Anxiety, Stress & Coping

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The effect of exercise and childbirth classes on

fear of childbirth and locus of labor pain control

Monika Guszkowska

To cite this article: Monika Guszkowska (2014) The effect of exercise and childbirth classes on
fear of childbirth and locus of labor pain control, Anxiety, Stress & Coping, 27:2, 176-189, DOI:
10.1080/10615806.2013.830107

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Anxiety, Stress, & Coping, 2014
Vol. 27, No. 2, 176
189, http://dx.doi.org/10.1080/10615806.2013.830107

The effect of exercise and childbirth classes on fear of childbirth and

locus of labor pain control
Monika Guszkowska*

Department of Socio-Cultural Foundations of Tourism, Faculty of Tourism and Recreation,

Józef Piłsudski University of Physical Education in Warsaw, Marymoncka 34, 00-986
Warsaw, Poland
(Received 17 November 2012; accepted 15 July 2013)

This study sought to track changes in intensity of fear of childbirth and locus of
labor pain control in women attending an exercise program for pregnant women
or traditional childbirth classes and to identify the predictors of these changes.
The study was longitudinal/non-experimental in nature and run on 109 healthy
primigravidae aged from 22 to 37, including 62 women participating in an exercise
program for pregnant women and 47 women attending traditional childbirth
classes. The following assessment tools were used: two scales developed by the
present authors
the Fear of Childbirth Scale and the Control of Birth Pain
Scale, three standardized psychological inventories for the big five personality
traits (NEO Five Factors Inventory), trait anxiety (State
Trait Anxiety Inven-
tory) and dispositional optimism (Life Oriented Test
Revised) and a question-
naire concerning socioeconomic status, health status, activities during pregnancy,
relations with partners and expectations about childbirth. Fear of childbirth
significantly decreased in women participating in the exercise program for
pregnant women but not in women attending traditional childbirth classes.
Several significant predictors of post-intervention fear of childbirth emerged:
dispositional optimism and self-rated health (negative) and strength of the belief
that childbirth pain depends on chance (positive).
Keywords: fear of childbirth; locus of labor pain control; exercise program;
childbirth classes

Introduction
The problem of how to reduce fear of childbirth is a big challenge for medical staffs
that prepare pregnant women for childbirth and care for them during labor. The need
to find effective ways of reducing fear of childbirth is becoming more and more urgent
due to the increasing number of cesarean deliveries on demand, without medical
indications (Bewley & Cockburn, 2002). This operative mean of pregnancy termination
has an array of maternal complications (placenta praevia, placenta accreta, uterine
rupture, excessive blood lose, maternal anemia and infection, hysterectomy) (Blanc,
Capelle, Bretelle, Leclaire, & Bouvenot, 2006; Irion, 2009). It may also have negative
psychological consequences, including post-traumatic stress disorder (Reynolds, 1997;
Sawyer, Ayers, Young, Bradley, & Smith, 2012), difficulties with breastfeeding, and
disorders associated with developing attachment with the child (Ayers, 2004; Green &

