Pregnancy related anxiety and general anxious or depressed mood and the choice for birth setting: a secondary data-analysis of the DELIVER study
Witteveen et al. BMC Pregnancy and Childbirth
Pregnancy related anxiety and general anxious or depressed mood and the choice for birth setting: a secondary data-analysis of the DELIVER study
A. B. Witteveen 0
P. De Cock 0
A. C. Huizink 1 2
A. De Jonge 0
T. Klomp 0
M. Westerneng 0
C. C. Geerts 0
0 Department of Midwifery Science, AVAG and the EMGO Institute for Health and Care Research, VU University Medical Center , Van der Boechorststraat 7, 1081 BT Amsterdam , The Netherlands
1 Department of Developmental Psychology, VU University Amsterdam , Amsterdam , The Netherlands
2 Department of Clinical Child and Family Studies, VU University Amsterdam , Amsterdam , The Netherlands
3 Institute for Health and Care Research, VU Medical Center , Amsterdam , The Netherlands
Background: In several developed countries women with a low risk of complications during pregnancy and childbirth can make choices regarding place of birth. In the Netherlands, these women receive midwife-led care and can choose between a home or hospital birth. The declining rate of midwife-led home births alongside the recent debate on safety of home births in the Netherlands, however, suggest an association of choice of birth place with psychological factors related to safety and risk perception. In this study associations of pregnancy related anxiety and general anxious or depressed mood with (changes in) planned place of birth were explored in low risk women in midwife-led care until the start of labour. Methods: Data (n = 2854 low risk women in midwife-led care at the onset of labour) were selected from the prospective multicenter DELIVER study. Women completed the Pregnancy Related Anxiety Questionnaire-Revised (PRAQ-R) to assess pregnancy related anxiety and the EuroQol-6D (EQ-6D) for an anxious and/or depressed mood. Results: A high PRAQ-R score was associated with planned hospital birth in nulliparous (aOR 1.92; 95% CI 1.32-2.81) and parous women (aOR 2.08; 95% CI 1.55-2.80). An anxious or depressed mood was associated with planned hospital birth (aOR 1.58; 95% CI 1.20-2.08) and with being undecided (aOR 1.99; 95% CI 1.23-2.99) in parous women only. The majority of women did not change their planned place of birth. Changing from an initially planned home birth to a hospital birth later in pregnancy was, however, associated with becoming anxious or depressed after 35 weeks gestation in nulliparous women (aOR 4.17; 95% CI 1.35-12.89) and with pregnancy related anxiety at 20 weeks gestation in parous women (aOR 3.91; 95% CI 1.32-11.61). Conclusion: Low risk women who planned hospital birth (or who were undecided) more often reported pregnancy related anxiety or an anxious or depressed mood. Women who changed from home to hospital birth during pregnancy more often reported pregnancy related anxiety or an anxious or depressed mood in late pregnancy. Anxiety should be adequately addressed in the process of informed decision-making regarding planned place of birth in low risk women.
Pregnancy; Anxiety; Mood; Planned place of birth; Midwife-led care
Current national and international guidelines in Western
countries, such as the UK and Canada, emphasize the
importance for women with a low risk for pregnancy and
childbirth complications to have a choice in maternity care
services and in planning birth place. This is in line with the
international focus to improve rates of physiologic labour
and birth [1–3]. In the UK, for example, low risk women
may choose to give birth in a free-standing midwifery
unit or at home with midwife attendance
(low-technology birth) or in an obstetric-unit (high-technology
birth). Correspondingly, in the Netherlands low risk
women routinely receive midwife-led care and may
choose between home or short-stay hospital birth –
both attended by their own midwife. If complications
arise, women are transferred to an obstetrician-led unit.
Despite the availability of low-technology birth
services to low risk women, in most Western countries
births usually take place in hospital nowadays. For
example, in the UK only 8% of women gave birth at home
or in a midwifery unit in 2007 . The highest rates of
home birth can still be found in the Netherlands,
although the Dutch home birth rate has significantly
declined as well from 32% between 2001 and 2003 to
21% between 2010 and 2012 . This decline may be
associated with the growing demand of medical pain
relief which is only available in obstetrician-led care [6, 7]
and with a change in policies regarding maternal risk
factors such as high BMI leading to more women
identified as having a medium- or high risk profile .
Another important factor, however, might be the
continuing debate on the safety of home birth in the
Netherlands [9, 10]. Although evidence regarding the
association of perinatal mortality or morbidity rates with
planned place of birth has long been rather conflicting
and hampered by methodological shortcomings [11–14],
recent large scale studies show greater consistency [15–18].
