Disorders, Fourth Edition, Text Revision. Itconsisted of past and current medical history anddetails of the medicines taken by the study women (22).

Every woman answered a sociodemographic ques-tionnaire assessing age, current employment status,marital status, level of education, attendance in pre-natal classes, and presence of other children.

We asked every woman an open question: ‘‘What isyour major fear about pregnancy?’’

Data Analysis

Data are presented as mean ± standard deviation.Sociodemographic differences between women with

Table 2. Demographic Characteristics of Women with Epilepsy and of Control Group

CharacteristicGroup with Epilepsy

(n = 50)Control Group

(n = 50) Mann-Whitney U p

Age (yr), mean ± SD 32.8 ± 4.7 31.8 ± 4.1 929.0 0.563Education (yr), mean ± SD 13.5 ± 3.4 13.4 ± 2.9 965.0 0.765

w2 p

Marital status, No. (%)Married 45 (90) 37 (74) 0.780 0.377With partner 5 (10) 12 (24) 2.882 0.090Divorced 0 1 (2) 1.00

Nulliparous 34 (68) 30 (63) 0.250 0.617Gestational age (yr) atW-DEQ A, mean ± SD

34.6 ± 1.6 33.6 ± 1.5 0.333 0.5

W-DEQ A =Wijma Delivery Expectancy/Experience Questionnaire version A.

Table 3. Mean Scores of Wijma Delivery Expectancy/Experience Questionnaire for Group with Epilepsy and Control Group

Questionnaires Group with Epilepsy (n = 50) Control Group (n = 50) t p

W-DEQ A 89.5 ± 21 78.9 ± 18.8 2.667 0.009Nulliparous 87.8 ± 19.5 77.3 ± 19.3 2.221 0.030Parous 93.1 ± 24.1 82.4 ± 17.6 1.406 0.170

W-DEQ B 89.1 ± 27.3 88.5 ± 23.5 0.121 0.904Nulliparous 88.1 ± 26.9 85.7 ± 24.5 0.390 0.698Parous 91.3 ± 28.9 95.1 ± 20.3 �0.405 0.685

Note: Values are given in mean ± SD.W-DEQA=WijmaDelivery Expectancy/Experience Questionnaire version A;W-DEQB=WijmaDelivery Expectancy/Experience Questionnaire version B.

BIRTH 35:2 June 2008 149

epilepsy and control women were assessed with theMann-Whitney U test and the chi-square test.

W-DEQ scores were analyzed using the two-tailedStudent t test for unpaired samples to determinewhether differences in fear of childbirth occurredbetween women with epilepsy and control women asa whole and according to parity.

Linear multiple regression analysis was performedto detect interactions between demographic and clin-ical variables and psychological test scores using theW-DEQ result as a dependent variable. A stepwiseselection procedure was used, with the alpha to enterset at 0.05 and the alpha to remove set at 0.10. Datawere analyzed using the SPSS for Windows (23). Sig-nificance was set at a p value of 0.05.

Results

Clinical characteristics of the women with epilepsyare shown in Table 1, and demographic characteristicsof the twogroupsare reported inTable 2.Nostatisticallysignificant differenceoccurredbetween the twogroups interms of age, education, marital status, gestational age,and parity. Thirty-four women with epilepsy wereprimiparous and 16 multiparous; 30 women withoutepilepsy were primiparous and 20 multiparous.

Table 3 shows the mean scores of each questionnairefor the women with epilepsy and control groups. Wefound a significant difference inW-DEQAmean scoresbetween the epilepsy and the control group, which wasmainly due to nulliparous women with epilepsy who

performed statistically significant higher scores on theW-DEQ A compared with the nulliparous controlwomen; in contrast, no significant differences occurredbetween parous women with or without epilepsy. Simi-larly, we found no differences in W-DEQ A (scoresbetween nulliparous and parous women with epilepsy[p=0.907] or without epilepsy [p=0.643]). AW-DEQA score greater than 84 was observed in 27 (54%) of50 women with epilepsy and 26 (52%) of 50 controlwomen.

We found no significant differences in the W-DEQB scores between women with epilepsy and healthycontrol women. A W-DEQ B score greater than 84was observed in 24 (48%) of 50 women with epilepsyand 22 (44%) of 50 of control women.