*Email: mguszkowska@wp.pl
# 2013 Taylor & Francis
 Anxiety, Stress, & Coping 177

Baston, 2003). Despite the risks involved, the number of cesarean sections is increasing
all over the world (Feinmann, 2002; Katz & Fuchs, 2008), including Poland (from
18.2% in 1999 to 28.8% in 2006
Troszyński, Niemiec, & Wilczyńska, 2008). An
estimated 6
8% of pregnant women would choose this method of delivery if they could
(Bewley & Cockburn, 2002; Hildingsson, Radestad, Rubertsson, & Waldenstrom,
2002). From 4% to 11% of cesarean sections in the United States are conducted upon
request, without medical indications (Chestnut, 2006).
Researchers have found that one of the significant reasons for requesting cesarean
section is fear of childbirth (Gamble & Creedy, 2001). Fear of childbirth is associated with
dysfunction of the labor process (Dole et al., 2003; Saisto, Ylikorkala, & Halmesmäki,
1999) and psychological problems during confinement. It predicts postpartum depres-
sion, anxiety, and disorder of maternal attachment (Hofberg & Ward, 2003).
The frequency of fear of childbirth differs from group to group and ranges from
23% to 64% (Areskog, Uddenberg, & Kjessler, 1981). It is generally thought that
clinical fear of childbirth complicates about 20% of pregnancies in developed
countries where it is most frequently assessed and that it reaches severe levels in
6
10% of pregnant women (Saisto & Halmesmäki, 2003).
One of the most common reasons why women fear childbirth is that they fear
pain. It is quite natural to fear pain to some extent. Nearly three quarters of pregnant
women in Finland express some fear of pain and nearly 90% plan to request some
form of anesthesia during labor (Kangas-Saarela & Kangas-Kärki, 1994). Fear of
pain during childbirth is the main reason for that pregnant women request cesarean
section in Finland (Saisto et al., 1999) and Sweden (Ryding, 1993; Sjögren, 1997).
Labor pain can be reduced by means of more or less invasive interventions. The
majority of feasible strategies are based on the fact that the experience of pain is very
subjective and largely dependent on psychological, including cognitive factors (Turk
& Melzack, 1992). A significant factor that reduces the perception of pain during
childbirth is a women’s belief that she is able to control pain (internal locus of
control) (Nettelbladt, Fagerstrom, & Uddenberg, 1976) and effectively apply such
methods of pain control as breathing exercises (Stockman & Altmaier, 2001).
Because cognitive factors influence the perception of pain during childbirth,
adequate preparation for labor may be an important preventive factor. Childbirth
classes providing information about labor and neonatal care are the most popular
form of preparation for labor. Access to information can help to reduce fear of
childbirth and neonatal distress (Saisto & Halmesmäki, 2003). They prepare
pregnant women and their partners for labor not only by providing information
but also by developing useful skills as well. This can help to reduce both partners’
anxiety and help them both to cope more effectively (Sieber, Germann, Barbir, &
Ehlert, 2006).
An alternative form of preparation for childbirth is exercise. In uncomplicated
pregnancies and when there are no risk factors, women are now encouraged to
engage in moderately intensive physical, mainly aerobic, exercise for at least
30 minutes a day most days a week or even daily (Artal & O’Toole, 2003; Davies,
Wolfe, Mottola, & MacKinnon, 2003; RCOG, 2006). Physical exercise programs for
pregnant women offer exercises tailored to the needs and capacities of this group,
including general development exercises to improve overall fitness and exercises
increasing the strength and elasticity of selected muscle groups and improving the
flexibility of the hip joints. Participants learn how to relax their muscles and breathe
178 M. Guszkowska