One such study in the UK found similar perinatal morbidity
and mortality rates for parous women in all birth settings
and for nulliparous women in obstetric and midwifery
units, but poorer outcomes for nulliparous women with
planned home birth . In the Netherlands, no increased
rates of mortality or morbidity among parous and
nulliparous low risk women were found among planned home
births compared to planned midwife-led hospital births
[16–18]. There is evidence to suggest that low risk women
who plan a home birth have a lower risk of obstetric
interventions, and a higher chance to give birth
spontaneously [19, 20]. Increased risk of interventions in a
hospital birth setting is reflected in costs as well. A
large prospective cohort study from the UK showed
that planned home birth was the most cost-effective
option for low risk women compared to obstetric,
freestanding or alongside midwifery units, particularly
for parous women . In the Netherlands, an
increase of costs of giving birth in hospital is (partly)
covered by charging low risk women with a payment of
approximately 300 euro’s for the short-stay in hospital.
This information is important for women in terms of
informed decision-making regarding place of birth and
other intrapartum care choices such as the possibility of
pain-relief , as well as in terms of their psychological
wellbeing such as an increased risk of potentially
distressing obstetric interventions depending on their planned
place of birth .
Previous reports have also shown that a variety of
other factors is associated with planned place of birth in
low risk women. Socio-demographic factors such as
nulliparity, younger age, ethnic minority, and lower
socioeconomic background characterize low risk women who
more likely plan a hospital birth compared to a home
birth [24–26]. Concerning attitudes of low risk women,
it has been found that women who plan a hospital birth
have more positive attitudes towards obstetric
technology and the availability of medical pain-relief during
birth [27, 28]. Women who plan a home birth, however,
tend to have a more fundamental trust in the
independent ability to give birth, the birth process itself, and value
the privacy of the home environment and the ability to
make decisions during the birth process [29–31]. Also,
positive attitudes of midwives regarding home birth and
a critical attitude to hospital birth for non-medical
reasons have been found to explain some of the variance
found in home birth rates across Dutch midwifery
practices . Positive attitudes towards home births among
UK maternal caregivers in general, are associated with
the amount of experience and confidence in managing
obstetric risks in home births and with maternal
caregivers’ beliefs about safety of home births . Other
interesting outcomes related to preferred place of birth
and risk perception have been found as well. A study in
the UK showed that nulliparous low risk women who
preferred a low-technology birth place in early pregnancy,
also received fewer ultrasounds during pregnancy
compared to matched low risk controls who preferred a
hightechnology labour in obstetric led-care .
Indeed, several studies have recently shown that
motivational factors relating to risk-perception and safety
seem critical in the choice of low risk women to plan
hospital instead of home birth [35–37]. Recently,
perceptions of safety and risk were found to be the
strongest determinants for choosing hospital birth in a
cohort of low risk Canadian women . Psychological
factors, especially pregnancy related anxiety, have been
found to be important predictors of pregnancy risk
perception [38, 39]. The latter is of interest, since about 80%
of low risk women has some worries about childbirth and
about 20% experiences more intense pregnancy related
fears or anxiety [40, 41]. Worries, anxiety and fear in
relation to pregnancy and childbirth are, however, different
concepts. Recent research shows that worries about
childbirth are often described as unspecific feelings and
thoughts while fear of childbirth concerns a strong feeling
connected to something specific . Also, more general
anxiety such as trait anxiety, has been found to predict
fear of childbirth  and should be differentiated from
pregnancy related anxiety . Furthermore, antenatal
depression and anxiety, as well as fear of childbirth, have
been found to be associated with adverse perinatal
outcomes such as pre-term birth [45–47].
It is thus highly relevant that maternity care
providers have information on the possible association
between these psychological symptoms of low risk
women and their choice in place of birth. If anxious or
depressed women are more likely to choose hospital
birth, health professionals can use this information to
better support women or to alleviate anxiety, for
example by giving evidence based information on place
of birth. This may further enable women to make a
well informed decision on place of birth. Very little
research, however, is available on associations between
psychological factors and planned place of birth. The
only study we know of showed that symptoms of
depression and health worries were related to a
preference of low risk nulliparous women for hospital birth
in obstetrician-led care . As far as we are aware, no
information is available on the association of
psychological characteristics and the choice for midwife-led
planned place of birth.
Based on the above, our first research aim was to
examine the association between pregnancy related
anxiety and general anxious or depressed mood with
planned place of birth. We hypothesized that low risk
women who plan a hospital birth will have higher levels
of pregnancy related anxiety such as fear of childbirth,
than women who plan a home birth. Pregnancy related
anxiety and general anxiety are not the same  and
pregnancy related anxiety also tends to influence general
anxiety over the course of pregnancy . We therefore
expected general anxiety, to be related to planned place
of birth as well. Since fear of childbirth shows temporal
changes throughout pregnancy  and a certain
proportion of low risk women changes their planned place
of birth throughout pregnancy (i.e. 28% of nulliparous
women in the UK ), our second research aim was to
examine whether changes in planned place of birth
throughout the course of pregnancy were associated
with anxiety. We hypothesized that a change in planned
place of birth from early to late pregnancy was
associated with pregnancy related anxiety and an anxious or
depressed mood early in pregnancy and/or with
becoming anxious or depressed in late pregnancy.
