Background
Childbirth fear is a health concern for women and their caregivers when expectant mothers are approaching birth or are in their postpartum transition [
1,
2]. During pregnancy, women with childbirth fear often experience emotional distress [
3,
4], and some might even request a cesarean section (CS) because of the fear [
5,
6]. The CS rate has increased worldwide in recent years, and this may be associated with elective cesarean delivery on maternal request [
7,
8]. After delivery, mothers with intense childbirth fear are more likely to have difficulties with maternal adjustment [
9] and mother-child adaptation [
10]. Previous research suggests that early identification of women at risk of childbirth fear and initiation of appropriate interventions are essential for women’s emotional well-being before and after birth [
11]. However, most studies were conducted in high-income countries, and little is known regarding childbirth fear in low-income countries, such as Malawi.
Childbirth fear can be described as feelings of uncertainty and anxiousness before, during, or after the delivery [
12,
13]. Childbirth fear in pregnant women is assessed based on their expectations of anticipatory delivery, while childbirth fear in postpartum women is measured with women’s actual childbirth experiences [
12,
13]. Evidence suggests that socio-cultural factors and health care services are likely to influence the extent of childbirth fear and the consequences associated with the fear [
14,
15]. In Malawi, maternal healthcare remains a major challenge due to high birth rates (41/1000 people) [
16] and the lack of resources in the health care system [
17‐
19]. Thus, mothers’ childbirth fear is often not assessed and cared for before and after the delivery. Despite considerable efforts are made to improve antenatal care (pregnant mothers have to attend at least 4 visits before delivery), hospital delivery with skilled birth attendant (i.e., by physicians or midwives), and postnatal coverage (including 1 week and 6 weeks of postpartum check-up) [
18,
20,
21], mothers in Malawi are likely to be afraid of childbirth due to socio-cultural beliefs (i.e., witchcraft), health care providers’ attitudes (i.e., being rude), and lack of support/companion [
22]. Childbirth fear continues to have a potential impact on women’s wellbeing, and this needs to be addressed directly with constant assessments and adequate care.
Childbirth fear is common in both pregnant and postpartum women in developed countries. The prevalence of childbirth fear is estimated to range from 16 to 27% during pregnancy [
5,
11‐
13], and around 22% after birth [
13]. A study in Sweden by Alehagen et al. [
23] found a positive association between childbirth fear during pregnancy and postpartum period. Zar et al. reported that women who were more afraid of childbirth during pregnancy were more likely to have fears during and after labor [
24]. A prospective correlational design study by Fenwick et al. found that antenatal fear significantly predicted the levels of postnatal fear [
25]. A review of the existing literature suggests that most of the studies on childbirth fear have either focused on pregnant or postpartum mothers, but not on both [
23]. Understanding childbirth fear in both pregnant and postpartum mothers is necessary for developing comprehensive psychological maternal care programs.
Previous studies on childbirth fear suggest that the demographic, obstetric characteristics, and social support, are potential factors associated with childbirth fear among childbearing women [
26‐
28]. Younger women are more likely to experience elevated fears than older women during childbirth [
26]. Women who are not educated or not working are more likely to be fearful than their counterparts [
26,
28]. First-time mothers are more prone to have childbirth fear than parous women [
11,
29]. Mothers who sustain perineal tears during delivery are at increased risk of being fearful [
27]. A lack of social support is associated with childbirth fear in women [
26]. To this date, no attempt has been made to understand such factors in Malawian women. Therefore, exploring these factors affecting women’s childbirth fear is the first step towards establishing regular assessments, proper educational interventions, and the provision of mental health care to childbearing women in Malawi.
Given that previous research indicated that women’s childbirth fear is related to their overall health and emotional well-being, it is imperative to explore such phenomena in Malawian women. To fill in gaps in the literature, we conducted a cross-sectional study to explore factors associated with childbirth fear in pregnant and postpartum women in Malawi. The specific aims of this research were to: (1) investigate the proportion of women who experience different levels of childbirth fear, and (2) examine factors such as demographic and obstetric characteristics, and social support, associated with childbirth fear in pregnant and postpartum women.
Discussion
The purpose of this study was to examine childbirth fear and related factors in pregnant and postpartum women in Malawi. Our results indicated that over 50% of women experienced moderate or high fear during the perinatal stage. In particular, pregnant women who were illiterate or unemployed were prone to have higher levels of childbirth fear. After birth, mothers who were illiterate, were unemployed, and had sustained perineal tears were at increased risk of having elevated fears. Perceived social support was not significantly associated with childbirth fear in pregnant or postpartum women. Our study extends the literature by examining factors correlated with women’s childbirth fear in Malawi, a developing country with a unique culture.