properly. Some exercises are specifically tailored to reduce back pain, especially low
back pain. The concluding relaxation session is also an important element.
Can exercise classes help to reduce pain of childbirth? At least two arguments can
be made in favor of a positive answer to this question. First, many studies in the field
of the psychology of physical activity suggest that physical exercise reduces both state
anxiety and trait anxiety (compare Biddle & Mutrie, 2008; Guszkowska, 2013) and
may therefore also reduce fear of childbirth. The level of anxiety in an imaginary
childbirth situation was lower in pregnant women who exercised during pregnancy
than in physically inactive pregnant women (Guszkowska, 2011; Guszkowska &
Dudziak, 2008). Second, the acquired ability to control one’s muscular tension and
breathing during labor can increase one’s belief in the controllability of labor pain, a
significant protector of fear of childbirth, as already mentioned.
The purpose of the present study was to compare changes in intensity of fear of
childbirth in women participating in an exercise program for pregnant women and
attending traditional childbirth classes. Additionally, the predictors of these changes
were looked for.
Various possible determinants of fear of childbirth have been scrutinized. These
include such demographic and socioeconomic factors as young maternal age, poor
education, and unemployment (Laursen, Hedegaard, & Johansen, 2008; Saisto &
Halmesmäki, 2003). Another significant predictor of fear of childbirth is lack of
social network and partner support (Melender, 2002; Ryding, Persson, Onell, &
Kvist, 2003; Saisto & Halmesmäki, 2003; Saisto, Salmela-Aro, Nurmi, & Halmes-
mäki, 2001). Low self-rated health predicted fear of childbirth in Danish national
birth cohort (Laursen, Hedegaard, & Johansen, 2008). Saisto, Salmela-Aro, Nurmi,
and Halmesmäki (2001) argue that fear of pregnancy and childbirth is relatively
stable and correlates with personality traits, especially trait anxiety, neuroticism, and
vulnerability. We may presume that the intensity of fear of childbirth will be
contingent on those stable psychological properties which affect the way we appraise
current events and our expectations concerning future events, as dispositional
optimism, i.e. a personality dimension expressed in generalized expectation of
positive events and the tendency to experience positive feelings and satisfaction with
life (Scheier & Carver, 1992). Level of optimism is positively related to internal locus
of control, and negatively related to anxiety (Scheier, Carver, & Bridges, 1994).
Another objective was to check whether participation in the two programs leads
to changes in beliefs concerning locus of control of labor pain, a significant predictor
of fear of childbirth (Guszkowska, 2012). A woman has internal locus of control of
pain of childbirth when she believes that she can control the intensity of her pain
experiences and external locus of control of pain of childbirth when she has no such
belief. In the latter case, she locates her beliefs in the medical staff (i.e. she believes
that doctors and midwives can alleviate her pain) on the one hand and in fate or
chance as determinants of pain of childbirth on the other hand (Skevington, 1990).

Method
Participants
The study was run on 109 women aged from 19 to 37 (M 29.05; SD 3.759) in
their 17th to 32nd week of pregnancy (M 27.58; SD 4.239) at the onset of the
 Anxiety, Stress, & Coping 179

study. All participants had higher education, lived in the capital city of Warsaw or the
Warsaw metropolis; 80.7% (n 88) were married and 19.3% (n 21) were in
common-law relationships but were not officially married; 52.3% (n 57) were not
working at the onset of the study and the remainder were working. All participants
had been occupationally active before they became pregnant. Women in multiple
pregnancies, women who had previously miscarried, and women with complications
of the present pregnancy were excluded.
The first group consisted of 62 pregnant women attending 50-minute-long
exercise classes, Nine Active Months, for pregnant women twice a week, conducted by
appropriately qualified fitness instructors. The program included general develop-
ment exercises with elements of Pilates, yoga, and body ball, exercises increasing
muscular strength and elasticity and joint flexibility, and relaxation and breathing
exercises. The program lasted for 8 weeks. Since the subject of interest in the present
research was the changes in fear of childbirth among pregnant women who exercised
regularly, a criterion for inclusion in the analysis was 75% attendance in the classes of
exercise program. The same criterion was applied to the second group.
The second group consisted of 47 pregnant women attending typical childbirth
classes twice a week. The program focused on education concerning pregnancy,
childbirth, puerperium and infant development, how to behave during labor, and
how to care for the newborn baby. The duration of the classes varied depending on
the subject, and classes ranged from 45 to 60 minutes. Classes were led by midwives
in cooperation with gynecologists, pediatricians, and psychologists and lasted
6 weeks.
The exercise group consisted of pregnant women who wished to take part in the
traditional prenatal classes organized by two obstetrics clinics in Warsaw. Women
who met the preliminary criteria (first, single, normally developing pregnancy; no
prior miscarriages or abortions; no contraindications to physical exercise) were given
the opportunity to participate in exercise classes for pregnant women. Women who
did not accept the offer were allowed to participate in the research project as a core
of the reference group. Exercise classes for subsequent groups began at the start of
each month; classes were conducted in groups of 6
10 participants. In the case of
pregnant women, the requirements for randomization may hardly be met without
depriving a number of subjects of the opportunity to participate in potentially
healthy activities. Due to the limited duration of pregnancy, it is impossible to create
a control group that would wait for an intervention. For this reason, the selection for
the groups was based on the participants’ own decisions.
Participation in the study was offered to 198 pregnant women who fulfilled the
criteria: 100 (50.5%) women agreed to take part in physical activities for pregnant
women, 62 of which (62%) met the criterion of required attendance (75% of the
classes
12 classes). More than half of this group (n 34; 54.8%) participated only in
physical activities and during the Nine Active Months program; they resigned from
traditional childbirth classes due to organizational reasons. Of the participants,
28 pregnant women (45.2%) participated in both physical activities and traditional
childbirth classes.
Out of all the pregnant women invited to the study, 70 women (35.3%) agreed to
take part in it, but without participating in physical activities (reference group). The
criterion of required attendance (75% of the classes
10 classes) was met by
47 subjects (67.1%). In both groups, the pregnant women who did not meet the
180 M. Guszkowska

