Multifactorial study of the relationship between fear of childbirth and mode of delivery
1 PHD, ASSISTANT PROFESSOR, KIRSEHIR AHI EVRAN UNIVERSITY, FACULTY OF MEDICINE, DEPARTMENT OF BIOSTATISTICS AND MEDICAL INFORMATICS, KIRSEHIR, TURKEY
2 MD, ASSOCIATE PROFESSOR, KIRSEHIR AHI EVRAN UNIVERSITY, FACULTY OF MEDICINE, DEPARTMENT OF OBSTETRICS AND GYNECOLOGY, KIRSEHIR, TURKEY
Abstract
Objective. This study investigated the relationship between fear of childbirth (FOC) and mode of delivery and proposed a cut-off value of FOC for an unselected Turkish pregnant population. Materials and Methods. This cross-sectional study was conducted between March 2019 and February 2020 at Kirsehir Ahi Evran University Obstetrics and Gynecology Polyclinic. The Wijma Delivery Expectancy (WDEQ-A) Scale and General Information Form were used for data collection. Results. Social-media effect, concern for disorder in baby, education level, and fear of vaginal bleeding were significant risk factors for the study groups. A new cut-off value of FOC was proposed based on the distribution of FOC scores as 69 (fourth quartile) for an unselected Turkish pregnant population. Conclusions. Training programs regarding delivery and pregnancy processes were recommended to be organized to reduce FOC. Moreover, the newly proposed cut-off value of FOC was recommended to be utilized in clinics.
Introduction
Childbirth can be defined as a very important event in the life of every woman. This remarkable event has significant psychological and emotional impacts [1,2]. However, fears arise during pregnancy regarding delivery and pregnancy processes for various reasons, such as: young age of mother, the concern of genetic disorder in the baby, anxiety about the physical conditions of the hospital, negative impact on the pregnancy through posts about the pregnancy process on social networks (social media effect), fear of being alone during childbirth, unplanned pregnancy and not receiving support from spouse or family, among others.
Studies have demonstrated that Fear of Childbirth (FOC) prevalence changes across countries, its worldwide prevalence reported being 14% via a meta-analysis [3]. The prevalence of FOC changes post-partum depression and stress disorders and can even prolong labor [1].
FOC can affect the mode of delivery. This fear has led to an increasing number of cesarean deliveries worldwide [4]. Consequently, it is a major cause of a cesarean delivery preference [5]. These preferences were prevalent in women who had a history of psychological and obstetrical situations [6]. This preference is also considered a right to self-decision-making in developed countries [7]. However, nulliparous women had a higher level of FOC [7], while low-risk pregnant women who preferred vaginal deliveries had the highest level of FOC compared to alternative delivery processes [8].
Several studies have so far focused on suggesting a new cut-off value for determining FOC levels for different populations. However, no consensus could be achieved regarding the common threshold value for FOC. Currently, Wijma Delivery Expectancy/Experience Questionnaire (WDEQ-A) [9] is the most common tool for assessing FOC, and its score of 85 has been commonly used to classify the fear. Despite its common use, this cut-off value may not be useful either to detect the fearful sample or discriminate between fearless and fearful groups in different samples. Therefore, it can be considered essential to propose a cut-off value to identify the levels of FOC and to specify factors associated with FOC based on the newly suggested cut-off value that can reflect the characteristics of the population in question. This study proposed a new cut-off value for FOC based on WDEQ-A scores of the participants and investigated the relationship between FOC and mode of delivery based on the newly suggested cut-off value for FOC.
Materials and Methods
This paper-based cross-sectional study was conducted between March 2019 to February 2020 at Gynecology and Obstetrics Policlinics of the Kirsehir Ahi Evran University Training and Research Hospital. This study was approved by Kirsehir Ahi Evran University non-interventional clinical studies ethical committee (Approval Time: 26/03/2019 - Approval Number: 2019-06/68).