Study design and study population
The data for the current paper were selected from
the DELIVER-dataset . This dynamic cohort study
consisted of women who completed up to three
questionnaires between their first appointment in the
midwifery practice and six weeks postpartum (between
September 2009 and March 2011). With purposive
sampling taking into account level of urbanization,
region and practice type, 34 out of the 519 midwife-led
care practices in the Netherlands were approached to
achieve a sample of 20 practices that were willing to
participate. From these practices, a total of 7685 women
participated by returning at least one questionnaire. All
participating women gave informed consent. Further
details on design, recruitment and non-response have
been published elsewhere .
Data from the participating women in the
DELIVERstudy were coupled with midwife-led care data
obtained from the Netherlands Perinatal Registry, the
‘Landelijke Verloskundige Registratie’ (LVR1) data
. Linkage succeeded in 74.8% (n = 5749) of all
participating women (see Fig. 1). In the Netherlands,
low risk women in midwife-led care are referred by
their midwives to obstetrician-led secondary care,
when risk factors arise during pregnancy, labour or
the postpartum period based on the List of Obstetric
Indications (LOI) . For this study, participants
who gave birth prematurely (<37 weeks) (n = 224) and
those with a high or medium risk indication according
to the LOI (for example twin pregnancy) (n = 393)
were excluded because in the Netherlands they are not
offered the choice of home birth. Information about
onset of labour, premature labour and risk factors was
obtained from LVR1. Furthermore, women who were
referred to obstetrician-led care during pregnancy and
were in obstetrician-led care at the onset of labour
were also excluded (n = 1375). This resulted in a
sample of low risk nulliparous and parous women with
a singleton pregnancy, who gave birth from 37 weeks
onwards who did not have an indication for
obstetrician-led care and who started labour under the
supervision of a primary-care midwife (n = 3757). For
our first research aim, data from the first
questionnaire administered between the first antenatal visit
and before 35 weeks of gestation were used. This
questionnaire contained information about planned
place of birth and psychological factors relevant to this
study. Women were therefore also excluded from our
study when the first questionnaire was not completed
and/or no data was available on planned place of birth,
PRAQ-R or parity (n = 903). This resulted in a sample
of 2,854 participating women. For our second research
aim, we selected participants who, in addition to the
first questionnaire, completed the second
questionnaire after 35 weeks of gestation as well (n = 1603).
Planned place of birth
Our primary outcome measure consisted of the question
to the client where she planned to give birth. A response
on this item was requested in both questionnaire one
(before 35 weeks of gestation) and two (after 35 weeks
of gestation). Women were able to choose from six
response options; 1) ‘at home’, 2) ‘in hospital,
midwifeled care’, 3) ‘in hospital, obstetrician-led care’, 4) ‘a birth
centre’, 5) ‘somewhere else, specifically…’ or 6) ‘do not
know yet’. Eighty-six women chose birth in hospital
under obstetrician-led care (option 3) although they
were in midwife-led care at the onset of labour. We
included these women in the planned hospital group
(midwife-led care; option 2). Probably these women planned
to have medicinal pain relief as soon as labour started,
for which they would have to be referred to
obstetrician led care, or some might have misunderstand the
question. Also, a few women planned to give birth in
‘a birth centre’ (option 4; n = 12). All birth centers at
the time of the study were located alongside an
obstetric unit in hospital. Hence, we aggregated options 3
and 4 together with option 2, i.e. planned hospital
birth (midwife- led). Responses from women planning
to give birth somewhere else (response option 5) were
carefully screened and recoded when applicable to one
of the response options. Option 6 was operationalized
Pregnancy related anxiety and anxious or depressed mood
The PRAQ-R, a revised and validated version of the
original 58 item PRAQ scale , contains 10 items
representing three correlated factors: fear of giving birth,
fear of bearing a physically or mentally handicapped
child, and concern about one's own appearance. Item
responses were on a 4-point scale, ranging from “definitely
true” to “definitely not true”. Good internal reliability of
the subscales as well as the total score was found .
For the parous subsample one item from subscale ‘fear
of giving birth’ had to be excluded; ‘I fear giving birth,
because I have never experienced this before’ . As a
result, scoring ranged on the subscale ‘fear of childbirth’
and total score deviated between parous and nulliparous
women. Continuous scores were calculated for all
subscales and the total score. The items were summed up,
resulting in possible total scores ranging from 10 to 40
for nulliparous women, and 9 to 36 for parous women.
