Abstract
Introduction
Pregnant women with fear of childbirth display an elevated risk of a negative delivery experience, birth‐related post‐traumatic stress disorder, and adverse perinatal outcomes such as preterm birth, low birthweight, and postpartum depression. One of the therapies used to treat fear of childbirth is eye movement desensitization and reprocessing (EMDR) therapy. The purpose of the present study was to determine the obstetric safety and effectiveness of EMDR therapy applied to pregnant women with fear of childbirth.
Material and methods
A randomized controlled trial (the OptiMUM‐study) was conducted in two teaching hospitals and five community midwifery practices in the Netherlands (www.trialregister.nl, NTR5122). Pregnant women (n = 141) with a gestational age between 8 and 20 weeks and suffering from fear of childbirth (i.e. sum score on the Wijma Delivery Expectations Questionnaire ≥85) were randomly allocated to either EMDR therapy (n = 70) or care‐as‐usual (CAU) (n = 71). Outcomes were maternal and neonatal outcomes and patient satisfaction with pregnancy and childbirth.
Results
A high percentage of cesarean sections (37.2%) were performed, which did not differ between groups. However, women in the EMDR therapy group proved seven times less likely to request an induction of labor without medical indication than women in the CAU group. There were no other significant differences between the groups in maternal or neonatal outcomes, satisfaction, or childbirth experience.
Conclusions
EMDR therapy during pregnancy does not adversely affect pregnancy or the fetus. Therefore, therapists should not be reluctant to treat pregnant women with fear of childbirth using EMDR therapy.
Keywords: childbirth, childbirth experience, EMDR, eye movement desensitization and reprocessing therapy, fear of childbirth, pregnancy, tocophobia
Eye movement desensitization and reprocessing therapy for pregnant women with fear of childbirth is safe.
Abbreviations
- CAU
care‐as‐usual
- EMDR
eye movement and desensitization therapy
- FoC
fear of childbirth
- RCT
randomized controlled trial
- WDEQ‐A
Wijma Delivery and Expectancy questionnaire—version A
Key message.
There is no evidence of obstetric harm following eye movement and desensitization therapy for pregnant women with fear of childbirth. Maternal and neonatal outcomes are similar to those of women receiving care‐as‐usual.
1. INTRODUCTION
Fear of Childbirth (FoC) is an important topic in obstetrics, and the literature suggests that FoC is not only associated with adverse psychological outcomes such as a negative delivery experience, the development of post‐traumatic stress disorder and postpartum depression, 1 , 2 , 3 but also with adverse perinatal outcomes such as requesting a planned cesarean section without medical indication, 4 , 5 preterm birth and lower birthweight. 6 , 7 The adverse effects of maternal stress on the fetus have been widely described. 8 , 9 , 10
The safety of interventions aimed at reducing FoC is a key concern. One randomized controlled trial (RCT) that compared group psycho‐education with relaxation (n = 131) vs care‐as‐usual (CAU, n = 240) found that women who received psycho‐education were significantly more likely to have a more positive birth experience 11 and vaginal delivery. 12 Furthermore, a recent RCT that examined the effectiveness of mindfulness‐based childbirth and parenting (n = 75) found a significant decrease in planned cesarean sections compared with “enhanced‐care‐as‐usual” (n = 66; i.e. two individual 90‐minute sessions by trained midwives with psycho‐education and making a coping plan). 13 Conversely, another study in which pregnant women were randomly allocated to telephone psycho‐education by a midwife (n = 170) vs CAU (n = 169) showed no significant reduction in overall and unplanned cesarean sections, nor in any other obstetric outcome compared to usual maternity care. 14 Also, in a study that compared cognitive behavioral therapy and informative appointments (n = 85) with CAU (n = 91), no difference in planned cesarean sections was found. 15 However, there are indications that the application of psychotherapeutic intervention during pregnancy can adversely affect obstetric outcomes. For instance, an RCT among pregnant women with antenatal depression and/or anxiety found that cognitive behavioral therapy (n = 140), compared with CAU (n = 142), led to elevated levels of maternal anxiety and depression, and indications for adverse effects of cognitive behavioral therapy on the infant's gestational age at delivery. 15 These findings underline the importance of greater clarity regarding the safety of psychotherapeutic interventions aimed at reducing anxiety and distress in pregnant women.