The inclusion criterion was defined as 18 years or older pregnant women, while pregnant under the age of 18 years were excluded. The sample size was determined by the G*Power (3.1.9.6) program, and 330 participants were calculated with 80% power and 5% error rate to detect a small effect size, namely, Cohen’s d = 0.2. Also, the Cronbach alpha internal consistency coefficient was calculated as 0.866 in this study. Data was collected via a validated Turkish version of the 33-item WDEQ-A Scale and General Information Form that was created by the researchers by reviewing the existing literature. The form included questions regarding sociodemographic (age, educational level, and occupation), obstetric (unplanned pregnancy, fear of bleeding during delivery, and concern for disorder in the baby after delivery), and social-related (social-media effect and fear of not being able to return to former social life after delivery) determinants. This study was conducted with the participants who provided written informed consent. The original W-DEQ is a 33-item questionnaire aiming to measure the FOC during pregnancy. The items are in the form of a six-point Likert scale yielding a minimum 0 and a maximum of 165 points [9]. The reliability and validity of the Turkish version of the scale have been studied previously [10]. Some items (2, 3, 6, 7, 8, 11, 12, 15, 19, 20, 24, 25, 27, and 31) were reverse-scored for the concordance.
Statistical Analysis Participants were divided into four categories based on the percentiles of their W-DEQ scores. Categories were defined as ‘Severe level of FOC’ (W-DEQ score ≥ 69, scores above the fourth quartile), ‘High level of FOC’ (scores in the second and third quartile; 49 ≤ WDEQ score ≤ 68), ‘Moderate level of FOC’ (scores in the first and second quartile; 34 ≤ WDEQ score ≤ 48), and ‘Low level of FOC’ (scores in below the first quartile; W-DEQ score ≤ 33). The mean ± standard deviation, median, minimum, and maximum values were calculated for quantitative variables; and frequencies and percentages were calculated for categorical variables. Kolmogorov- Smirnov test was used for normality assumption. Independent samples t-test, Mann–Whitney U tests Kruskal-Wallis test, and One-Way Analysis of Variance (ANOVA) was used for group comparisons depending on the normality of the quantitative data. Multiple binary logistic regression analysis was used to identify the factors related to FOC. The newly proposed cut-off value for FOC was used while forming the logistic regression model. Independent Samples t-test, Mann–Whitney U tests, and Chi-Square test were performed before the multiple logistic regression analysis to identify the variables for the final model. Variables with a p-value < 0.20 in the univariate analysis were included in the final multiple logistic regression model. The backward-Wald method was used for variable selection. Adjusted odds ratios (AOR) and their 95% confidence intervals (CIs) were reported. Moreover, the area under the curve (AUC) values were calculated for regression models to determine their discrimination powers. Sensitivity and specificity values were calculated for the newly proposed cut-off value of FOC. Furthermore, Cohen’s Kappa was calculated to measure the agreement between the previously proposed cut-off values and newly-proposed cut-off value. The R programming language (R Core Team, 2020) was used for the analysis. The significance level was taken as 0.05.
Results
A total of 330 pregnant women were included in the current study. The overall mean and median ages were 27.55 and 27 years, respectively (range: 18–45 years; standard deviation: 5.743 years). The mean WDEQ-A score was 52.52 ± 25.034, (range: 4–122; median: 48.5). The baseline characteristics of the participants are presented in Table 1.
The proposed cut-off value was based on the distribution of the FOC scores, the fourth quartile of the scores as 69 was proposed for determining FOC in unselected Turkish population. A statistically significant difference between the prevalence of low, moderate, high, and severe FOC in terms of quantile classification and the prevalence of FOC in terms of widely accepted FOC cut-off value of 85 as proposed by Wijma et al [9] (χ2: 13.785, p-value < 0.001). However, the prevalence of FOC was observed to be similar across the delivery mode (χ2:1.281, p-value: 0.865), and maternal age groups (χ2:2.036, p-value: 0.361).
The mean FOC levels were 54.04 ± 24.957, 52.227 ± 25.724, and 51.227 ± 24.18 for the previously cesarean, nulliparous, and previously vaginal delivery groups, respectively (p=0.668). Furthermore, the highest FOC levels were observed in self-employment workers (62.722 ± 31.301), while the lowest levels were observed in women without any concern for disorder in the baby (44.77 ± 22.898). The group comparison results are presented in Table 2.