Higher scores reflect higher levels of pregnancy related
anxiety. A dichotomous cut-off score of 26 and higher
and 21 and higher was chosen for nulliparous and
parous subsamples respectively, hereby identifying the 15%
highest scoring women on the PRAQ-R total score,
similar to the procedure in a recent validation study of
pregnancy related anxiety measures including the PRAQ-R
. The PRAQ-R was assessed in the first DELIVER
The EQ-6D measures health-related quality of life in 6
domains: mobility, self-care, usual activities,
pain/discomfort, anxiety/depression, and cognitive functioning
. All dimensions are single items. For the current
paper we selected the item covering the
anxiety/depression domain, i.e. How is your mood at this moment?
Response options were ‘not at all, moderately or severely
anxious or depressed’, respectively. The responses were
dichotomized into ‘not anxious or depressed’ or ‘anxious
or depressed’. Responses on the EQ-6D were collected
in both DELIVER questionnaires (Q1: before 35 weeks
and Q2: after 35 weeks).
Potential confounding factors
Background characteristics were obtained from the
DELIVER-study. Maternal age was constructed using
age in years at the time of completion of the DELIVER
questionnaire and was subsequently divided into three
categories. Gestational age at time of completion of the
questionnaire was continuous (in weeks). Ethnicity was
constructed using the responses on nationality in the
DELIVER data. Ethnicity was dichotomously operationalized
as ‘Dutch’ (when both parents are born in the
Netherlands) or ‘non-Dutch’ (when at least one of the
parents is born in another country). For socio-economic
status status-score was calculated by the National Institute
for Social Research. It is based on the mean income,
employment rate, and educational level of the
neighborhood determined by the woman’s postal code. The
statusscore was linked to the DELIVER dataset, through postal
codes and it was divided in tertiles with 1 representing
high socio-economic status. Pre-pregnancy BMI was
calculated based on women’s reported weight before
pregnancy and their height. In case of missing values, data on
pre-pregnancy weight and height from the electronic
records completed by midwives were used if available.
Maternal age, ethnicity and socioeconomic status were
entered as possible confounders based on previous
research showing a relation of these factors with both
planned place of birth  and the risk of maternal
antenatal depression and anxiety [56–59]. Maternal body mass
index (BMI) was also entered as a possible confounder
since a positive correlation was demonstrated between
pre-pregnancy BMI and anxiety and depressive symptoms
 and between BMI and (planned) place of birth .
Potential confounding influence of the obstetric
factors ‘previous pregnancy loss (due to miscarriage or
termination of pregnancy)’ in nulliparous women and
‘history of assisted vaginal delivery (AVD)’ and ‘previous
place of birth’ in parous women was explored as part of
the sensitivity analyses performed. Research for
example shows that women with a certain obstetric
history such as miscarriage have greater
pregnancyspecific anxieties  and more often prefer a hospital
birth in obstetric-led care  than pregnant women
without such history. In the sensitivity analyses, we
examined whether the association between anxiety and
planned place of birth changed when these factors were
entered in the regression model.
For descriptive purposes, percentages of background
characteristics were calculated according to planned place of
birth (either home, hospital or undecided) stratified by
parity. Univariate differences were analysed using χ2 tests.
We stratified our analyses by parity because nulliparous
and parous are inherently different according to previous
labour experiences and differ in level and content of fear
(of childbirth) and anxiety  and planned place of birth
. Furthermore, background characteristics of low risk
participants who were excluded from the analyses because
of incomplete data (i.e. questionnaire one, n = 903 and
two, n = 1251), were compared to the participants
included, respectively n = 2854 and n = 1603 (see Fig. 1).
For the first research aim, a multinomial logistic
regression model was conducted to estimate the association of
pregnancy related- and general anxiety measures (separate
independent variables) with planned place of birth as
dependent variable. Planned home birth was the
reference category for these comparisons. In a
multivariable logistic regression model the associations were
adjusted for potentially confounding factors maternal
age, SES, BMI and ethnicity.
For the second research aim, binomial logistic
regression analyses were performed on subsamples of
nulliparous and parous women who completed the first and the
second DELIVER questionnaire in order to assess
associations between a change in planned place of birth from
before 35 weeks to after 35 weeks gestation and a) high
pregnancy-specific anxiety (a score above the PRAQ-R
cut-off score); b) an anxious or depressed mood (EQ-6D)
before 35 weeks gestation; and c) a change from a
nonanxious or non-depressed mood (EQ-6D) before 35 weeks
to anxious or depressed mood after 35 weeks of gestation.