criterion of attendance did not differ significantly in terms of sociodemographic

variables, fear of childbirth, and locus of labor pain control in the first measurement
in comparison with the subjects whose measurements were analyzed.
As the selection of the groups did not meet all the conditions of randomization,
the groups were compared by significant characteristics relevant to the research. The
subjects whose measurements were analyzed differed significantly regarding propor-
tions of women in their second and third trimester (x2 5.169; p .023). In the
exercise group, the number of women in the second and third trimester was balanced.
In the childbirth class group most women were in their third trimester (n 33,
71.7%). For this reason, this variable was controlled (was entered as a covariate in
time condition analysis). No significant differences between the two groups were
found for age (F(1, 108) 0.135; p .714), marital status (x2 1.025; p .353),
employment during pregnancy (x2 1.919; p .166), self-rated health (x2 6.117;
p .106), self-rated physical fitness (x2 3.454; p .178); planning family childbirth
(x2 2.594; p .273), or planning to be anesthetized during labor (x2 1.595;
p .810).

Materials and procedure

To assess fear of childbirth, the present authors developed The Fear of Childbirth
Scale. This scale has 14 items addressing feelings relating to childbirth, both fears
(7 items, e.g. I am worried that something bad will happen to me or my baby during
childbirth) and their absence (7 items, e.g. I feel safe when I imagine the childbirth). A
four-point response format was used (from 1
definitely disagree to 4
definitely
agree). The first version of the scale was administered to 56 pregnant women.
Discriminant power was computed for each item. It ranged from .565 (It gives me
pleasure to think about the birth) to .900 (I get the jitters when I think what will happen
to me during the birth) and was good. Reliability is very satisfactory (Cronbach’s a
.922). The general score correlates significantly with the State
Trait Anxiety
Inventory (STAI) trait anxiety score (r .553, p B.001) and therefore the scale
may be viewed as valid.
A measure of locus of labor pain control (The Control of Childbirth Pain Scale)
was developed, modeled after Skevington’s Beliefs about Pain Control Questionnaire
(Juczyński, 2001). It has nine items. Three items measure internal locus of labor pain
control (e.g. By taking good care of myself I can reduce the experience of pain during
childbirth), four items measure the effect of medical staff (e.g. Relief from labor pain
largely depends on the doctors), and two measure the significance of random factors
for the experience of labor pain (e.g. Lack of pain during childbirth is largely a matter
of luck). Like in the original, a six-point response format was used (from 1

definitely disagree to 6
definitely agree). The original version of the scale was
administered to 56 pregnant women. Discriminant power was calculated for each
item and it ranged from .542 (By taking good care of myself I can reduce the
experience of pain during childbirth) to .890 (If I am going to suffer during childbirth I
shall suffer no matter what I do) and can be viewed as good. Reliability is very
satisfactory (Cronbach’s a .785).
The Fear of Childbirth Scale and The Control of Childbirth Pain Scale were
administered twice, in the first week of classes and two months later, upon
termination of the classes.
 Anxiety, Stress, & Coping 181

