Factors of the childbirth fear among nulliparous women in Iran

Childbirth is a natural process. It is considered a critical event in the life of a woman. This unpredictable process may be associated with complications and risk of death for both mother and child. Moreover, it affects a woman's thoughts and feelings. These feelings involve happiness and confidence to concern and fear [1‐8].

Fear of childbirth (FOC) is an anxiety associated with expected childbirth. FOC manifests itself in phobias, nightmares, physical problems, and concentration problems. It is often related to requesting a cesarean section (CS) [9‐13].

In recent years, FOC has increased. According to previous reports, FOC has been found in about 20% of pregnant women. Globally, the prevalence of FOC has varied from 5% to more than 40%. According to existing studies, this prevalence has been reported in European countries from 6.3 to 14.8%. It is also estimated that 25% of pregnant women have FOC in Iran [4, 5, 13‐16].

In general, FOC may have several risks, such as abortion, posttraumatic stress disorder, depression, risk of birth trauma such as fistula, risk of dystocia, hypertension and preeclampsia, preterm labor, labor intolerable pain, reduced quality of life, as well as harmful effects on the children such as low birth weight and impaired immune system. Therefore, FOC and its complications are likely to increase obstetric interventions and subsequent health care costs [9, 13, 15‐21].

Various studies have identified various potential causes of FOC, including the following: personality traits, concerns about baby health, low educational status, history of childhood sexual and physical violence, inadequate awareness, interactions with medical staff, fear of the unknown, birth-related problems and procedures, internalizing other women's negative stories, being a nulliparous, rural living, low self-efficacy, lack of social support, cultural differences, race and ethnicity, and self-esteem [1, 4, 8, 13, 22‐24].

Therefore, it is noteworthy that FOC affects the women's decision to choose the delivery method and is more prevalent in nulliparous women. Findings of a cohort study by Räisänen et al. (2014) revealed that CS rates for women with FOC were more than four times higher than those without FOC. Based on the available meta-analysis study conducted in Iran, FOC was the first cause of CS. Also, FOC has a multidimensional nature and varies in different regions with different socio-cultural characteristics, and assessment of individual needs to reduce FOC should be considered [4, 13, 23, 25, 26].

According to the literature, it seems necessary to conduct a study to identify the factors of FOC among nulliparous women in Iranian culture. Moreover, a review was a requirement to proceed with the next stage of this study, a future clinical trial in this area in Iran. Hence, this study aimed to investigate FOC factors among nulliparous women in Iran. Hopefully, the results of this study will be helpful as a phase from the main research of the authors in designing educational content for a future clinical trial to manage and reduce FOC and consequently reduce the rate of CS.

This study was conducted based on the PRISMA statement. The study's research question was the factors related to the FOC among Iranian nulliparous pregnant women are.

This study was conducted to investigate the factors associated with FOC in nulliparous women in Iran. Six articles on the factors of FOC in nulliparous women were reviewed for this study. The overall results of this study showed factors of the FOC in nulliparous women were biological factors including the process of labor and childbirth and labor pain, concern for the baby factor including harm to the baby and baby infirmity, psychological factors including painful injections during labor and suturing in childbirth, and individual factors including loss of control during labor.

According to the present study's findings, one of the factors influencing the FOC in nulliparous women was the biological factor with sub-factors the process of labor and childbirth and labor pain. So that fear of pain and the process of labor and childbirth in half of the reviewed studies was the first common cause of FOC, and in the other half was the third [29‐34]. These findings were consistent with the results of other studies; the fear of pain was the first, the second, and the third cause of FOC in these studies, respectively [35‐37]. Similarly, Serçekuş et al. argued that the most common reason for FOC in primiparous women is fear of labor pain [38]. In comparison, in the study of Tsui et al., the first factor identified for the cause of FOC was negative stories followed by negative attitudes or moods. In her study, a quarter of the study population was multiparous women [39]. However, studies consistent with our study have been performed among nulliparous women, except for 10% of the study sample of Demšar et al. [35‐37]. Therefore, the study's target population has probably been influential in the common cause of FOC. Moreover, although in the study of Mortazavi et al., FOC did not differ in terms of parity, nonetheless, women's experiences of FOC are influenced by many individuals and social patterns, including negative stories, negative attitudes, mood-related aspects, and a previous negative experience of childbirth as the main causes of FOC in multiparous women and fear of pain as one of the common causes of FOC in nulliparous women likely because of the first experience [24, 25, 39‐41].

