Pregnancy, labour and parenting are important processes during a woman’s life. Childbirth in a family influences women thinking and feeling about their life situations and their role during motherhood [1]. Childbirth may be a potentially life-threatening event for mother and neonate in the developing country, but in developed countries, childbirth is a positive life event with minimal complication for mother and fetus [2]. FOC is frequent among pregnant women. It seems that about 80% of pregnant women may experience different levels of childbirth fear [3] and 6-13% of them experience severe FOC [4]. Negative factors associated with FOC are sleep disturbance [5], prenatal depression [6], increased using of prenatal healthcare [7], and maternal request for elective cesarean section. Indeed, they demand pain relief with epidural anaesthesia and have negative childbirth experiences. Women with FOC may develop postpartum depression and it may lead to lower rates of breastfeeding [8-10]. In some studies, demanding for cesarean section were due to FOC among primiparous women [11,12].
The highest rate of cesarean section is the common health problem in the world. According to the World Health Organisation (WHO) study, between 2000 and 2013, the cesarean section rate increased from 35% to 56.1% in Iran [13]. Recently, the rate of cesarean section in Iran has been estimated about 48% [14]. Depression is a common complication during pregnancy and postpartum period. More than 70% of women express symptoms of depression during pregnancy and 10-15% of women report symptoms of postpartum depression [15]. Hormonal changes occur during pregnancy may increase vulnerability for depression [16]. The highest rate of depression in women is between 25-44 ages that may be linked to maternal depression (antepartum and postpartum) [17]. Kheirabadi GR and Maracy MR, reported that the prevalence of prenatal and postpartum depression in Iranian women were 22.8% and 20.1%, respectively [18]. It has been reported that depression can cause premature childbirth, fetal growth restriction and postnatal complications [15]. Prenatal depression is associated with high blood pressure, pre-eclampsia, and gestational diabetes [19]. Storksen HT et al., demonstrated that both anxiety and depression could increase the prevalence of FOC [20].
Furthermore, Molgora S et al., suggested that anxiety and couple adjustment predict FOC and clinical depression predict severe fear. Low levels of couple satisfaction increase probability and feeling of FOC [21]. However, other researchers emphasised that FOC is not linked to anxiety and depression. These results suggest that less research has been done on the correlation between FOC and depression [5]. Therefore, the present study was conducted with an aim to determine the predictors of fear of childbirth among pregnant Iranian women.
Materials and Methods
This cross-sectional study was conducted on 230 Iranian primiparous pregnant women between 24 and 30 weeks of pregnancy, living in Ardabil, Iran. The study was conducted between February and December 2018.
The sample inclusion criteria were age between 18 to 35 years old, primiparous women with a singleton pregnancy, not being at high risk for blood pressure and gestational diabetes, not having abnormalities of amniotic fluid and infertility history and having at least secondary school literacy. The pregnant women who had cardiovascular disorders, hepatic diseases, and unwanted pregnancy at the time of recruitment were excluded from the study.
The sample size was determined to be 192 women and it was determined using Stroksen HT et al., study results on FOC [20] considering a confidence interval of 95%, a precision (d) of 0.05 around the mean (m=56.8) and Standard Deviation (SD)=20.1. Therefore, considering a 20% possible loss, the final sample size was estimated to be 230.
Sampling
Sampling was started after obtaining Ethics Code (code: IR.TBZMED.REC.1396.837) from the Ethics Committee of Tabriz University of Medical Sciences. Sampling was conducted through cluster method and among all health centres of Ardabil city, which has 17 centres, one-third of them were randomly selected using the website: www.random.org. Then, a list of pregnant women between 24 and 30 weeks of pregnancy covered by each centre was prepared using the Integrated Health System and they were invited by a phone call to participate in the study. Then, the women were evaluated for inclusion and exclusion criteria. All the women who accepted to participate and signed the informed consent completed the questionnaires.
Measures
Participants completed the socio-demographic characteristics questionnaire, EPDS and WDEQ-A.
