The role of the family doctor in relation to anxiety in childbirth

It has been reported that among 20–80% of pregnant women express worries and fears in relation to their pregnancy or upcoming childbirth fear of childbirth, but levels of severity of anxiety symptoms are variable. For example, has been communicated fear levels were higher in Australian women when compared to a Swedish sample [1]. For a great deal of these women the fears are strong enough to be clinically relevant. However, estimations of prevalence are equivocal, presumably due to the lack of clear-cut definitions and conceptualizations of the concept to be measured [2]. They can be identified as the most important factors associated with the fear of childbirth, labor problems and obstetric characteristics, such as parity and mode of delivery in the previous pregnancy. Logically, new mothers have higher levels of fear than women who had given birth before. So, data from different studies support the fact that nulliparous women experience more fear than women parous children before birth. A previous surgical birth is a key fact as a provocative cause of fear and anxiety. On the contrary, experiencing a previous normal birth is a protective element of the fear of childbirth [3,4].


Introduction
It has been reported that among 20-80% of pregnant women express worries and fears in relation to their pregnancy or upcoming childbirth fear of childbirth, but levels of severity of anxiety symptoms are variable. For example, has been communicated fear levels were higher in Australian women when compared to a Swedish sample [1]. For a great deal of these women the fears are strong enough to be clinically relevant. However, estimations of prevalence are equivocal, presumably due to the lack of clear-cut definitions and conceptualizations of the concept to be measured [2]. They can be identified as the most important factors associated with the fear of childbirth, labor problems and obstetric characteristics, such as parity and mode of delivery in the previous pregnancy. Logically, new mothers have higher levels of fear than women who had given birth before. So, data from different studies support the fact that nulliparous women experience more fear than women parous children before birth. A previous surgical birth is a key fact as a provocative cause of fear and anxiety. On the contrary, experiencing a previous normal birth is a protective element of the fear of childbirth [3,4].

Clinical aspects of the tokophobia
Tokophobia is a specific and harrowing condition that needs acknowledging. Fear of childbirth is commonly framed as a phenomenon within the domain of anxiety. Phobic avoidance of pregnancy may date from adolescence (primary tokophobia), be secondary to atraumatic delivery (secondary tokophobia) or be a symptom of prenatal depression (tokophobia as a symptom of depression) [5].
The physiological aspects of fear and anxiety include responses such as palpations, hyperventilation, dizziness, etc., automatic negative thoughts, negative beliefs and expectations about oneself, others, the world or the future. In mothers with high anxiety trait, increased sensitivity to anxiety, or anxiety disorders, increases the number of perceived body sensations that can be misinterpreted catastrophically [6].

The biological founding of the fear of childbirth (or tokophobia)
The fear of childbirth is a complex phenomenon that involves elements related to sociology, psychology, biology, personal history and many other aspects. Thus, from the sociological point of view, one should consider the general educational factors of each country, often based on elements of traditions and religious; from the point of view of biology, it could be investigated in relation to the behaviour of primates and the problem of separation of mother and offspring, etc. Therefore, there are several psychosocial factors that surround the parturient and that play a very important role in childbirth, many of them already present from the beginning of pregnancy or even before, such as the cultural and socioeconomic environment, personality and degree of psychological maturity of the mother, her ideas about femininity and motherhood, her emotions, feelings and experiences during pregnancy, the relationship between the couple, fear of pain, anxiety generated by other aspects such as hospitalization, separation of the son who has been intimately bound to her, her future responsibility over him, etc. [7][8][9].
It is necessary to emphasize the biological meaning of the process of the childbirth: the separation of two organisms that until that moment have lived together; After the expulsion, the baby acquires a life of its own, taking charge of a great variety of physiological functions that until that moment the mother performed. For its part, the mother, who spent so many anxieties to adapt psychologically, metabolically, hormonally and ultimately, physiologically, to the stage of pregnancy, must go through a new process of adaptation, returning to the usual situation of non-pregnancy [10].
This transition reactivates deep anxieties in the parturient: the anxiety of separation, the anguish of birth and the readjustment to change, which refers to the anxiety of loss and fear of the unknown, including the change of the family balance [10,11].

The four categories of fear of childbirth
Although the psychological mechanisms of childbirth and anxiety and fear of childbirth are largely unexplored, and so, they should be the subject of further investigation [5], four categories of fear of childbirth have been described in pregnancy and related anxiety [12]: 1. In the process of delivery: fear of pain, prolonged labor, loss of control, being left alone during delivery, fear of her own incompetency. 4. Healthcare quality: hospital facilities, lack of trust in maternity staff and lack of trust in obstetricians.
In summary, anxiety over the deliver is related to lack of trust in the obstetrical staff, fear of own incompetence, fear of death of mother, infant or both, intolerable pain or loss of control. A previous complicated delivery predisposed for fear of death [13].
Regarding the moments susceptible to generate anxiety in childbirth, we can mention the perception of contractions, premature rupture of the membranes, the arrest of labor, admission to hospital, the period of dilation, the expulsive period, and the episiotomy. The perception of dilation contractions is variable and can cause some restlessness, uncertainty and anguish, which once recognized can leave a state of serenity, or, in cases of extreme sensitivity can produce a muscular contracture as a defensive attempt [10].
The premature rupture of the membranes causes anxiety because it indicates the beginning of the process, because it is a new uncontrollable sensation and because it can be associated with complications in popular fantasy.

Medical acts as the source of fear
Admission to the hospital determines another outbreak of anxiety, as well as later the period of dilation, which causes anal evacuative reflex-type stimuli, which can be frightening and painful; according to Freud's description, this phase reactivates the infantile fantasies and anguish of sphincter learning, as well as that for the unconscious, the moment of birth, means a castration and in the expulsive period it threatens to take place. On the other hand, episiotomy is incorporated into the unconscious as castration [10,14].

The place of the family doctor
In this context, general medicine / family medicine is in an ideal situation to observe from family precedents up to the last consequences of any problem of health, and to observe the transition into motherhood and its encounter with health care service, which is a fundamental turning point or transition in the women life course, and to can make anticipatory prevention about anxiety and fear of childbirth, by clarifying the anxieties of pregnancy during individual doctor-pregnancy interviews, and group meetings [15][16][17].
Because data suggest that women with fear of childbirth may have identifiable vulnerability characteristics, such as poor mental health and poor social support, and there is a certain number of key elements of anxiety in childbirth that can be identified, as fears of the unknown, potential for injury, pain, capacity to give birth, losing control, and adequacy of support from care providers [18], if the personality of the pregnant woman has been duly studied during her preparation for childbirth, and women suffering from anxiety of partum are screened routinely before delivery, identifying during pregnancy the women at risk for negative psychological response to childbirth and it is offered proper care, these crises can be prevented, diminishing their intensity and finding the professionals in possession of broader resources to solve them [10,19].
For these women, family doctor should evaluate the facilitate rather than interrupt the process, to think beyond verbal communication towards a wider concept of communication that involves silence and intercorporeality, provide supportive care during pregnancy, focusing on the subjective experience of the birth, and offer psycho-education and psychosomatic support, to prevent fear of childbirth [11,[20][21][22][23][24][25].