Several (‘change’) outcome variables were constructed: 1)
from planned home birth to planned hospital birth (or
undecided) compared with planned home birth in both
early and late pregnancy and 2) from planned hospital
birth to planned home birth (or undecided) compared
with planned hospital birth in both early and late
pregnancy. Compared to women who did not change their
planned place of birth throughout pregnancy, we expected
women who changed from hospital to home to be less
anxious and women who changed from home to hospital
birth to be more anxious, respectively. Associations for
the second research aim were adjusted for SES only (three
categories operationalized into two dummy-variables), due
to the smaller N and the rule of thumb of a minimum of
ten events in the outcome variable per covariate. We
chose SES as a necessary potential confounder because of
the fact that it is correlated with education, and ethnicity
and because low SES is associated with higher
psychological distress levels . Furthermore, as shown in
Table 1, both nulliparous and parous women were
significantly different in SES according to planned place of birth.
Additionally, sensitivity analyses were performed. First,
we examined whether associations found between
pregnancy anxiety and anxious or depressed mood and planned
place of birth were influenced by the factors gestational
age at the moment of completing the first questionnaire in
nulliparous and parous women, previous pregnancy loss in
Table 1 Baseline characteristics of low-risk women in midwife-led care according to planned place of birth (Continued)
Previous birth place
Data shown: no. (%) of women
aPregnancy loss before 24 weeks of gestation (due to miscarriage or termination of pregnancy)
bGestational age at the moment of completing the first questionnaire
nulliparous women and history of assisted vaginal delivery
(AVD) and previous birth place in parous women. Second,
in a separate analysis robust variance estimation was used
to allow for clustering of women within midwifery
practices. Third, for a small number of women, the LVR1 data
showed some discrepancies for the onset of labour in
midwife-led care. Therefore, we conducted sensitivity
analyses for women without any discrepancies in the definition
for onset of labour in midwife-led care.
All results are expressed as adjusted odds ratios with
95% confidence intervals and P values. Statistical
significance was considered reached at P 2-sided < 0.05. For
(multinomial and binary) logistic regression analysis we
assumed that the independent variables were linearly
related to the log odds. All analyses were performed with
SPSS version 20.0 for Windows and Stata version 12.
Background characteristics of low risk women in
midwife-led care that were excluded because of
incomplete or missing data (n = 903; Fig. 1) differed not
significantly (p > 0.05) from those included (n = 2854)
according to SES and ethnicity. These women excluded
were, however, significantly different (p < 0.05) in age
(i.e. < 25, 11.3% vs. 10.1%; 25–34, 67.1% vs. 71.8%; > 35;
21.5% vs. 18.2%, respectively) and parity (i.e. nulliparous
51.3% vs. 44.3%, respectively). Nulliparous women (n =
2,854) completed the first DELIVER questionnaire at a
mean of 20.2 (SD 6.6) weeks gestation and parous
women at 20.4 (SD 6.4) weeks gestation. Of the
nulliparous women, 484 (38.3%) planned to give birth at home,
620 (49%) in hospital, and 161 (12.7%) were undecided.
Of the parous women, 847 (53.3%) intended to give birth
at home, 614 (38.7%) in hospital, and 127 (8.0%) were
undecided. From the sample of 2854 low risk women,
we selected women (n = 1603; Fig. 1) who also
completed questionnaire 2 in the third trimester of
pregnancy (i.e. at a mean of 37.4 weeks (SD 1.4) for both
nulliparous and parous women). Background
characteristics (age, socioeconomic status, parity and ethnicity) of
low risk women in midwife-led care that were excluded
because of incomplete or missing data on questionnaire 2
(n = 1,251; Fig. 1) differed significantly (p < .05) from those
included in the analyses (n = 1603) in ethnicity (i.e. 9.8%
vs. 4.5% of non-Dutch origin, respectively), SES (i.e. low
23.1% vs. 28.8%; medium 47% vs. 48.5%; high 29.9% vs.
22.7%, respectively), and age (i.e. < 25, 13.9% vs. 7%; 25–
34, 69.1% vs. 73.9%; > 35; 17% vs. 19.1%, respectively).
Background characteristics and planned place of birth
Table 1 shows that nulliparous and parous women who
reported in the first questionnaire that they were
planning to give birth at home, were more often of Dutch
origin, had a medium socio-economic status and had a
higher gestational age compared to women in the other
two groups (i.e. planning a hospital birth or being
undecided regarding planned birth place). Nulliparous
women planning to give birth at home were more often
younger and less often had a previous pregnancy loss
than women in the other two groups. Parous women
planning to give birth at home less often had a history of
AVD compared to women in the other two groups. In
general, nulliparous and parous women undecided about
planned place of birth were somewhere in-between the
women who planned a home birth and women who
intended to give birth at a hospital according to
background characteristics. The majority of parous women in
the planned home birth group previously gave birth at
home as well. Of the parous women currently planning a
hospital birth, approximately one-third previously gave
birth in hospital in midwife-led care as well, while
twothird previously gave birth in obstetrician-led care. The
majority of parous women undecided about place of birth
previously gave birth in hospital in obstetrician-led care.