The OptiMUM‐study, an RCT aimed at determining the effectiveness and safety of therapy in pregnant women with FoC, showed no significant difference between eye movement desensitization and reprocessing (EMDR) therapy and CAU, with large decreases in FoC in both groups. In addition, no worsening of FoC symptoms or other adverse effects on patients' psychological health was observed. 16 The purpose of the current study was to determine the outcomes of obstetric variables in this RCT. We hypothesized that EMDR therapy would not be associated with significantly more obstetric complications than CAU. We hypothesized that EMDR therapy would result in a lower percentage of cesarean sections and more positive childbirth experiences compared with CAU. Furthermore, we hypothesized that EMDR therapy would not be associated with significantly more neonatal complications than CAU.
2. MATERIAL AND METHODS
2.1. Study design
The OptiMUM‐study consisted of two RCTs with an overlapping design, both evaluating the safety and effectiveness of EMDR therapy in pregnant women. The study protocol has been published previously. 17 One RCT was conducted among pregnant women with post‐traumatic stress disorder and was published as a systematic review and a case study. 18 The (primary) psychological outcomes of the other trial that pertained to the effectiveness of EMDR therapy on FoC has recently have been published. 16
2.2. Participants
Participants in the study were recruited between February 2015 and November 2019 in the outpatient settings of two hospitals and five community midwifery practices in the city of Amsterdam, the Netherlands. During their antenatal consultation, all pregnant women with a gestational age between 8 and 20 weeks who mastered the Dutch language were invited to participate in the screening for FoC. Participants were eligible to participate in the RCT in the case of FoC based upon a sum score of ≥85 on the Wijma Delivery and Expectancy questionnaire—version A (WDEQ‐A 19 ). The exclusion criteria were age below 18 years old, current psychological treatment, the presence of post‐traumatic stress disorder, a psychotic disorder, or an intermediate/high suicide risk as indexed using the Mini international neuropsychiatric interview‐plus. 20 A more detailed description of the instruments that were used has been published in our protocol. 17
2.3. Procedure
All women with a positive FoC screen were invited to participate in a clinical interview to assess psychological comorbidities. In case no exclusion criteria were present, women were randomly allocated by an independent computer program (Castor EDC, 2019) to either EMDR therapy or CAU on a 1:1 allocation ratio. No restrictions or stratification factors were applied. The caregivers and assessors were blinded to the randomization results. Two to three months after delivery, the women received an email survey including validated questionnaires about the experience of pregnancy and childbirth, and questions about possible treatment or support to which they had been referred, or which they had arranged themselves for their FoC symptoms.
2.4. Interventions
Participants in the EMDR therapy group received (a maximum of) three EMDR therapy sessions of 90 minutes carried out by a psychologist, in addition to their standard antenatal care. All psychologists involved in this study had completed 2 years of postgraduate training as a clinical psychologist and had at least 1 year of experience in providing EMDR therapy after they completed a basic and an advanced training in EMDR therapy accredited by EMDR Europe. EMDR therapy was conducted according to the Dutch version of the standard EMDR protocol 21 , 22 using rapid eye movements. If necessary, it was allowed to maximize the taxation of patients' working memory with alternating tactile stimulation using techniques from EMDR 2.0. 23 EMDR therapy includes a three‐pronged approach focused on past experiences that caused the fear, catastrophic thoughts that fueled patient's anticipatory fear (flashforward procedure), and the application of a mental video check of images leading to current distress. 22
Participants in the CAU group received regular antenatal care including standard obstetric consultations with a doctor or midwife. No intervention aimed at reducing FoC was routinely offered; however, assuming good clinical care, anxious women could be referred according to their own local clinical guidelines or empirical experience.