Naime Meric Konar & Selda Songur Dagli
Variable n (%)
FOC Score
p-value Mean ± SD Median [Min - Max]
Educational Level
Primary School 6 (1.8) 53.75 ± 25.114 51 [14 - 104]
0.525 Secondary School 40 (12.1) 49.818 ± 23.045 46 [4 - 108] High School 66 [20] 50.749 ± 24.513 46 [6 - 122]
University - College 115 (34.8) 55.796 ± 26.336 52 [10 - 118] None 103 (31.2) 51.5 ± 34.057 41 [17 - 113]
Occupation
Housewife 244 (73.9) 51.328 ± 24.025 48 [4 - 121]
0.263 Worker 11 (3.3) 51.091 ± 29.477 45 [7 - 97]
Officer 57 (17.3) 54.649 ± 26.077 53 [10 - 116] Self-Employed 18 (5.5) 62.722 ± 31.301 49 [22 - 122]
Planned Pregnancy Yes 215 (65.2) 50.921 ± 24.636 47 [6 - 118] 0.124 No 115 (34.8) 55.496 ± 25.603 52 [4 - 122]
Parity
1 141 (42.7) 52.227 ± 25.724 48 [10 - 122]
0.229 2 94 (28.5) 54.947 ± 23.271 54 [7 - 113]
3 55 (16.7) 46.855 ± 25.127 43 [6 - 121] 4+ 40 (12.1) 56.6 ± 26.005 51 [4 - 103]
Number of Alive Children
0 . .
0.549 1 111 (33.6) 53.586 ± 24.902 51 [7 - 113]
2 53 (16.1) 49.717 ± 23.988 46 [6 - 121]
3+ 25 (7.6) 55.32 ± 24.711 51 [4 - 103]
Mode of Delivery
Formerly Cesarean 111 (30.6) 54.04 ± 24.957 51 [6 - 121]
0.668 Nulliparous 53 (42.7) 52.227 ± 25.724 48 [10 - 122] Formerly Vaginal 25 (26.7) 51.227 ± 24.18 47 [4 - 104] Problems in Previous Pregnancies Yes 49 (25.9) 49.51 ± 26.661 42 [12 - 121] 0.133 No 140 (74.1) 53.857 ± 23.797 52 [4 - 113]
Problems in Current Pregnancy Yes 63 (19.1) 54.73 ± 26.359 50 [15 - 121] 0.61 No 267 (80.9) 51.993 ± 24.733 48 [4 - 122] Taking Training during Pregnancy
Yes, I did have 29 (8.8) 53.586 ± 27.982 57 [12 - 98]
0.947 Yes, I'm taking currently 7 (2.1) 50.286 ± 23.464 45 [21 - 82] No 294 (89.1) 52.463 ± 24.847 48 [4 - 122]
Social Media Effect Yes 117 (35.5) 59.735 ± 25.217 56 [10 - 121] <0.001 No 213 (64.5) 48.549 ± 24.084 45 [4 - 122]
Unqualified Health Personnel Yes 191 (57.9) 55.288 ± 24.702 52 [6 - 122] 0.009 No 139 (42.1) 48.705 ± 25.704 44 [4 - 118] Concern for not being able to return
former socail life after delivery
Yes 98 (29.7) 60.663 ± 24.961 61 [15 - 121] <0.001 No 227 (70.3) 49.163 ± 24.406 45 [4 - 122] Concern for not being able to provide
good life standard to the baby
Yes 114 (35.2) 55.535 ± 26.756 53 [7 - 122] 0.13 No 210 (64.8) 51.11 ± 24.123 46 [4 - 121] Fear of bleeding during delivery Yes 161 (49.8) 59.36 ± 25.168 56 [15 - 122] <0.001 No 162 (50.2) 46.296 ± 23.286 44 [4 - 121]
Concern for Disorder in Baby
after Delivery Yes 190 (58.5) 58.216 ± 25.153 56 [6 - 122] <0.001 No 135 (41.5) 44.77 ± 22.898 38 [4 - 122] Fear of the effect of chemicals (drug, cigarette, alcohol etc.) taken during
pregnancy on baby
Yes 128 (40) 56.828 ± 27.021 54 [6 - 122]
0.013 No 192 (60) 49.526 ± 23.47 45 [4 - 118] *Social Medica Effect stands for the negatively affection from the news or posts about pregnancy process on social media. SD: Standard deviation Mode of Delivery Predictor β SE (β)
Odds Ratio
(OR)
95% Confidence Interval for Odds
Ratio (OR)
p-value Formerly Cesarean
Social Media Effect -1.097 0.495 0.334 0.127 - 0.881 0.027
Concern for Disorder in Baby after Delivery -1.525 0.675 0.218 0.058 - 0.817 0.024
Constant -0.085 0.405 1.089 0.834 Formerly Vaginal
Educational Level / Primary School Ref. Ref. Ref. Ref. Ref.