The socio-demographic characteristics questionnaire included about age, residence, marital status, spouse’s age, level of education of women and her spouse, occupation of the women and her spouse, income etc.
In this study, the severity of childbirth fear was measured using the WDEQ-A. WDEQ-A has been developed to measure the severity of FOC [22] and has been validated by Mortazavi F, in Iranian women samples [23]. It consisted of 33 items measuring stress and fear during the delivery. Each question was scored from 1 to 6 points. A score ≤37 was considered low fear, a score between 38 and 65 reported moderate fear and a score equal to or greater than 66 considered high fear and a score above 85 reported severe fear [24].
The EPDS was composed of 10 questions with a 0-30 total score for postpartum and prenatal depression [25]. This scale has been validated in Iran by Kani A et al., [26] and a score of 12 or more was considered as depression. Questions 1, 2, 4 are scored from 0 to 3 and questions 3, 5, 6, 7, 8, 9, 10 were scored from 3 to 0. [Appendix 1] shows the EPDS.
Statistical Analysis
Data were analysed using SPSS software version 23.0. Descriptive statistics including frequency, percentage, mean and standard deviation were used to describe the data related to the socio-demographic characteristics, FOC and depression. Normality of the quantitative data was measured by Skewness and Kurtosis tests. The Pearson’s statistical test was used to determine the correlation between depression and FOC. The relationship between the socio-demographic characteristics and FOC was determined using independent t-test and one-way analysis of variance (ANOVA). Then, a General Linear Model (GLM) was used to control confounding variables and explaining variance and estimating the effect of each independent variable (socio-demographic characteristics and depression) on the dependent variable (FOC). The p-value of <0.05 was considered significant.
Results
Among the 230 women in the present study, more than half of them (43.9%) were over 25-year-old and husbands of more than one-third of the women (37.8%) were in the age between 30 and 35 years old. Almost half of the participants (46.1%) and their husbands (42.2%) had a university education level. The majority of the participants (89.1%) were housewife. About two-thirds of the participants (68.3%) stated that the household income was somewhat sufficient. In more than half of the participants (56.5%), the gender of fetus was male. Most of the pregnant women (83%) have participated in prenatal childbirth education classes. About three-quarters of participants (71.1%) stated that they had received information about FOC from other sources which half of them (52.7%) had received this information from their friends. Most pregnant women (76.5%) stated that one of their relatives had childbirth in the last year and one-third of them (34.6%) had received experience from their relatives that vaginal delivery is scary and painful [Table/Fig-1].
The relationship between socio-demographic characteristics and fear of childbirth (n=230).
| Variable | Number (%) | Mean (SD) | p | Variable | Number (%) | Mean (SD) | p |
|---|
| Age | 0.205‡ | Husband age | 0.876‡ |
| 20 and lower | 47 (20.5) | 58.25 (24.9) | | <30 | 60 (48.8) | 23.8 (8.4) | |
| 21-25 | 82 (35.6) | 62.32 (29.5) | | 30-35 | 79 (37.8) | 24.3 (7.0) | |
| Higher than 25 | 101 (43.9) | 55.4 (23.4) | | 35 and higher | 61 (13.4) | 24.3 (6.7) | |
| Education level | 0.557‡ | Husband’s education level | 0.794‡ |