2.5. Measurements
The primary outcome of the OptiMUM‐study was FoC as measured by the WDEQ‐A. The WDEQ 24 is a 33‐item self‐report questionnaire assessing FoC (WDEQ‐A) or the cognitive appraisal (experience) of childbirth (WDEQ‐B). Although this questionnaire was designed as a monofactorial scale with a sum score ranging from 0 to 165, evidence suggests that it can also be used dichotomously with a cut‐off of ≥85 for clinically relevant FoC. 25
The questionnaire sent to all participants 2–3 months after childbirth consisted of three self‐reported outcome measures: WDEQ‐B, satisfaction with pregnancy and childbirth, and the Childbirth Perception Scale. Satisfaction about pregnancy and childbirth was evaluated using the questions “how satisfied were you about your pregnancy” and “how satisfied were you about your childbirth” on a scale from 0 (extremely unsatisfied) to 10 (extremely satisfied). The Childbirth Perception Scale is a 12‐item Dutch questionnaire that measures the perception of delivery and the first postpartum week, and has adequate psychometric properties with good internal consistency. 26
Obstetric outcome data were extracted from obstetric medical records. In the Netherlands, antenatal appointments for women with low‐risk pregnancies can take place in first‐line midwifery practices, and women choose whether to deliver at home or in a hospital with their own community midwife. Antenatal appointments and deliveries of women with medium‐ or high‐risk pregnancies occur in a hospital setting under the supervision of an obstetrician. Transfer of care during birth was defined as referral during labor or postpartum period: (a) from home or hospital setting under supervision of a community midwife (low risk) to a hospital setting under supervision of an obstetrician (medium/high risk), or (b) from a general hospital (medium/high risk) to a tertiary referral center (high risk). No interim analysis was conducted. As a result of the low number of adverse obstetric outcomes, composite neonatal and maternal outcomes were defined based upon clinical relevance. The maternal composite outcome included: postpartum hemorrhage (>1 L blood loss regardless of mode of delivery, in accordance with the definition of the Dutch national guidelines 27 ), third‐ or fourth‐degree perineal tears (obstetric anal sphincter injury), and cesarean section. The neonatal composite outcome included: Apgar score after 5 minutes <7, umbilical artery pH ≤7.05, and admission to a neonatal intensive care unit.
2.6. Statistical analyses
Differences between groups in baseline characteristics, and the comparison between the treatment group and CAU on all obstetric outcomes were analyzed using two‐tailed independent t test (continuous variables) and chi‐squared (categorical variables), or Mann‐Whitney U test and Fisher's exact test when appropriate. The analysis of mode of delivery using mode of delivery as an independent variable, was conducted using a logistic regression analysis, adjusting for significant variables. All analyses were performed according to intention‐to‐treat, with significance levels set at α = 0.05. Statistical analyses were carried out using IBM SPSS Statistics for Windows, version 27.
2.7. Ethics statement
The study protocol was approved by the Medical Research Ethics Committee of the OLVG Hospital (reference number NL49305.100.14) on November 18, 2014 and registered prospectively (www.trialregister.nl, NTR5122), which is now included in the International Trial Registry Platform (ICTRP) (accessible through https://trialsearch.who.int/Trial2.aspx?TrialID=NTR51220). The RCT was registered on March 31, 2015, with the first participant included on April 1, 2015. There was no active patient or public involvement in the design of this trial.
3. RESULTS
Figure 1 shows the flowchart of patient inclusion. Of the 28 women in the CAU group who replied to the postpartum survey, six women (21.4%) reported that they had initiated treatment by a psychologist themselves during pregnancy, of which half received EMDR therapy. Demographic and clinical characteristics can be seen in Table 1.
FIGURE 1.
Flowchart. CAU, care‐as‐usual; EMDR, eye movement desensitization and reprocessing therapy.
TABLE 1.
Demographic and clinical characteristics at baseline.
| EMDR therapy group (n = 70) | CAU group (n = 71) | |
|---|---|---|
| Age (years) | 33.5 ± 5.0 | 34.6 ± 4.6 |
| Gestational age at randomization (days) | 115.6 ± 23.2 | 121.0 ± 23.1 |
| Ethnicity d | ||
| Dutch | 55 (78.6) | 60 (84.5) |
| Other, European | 7 (10.0) | 6 (8.5) |
| Other, non‐European | 6 (8.6) | 5 (7.0) |
| Mixed | 2 (2.9) | 0 (0.0) |
| Educational level a , d | ||
| Low | 2 (2.9) | 0 (0.0) |
| Middle | 13 (18.9) | 9 (8.8) |
| High | 54 (80.6) | 58 (86.6) |
| Married/co‐habiting with partner d | 68 (97.1) | 63 (88.7) |
| Parity | ||
| Nulliparous | 33 (47.1) | 34 (47.8) |
| Multiparous | 37 (52.9) | 37 (52.1) |
| Pregnant after fertility treatment d | 12 (17.1) | 7 (9.9) |
| Multiple pregnancy c | 4 (5.7) | 4 (5.6) |
| Cesarean section in history | 12 (16.9) | 8 (11.4) |
| Traumatic experiences (general) b | 60 (85.7) | 63 (88.7) |
| Previous traumatic childbirth experience b | 31 (44.3) | 30 (42.3) |
| Previous EMDR therapy (event) d | 13 (18.6) | 9 (12.7) |
| Traumatic childbirth | 4 (5.7) | 4 (5.6) |
| Sexual assault | 2 (2.9) | 0 (0.0) |
| Other | 7 (10.0) | 5 (7.1) |
Note: All variables are in mean ± standard deviation or number (%).