Educational Level / Secondary School -2.008 0.876 0.134 0.024 - 0.747 0.022
Educational Level / High School -3.406 1.184 0.033 0.003 - 0.338 0.004
Educational Level / University - College -0.953 0.719 0.386 0.094 - 1.578 0.185
Fear of Bleeding during Delivery -1.592 0.668 0.203 0.055 - 0.754 0.017
Constant 0.757 0.646 2.132 0.242
Nulliparous
Unplanned pregnancy 1.300 0.579 3.669 1.180 - 11.405 0.025
Social Media Effect -1.049 0.505 0.35 0.130 - 0.942 0.038
Concern for Disorder in Baby after Delivery -1.068 0.533 0.344 0.121 - 0.977 0.045
Concern for not being able to return former
socail life arter delivery -1.435 0.494 0.238 0.09 - 0.627 0.004
Fear of Bleeding during Delivery -1.678 0.583 0.187 0.060 - 0.585 0.004
Constant 2.497 0.936 12.147 0.008
All-sample
Concern for Disorder in Baby after Delivery -1.083 0.402 0.339 0.154 - 0.744 0.007
Constant -0.273 0.314 0.761 0.351 SE: Standard Error The results of four different binary logistic regression models (all sample, pregnant women with previously caesarean birth experience group, nulliparous group, and vaginal delivery groups) revealed that the concern for any disorder in the baby after the delivery was a significant risk factor for all sample groups (AOR = 0.339, 95% CI = 0.154–0.744; p = 0.007).
The social-media effect (AOR = 0.334, 95% CI = 0.127– 0.881; p = 0.027) and concern for any disorder in baby after the delivery (AOR = 0.218, 95% CI = 0.058–0.817) were significant risk factors for caesarean delivery group; education level (AOR = 0.134, 95% CI = 0.024–0.747; p = 0.022 for secondary school and AOR = 0.033, 95% CI =0.003–0.338; p = 0.004 for high school) and fear of bleeding during delivery (AOR = 0.203, 95% CI = 0.055– 0.754; p = 0.017) were significant risk factors in the vaginal delivery group; while unplanned pregnancy (AOR = 3.669, 95% CI = 1.180–11.405; p=0.025), social-media effect (AOR = 0.350, 95% CI = 0.130–0.942; p=0.038), fear of bleeding during delivery (AOR = 0.187, 95% CI = 0.060– 0.585; p = 0.004), concern for any disorder in the baby after the delivery (AOR = 0.344, 95% CI = 0.12–0.977; p = 0.045), and fear of not being in formal social life after delivery (AOR = 0.238, 95% CI = 0.090–0.627; p = 0.004) were significant determinants for the nulliparous group.
The discriminative powers of these regression models were 0.683 (95% CI: 0.614–0.752), 0.691 (95% CI: 0.574– 0.808), 0.783 (95% CI: 0.659–0.906), and 0.833 (95% CI: 0.759–0.907) for all samples, pregnant women with the former cesarean experience group, vaginal delivery group, and nulliparous group, respectively.
In this study, the sensitivity, specificity, and Cohen’s Kappa measures were calculated based on the consideration of other cut-off values that were defined in literature as gold-standard for the WDEQ-A score of FOC. The sensitivity, specificity, and Cohen’s Kappa statistics of other cut-off values in the literature were calculated as follows: (a) 50, sensitivity: 56.6%, specificity: 100%, and Cohen’s Kappa: 0.502; (b) 60, sensitivity: 70.9%, specificity: 100%, and Cohen’s Kappa: 0.752; (c) 66, sensitivity: 89.2%, specificity: 100%, and Cohen’s Kappa: 0.922; (d) 71, sensitivity: 100%, specificity: 98.8%, and Cohen’s Kappa: 0.975; (e) 81, sensitivity: 100%, specificity: 89.2%, and Cohen’s Kappa: 0.723; (f) 85, sensitivity: 100%, specificity: 85.2%, and Cohen’s Kappa: 0.577; and (g) 100, sensitivity: 100%, specificity: 78.7%, and Cohen’s Kappa: 0.252.
These results demonstrated that the newly proposed threshold value has good agreement with the previously proposed cut-off values.