Childbirth fear
Our study revealed that childbirth fear is common in Malawi. During pregnancy, about 20% of women had a relatively high level of fear (with a score on the WDEQ-A of ≥66), a distribution similar to previous studies that used the same assessment tool in Canadian (25%) [
38], Australian (24%~ 27%) [
25,
39], and Swedish (26%) [
24] women. A recent review suggested that most studies on childbirth fear were conducted in high-income countries, and the prevalence estimate greatly varied due to different measures and definitions [
40]. Results of our study indicated that childbirth fear also exists among women in a low-income country, and the level of childbirth fear was similar to those of women in high-income countries despite differences in birth rates, medical resources and practices, and cultural values [
41,
42]. Childbirth as a natural event accompanied by labor pains and potentially unpredictable variables in the process might partly explain why women in different regions or cultures also share similar levels of childbirth fear [
7,
43]. A study by Fenwick et al. revealed that women were concerned about the length of time experiencing pain and were more receptive to chemical forms of pain reduction [
43]. However, women in a low-resource setting might not opt to receive pain medication during childbirth, as such medications are rare and expensive [
44]. Offering women the option to receive pain medication and making the medication available upon request might ease women’s childbirth fears. In high-resource countries, mental health care is usually an integrated part of healthcare systems. Besides medically necessary resources, care of women’s emotional well-being during and after pregnancy often includes educational sessions on childbirth, opportunities for professional consultation, and meetings with various social support groups [
45‐
47]. Addressing mental healthcare issues can be a challenging task in Malawi. Given the country’s high rates of childbirth [
15], maternal mortality [
48], and infant mortality [
49], health care for women typically focuses on physical health while ignoring mental health. Our data clearly indicated that the level of childbirth fear was similar between Malawian women and women in high-resource countries, suggesting that the need for mental health care for women in Malawi is also essential to their overall well-being.
Our data indicated that relatively few postpartum women (10%) reported a high level of fear (WDEQ ≥66), compared to pregnant women. As reported by Fenwick et al. [
25] and Zar et al. [
12], women’s fear levels over the perinatal period decreased for nulliparous and multiparous women in the high-fear group. However, Fenwick et al. [
25] also pointed out that women who experienced childbirth interventions (e.g., a CS) may have an increased level of postpartum fear, and therefore, special attention and care are necessary for this population. Our study found postpartum women had low childbirth fear and this might possibly be related to the fact that the majority of our study sample were multiparous and had had a vaginal birth without additional interventions. Although our data also indicated a low proportion of fear after delivery, women’s fear did not completely cease or disappear. Therefore, it is necessary to provide assessments and care on a regular basis following childbirth in order to prevent potential adverse outcomes that might have an impact on future pregnancies and childbirths [
4].
Demographic factors associated with childbirth fear
In this study, we found a significant association between childbirth fear and women’s educational level. Women who were illiterate were more likely to report a higher level of childbirth fear during pregnancy and in the postpartum period than their more highly educated counterparts. Previous work by Laursen et al. [
26] and Salomonsson et al. [
28] also found a significant association between these two factors, although the relationship between them was not clear. It is possible that uneducated women do not usually comprehend childbirth information and make informed choices. Conversely, Saisto et al. found no significant association between women’s educational backgrounds and their fear of childbirth [
50]. More research is needed to examine the association between women’s educational level and childbirth fear. In any case, providing educational programs designed specifically for illiterate women in Malawi may help reduce their fears and promote their emotional well-being before and after childbirth.
We found that a woman’s unemployment status was significantly associated with a higher level of fear during pregnancy and after childbirth. Our results concurred with previous studies in Denmark [
26] and Finland [
50], which also suggested that unemployed women were at higher odds of having childbirth fear. Saisto et al. [
50] suggested that unemployment was a socioeconomic factor that may be linked to women’s childbirth fear. On the contrary, other researchers reported that employed women were more likely to experience childbirth fear and seek treatment for psychological well-being [
39,
51]. Toohill et al. [
39] further reported that mothers who were employed were more likely to have a high level of fear, compared to mothers who were not engaged in paid work. Given the mixed results of women’s employment status with childbirth fear, it is important to conduct more studies to further understand such associations in Malawian women. Our results suggest a need to incorporate mental health care into perinatal care for unemployed women in Malawi.