| Secondary school | 14 (6.1) | 63.14 (20.9) | | Elementary | 8 (3.5) | 67.7 (26.8) | |
| High school | 26 (11.3) | 53.3 (27.3) | | Secondary | 20 (8.7) | 57.9 (26.2) | |
| Diploma | 84 (36.5) | 60.5 (27.1) | | High school | 18 (7.8) | 55.6 (20.4) | |
| University | 106 (46.1) | 57.5 (25.8) | | Diploma | 87 (37.8) | 59.8 (26.2) | |
| Job | 0.451‡ | University | 97 (42.2) | 57.1 (27.1) | |
| Housewife | 205 (89.1) | 24.3 (7.4) | | Husband’s job | 0.855‡ |
| Employed | 25 (10.9) | 22.7 (6.1) | | Unemployed | 2 (0.9) | 24.1 (7.3) | |
| Income | | | 0.007*‡ | Worker | 35 (15.2) | 23.6 (5.9) | |
| Completely sufficient | 46 (20) | 22.8 (7.6) | | Employed | 36 (15.7) | 23.7 (7.0) | |
| Somewhat sufficient | 157 (68.3) | 24.22 (7.0) | | Shopkeeper | 54 (23.5) | 24.3 (8.0) | |
| Insufficient | 27 (11.7) | 27.20 (8.7) | | Other | 103 (44.8) | | |
| Fetus gender | 0.032*‡ | Recent childbirth in relatives | 0.315‡ |
| Female | 100 (43.5) | 62.6 (25.6) | | Yes | 176 (76.5) | 57.5 (26.4) | |
| Male | 130 (56.5) | 55.2 (26.1) | | No | 54 (23.5) | 61.5 (25.1) | |
| Satisfaction of fetus gender | 0.163‡ | Recent childbirth experiences | 0.408‡ |
| Yes | 222 (96.5) | 58 (25.8) | | NVD is scary | 62 (34.6) | 58 (26.2) | |
| No | 8 (3.5) | 71.1 (32.9) | | CS is scary | 18 (10.1) | 52.2 (26) | |
| Husband’s satisfaction of fetus gender | 0.073‡ | Obtaining information from other sources | 0.810‡ |
| Yes | 221 (96.1) | 57.8 (26.1) | | Yes | 162 (71.1) | 58.9 (26.2) | |
| No | 9 (3.9) | 73.7 (22.7) | | No | 66 (28.9) | 57.9 (26.1) | |
| Prenatal education classes | 0.502‡ | Which sources | 0.462‡ |
| Yes | 191 (83) | 57.9 (25.8) | | Health sources | 4 (2.4) | 48 (32.1) | |
| No | 39 (17) | 61 (27.9) | | Lectures | 11 (6.7) | 52.3 (20.3) | |
| | | | Friends | 87 (52.7) | 61.5 (26.9) | |
| | | | Health workers | 63 (38.2) | 57 (25.1) | |
*p<0.05 for relationship between socio-demographic characteristics and fear of childbirth scores.
‡One-way ANOVA, ‡Independent t-test
The mean (standard deviation) of the FOC was 58.4 (26.1) from the available range of 0 to 165. The mean of the depression score was 8.9 (5.1) from the attainable score of 0 to 30. There was significantly positive correlation between depression and FOC scores based on Pearson’s statistical test (p<0.001, r=0.51) [Table/Fig-2]. According to the scores of WDEQ-A, 23.0% of the pregnant women had mild fear, 35.7% of them had a moderate fear, 28.7% of them had high fear and 12.6% of them had severe fear [Table/Fig-3].
The status of the fear of childbirth and depression and their relationship with each other (n=230).
| Variable | Mean (SD)* | Obtainable score range | Obtained score range | Relationship with depression r (p) |
|---|
| Fear of childbirth | 58.4 (26.1) | 0 to 165 | 5 to 133 | 0.51 (<0.001) |
| Depression | 8.9 (5.1) | 0 to 30 | 0 to 23 | |
*Standard deviation
Severity of fear of childbirth in the pregnant primiparous women (n=230).
| Fear of childbirth | Frequency | Percentage (%) |
|---|
| Low (<37) | 53 | 23.0 |
| Moderate (38-65) | 82 | 35.7 |
| High (66-85) | 62 | 28.7 |
| Severe (>85) | 29 | 12.6 |
Based on independent t-test and one-way ANOVA, there was a statistical significant relationship between income and gender of the fetus with FOC (p<0.05) [Table/Fig-1]. These variables with depression variable were entered into the GLM. The variables of depression, income and gender of the fetus have a statistically significant relationship with FOC and they explained 28.5% of the variance in FOC scores [Table/Fig-4].