Naime Meric Konar & Selda Songur Dagli
Table 1. Baseline characteristics and group comparison results (all the samples)
| Table 1. Baseline characteristics and group comparison results (all the samples) | ||||||
|---|---|---|---|---|---|---|
| Variable | n (%) | FOC Score | p-value | |||
| Mean ± SD | Median [Min - Max] | |||||
| Educational Level | Primary School | 6 (1.8) | 53.75 ± 25.114 | 51 [14 - 104] | 0.525 | |
| Secondary School | 40 (12.1) | 49.818 ± 23.045 | 46 [4 - 108] | |||
| High School | 66 [20] | 50.749 ± 24.513 | 46 [6 - 122] | |||
| University - College | 115 (34.8) | 55.796 ± 26.336 | 52 [10 - 118] | |||
| None | 103 (31.2) | 51.5 ± 34.057 | 41 [17 - 113] | |||
| Occupation | Housewife | 244 (73.9) | 51.328 ± 24.025 | 48 [4 - 121] | 0.263 | |
| Worker | 11 (3.3) | 51.091 ± 29.477 | 45 [7 - 97] | |||
| Officer | 57 (17.3) | 54.649 ± 26.077 | 53 [10 - 116] | |||
| Self-Employed | 18 (5.5) | 62.722 ± 31.301 | 49 [22 - 122] | |||
| Planned Pregnancy | Yes | 215 (65.2) | 50.921 ± 24.636 | 47 [6 - 118] | 0.124 | |
| No | 115 (34.8) | 55.496 ± 25.603 | 52 [4 - 122] | |||
| Parity | 1 | 141 (42.7) | 52.227 ± 25.724 | 48 [10 - 122] | 0.229 | |
| 2 | 94 (28.5) | 54.947 ± 23.271 | 54 [7 - 113] | |||
| 3 | 55 (16.7) | 46.855 ± 25.127 | 43 [6 - 121] | |||
| 4+ | 40 (12.1) | 56.6 ± 26.005 | 51 [4 - 103] | |||
| Number of Alive Children | 0 | . | . | 0.549 | ||
| 1 | 111 (33.6) | 53.586 ± 24.902 | 51 [7 - 113] | |||
| 2 | 53 (16.1) | 49.717 ± 23.988 | 46 [6 - 121] | |||
| 3+ | 25 (7.6) | 55.32 ± 24.711 | 51 [4 - 103] | |||
| Mode of Delivery | Formerly Cesarean | 111 (30.6) | 54.04 ± 24.957 | 51 [6 - 121] | 0.668 | |
| Nulliparous | 53 (42.7) | 52.227 ± 25.724 | 48 [10 - 122] | |||
| Formerly Vaginal | 25 (26.7) | 51.227 ± 24.18 | 47 [4 - 104] | |||
| Problems in Previous Pregnancies | Yes | 49 (25.9) | 49.51 ± 26.661 | 42 [12 - 121] | 0.133 | |
| No | 140 (74.1) | 53.857 ± 23.797 | 52 [4 - 113] | |||
| Problems in Current Pregnancy | Yes | 63 (19.1) | 54.73 ± 26.359 | 50 [15 - 121] | 0.61 | |
| No | 267 (80.9) | 51.993 ± 24.733 | 48 [4 - 122] | |||
| Taking Training during Pregnancy | Yes, I did have | 29 (8.8) | 53.586 ± 27.982 | 57 [12 - 98] | 0.947 | |
| Yes, I'm taking currently | 7 (2.1) | 50.286 ± 23.464 | 45 [21 - 82] | |||
| No | 294 (89.1) | 52.463 ± 24.847 | 48 [4 - 122] | |||
| Social Media Effect | Yes | 117 (35.5) | 59.735 ± 25.217 | 56 [10 - 121] | <0.001 | |
| No | 213 (64.5) | 48.549 ± 24.084 | 45 [4 - 122] | |||
| Unqualified Health Personnel | Yes | 191 (57.9) | 55.288 ± 24.702 | 52 [6 - 122] | 0.009 | |
| No | 139 (42.1) | 48.705 ± 25.704 | 44 [4 - 118] | |||
| Concern for not being able to return former socail life after delivery | Yes | 98 (29.7) | 60.663 ± 24.961 | 61 [15 - 121] | <0.001 | |
| No | 227 (70.3) | 49.163 ± 24.406 | 45 [4 - 122] | |||
| Concern for not being able to provide good life standard to the baby | Yes | 114 (35.2) | 55.535 ± 26.756 | 53 [7 - 122] | 0.13 | |
| No | 210 (64.8) | 51.11 ± 24.123 | 46 [4 - 121] | |||
| Fear of bleeding during delivery | Yes | 161 (49.8) | 59.36 ± 25.168 | 56 [15 - 122] | <0.001 | |
| No | 162 (50.2) | 46.296 ± 23.286 | 44 [4 - 121] | |||