To assess personality traits, standard psychological scales were used. The NEO-
Five Factor Inventory, by Costa and McCrae (Zawadzki, Strelau, Szczepaniak, &
Śliwińska, 1998), enabled the five personality dimensions included in the Big Five
model to be studied: neuroticism, extraversion, openness to experience, agreeable-
ness, and conscientiousness. Its reliability in the Polish population measured by
Cronbach’s a varied between .68 and .82.
The Life Oriented Test
Revised, by Scheier, Carver, and Bridges (Juczyński,
2001), was designed to examine the optimism meant as personality trait. The
reliability in Polish population was satisfactory (Cronbach’s a .76); the validity was
estimated based on correlations with self-esteem, positive emotionality, and coping
style.
Trait anxiety (X-2) scale of STAI by Spielberger (Wrześniewski, Sosnowski, &
Matusik, 2002) allowed the level of intensity of anxiety meant as a personality trait to
be assessed. The reliability of the Polish version of the scale was valued on the basis
of inner consistency (Cronbach’s a for appropriate age group .89). The validity of
the scale was estimated by correlating its results with different personality
dimensions.
A questionnaire developed by the present author concerning basic information
about participants (age, marital status, education, employment), course of preg-
nancy, self-rated health, and physical fitness was also administered (five-point Likert
scale from 1
very poor to 5
very good), rating of partner support (five-point scale).
The research project was accepted by the Senate Ethics Commission of the Józef
Piłsudski University of Physical Education in Warsaw.

Results
The changes of fear of childbirth
To test the significance of change in level of fear of childbirth and differences in
intensity of fear of childbirth depending on type of intervention (0
childbirth
classes; 1
exercise classes), an univariate analysis of variance with repeated
measures (timetype of intervention) with trimester as a covariate was conducted
(Table 1). Main effect for time was not significant. Only a significant interaction was
found between time and condition (Figure 1). When the changes in both groups were
analyzed separately, a significant reduction of fear of childbirth was found only in the
women attending exercise classes, F(1, 61) 18.449; p B.001; h2 0.232. No
significant difference was found in the women attending childbirth classes, F(1,
46) 0.407; p .05.
Main effects for group were statistically insignificant. When the two groups were
compared for level of fear of childbirth by means of one-way analysis of variance, no
significant effects were found either for pretest, F(1, 108) 2.530; p .05 or for
posttest, F(1, 108) 0.027; p .05.
Next, an index of change in fear of childbirth was calculated. The value of the
first assessment in the first week of classes was subtracted from the value of the
second assessment upon termination of the classes preparing for childbirth to obtain
an index of change. The negative values (index of change B0) mean decrease of fear
of childbirth. The positive values (index of change 0) indicate that fear of
childbirth increased. The larger the absolute value of the index the greater the
182 M. Guszkowska

Table 1. Fear of childbirth and locus of labor pain control according to time and condition.

Time Condition ANOVA Trimester

Exercise
Pretest Posttest classes Childbirth Time Condition Interaction Covariant
Variable M M Ma classes Ma F; p; h2 F; p; h2 F; p; h2 F; p; h2

Fear of 31.89 30.93 31.92 30.72 0.76; 0.68; 7.50; 0.22

Childbirth (7.57) (7.59) ns ns .007; .066 ns
Locus of labor pain control
Internal 12.35 12.31 11.94 12.63 0.20; 2.19; 0.039; 0.98;
(2.14) (3.58) ns ns ns ns
Powerful 11.94 12.36 12.99 11.52 0.88; 4.87; 2.97; 0.14;
others (3.48) (3.92) ns .030; .044 ns ns
Chance 6.66 7.63 7.42 6.78 0.47; 1.70; 3.05; 0.16;
(2.35) (3.43) ns ns ns ns
a
Estimated edge mean.

decrease/increase of fear of childbirth level. The results of one-way analysis of

variance for the two groups revealed a significant difference, F(1, 108) 7.585; p
.007. The mean for women attending childbirth classes is negative (M 2.06;
SD3.785), indicating that their fear level decreased significantly. The mean for
women attending the exercise classes is nearly nil (M 0.36; SD5.303), which
means no change in fear of childbirth.
Since almost one-half of the pregnant women who took part in the exercise
program (n 28) participated in the traditional childbirth classes as well, they were
compared with the pregnant women who did not attend childbirth classes (n 32).
There were no significant differences with regard to fear of childbirth either in
the first measurement, F(1, 61) 0.256; p .05 or in the second measurement,