Pregnancy related anxiety and general anxious or
depressed mood with planned place of birth
Table 2 shows that parous women who were anxious or
depressed (EQ-6D) had significantly increased odds for
planning a hospital birth and for being undecided relative
to planning a home birth. Both nulliparous and parous
women with a pregnancy related anxiety level (PRAQ-R
total symptom level) within the 15% highest scores had
significantly increased odds for planning a hospital birth
relative to planning a home birth. Furthermore, with every
unit increase on the PRAQ total symptom scale, the odds
were significantly elevated for planning a hospital birth or
for being undecided, i.e. 6 to 8%, respectively, relative to
planned home birth. Similarly, on the PRAQ subscales
‘fear of childbirth’ and ‘fear of a handicapped child’,
nulliparous and parous women had significantly elevated
adjusted odds for planning a hospital birth and for being
undecided, all relative to planning a home birth. For
subscale ‘fear of own appearance’, the adjusted odds were
only significantly elevated for nulliparous and parous
women who intended to give birth in hospital.
Change from early to late pregnancy in planned place
Of the women who completed both questionnaires (i.e.
before 35 weeks and after 35 weeks gestation; N = 727
nulliparous and N = 876 parous), 81.6% nulliparous
women and 89.2% parous women (Fig. 1), did not change
their initially planned place of birth later in pregnancy.
Table 3 shows that nulliparous women who changed their
initial plan of home birth to hospital birth after 35 weeks,
significantly more often report an anxious or depressed
mood after 35 weeks while not being anxious or depressed
Table 2 Association between planned place of birth and pregnancy anxiety and general anxious/depressed mood
Nulliparous n = 1265
Planned home birth
(n = 484/38.3%)
Parous n = 1589
Planned home birth
(n = 847/53.3%)
Planned hospital birth
(n = 620/49%)
(n = 161/12.7%)
Planned hospital birth
(n = 614/38.6%)
PRAQ total > cut offa
PRAQ total score
PRAQ fear childbirth
PRAQ fear handicapped child
PRAQ fear own appearance
aOR: odds ratios were adjusted for age, SES, BMI and for ethnicity
Odds ratios are calculated relative to planned home births (n = 1265, nulliparous women; n = 1589 parous women)
anulliparous women PRAQ total score of 26 and higher; parous women PRAQ total score 21 and higher
b = <.05 c = <.01 d = < .0001
Table 3 Associations between changes in planned place of birth and pregnancy anxiety and general anxious/depressed mood
PRAQ total > cut off or anxious/depressed 20wks
Anxious/depressed at 20 wks. (EQ6D)
Change not anxious/depressed at 20 wks.
to anxious/depressed at 37 wks. (EQ6D)
Nulliparous (n = 633)a
Home – home
(n = 279/38.4%)
Home – hospitalb
(n = 18/2.5%)
(n = 300/41.3%)
ORs adjusted only for two dummy-categories SES due to the smaller N and the rule of thumb of a minimum of ten events in the outcome variable per covariate
aExcluded: n = 94 clients undecided regarding planned place of birth at 20 wks
bIncluded: n = 5 clients who changed from home to undecided
cIncluded: n = 5 clients who changed from hospital to undecided
d = <.05
at 20 weeks, relative to nulliparous women who did not
change their planned home birth (OR 4.17, CI 1.35–
12.89). Parous women who changed their initial plan of
home birth into a hospital birth after 35 weeks, more
often had a high level of pregnancy related anxiety at
20 weeks than women who did not change their planned
place of birth at home (OR 3.91, CI 1.32–11.61). Among
nulliparous and parous women no significant associations
were found between anxiety scores based on PRAQ-R and
EQ-6D and changing from planned hospital to planned
home birth (Tables 3 and 4, respectively).
Additional analyses showed that gestational age at the
moment of completing the first questionnaire in
nulliparous and parous women, loss of previous pregnancy due to
miscarriage or termination of pregnancy in nulliparous
women and obstetric history of AVD and previous place
of birth in parous women, did not moderate the presented
associations between pregnancy related- and general
anxiety and depressed mood with planned place of birth
(Table 2). More specifically, associations remained
unchanged when adding these factors to the multinomial
regression models. Furthermore, multinomial logistic
regression analyses were performed only in the subsample
of women without any discrepancies regarding onset of
labour (n = 116 women with discrepancies were left out).
Results for planned place of birth and pregnancy related
anxiety and general anxious or depressed mood also
remained unchanged (data not shown). Taking account of
clustering of women within each midwifery practice, also
yielded similar results (data not shown).
The most salient finding of our study is that women
planning a hospital birth and those who were undecided about
their planned place of birth, reported higher levels of
pregnancy related anxiety at 20 weeks gestation than women
who planned a home birth. Among parous women, an
anxious or depressed mood was only significantly more
often reported by women planning a hospital birth and
those who were undecided about their planned place of
birth compared to women who planned a home birth.