Abbreviations: CAU, care‐as‐usual; EMDR, eye movement desensitization and reprocessing therapy.
Low: completed elementary school (Dutch: basisschool, VMBO). Middle: completed high school or applied sciences (Dutch: HAVO, VWO, MBO). High: completed degree (Dutch: HBO, WO).
Defined by Life Events Checklist‐5].
All were twin pregnancies.
Five missing (4 CAU, 1 EMDR).
3.1. Pregnancy
No significant differences in pregnancy characteristics were found between groups (Table 2). Two unexplained intrauterine fetal deaths occurred in the CAU group, at 21 and 38 weeks of gestational age, vs none in the EMDR group.
TABLE 2.
Pregnancy and childbirth outcomes.
| EMDR therapy group (n = 70) | CAU group (n = 71) | p‐value | |
|---|---|---|---|
| Pregnancy | |||
| Hospital admission | 12 (17.1) | 7 (10.1) e | 0.350 |
| Total days of admission a | 5 (1–15) | 4 (1–11) | 0.649 |
| Hypertensive disorder | 6 (8.6) | 4 (5.8) e | 0.750 |
| Gestational diabetes | 7 (10.0) | 4 (5.8) e | 0.530 |
| Placental abruption | 0 | 1 (1.4) e | 0.500 |
| Premature rupture of membranes | 4 (5.7) | 4 (5.8) e | 1 |
| Intrauterine fetal death (>22 weeks GA) | 0 | 1 (1.4) e | 0.500 |
| Childbirth | |||
| Planned location of birth | 0.101 | ||
| Home | 4 (5.7) | 10 (14.5) e | |
| Hospital low risk | 7 (10.0) | 7 (10.1) e | |
| Hospital medium/high risk | 59 (84.3) | 52 (75.3) e | |
| Actual location of birth | 0.787 | ||
| Home | 2 (2.9) | 2 (2.9) e | |
| Hospital low risk | 2 (2.9) | 4 (5.8) e | |
| Hospital medium/high risk | 66 (94.3) | 63 (91.3) e | |
| Transfer of care during delivery | 7 (10.0) | 13 (18.9) e | 0.154 |
| Gestational age at delivery (days) a | 275 (267–282) | 275 (270–280) | 0.828 |
| Preterm birth (<AD37 GA) | 9 (12.9) | 9 (13.0) e | 0.587 |
| Onset of labor | 0.542 | ||
| Spontaneous | 29 (42.0) d | 30 (43.5) e | |
| Induced | 24 (34.8) d | 28 (40.6) e | |
| Planned cesarean section | 16 (23.2) d | 11 (15.9) e | |
| Mode of delivery a | 0.364 | ||
| Spontaneous (vaginal) | 33 (47.1) | 43 (61.4) d | |
| Instrumental (vaginal) | 6 (8.6) | 6 (8.6) d | |
| Planned cesarean section | 16 (22.9) | 11 (15.7) d | |
| Unplanned cesarean section | 15 (21.4) | 10 (14.3) d | |
| Augmentation of labor using oxytocin | 31/50 (62.0) g | 34/59 (58.0) g | 0.698 |
| Pain relief | 30/51 (58.8) g | 36/60 (60.0) g | 0.527 |
| Epidural analgesia | 16 (31.3) | 22 (36.7) | 0.258 |
| Intravenous opiates (remifentanil®) | 13 (25.5) | 17 (28.3) | 0.416 |
| Other | 1 (2.0) | 0 | |
| Duration active first stage (min) a | 376 (242–611) | 317.50 (205–507) | 0.281 |
| Duration second stage (min) a | 26 (13–62) | 28 (14–50) | 0.982 |
| Duration third stage (min) a | 9.5 (5–17) | 11 (7–17) | 0.362 |
| Blood loss (mL) d | 325 (312.5) | 300 (300) | 0.667 |
| Postpartum hemorrhage (>1 L) | 5 (7.1) | 3 (4.4) f | 0.375 |
| Manual removal of placenta | 1 (1.4) | 1 (1.5) f | 0.745 |
| Blood transfusion | 0 | 0 | NA |
| Prelabor rupture of membranes (>24 h) | 5 (7.1) | 6 (8.8) f | 0.480 |
| Intrapartum fever (≥38°C) | 1 (1.4) | 4 (5.9) f | 0.174 |
| Perineal damage (rupture or episiotomy) | 33 (49.2) f | 38 (55.9) f | 0.855 |
| Episiotomy | 11 (16.4) f | 13 (19.1) f | 0.427 |
| Third‐ or fourth‐degree tear | 2 (2.9) | 2 (2.9) f | 0.679 |
| Hospital admission days including/following birth a | 2 (1–4) | 2 (1–3) | 0.219 |