Figure 1. Changes of fear of childbirth in pregnant women attending physical exercise classes
or childbirth classes.
 Anxiety, Stress, & Coping 183

F(1, 61) 0.480; p .05. Neither subgroup differed significantly with regard to the
index of change, F(1, 61) 0.121; p .05, which was negative in both subgroups.

Predictors of post-intervention fear of childbirth

One of the objectives of the present study was to identify the predictors of fear of
childbirth upon termination of the exercise classes or childbirth classes. A forward
stepwise regression analysis was therefore performed on entire sample.
Five groups of potential predictors were distinguished: (i) activities preparing for
childbirth (participation in childbirth or exercise classes for pregnant women);
(ii) demographic and economic factors (age, marital status, week of pregnancy,
employment during pregnancy); (iii) social factors (partner support, planned family
birth); (iv) cognitive factors (beliefs concerning locus of control of labor pain, self-
rated health); (v) personality traits (neuroticism, extraversion, openness to experi-
ence, agreeableness, and conscientiousness; trait anxiety, and dispositional opti-
mism).
When all the factors were introduced into the equation three significant
predictors accounting for 20% of the variance of fear of childbirth in pregnant
women upon termination of the intervention were identified: self-rated health and
dispositional optimism (negative predictors) and chance (external locus of labor pain
control
positive predictor) (Table 2). Intense fear of childbirth can be expected in
pregnant women with low health self-ratings, who have pessimistic expectations, and
who believe that labor pain largely depends on factors beyond their control (fate,
random factors, or luck).

Predictors of change of fear of childbirth degree

Forward stepwise regression analysis was applied to identify the predictors of change
in fear of childbirth in the entire sample. All potential predictors mentioned above
were entered into the equation. The only significant predictor of change in level of
fear of childbirth was type of intervention (0
childbirth classes; 1
exercise classes).
This predictor was negative (b 0.244; t 2.462; p .016), meaning that higher
value of the change index (a smaller decrease in fear level or its increase) can be
expected in group 0 (childbirth classes). In pregnant women participating in exercise
classes (group 1) lower values of the change index (i.e. greater decrease in fear of
childbirth level) can be expected. This was the only significant predictor we were able
to identify. It is important to note, however, that this predictor accounted for only 5%
of the variance, R2 .050; F(1, 107) 6.059; p .016.

Table 2. Predictors of fear of childbirth upon termination of interventions.

Predictor b t p Model

Optimism 0.292 3.22 .002 R2 .210;

Chance 0.264 2.93 .004 F 9.58;
Self-rated health 0.260 2.87 .005 p B.0001
184 M. Guszkowska

The changes of locus of labor pain control

The purpose of the last analyses was to identify the changes of locus of labor pain
control and differences in these changes depending on type of intervention and
trimester of pregnancy. Analysis of variance with repeated measures (time 
condition) with trimester as a covariate was conducted (Table 1).
Internal locus of birth pain control did not change in time and did not differ
depending on condition. None of the interactions was significant either.
No significant changes were found in the whole sample in the belief that labor
pain will depend on the medical staff (powerful others). This belief was stronger
among the pregnant women who attended childbirth classes (a significant group
effect). There was no significant interaction between time of measurement and type
of intervention.
No significant difference in belief that labor pain would depend on fate, luck, or
other factors beyond the pregnant woman’s control was found depending on type of
intervention or time. The interaction between these factors was also insignificant.

