Background
Childbirth is one of the most notable events in a woman’s life. It transitions women to motherhood and has substantial physical as well as emotional impacts. In many Western countries, the childbirth process has been medicalized and childbirth is thus mostly performed in hospitals, where it is managed by medical professionals with the use of technology [
1]. Technological births such as the cesarean section (CS) and use of epidural analgesia (EA) may be lifesaving and alleviate women’s pain during birth, but they may also have adverse effects on mothers’ health and well-being [
2,
3].
Women often take part in the decision-making process regarding their deliveries and it is important to understand the factors that influence women’s childbirth preferences. Cultural norms regarding motherhood and birth shape women’s perceptions regarding what birth is and how it should be managed. Several studies have found differences between cultures in terms of women’s preferences regarding CS [
4,
5], EA [
6,
7], and levels of fear of childbirth (FOC) [
8‐
10]. In addition, preliminary findings suggest that the known association between FOC and preferences for CS [
11,
12] may be culture-bound [
5,
13]. In the current study, we wished to compare women’s childbirth preferences and the way they relate to FOC between two Western countries - Norway and Israel.
Birth culture in Norway and Israel
In Norway - and Scandinavia as a whole - there is a strong norm of pregnancy and childbirth being
natural processes. Antenatal care is primarily midwife-led and patient-centred with a focus on shared decision-making and on avoiding unnecessary examinations [
14]. For example, there is usually only one regular ultrasound scan during the entire pregnancy, and except for several blood tests early in pregnancy, measurement of fundal height and blood pressure, not many medical tests are conducted in healthy women with low-risk pregnancies [
14]. The CS rate is relatively low compared to other Western countries (with 6.6% elective and 10.5% emergency CS) [
15]. Home birth rates are close to 3% [
16], and for low-risk pregnancies, the main birth attendant is a midwife [
14]. Another relevant cultural norm relates to individualism and female autonomy. As Norwegian women’s roles in modern society have changed over the last 50 years, so have their reproductive patterns. Norwegian women feel that they have the individual freedom to plan their reproduction; therefore, they increasingly devote less of their lives to pregnancy and childcare [
17]. Consequently, in the last century, the number of children born per woman has steadily declined. In 2015, the fertility rate for women in Norway was 1.71 [
18].
Israel, conversely, is more pro-natal and patriarchal [
19] and has the highest fertility rate (3.1) among the Organization for Economic Co-operation and Development (OECD) countries (average in the OECD is 1.7) [
18]. Israeli women are expected to be mothers, and birth has been referred to as a “national mission” aimed at increasing the Jewish population, which was reduced during World War II [
19,
20]. Childlessness is highly stigmatized; therefore, having a child is in practice not a choice but an obligation. Israel is one of the leading nations in reproductive technologies and provides subsidised fertility treatments for up to two children [
19]. Moreover, there is pressure to have “perfect” babies [
21], which coincides with the excessive medicalization of women’s reproductive health [
19,
20,
22]. Women are offered numerous antenatal ultrasound scans and various tests over the course of the pregnancy to ensure the healthy development of the baby. Practices such as preimplantation genetic testing or abortions for unspecified foetal anomalies are legal and not uncommon compared to other countries [
23]. In some hospitals, the use of EA reaches up to 90% among nulliparae [
24], and overall CS rates are 19.0% [
25], exceeding the 10–15% rates recommended by the World Health Organization [
26]. Home birth is discouraged (less than 1% rate) [
20], and while midwives do attend uncomplicated births, obstetricians oversee them.
Conceptualization of fear of childbirth
Being concerned about birth is a normal and prevalent emotion. While some women may show little FOC; others might experience moderate, adaptive, and harmless levels; and, for some women, this fear may be a dominant emotion during pregnancy and may seriously influence their daily lives [
27]. However, there is no single, agreed-upon definition of FOC (for a detailed discussion, see the systematic review by Nilsson et al., [
10]). The content of what women fear may differ among individuals and may involve different domains of the birth process, such as: fear that labor will be accompanied by intolerable pain, fear of not being competent to give birth, or concerns about the health of the baby [
28‐
30].