Concern for the baby factor with sub-factors of the harm to the baby and baby infirmity was another factor of FOC among nulliparous women in this study. These were common reasons for FOC in the studies conducted by Khorsandi et al., Farajzad touli et al., and Negahban et al. [30, 31, 34]. This finding was congruent with a study by Saisto et al. and Abd El-Aziz et al. [35, 36]. By contrast, harm to the baby and baby infirmity were not found as a common cause of FOC in other studies in nulliparous women [25, 37‐39, 41‐45]. In this study, concern for the baby factor as a common cause of FOC can be interpreted as follows:

1) The study's participants were nulliparous women without experience of childbirth. They most likely worried about their baby's health after hearing terrible stories about the negative impact of birth on the baby's health. As the study finding by Sen et al. showed the 69% of women who had heard about their relatives having a bad birth were affected by these experiences [46], 2) Knowing a woman who has delivered an injured or disabled child, and 3) This child was a golden baby for them because he/she was their firstborn. Hence, they are more concerned about his/her health. To that end, in a study by Ternström et al., the expectation of the birth of the first child was reported as a factor associated with FOC among pregnant women [47].

In line with the results of this study, psychological factors (including painful injections during labor and suturing in childbirth) were one of the factors of FOC in nulliparous women, no study was found [29]. Only in a study, fear of needles was one of FOC causes, which was a less common finding [37]. It can be argued that the psychological factor may include different sub-factors in other studies, or the psychological factor may be a sub-factor of another factor [43]. Regarding this finding, it seems that nulliparous women are afraid of the intervention of medical staff in the labor process in Iran. This fear will probably be managed if more attention is paid to the relationship between the medical staff and the patient in medical settings.

In addition to the above, the present study showed the individual factor (loss of control during labor) was the last factor of the FOC among nulliparous women [29]. In agreement with this finding, Lowe found fear of losing control during delivery was most frequently cited by primiparous women [48]. Furthermore, in the research by Geissbuehler et al., fear of losing control was one of the most frequent answers concerning FOC, which confirms the present study finding [49]. Nonetheless, in a study by Demšar et al., ‛fear of having no control over the situation’ and ‛fear of losing control during birth’ were the second and eighth most common factors of FOC [37]. Therefore, it is noteworthy that in this study, nulliparous women may have this fear due to lack of experience of vaginal childbirth, unfamiliarity with the labor process, and lack of skills to manage the situation. With this in mind, it is possible to strengthen the individual skills of pregnant women in this field by holding problem-solving workshops, talking about positive experiences, and having group discussions.

In general, studies showed that FOC reasons are divided into several categories: social factors (e.g., lack of social support), biological factors (e.g., fear of pain), psychological factors (e.g., mental health problems, past traumatic events, and fear of being a parent) or secondary factors (e.g., previous childbirth experiences) [5, 11, 22, 50]. Some of these factors were also evident in our study. But factors related to fear of harm to the baby and inability during labor were more common in the current study. Based on studies, women's experiences of FOC are also influenced by cultural contexts and environments [4, 46, 50]. Therefore, it seems that this fear can be overcome by creating the right insight [51].

This study focuses on the factors of FOC in nulliparous women in Iran. Based on the study results of the factors of the FOC in nulliparous women were biological (the process of labor and childbirth and labor pain), concern for the baby (harm to the baby and baby infirmity), psychological (painful injections during labor and suturing in childbirth), and individual (loss of control during labor). It was observed concern for the baby factor was more common in this study. In conclusion, the women's FOC regarding these factors can be reduced by increasing their assurance about child health, providing appropriate training during pregnancy, explaining the whole process of childbirth and making it more accessible, raising maternal awareness about pain-relief methods during labor in hospitals, talking about positive experiences, holding problem-solving and enabling workshops, improving the interaction between medical staff and pregnant women, as well as providing appropriate conditions for further care and support after birth. In future research, the authors intend to concentrate on conducting a qualitative study in this area to complement the findings of this study.