| Maternal hospital re‐admission | 0 | 2 (2.8) | 0.241 |
| Maternal death | 0 | 0 | 1 |
| Problems during puerperium | 6 (8.6) | 6 (8.8) f | 1 |
| Composite maternal outcome b , c | 34 (48.6) | 22 (31.0) | 0.084 |
| Patient perspective | |||
| Experiences of childbirth (WDEQ‐B)—continuous scale (range 0–165) | 71.61 (27.9) | 62.10 (26.5) | 0.590 |
| Experiences of childbirth (WDEQ‐B)—dichotomous ≥85 (N) | 7 (10.0) | 6 (8.45) | 0.280 |
| Childbirth Perception Scale (range 0–36) | 19.89 (3.6) | 20.02 (2.9) | 0.870 |
| Satisfaction scale—pregnancy (range 1–10) a | 7.5 (7–9) | 7 (6–8) | 0.320 |
| Satisfaction scale—childbirth (range 1–10) a | 5 (6–9) | 7 (5–9) | 0.800 |
Note: All variables are in median (interquartile range) or number (%). Unless stated otherwise, n and % are calculated excluding missing data.
Abbreviations: CAU, care‐as‐usual; EMDR, eye movement desensitization and reprocessing therapy; GA, gestational age.
Non‐normally distributed data, reported in median (interquartile range).
Logistic regression.
Maternal composite outcome: postpartum hemorrhage, third‐ or fourth‐degree perineal rupture, cesarean section.
One participant missing.
Two participants missing.
Three participants missing.
Four or more participants missing, exact number listed.
3.2. Childbirth characteristics
Childbirth characteristics are shown in Table 2. Eighteen (12.9%) women delivered preterm (before 37 weeks of gestational age), with no difference between the groups (EMDR therapy: n = 9; CAU: n = 9, p = 0.587). Of all preterm births, respectively one (EMDR therapy: 23+4 weeks) and two (CAU: 19+0 and 23+1 weeks) births were premature (before 24 weeks of gestation). Both preterm deliveries in the CAU group were iatrogenic termination of pregnancies because of severe congenital abnormalities.
The onset of labor did not differ between the groups (p = 0.542). In total, of the 138 women for whom the start of their labor was described, 59 (42.1%) labors started spontaneously, 52 (37.7%) were induced, and 27 (19.3%) were planned cesarean sections. The mode of delivery did not differ between the groups (p = 0.364). There were 76 (54.3%) spontaneous deliveries, 12 instrumental deliveries (8.6%), 25 (17.9%) unplanned cesarean sections, and 27 (19.3%) planned cesarean sections. A multivariable analysis showed no difference between groups regarding the percentage of planned (p = 0.459) and unplanned (p = 0.166) cesarean sections, or cesarean sections altogether (p = 0.110) (see Tables 3 and 4).
TABLE 3.
Results of multiple regression analysis regarding mode of delivery.
| Univariate OR (95% CI) | p | Multivariable aOR (95% CI) | p | |
|---|---|---|---|---|
| I. Cesarean sections (total) | 0.110 | |||
| CAU vs EMDR group a | 1.86 (0.93–3.72) | 0.082 | 1.90 (0.87–4.15) | |
| Multiple pregnancy | 3.09 (0.70–13.47) | 0.135 | ||
| Preterm birth | 1.81 (0.69–5.10) | 0.214 | ||
| Cesarean section in history | 5.17 (1.84–14.52) | 0.002 | 12.80 (3.40–48.26) | |
| Induction of labor | 0.38 (0.18–0.82) | 0.014 | 0.43 (0.18–1.01) | |
| Parity | 0.51 (0.25–1.03) | 0.063 | 0.16 (0.06–0.45) |
Abbreviations: aOR, adjusted odds ratio; CAU, care‐as‐usual; CI, confidence interval; EMDR, eye movement desensitization and reprocessing therapy; OR, odds ratio.
Reference is the CAU group.
TABLE 4.