One of the most widely-used instruments to measure prenatal FOC is the Wijma Delivery Expectancy Questionnaire (W-DEQ) version A [
31]. The scale has 33 items and may be used as a dichotomous scale (with varying cut-off scores to denote severe FOC (see for example [
9,
30]) or as a continuous variable (see for example [
8]). The scale was originally used as a unidimensional instrument measuring FOC [
31]. Recently, researchers have suggested that there may be disadvantages to constructing fear by totalling scores on the W-DEQ [
32]. Indeed, when examining the scale, it is noticeable that it reflects not only different fears women may have regarding birth but also other fears and expectations regarding the birth experience. This observation has been empirically supported by several studies that extracted separate factors from the scale [
8,
30,
33,
34]. These factors operationalize the conceptual dimensions of women’s fears. Although there is no clear and agreed upon definition of FOC, a similar structure found in different cultures suggest women view childbirth along similar lines. Some of the common dimensions that were identified within the W-DEQ are: general or pain fear, concerns regarding isolation or loneliness during birth, lack of positive anticipation, and concerns for the child’s health [
33]. In a large Norwegian study by Garthus-Niegel et al. [
35], the number of items in the scale was reduced to 25 and six different factors of the W-DEQ were identified using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Relating to the different dimensions of FOC may improve the assessment of their correlates, as some studies have found differences in the way the factors associate with childbirth preferences [
30].
The current study
Though there are similarities between Norway and Israel (similar CS rates, midwives as main birth attendants, low home birth rates) they clearly have different birth cultures and normative expectations regarding motherhood, which might have implications for birth preferences and FOC. Therefore, the aim of this paper was: (a) to compare childbirth preferences of CS and EA between the two countries; (b) to compare FOC levels as measured by the W-DEQ between expectant mothers in Israel and Norway; and, (c) to investigate how FOC factors are related to the women’s preferences for CS and EA in the respective countries.
Discussion
Our findings showed both similarities and differences related to the perception of childbirth in Norway and Israel. Women’s preferences regarding CS and EA differed between the two countries. The six-factor structure of W-DEQ version A, reported earlier in the Norwegian sample [
35], was validated in this study with data from pregnant women in Israel. In both countries, first-time mothers reported more FOC compared to women who had previously given birth. FOC levels differed by country, with Norwegian women scoring higher on some factors and Israeli women on others. Among Norwegians, FOC levels were related to their childbirth preferences while among Israelis they were not.
These differences reflect the overall more natural birth culture in Norway, compared to the more medicalized practices in Israel. This is seen in women’s preferences: while most women (over 90%) in both countries wished to have a vaginal delivery, about three quarters of the Israeli women preferred EA, while over three quarters of the Norwegian women preferred
not to have it. These findings are consistent with the much lower EA use in Norway [
41] compared to Israel [
25]. In Norway, the emphasis is on women’s autonomy, first in choosing to have a child and later in the process of natural labor and delivery [
17]. The natural birth discourse begins in pregnancy and focuses more on the woman’s role and her strength to carry it out and less on the possible risks during birth. Unless there is a known risk factor (such as older age), women undergo only basic pregnancy check-ups with a midwife and only one ultrasound scan during the entire pregnancy, which is performed at around 17–19 weeks of gestation [
14]. It is not surprising that Norwegian women, who are expected to give birth naturally, are less inclined to plan the use of medical pain relief.
In contrast, in Israel the discourse around pregnancy and childbirth is much more medical. Pregnant women undergo monthly check-ups in an obstetrician’s office, which most often include an ultrasound examination. In addition, extensive blood tests are taken, and elaborate ultrasound scans of all fetal systems are performed by specialists at around 13–17 and 20–23 weeks of gestation. This risk-instilling environment promotes the search for the “perfect baby” [
21], which is supported by the medical, legal, and religious establishment in Israel [
23]. Childbirth preparation classes and labor room tours provide much information about medical interventions during childbirth, and it is legitimate to plan for and ask about various interventions and ways to ensure maternal and fetal safety. The Ministry of Health recently set guidelines to manage natural birth in hospitals, which denote that natural birth is not the norm [
42]. Medical interventions are frequently used, from birth induction (15.2% of births), to EA (42.5% of births) and elective CS (13.8% of all births) to surgically-assisted emergency vaginal (5.5% of births) or CS (5.2% of all births) [
25]. Altogether, the focus is more on birth as a painful and risky process and on ensuring that the perfect child is produced [
22]. Therefore, it is not surprising that Israeli women, who often view birth pain as a medically needless inconvenience, were more concerned with pain and wished to have EA.