At birth, none of the newborns presented with anymajor or minor congenital anomalies. We found a sig-nificant relationship between W-DEQ A and W-DEQB results and seizure frequency (p<0.05): women withhigher seizure frequency showed higher scores in thequestionnaires.

Figure 1 presents women’s responses to the openquestion: ‘‘What is your major fear about the preg-nancy?’’ Women with epilepsy were significantly morescared about malformations than control women (p=0.004), whereas the latter group reported more fear ofpain than those with epilepsy (p = 0.005). No otherdifferences were present.

Discussion

This study was performed to assess the fear of child-birth in a group of pregnant women with epilepsywhen compared with a group of healthy women. Wefound that the item total scores of the W-DEQ Abetween the two groups were significantly differentwhen the questionnaire was administered during preg-nancy: women with epilepsy experienced more fearduring pregnancy compared with the control women.In contrast, the difference inW-DEQ B scores was notsignificant between the two groups, which indicatesthat the experiences and feelings about childbirth inwomen with epilepsy after delivery are almost thesame as those in women without epilepsy.

Nulliparous women with epilepsy showed more fearduring pregnancy than nulliparous control women,whereas parity was not associated with more intensefear.

The linear regression analysis performed indicatedthat seizure frequency was associated with both W-DEQ A and W-DEQ B.

Labor pain, like pain in general, is subjective andcan lead to a fear of delivery (24). Childbirth-relatedfears range from almost total absence to very high

0

10

20

30

40

50

60

Malformations * Pain * Seizures Nothing

perc

ent

Fig. 1. The graph shows answers to the open question‘‘What is your major fear about the pregnancy?’’ forwomen with epilepsy (white bars) and healthy controlwomen (gray bars). *p<0.05.

150 BIRTH 35:2 June 2008

levels of fear (25). Saisto et al showed that duringpregnancy, women experience fear of premature birth,of obstetric injuries, of intolerable pain, and fear forthe health and life of the baby (26).Fear of childbirth can have wide-ranging effects on

mothers and their relationships, particularly on mar-ital functioning: women have reported negative con-sequences on their relationship with their partners,including disagreements and sexual dysfunction (27).Szeverenyi et al have reported that women whojudged their partner’s support as more effective hada lower fear of childbirth (28). A high level of fearcould inhibit the postpartum adaptation process(29). Fear of childbirth has gained growing attentionall over the world, and several obstetric departmentshave established qualified teams to support womenwho suffer from such fears. These teams comprisemidwives, obstetricians, psychologists, social workers,and psychiatrists. Several recent studies have demon-strated the efficacy of psychotherapeutic interventionsfor the acute treatment of fear of childbirth (30,31).The results of the present study show that women

with epilepsy are at higher risk than those without thedisease and highlight the importance of identifyingthose women with intense fear during pregnancy toprovide them with better clinical and psychologicalmanagement. Women with epilepsy have many con-cerns about the effects of their disease and the use ofantiepileptic drugs on their unborn children. Theseconcerns fall mainly into four areas: increased seizurefrequency, risk of birth defects, risk associated withbreastfeeding, and psychomotor problems associatedwith the use of antiepileptic drugs (32). In our study,women with epilepsy were more scared of possibleoffspring malformations than of labor pain whencompared with healthy women, suggesting that theirfear of childbirth might be related to the disease itselfthan to pregnancy and labor.Studies have shown that many of these fears can be

minimized with appropriate counseling (18,33). Dur-ing counseling, it is important to explain the effects ofantiepileptic drugs on the fetus and the newborn, thedanger of seizures during pregnancy, the process ofpregnancy, childbirth and postpartum, and the possi-bility of inheritance of epilepsy by children.

Conclusions

This study confirms the importance of fear-of-child-birth assessment, especially in women with epilepsy.Our findings offer a starting point for further inves-tigations based on a larger sample to obtain clearerand more reliable information and to offer profes-sional and qualified support to women who experi-

ence such fears. On the basis of these results, wesuggest the establishment of a psychoeducation sup-port group to help women with these psychologicalproblems.

Acknowledgments

We thank all the mothers who generously and en-thusiastically participated in the study. We alsothank the staff of the Department of Obstetrics andGynecology, St. Paolo Hospital, for their assistance.

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