Discussion
The principal objective of this study was to identify the effects of two types of
activities preparing for childbirth, i.e. traditional childbirth classes and physical
exercise classes, on the intensity of fear of childbirth. The study did not find a
significant reduction of fear of childbirth in the entire sample. However, when the
data were analyzed separately for pregnant women attending childbirth classes and
exercise classes, it was found that fear of childbirth only decreased in the latter group.
A significant interaction between time and condition was also found, lending further
support to the conclusion that type of intervention is important. Still further support
was found when the mean change index was analyzed: the value of this index was
negative only in the exercise classes group and was significantly lower than in the
participants of traditional childbirth classes. Type of intervention was also the only
significant predictor of the value of this index. It may be assumed that exercise
classes could be an effective way of reducing fear of childbirth.
The findings for pregnant women participating in exercise classes are consistent
with the results of an earlier comparative study which found that women who were
physically active during pregnancy had lower levels of anxiety when asked to imagine
labor (Guszkowska, 2011; Guszkowska & Dudziak, 2008). The lack of fear reduction
in pregnant women attending traditional childbirth classes has not been confirmed
by other researchers, however, who found a significant reduction in intensity of fear
of childbirth in this group (Stangert, Cendrowska, & Szukiewicz, 2009).
We must therefore ask why the women participating in the Nine Active Months
program experienced a significant reduction in fear of childbirth, whereas no such
change was experienced by women attending childbirth classes. Let us focus on the
former group first. In both the comparative study in general population and the
study of pregnant women, data were obtained confirming the anxiety-reducing
effects of physical exercise, both immediate (acute effect of a single session of
physical exercise) and postponed (effect of participation in a systematic physical
exercise program). For example, physically active pregnant women demonstrated
fewer anxiety symptoms compared with women who refrained from physical exercise
 Anxiety, Stress, & Coping 185

during pregnancy (Goodwin, Astbury, & McMeeken, 2000). Pregnant women

attending group physical exercise classes preparing for childbirth had more positive
mood as demonstrated, by example, by lower levels of anxious tension (Guszkowska,
2011). Koltyn (1994) found that pregnant women demonstrated a significant
reduction of anxiety after a single session of aerobic physical exercise. Lox and
Treasure (2000) found both reduced anxiety in pregnant women directly following a
single session of physical exercise in water and long-term effects following 6 weeks of
systematic exercise. If physical exercise helps to reduce general anxiety and tension, it
may also help to reduce fear of approaching childbirth.
The failure to find the expected changes in women attending childbirth classes
may be due to these women’s level of education
higher than in the general
population. Educational interventions, providing information on labor, are an
effective way of reducing fear but mainly in women who lack such information
(Gayathri, Raddi, & Metgud, 2010).
It should be noted that the study did not meet the requirements of randomiza-
tion, and the selection for the groups was made on the basis of the subjects’
preferences. Therefore, the option cannot be excluded that the exercise classes group
included pregnant women who had qualities that maximized the benefits of such
childbirth classes. Both groups were compared in terms of sociodemographic and
personality variables that could play the role of predictors of fear of childbirth. The
only significant difference was in the trimester of pregnancy, so a variable, namely a
covariate, was introduced into the analyses. There was no significant difference
between the groups with regard to the initial level of fear of childbirth. However,
when more attention is paid to the arithmetic means (Figure 1), it can be observed
that the arithmetic mean value was slightly higher in the group of women
participating in physical activities, which gave more space for a potential change.
At the low output level, it is difficult to have a significant decrease in intensity, which
is usually referred to as the floor effect. This phenomenon has been described in
research on the impact of different forms of intervention on emotional states
(Guszkowska, 2013).
Interpretation of the results can be further hampered by the fact that almost one-
half of the pregnant women who exercised took part in the traditional childbirth
classes, too. Therefore, it may be expected that in this group, the effects of two forms
of preparation for childbirth would accumulate. However, the conducted compar-
isons showed that additional participation in the traditional childbirth classes did
not contribute to a greater decrease in fear of childbirth (the index of change in both
subgroups did not differ significantly).
An important predictor of fear of childbirth is dispositional optimism which
indicates a generalized expectation of positive feelings and satisfaction with life
(Scheier & Carver, 1992). It correlates negatively with depression, helplessness, and
anxiety (Scheier, Carver, & Bridges, 1994). According to cognitive theories of stress
and emotion, the cognitive system contributes significantly to the instigation of
emotions. Dispositional optimism affects people’s appraisal of current events and
their expectations concerning future events and is therefore one of the determinants
of intensity of fear of childbirth.
A second significant (and negative) predictor of fear of childbirth is self-rated
health. A group of Swiss researchers (Sieber et al., 2006) also found that poor health
was a positive predictor of fear of childbirth. Fear of childbirth involves fear of death,
186 M. Guszkowska