Results of two secondary multiple regression analyses.
| Univariate OR (95% CI) | p | Multivariable aOR (95% CI) | p | |
|---|---|---|---|---|
| II. Planned cesarean section | 0.459 | |||
| CAU vs EMDR group a | 1.59 (0.68–3.73) | 0.286 | 1.41 (0.57–3.52) | |
| Previous cesarean section | 7.87 (2.82–21.96) | <0.001 | 7.67 (2.73–21.46) | |
| III. Unplanned cesarean section | 0.166 | |||
| CAU vs EMDR group a | 1.64 (0.68–3.94) | 1.96 (0.76–5.05) | ||
| Parity | 0.15 (0.05–0.48) | 0.001 | 0.150 (0.05–0.47) |
Abbreviations: aOR, adjusted odds ratio; CAU, care‐as‐usual; EMDR, eye movement desensitization and reprocessing therapy; OR, odds ratio.
Reference is the CAU group.
Reasons for planned (p = 0.456) and unplanned (p = 0.752) cesarean sections did not differ between the groups. Interestingly, the reasons for induction of labor did differ between groups: in the CAU group, seven times more women requested an elective induction of labor without medical indication than in the EMDR group (EMDR therapy: n = 1; CAU: n = 7, p = 0.048). The most common reasons for planned cesarean sections were repeat cesarean (n = 11, out of 20 women with a previous cesarean section), abnormal presentation of the fetus including breech position (n = 7), maternal indication (n = 4) consisting of previous uterine surgery or persistent symptoms after obstetric anal sphincter injury as a result of previous childbirth. Two women (without cesarean section in history) requested a planned cesarean section due to FoC, both had completed EMDR therapy. Reasons for unplanned cesarean sections were fetal distress (n = 12), failure to progress in first stage of labor (n = 8), failure to progress in second stage of labor (n = 2), unexpected breech (n = 1), failed induction (n = 1), or unknown (n = 1). These reasons did not differ between groups (p = 0.752).
Nineteen women (13.5%), 13 of whom were nulliparous, were transferred between healthcare providers: 12 women from the CAU group, and seven from the EMDR therapy group, with no significant difference being observed between the two groups (p = 0.154). Of those women who planned to give birth at home with their community midwife, 61.5% had not given birth before. The transfer between healthcare providers mostly occurred during the dilation stage (first stage) of childbirth (n = 17). The most common reasons for transfer were a request for pain relief during birth (EMDR therapy: n = 3; CAU: n = 6), meconium‐stained amniotic fluid (EMDR therapy: n = 2; CAU: n = 2) and prolonged prelabor rupture of membranes (more than 24 h of ruptured membranes before the onset of labor; EMDR therapy: n = 0; CAU: n = 2).
3.3. Patient perspectives
No significant differences between EMDR therapy and CAU were found regarding satisfaction about pregnancy (median = 7.5, U = 544, z = −1.01, p = 0.32) or childbirth (median = 5.0, U = 587, z = −0.255, p = 0.80) in the Satisfaction Scales Childbirth and Pregnancy. The WDEQ‐B showed no differences between groups either continuously (p = 0.59) or dichotomously (p = 0.28) (Table 2).
3.4. Neonatal outcomes
From 141 women, 145 living children were born. Three children were born before viable age and did not survive. No significant differences were found between the groups (Table 5).
TABLE 5.
Neonatal outcomes.
| EMDR therapy group (n = 70) | CAU group (n = 71) | p‐value | |
|---|---|---|---|
| Birthweight, g | 3255.87 ± 719.4 | 3190.12 ± 805.8 | 0.974 |
| Birthweight centile a | 49.5 (24–80) | 49.5 (19–67) | 0.416 |
| Fetal growth restriction (birthweight <p10) | 12 (17.1) | 12 (17.6) d | 0.558 |
| Macrosomia (birthweight >p95) | 5 (7.1) | 6 (8.8) d | 0.480 |
| Apgar at 1 min a | 9 (8–9) | 9 (8–9) | 0.259 |
| Apgar at 5 min a | 10 (9–10) | 10 (9–10) | 0.293 |
| Apgar at 5 min <7 | 2 (2.9) | 4/67 (6.0) e | 0.320 |
| Umbilical artery pH | 7.17 (0.1) | 7.14 (0.09) | 0.183 |
| Umbilical artery pH <7.05 | 2 (2.9) | 1 (1.4) | 0.496 |
| Shoulder dystocia | 1 (1.4) | 1 (1.4) c | 0.748 |
| Pediatrician consult | 33 (47.1) | 27 (39.7) c | 0.217 |
| Baby admitted to pediatrics/neonatal ward | 26 (37.1) | 20/67 (29.9) e | 0.235 |
| Baby admitted to NICU | 1 (1.4) | 3 (4.3) c | 0.304 |
| Congenital disorder | 1 (1.4) | 3 (4.4) d | 0.299 |
| Neonatal death | 0 | 0 | NA |
| Perinatal death | 1 (1.4) | 1 (1.5) d | 0.745 |
| Type of feeding | 0.930 | ||
| Breastfeeding | 39/62 (62.9) e | 33/54 (61.1) e | |
| Bottle feeding | 11/62 (17.7) e | 9/54 (16.7) e | |
| Combination | 12/62 (19.4) e | 12/54 (22.2) e | |
| Composite neonatal outcome b | 4 (5.7) | 6 (8.5) | 0.381 |
Note: All variables are in mean ± SD, median (interquartile range) or n (%). Unless stated otherwise, n and % are calculated excluding missing data.