Overall, the vast majority of women did not change their
initially planned place of birth later in pregnancy. A
change from planned home birth around 20 weeks to
hospital birth after 35 weeks pregnancy was, however,
associated with a change from a non-anxious or depressed to an
anxious or depressed mood later in pregnancy in
nulliparous women and with a high level of pregnancy related
anxiety around 20 weeks pregnancy in multiparous women.
An important strength of our study is the large sample
size that gave us the ability to analyze several subgroups
and to adjust for potential confounders. The only
previous study into psychological symptomatology and
planned place of birth showed unadjusted analyses .
We cannot rule out some residual confounding
completely, but since the potential confounding factors that
were included only had little impact on the associations,
these residual factors are unlikely to change the
associations to a great extent. Furthermore, the two prospective
measurements of planned place of birth during pregnancy
made it possible to assess whether women tend to change
their mind on planned place of birth and whether such a
change is related to an anxious or depressed mood.
Selecting women who started labour in midwife-led care and
Table 4 Associations between changes in planned place of birth and pregnancy anxiety and general anxious/depressed mood
PRAQ total > cut off or anxious/depressed 20wks
Anxious/depressed at 20 wks. (EQ6D)
Change not anxious/depressed at 20 wks.
to anxious/depressed at 37 wks. (EQ6D)
Parous (n = 814)a
(n = 492/56.2%)
Home – hospitalb
(n = 17/1.9%)
(n = 282/32.2%)
Hospital – homec
(n = 23/2.6%)
ORs adjusted only for two dummy-categories SES due to the smaller N and the rule of thumb of a minimum of ten events in the outcome variable per covariate
aExcluded: n = 62 clients undecided regarding planned place of birth at 20 wks
bIncluded: n = 3 clients who changed from home to undecided
cIncluded: n = 13 clients who changed from hospital to undecided
d = <.05
excluding women with medical risk factors to rule out
potential selection bias, is a clear strength as well.
Although these data could only be obtained through
linkage with the Dutch Perinatal Registry which might be a
limitation, sensitivity analyses excluding women with
discrepancies yielded similar results. A limitation
regarding our study sample is that women who had to be
excluded from our original data-set because of missing
data were more often nulliparous and women who were
lost after the first questionnaire assessment had more
often a lower SES, non-Dutch ethnic background and
younger age. However, it seems highly unlikely that the
association between anxiety and mood and planned place
of birth would be in the opposite direction in these
nonresponders. Also, there is evidence from a large
epidemiological longitudinal study that this type of attrition does
not necessarily influence the results . Nevertheless, we
cannot rule out that this type of attrition has some effect
on generalizability of our findings. Limitations regarding
measurement-instruments are that the EQ-6D is a generic
descriptive measure based on a self-reported three-level
multiple choice question, which is minimal and not
detailed enough to examine specific aspects of anxiety and
depression. Another limitation of the EQ6D is that this
anxiety/depression dimension has not been validated in a
pregnant population . Moreover, although the
PRAQR has been shown to have good content and construct
validity of pregnancy specific anxiety in nulliparous and
parous women [47, 53], a measure specifically assessing
fear of childbirth such as the Wijma-Delivery Expectancy
Scale (W-DEQ) might have given a deeper understanding
of which aspects of fear of childbirth particularly relate to
planned place of birth [43, 64].
Interestingly, our findings only partly agree with those of
Van Haaren-ten Haken et al.  who found planned
hospital birth to be associated with higher levels of depressive
symptomatology and health-worries only in low risk women
receiving obstetrician-led care during pregnancy, while
pregnant women in midwife-led care did not show these
differences in symptomatology for planned place of birth
either at home or in hospital. However, they found a similar
trend of higher symptom levels in women in midwife-led
care planning a hospital birth compared to home birth .
Therefore, this discrepancy in findings might well be due to
our larger sample size. Our findings correspond with
recent research showing that women in midwife-led care
who decide to plan a hospital birth or who have difficulty
in choosing their place of birth, determine their choice
largely on their perceptions of risk and safety . Risk
perception during pregnancy, a factor shown to affect the
choice regarding place of birth [34–39], might explain the
associations found in our study between pregnancy related
anxiety and general anxious or depressed mood with
planned place of birth in hospital. In fact, recent research
has indicated that compared to other significant predictors
such as maternal or gestational age, pregnancy related
anxiety was the strongest predictor of risk perception
during pregnancy, at least in nulliparous women .
In the current study both nulliparous and parous women
with higher levels of pregnancy specific anxiety and fear of
childbirth more often planned a hospital birth or were
undecided. The source of pregnancy related fears, however,
might differ between nulliparous and parous women. High
trait anxiety, for instance, has been found to be an
important predictor of fear of childbirth in nulliparous women
, while in parous women a previous negative birth
experience has been shown to be a strong predictor [65, 66].