pain, and surgical intervention (Neuhaus, Scharkus, Hamm, & Bolte, 1994; Ryding,
1993; Saisto et al., 1999; Sjögren & Thomassen, 1997; Szeverényi, Póka, Hetey, &
Török, 1998). Women with poorer self-rated health may fear childbirth more often
for these reasons.
Yet another predictor of the intensity of fear of childbirth is external locus of
labor pain control (attribution to chance factor). Pregnant women who express a
strong belief that the intensity of labor pain will depend on external factors over
which they have no control are more likely to fear childbirth. During labor, these
women will presumably be less willing to engage in various behavioral pain-reducing
strategies and their beliefs are more likely to be confirmed due to self-fulfilling
prophecy.
Beliefs concerning factors responsible for the intensity of labor pain may be
modified with the help of cognitive interventions. Preparation for childbirth should
include efforts to strengthen the expectant mother’s belief that she can control her
labor and the intensity of labor pain. One of the purposes of the present study was to
determine the changes of locus of labor pain control in pregnant women attending
traditional childbirth classes and participating in the Nine Active Months program.
Women who believe that they can control labor pain continue to hold this belief
whatever the intervention. No significant changes were found in the whole sample in
the belief that labor pain will depend on the medical staff (powerful others) and on
fate, luck, or other factors beyond the women’s control (chance). If we consider that
latter factor was a significant positive predictor of fear of childbirth, no change must
be viewed as adverse. Locus of control can be viewed as a stable personality trait
which is less susceptible to situational factors although this hypothesis needs to be
tested empirically, of course.
The present study has a number of important limitations. The first one is the
nonrepresentative sample. Only women with higher education, financially stable,
living in the capital city or metropolis, who had never had children before, and whose
pregnancy was normal were studied. None of the findings established in this study
can be generalized beyond this sample.
The second limitation has to do with lack of complete randomization of the two
studied groups. Participants were pregnant women voluntarily attending childbirth
classes or women voluntarily responding to the invitation to attend physical exercise
classes. These groups were not matched for all the potential variables which could
have affected the outcome, i.e. advancement of pregnancy. We cannot rule out the
influence of differences in health (the women attending physical exercise classes had
to provide a doctor’s certificate certifying the lack of counter-indications for
participation; no certificate was requested from the women attending the childbirth
classes). The next difference is program duration. The Nine Active Months program
usually lasted longer than the childbirth classes. Complete randomization is very
difficult to achieve in studies of pregnant women if only because we cannot create a
typical waiting list. However, future researchers must do their best to match groups
as far as possible for potential intervening and interfering variables.

Conclusions
The present findings suggest that physical exercise classes for pregnant women
reduce fear of childbirth more effectively than traditional childbirth classes in well-
 Anxiety, Stress, & Coping 187

educated primigravidae living in the capital city of Warsaw whose pregnancy is

uncomplicated. Since we can predict the intensity of fear of childbirth upon
intervention termination in this sample on the basis of cognitive factors (optimism,
self-rating health, and chance), we should modify future interventions to reduce fear
of childbirth in this sample of pregnant women so as to modify their beliefs
concerning labor and the degree to which they themselves, the medical personnel,
and chance factors control labor pain.

Acknowledgments
This research was financed under project number NN 404 017838, ‘‘The influence of pregnant
women’s physical activity on their mental and physical health, the course of pregnancy, and
childbirth’’, by the Ministry of Science and Higher Education in Poland.

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