Abbreviations: CI, confidence interval; CS, cesarean section; NICU, neonatal intensive care unit; RR, relative risk.
Non‐normally distributed data, reported in median (IQR).
Neonatal composite outcome: Apgar after 5 min <7, pH <7.05, admission to NICU.
Two participants missing.
Three participants missing.
Four or more participants missing, exact number listed.
4. DISCUSSION
The results of this study support our hypothesis that EMDR therapy is not associated with more obstetric or neonatal complications than CAU. Conversely, the results were not supportive of our second hypothesis in that EMDR therapy did not result in a lower percentage of cesarean sections or more positive childbirth experiences compared with CAU. An unexpected finding was that seven times more women in the CAU group received induction of labor at maternal request without medical indication.
Although, as far as we are aware, no previous RCT has investigated neonatal outcomes before, our results are in line with the limited number of previous studies that evaluated obstetric outcomes after treatments for FoC in pregnant women, showing no increase in adverse perinatal events or cesarean sections after treatment for FoC. 13 , 28 This supports the notion that EMDR therapy for pregnant women with FoC does not lead to obstetric complications.
Contrary to our hypothesis, we found no reduction in the percentage of cesarean sections in the EMDR therapy group compared with the CAU group. Although this result is at odds with several previous studies that found a reduction in cesarean sections after treatment aimed at reducing FoC, 12 , 13 it corresponds to some other studies showing no effect. 29 , 30 An example of the latter is a study by Fenwick et al., 29 who found an overall percentage of cesarean sections of 34% for the psycho‐education group vs 42% for the usual maternity care group (p = 0.27), with a planned cesarean rate of 16%. The fact that no difference was found between the two conditions in any of the primary outcome variables, 16 could explain why no differences in the proportion of performed cesarean sections were found between the EMDR therapy and the CAU group.
We did not expect to find such a high percentage of both planned and unplanned cesarean sections in our study, which is much higher than the Dutch general population based on the Dutch national obstetric database (planned cesarean sections 19.6% vs 9.2%, unplanned cesarean sections 17.9% vs 8.5%, respectively; Perined, 2020). Further analyses among subgroups of our study regarding parity and planned vs unplanned cesarean section showed that in almost all the subgroups the cesarean rates were higher compared with the general population, and only the percentage of unplanned cesarean sections in multiparous women was comparable with that of the general population (5.8% vs 4.8%; Perined, 2020). A possible explanation may be that FoC during pregnancy is known to be accompanied by an increased risk of adverse obstetric outcomes. Compared with a general (medium/high risk) Dutch hospital setting, in addition to a higher risk of cesarean section, we also found that our sample had a relatively high percentage of preterm births (13% vs 9%; Perined, 2020). There may be a selection bias because our study included relatively more pregnant women from a medium/high‐risk hospital setting than the Dutch general pregnant population. However, this cannot explain the high percentage of cesarean sections: the overall percentage of cesarean sections in hospital setting in the national database is 24% (Perined, 2020), which corresponds with the included hospital, and does not explain the 37.2% in our sample. Another potential factor that could have contributed to the high percentage of cesarean sections and preterm births is the high percentage of women who conceived through fertility treatments such as ovulation induction, intrauterine insemination, in vitro fertilization, and intracytoplasmic sperm injection. There is growing evidence that women who conceive after fertility treatment show an elevated risk of obstetric complications, including cesarean section (relative risk 1.56) and preterm birth (odds ratio [OR] 1.93 at <37 weeks of gestation, OR 3.27 at <32 weeks of gestation). 31 Our study found that 13.5% of participants conceived after receiving fertility treatment, which is substantially higher than the 3.4% fertility treatment rate observed in the Netherlands during the middle year of our inclusion period, 2017 (Perined, 2017). However, it should be noted that 48.5% of the conception methods in these national Perined data are missing. Therefore, it is not possible to accurately estimate the percentage of Dutch pregnant women who conceived through fertility treatment, but the percentage was very likely to be significantly lower than in our study.