While most women in both samples would not choose delivery by CS, 10% of the Norwegian women were inclined to choose a CS if they could, compared to only 5% of the Israeli women. It is possible that since women in Norway have more autonomy and are more involved in the decision-making process during birth [
14], they are more likely to consider asking for a CS. This finding is in concordance with the relatively high known rate of 7.6% CS by maternal request out of all CS in Norway [
43] and lower rate of 2.1% in Israel [
25]. It is important to note that the higher fertility rates in Israel may also explain these findings [
19]. Because of the adverse effect CS could have on future reproduction and birth, women who wish to have more children would rather avoid a CS [
44].
The six factors that were identified in the Norwegian sample [
35] were also present in the Israeli sample. Thus, despite the differences in the birth culture in these countries, there seems to be a uniform core to FOC dimensions as reflected by the W-DEQ factors. The concurrent exploration of the factors adds richness to the cross-cultural comparison, as it allows researchers to address nuances otherwise overlooked. These factors seem to represent a variety of cognitive expectations and concerns which may be culturally influenced, as in our case. It is possible that the “fear” factor, which was most strongly associated with childbirth preferences, is separable from the rest of the factors that tap into women’s expectations [
34]. Therefore, for certain purposes, it may be helpful or sufficient to use the shorter six-item fear factor, as in, for example, studies that want to focus on fear or in settings where a brief screening tool is needed.
While the W-DEQ structure replicated across the two cultures, there were substantial differences between Norwegian and Israeli women in our study in the levels reported on the FOC factors. Norwegian women were significantly more concerned with the factors associated with the subjective birth experience: They were concerned about the birth not turning out “as it should be” – natural and joyful, a powerful and empowering experience, during which they would feel strong and confident. They worried about having a negative experience. Compared to them, Israeli women, who are often surrounded by family members or other support (such as a doula) during labor and delivery, were barely concerned that they would feel lonely and deserted. Israeli women were more worried about the birth process and outcomes – they were more likely to report fear of the birth in general, of the pain, tension, and possible panic and loss of control. They were also more worried about the health and safety of the baby. This could also be explained by the cultural difference in the number of desired children: If you plan to give birth to only one or two children, as most women in Norway do, you may be more invested in having the ultimate birth experience. On the other hand, when you know you are likely to have three or more children, even if one of these experiences is more difficult, you will also have more chances for a good birth experience.
In Norway, as in other Scandinavian countries, there is much research on and more awareness of FOC [
9,
32] and it is more acceptable to request a CS for that reason [
45,
46]. Indeed, among Norwegian women, scores on all six factors of W-DEQ were correlated with a greater preference both for EA and CS. Regarding the Israeli sample, previous findings showed that while many Israeli women endorsed medical beliefs about birth and preferred giving birth under medical supervision [
22], at the same time most of them also believed that birth is a natural process [
47]. This belief coincides with the medical system’s strong discouragement of CS by maternal request, thus creating very low rates of CS with no medical indication [
25]. The high usage of EA and low rates of CS by maternal request likely both reflect physicians’ beliefs and preferences and women’s agreement with them and are thus different manifestations of the medicalization of childbirth in Israel. The flip-side of these findings can be seen in the lack of associations between the FOC factors and the Israeli women’s preferences. These correlations were very weak, all significantly lower than the ones found in the Norwegian sample. In countries where the medical system does not encourage a diversity of choices in childbirth [
19], it is possible that FOC has less of an effect on women’s preferences.
Strengths and limitations
Similar to most of the research on FOC, our study is limited by focusing only on Western countries. Its strength lies in comparing two countries that are similarly modern yet of quite different birth cultures, thus uncovering both the common elements and the differences in the possible effects of FOC. Several methodological limitations must be acknowledged. Firstly, translation of the W-DEQ (into Norwegian and Hebrew) might affect the understanding of the items; thus, even with careful translation, differences may have resulted from the wording of the scale or the different expressions of emotions in each culture. To ensure as accurate a translation as possible, we used forward and backward translation, both done from the English version. Secondly, we determined the structure of the Israeli data by conducting CFA of the Norwegian six-factor solution but did not present an autonomous solution. Our study did not aim to uncover the ideal structure for the Israeli data, but rather tested whether the Norwegian structure was adequate so that it could be used as a basis for the cross-national comparison. The six-factor solution presented should be cautiously utilized. We recommend that before applying this model to other cultures, it should be cross-validated and tested and that the WDEQ structure should be confirmed in the specific data. Lastly, the findings were derived from secondary analyses of existing data from two studies that were not planned or executed simultaneously, which may have affected the comparability of the data. Therefore, the differences in childbirth preferences should be interpreted with caution. Nonetheless, both studies were based on large samples from clinical settings, allowing for the possibility to compare country trends in childbirth preferences and their relation to FOC.