Interestingly, the majority of parous women in our study
previously gave birth in obstetrician-led care and thus had a
greater likelihood of having experienced obstetric
interventions and having experienced fear of childbirth [27, 65].
Associations between anxiety and planned place of birth in
parous women remained unchanged, however, when a
history of assisted vaginal delivery was additionally
controlled for. Although fear for the child’s health was the
commonest fear reported in a large cohort study of
pregnant women , fear of bearing a handicapped
child was less strongly associated with planned hospital
birth that the fear of giving birth. This might be
another indication that the association found between
pregnancy anxiety, e.g. fear of giving birth, and planned
place of birth, is at least partly a reflection of issues that
concern perception of risk and safety.
Our findings are in line with other recent findings
showing that it is not unlikely for low risk women, in particular
nulliparous women, to change their planned place of birth
throughout pregnancy . Our results show that a
negative change in mood (i.e. anxious/depressed) from earlier
to late pregnancy is related to a change from a planned
home- to hospital birth in late pregnancy in nulliparous
women. Interestingly, parous but not nulliparous women
with a high total PRAQ-R score at 20 weeks gestation
more often changed their plan from home- to hospital
birth. This adds new insights to previous research
demonstrating that anxiety levels may fluctuate within individuals
from early to late pregnancy . We did not find any
significant changes in anxiety related to a change in planned
hospital- to home birth.
With regard to background characteristics associated
with planned place of birth, our findings generally agree
with previous research [16, 31]. Contrary to previous
findings [16, 68], however, nulliparous women planning
a hospital birth were more often older than women in
the planned home birth group. As suggested in previous
research , this discrepancy is likely caused by the fact
that other studies used samples including both
nulliparous and parous women, with the latter being more often
older and more often to plan a home birth [16, 68].
Our findings are of interest for maternity care providers
who may be unaware of the association of (pregnancy
related) psychological symptomatology and planned place
of birth. Maternity care providers should explore any
pregnancy related or general distress and should
acknowledge its role during the process of decision-making
regarding planned place of birth. They might also consider
referral to antenatal psychological and childbirth
educational interventions [69, 70] that seem promising for
women with (a higher risk of ) maternal distress . This
may reduce the influence of anxiety on the choice of place
of birth. In addition, birth outcomes may be improved as
low birth weight and fetal growth restriction are, to some
extent, related to maternal anxiety .
In conclusion, this study demonstrated that in low risk
nulliparous and parous women, pregnancy related
anxiety and general anxious and depressed mood (in parous
women only) are significant factors in planning place of
birth, adjusted for potential confounders. The majority
of low risk women did not change their planned place of
birth throughout pregnancy but nulliparous women who
reported an anxious or depressed mood in late
pregnancy and parous women with a high pregnancy related
anxiety more often changed planned birth place from
home to hospital. Presence of maternal distress during
pregnancy, either in general or related to childbirth,
should be carefully explored and adequately addressed
in the process of informed decision-making regarding
planned place of birth. Future studies should assess
whether taking into account these psychological factors
also results in more effective decision-making and
whether this positively affects labour satisfaction rates
and pre- and postnatal anxiety levels.
aOR: adjusted odds ratio; AVD: Assisted vaginal delivery; BMI: Body mass
index; CI: Confidence interval; DELIVER: Data EersteLIjns VERloskunde;
EQ6D: EuroQol-6Dimensions; LOI: List of obstetric indications; LVR1: Landelijke
Verloskundige Registratie 1; PRAQ-R: Pregnancy related anxiety
questionnaire-revised; SD: Standard deviation; SES: Socioeconomic status;
UK: United Kingdom
We would like to acknowledge E. Spelten, project leader of the DELIVER
study and M. Pereboom who helped to recruit midwifery practices and to
collect data. We would also like to thank M. Westerneng and R. Baron for
data-management and research agency NIVEL for linking of data. We are also
very grateful to all pregnant women and their midwifes for their time and
effort to take part in the study.
Availability of data and materials
The data analyzed for the current study is available from the corresponding
author on reasonable request.
All authors contributed substantially to the study. ABW analyzed the
data and prepared the manuscript, CCG and PdC supervised each step
in the data-analysis and the interpretation of findings, TK supervised the
collection of the DELIVER-data from the midwifery practices, MW helped
with management of the data, AH and AdJ as experts to the research subject
contributed substantially to further revisions of the paper, AdJ is also the
initiator of the study. All authors read and approved the final manuscript.
The authors declare they have no competing interests.
Consent for publication
Ethics approval and consent to participate
The DELIVER study has an approval from the Medical Ethics Committee of
the VU University Medical Centre Amsterdam (2009/284). All participants
were informed about the study and were asked to participate by their
consulting midwife. Participants were included on the basis of opting-out
and gave informed consent. Client participation was voluntary and they
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