Obstetric factors associated with childbirth fear
The mode of birth was significantly related to childbirth fear in this study. However, the result was statistically insignificant after adjusting for other variables. Our results are similar to previous findings by Fenwick et al. [
25] and Johnson et al. [
32], who found no association between childbirth fear and a CS delivery. Johnson et al. in their study specified that most women were generally more frightened of childbirth (mean scores of the WDEQ of > 60) across all types of delivery [
32]. However, Ryding et al. did not find the same association but found that women who underwent a CS were at a greater risk of anxiety, had poorer stress-coping abilities, and had higher levels of childbirth fear [
52]. Childbirth fear being associated with a CS may be attributed to negative birth experiences, and some women considered such a birth intervention to be a traumatic event [
53]. Additionally, a CS is major surgery usually accompanied by poor physical and psychological outcomes [
54‐
56]. Medical systems and cultural factors of different countries might contribute to the mixed results of childbirth fear and CS delivery [
25]. In our study, most mothers clearly indicated their preference for a vaginal birth as opposed to a CS. As the CS rate is rising globally (26%) [
8], the rate in Malawi is only around 5% [
57], possibly due to limited access to CSs in Malawi. Although current conditions in Malawi do not allow women to have a CS by choice, this might not necessarily have an adverse impact on their childbirth fear. Instead, this creates an opportunity for women to reflect on their childbirth experiences in relation to their fears under professional guidance as recommended by other studies [
46] and not to choose a CS due to fear of childbirth. Future investigations on the association between a CS delivery and childbirth fear among perinatal women are needed.
We found that women with perineal damage (tears) after delivery tended to be at risk of childbirth fear. A study by Areskog et al. reported that women’s fears were associated with physical damage to themselves [
58]. Serçekuş et al. also reported a similar result in their qualitative study that women’s fears may be associated with episiotomies [
27]. A study conducted in Australia reported that concern about perineal tearing may lead to childbirth fear in childbearing women and the decision to have a CS as an easier option for birth [
43]. In Malawi, episiotomy is not a standard practice. Therefore, the significant association between women’s fear and perineal tears might be related to pains experienced during and after suturing. Furthermore, potential complications that underline sexual activities resulting from perineal tears might be of concern for some women [
59]. Concerns about perineal damage by Malawian women warrant the need for healthcare professionals to attend to women’s pain levels by administering anesthesia upon a woman’s request, provide instructions for perineal management, inform the patient about potential complications, and facilitate checkup visits [
60]. Furthermore, it is important that healthcare professionals take cautious actions to minimize the extent of perineal damage during birth in order to optimize birth and emotional outcomes.
Social support
Women in our study who received less social support during pregnancy reported higher levels of childbirth fear. However, the result was statistically insignificant after adjusting for other variables. Previous studies also reported that a woman’s lack of social support was associated with childbirth fear [
7,
26,
61], as having social support may act as a buffer in stressful situations [
62]. However, Haines et al. refuted such a relationship and found that personal or social characteristics of women had no connection with childbirth fear, especially in rural townships with a sense of community that reduced the need for direct support [
63]. This potentially explains why the results were not significant after adjusting for other confounders in our study. In Africa including Malawi, reproductive health issues such as childbirth are considered a woman’s responsibility [
64,
65]. Thus, women rely on each other in times of childbirth [
66], hence fostering community support. Although social support was not significant after adjusting for other variables in pregnant women, identifying and providing long-lasting social support [
50,
61] by families and significant others are vital during pregnancy.
Study limitations
When interpreting results of this study, some limitations need to be considered. Our study used a cross-sectional design to explore possible factors associated with childbirth fear which cannot show the cause-and-effect relationships. However, as the first study investigating childbirth fear in Malawi, our findings provide a basis for understanding childbirth fear in pregnant and postpartum women. Future studies can consider study designs that are longitudinal in nature to draw such causal inferences. The generalizability of results to high-risk women and other hospitals is limited, because our study only included women with no complications in a single hospital. We recommend further studies to incorporate high-risk women and women in various districts and central hospitals for the purpose of increasing generalizability. As most women in our study were illiterate, the researchers helped the illiterate participants to fill out the questionnaires. This could potentially underestimate their responses if they perceived less privacy.