The current study found a significant reduction in elective inductions of labor at maternal request in the EMDR group compared with that in the CAU group. It is known that the presence of FoC is associated with so called non‐urgent obstetric interventions, such as induction of labor, planned cesarean sections, and pain relief on maternal request without other medical indication. 13 , 32 Despite the fact that, based on questionnaire research, indications have been found for a reduction in preferences for such non‐urgent obstetric interventions, in clinical practice no actual measured reduction of these interventions after treatment for FoC has been demonstrated. 12 , 29
The current RCT provides the first comprehensive assessment of obstetric and neonatal outcomes in pregnant women with FoC who received EMDR therapy compared with those with CAU. Intervention studies on FoC that evaluate obstetric outcomes are scarce. In our study all pregnant women were screened, and women were included from both hospital (medium/high risk) and community midwifery practices (low risk) settings. This resulted in the inclusion of both low‐ and high‐risk pregnancies, thereby enhancing generalizability. The choice of the widely translated and validated WDEQ‐A enabled the comparison of our population with other studies. However, there are several limitations of the present study that need to be mentioned. First, there is no third arm including matched controls from other organizations to rule out the possibility that differences in care (rather than only in pregnant women) contributed to the outcomes. It is possible that, as a result of hospitals and practices participating in this study and caregivers receiving educational introduction presentations, awareness of FoC‐informed maternity care has improved. Related to this, the fact that there is no standard treatment for FoC available, may explain the high number of women in the CAU group who initiated treatment for FoC themselves (21.4%). Second, simply participating in the study, including undergoing the screening procedure and two comprehensive clinical interviews, may have had positive effects on the women in the CAU group. Both educated healthcare providers and personal attention during research appointments may have improved the care and thereby outcomes for the CAU group. Finally, our study population was predominantly comprised of highly educated and cohabiting/married participants from a high‐income country with good public health services.
The findings of the current study have important implications for clinical practice, as clinicians (both mental health professionals and obstetricians/midwives) should refrain from being reluctant to conduct EMDR therapy in pregnant women with FoC. Given the lack of studies evaluating the induction of labor at maternal request, future studies should include women requesting induction of labor without a medical indication, assessing the reasons for this, and determining the effectiveness of EMDR therapy, including its obstetric outcomes.
5. CONCLUSION
Although the present study showed no reduction in cesarean sections or more positive experiences of childbirth, the results provide support for the notion that applying EMDR therapy during pregnancy does not adversely affect pregnancy outcomes or the unborn child. More importantly, the application of EMDR therapy was found to be associated with fewer maternal requests for labor induction without medical indication compared with CAU. Therefore, therapists should not be reluctant to treat pregnant women with FoC using EMDR therapy.
AUTHOR CONTRIBUTIONS
All authors have made substantial contributions to the design of this study and were involved in critically revising the manuscript and accepted the final manuscript. MB drafted the manuscript under the supervision of AdJ and MvP.
FUNDING INFORMATION
The OptiMUM‐study received grants from the Stichting EMDR Nederland (Dutch EMDR Association), Fonds Gezond Geboren, Stichting Teaching Hospital OLVG, and Stichting Wetenschap OLVG, all awarded to the principal investigator MvP.
CONFLICT OF INTEREST STATEMENT
AdJ has been a board member of the Dutch EMDR Association and EMDR Europe Association, and receives fees for courses and books about trauma and EMDR. The other authors have no potential conflicts of interest.
Baas MAM, Stramrood CAI, Dijksman LM, Vanhommerig JW, de Jongh A, van Pampus MG. How safe is the treatment of pregnant women with fear of childbirth using eye movement desensitization and reprocessing therapy? Obstetric outcomes of a multi‐center randomized controlled trial. Acta Obstet Gynecol Scand. 2023;102:1575‐1585. doi: 10.1111/aogs.14628
DATA AVAILABILITY STATEMENT
The data set is available from the corresponding author, M. G. van Pampus, upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data set is available from the corresponding author, M. G. van Pampus, upon reasonable request.