Predictors of fear of childbirth based on the General Linear Model (n=230).
| Variable | B (CI 95%*) | p-value |
|---|
| Depression | 2.6 (2.0 to 3.2) | <0.001 |
| Sufficiency of income for living expenses |
| Completely sufficient (Reference‡) | 0 | |
| Somewhat sufficient | 5.5 (-5.4 to 16.4) | 0.322 |
| Insufficient | 10.1 (1.0 to 19.2) | 0.029 |
| Fetus gender | | |
| Male (Reference‡) | 0 | |
| Female | 7.3 (1.4 to 13.1) | .015 |
*Confidence Interval
Adjusted R square=28.5%
‡Reference category was considered as the comparison category. The coefficients show the difference between each category and the reference category.
Discussion
The results of the present study showed that there is a significant positive correlation between depression and FOC among the primiparous pregnant women. Based on the general linear model, depression variables, non-male fetal gender and family income were predictors of the FOC.
In the present study, 22.1% of the pregnant women had mild fear, 34.2% of them had a moderate fear, 27.5% of them had high fears and 12.1% of them had severe fear. Various studies reported that women with anxiety disorders and depression are at risk of FOC. Similar to the present study results, Hall WA et al., reported a high level of anxiety and FOC in one-fourth of the pregnant women [5].
In our results, there was a positive significant correlation between prenatal depression and FOC. In a study by Stroksen HT et al., which done on 1642 pregnant women, they found that more than half (56.2%) of the women with FOC did not have anxiety or depression, but anxiety and depression increased the prevalence of FOC [20] which is similar to the present results. In another study, Molgora S et al., evaluated role of anxiety, depression and couple adjustment on FOC in 426 primiparous Italian pregnant women, they reported that anxiety and couple adjustment can predict FOC but depression cannot predict severe childbirth fear [21]. Few studies have been reported the relationship between prenatal depression and childbirth fear [20,21], but there are more studies on the relationship between postpartum depression and FOC [19,25].
The present study also showed that there was a significant relationship between fetal sex and FOC (p=0.015), hence, the women who had female fetus had more childbirth fear. In European countries, it found that FOC was reported by 11% of all women [27], but in Asian countries such as Iran and Yemen, score of childbirth fear was significantly higher in the pregnant women [23]. In accordance with our study, Kempe et al., reported FOC in women whose fetus was female. In Yemen, socio-cultural factors have an important role in triggering childbirth fear [28]. The present results may be explained by which male gender is more acceptable in most societies [29]. In most Asian and African countries, parents’ happiness after childbirth is based on the gender of the child but in European and North American countries, there is no priority for child’s gender. In Asia and Africa, boys are in clear superiority [30]. Sex preference is one of the cultural issues of countries including Iran. Iran is one of the most ethno-culturally diverse societies in the world including Turks, Fars, Kurds, Tats and Turkmans. In some ethnicity groups, boys have always been preferred over girls [31]. Thus, this may cause fear and worry in parturient mothers. As a result, gender equality must be promoted by countries.
The present results showed that there is a significant relationship between family income and FOC. Similar to the present finding, other studies also reported a significant relationship between family income and childbirth fear [32,33]. It seems that in low-income families, there are fewer opportunities to carry out elective cesarean section [34]. Therefore, women with lower economic status report more fear because they cannot afford cesarean section and, therefore, are forced to choose vaginal delivery [33]. Also, financial worries may contribute to fear [24].
Limitation
The limitation of this study was that only primiparous women who referred to health centres of Ardabil city were included. Therefore, it may exclude multiparous women and women who live in the rural region, so it should be cautiously generalised.
Conclusion
The present finding showed that more than three-fourths of primiparous women suffer from moderate to severe level of FOC and depression may influence childbirth fear. Therefore, the identification of depressed pregnant women and medication or psychotherapy of them can eliminate symptoms of FOC and reduce unnecessary cesarean section.
*p<0.05 for relationship between socio-demographic characteristics and fear of childbirth scores.‡One-way ANOVA, ‡Independent t-test*Standard deviation*Confidence IntervalAdjusted R square=28.5%‡Reference category was considered as the comparison category. The coefficients show the difference between each category and the reference category.