| Concern for Disorder in Baby after Delivery | Yes | 190 (58.5) | 58.216 ± 25.153 | 56 [6 - 122] | <0.001 | |
| No | 135 (41.5) | 44.77 ± 22.898 | 38 [4 - 122] | |||
| Fear of the effect of chemicals (drug, cigarette, alcohol etc.) taken during pregnancy on baby | Yes | 128 (40) | 56.828 ± 27.021 | 54 [6 - 122] | 0.013 | |
| No | 192 (60) | 49.526 ± 23.47 | 45 [4 - 118] | |||
| *Social Medica Effect stands for the negatively affection from the news or posts about pregnancy process on social media. SD: Standard deviation |
Table 2. Results of multiple logistic regression analysis
| Table 2. Results of multiple logistic regression analysis | |||||||
|---|---|---|---|---|---|---|---|
| Mode of Delivery | Predictor | β | SE (β) | Odds Ratio (OR) | 95% Confidence Interval for Odds Ratio (OR) | p-value | |
| Formerly Cesarean | Social Media Effect | -1.097 | 0.495 | 0.334 | 0.127 - 0.881 | 0.027 | |
| Concern for Disorder in Baby after Delivery | -1.525 | 0.675 | 0.218 | 0.058 - 0.817 | 0.024 | ||
| Constant | -0.085 | 0.405 | 1.089 | 0.834 | |||
| Formerly Vaginal | Educational Level / Primary School | Ref. | Ref. | Ref. | Ref. | Ref. | |
| Educational Level / Secondary School | -2.008 | 0.876 | 0.134 | 0.024 - 0.747 | 0.022 | ||
| Educational Level / High School | -3.406 | 1.184 | 0.033 | 0.003 - 0.338 | 0.004 | ||
| Educational Level / University - College | -0.953 | 0.719 | 0.386 | 0.094 - 1.578 | 0.185 | ||
| Fear of Bleeding during Delivery | -1.592 | 0.668 | 0.203 | 0.055 - 0.754 | 0.017 | ||
| Constant | 0.757 | 0.646 | 2.132 | 0.242 | |||
| Nulliparous | Unplanned pregnancy | 1.300 | 0.579 | 3.669 | 1.180 - 11.405 | 0.025 | |
| Social Media Effect | -1.049 | 0.505 | 0.35 | 0.130 - 0.942 | 0.038 | ||
| Concern for Disorder in Baby after Delivery | -1.068 | 0.533 | 0.344 | 0.121 - 0.977 | 0.045 | ||
| Concern for not being able to return former socail life arter delivery | -1.435 | 0.494 | 0.238 | 0.09 - 0.627 | 0.004 | ||
| Fear of Bleeding during Delivery | -1.678 | 0.583 | 0.187 | 0.060 - 0.585 | 0.004 | ||
| Constant | 2.497 | 0.936 | 12.147 | 0.008 | |||
| All-sample | Concern for Disorder in Baby after Delivery | -1.083 | 0.402 | 0.339 | 0.154 - 0.744 | 0.007 | |
| Constant | -0.273 | 0.314 | 0.761 | 0.351 | |||
| SE: Standard Error |
Discussion
In this study, we aimed to analyze the relationship between FOC and mode of delivery and to propose a new cut-off value of FOC for unselected Turkish pregnant population.
The prevalence of FOC was 28.7, 24.1, and 21.6% in pregnant women with previous cesarean experience, nulliparous, and vaginal delivery groups, respectively. Moreover, the previously cesarean-experienced group had slightly higher FOC scores compared to the other two groups. Our findings showed either similarities [11,12] or conflicts [8,13] in this regard. In this study, we proposed a new cut-off value of FOC for the pregnant population based on the quartiles of the WDEQ-A scores of the participants. To the best of our knowledge, this is the first study to propose a threshold value of FOC for unselected Turkish-pregnant population. Previous studies have proposed cut-off values of FOC based on either the distribution of WDEQ-A scores [14-19] or their clinical representation [20]. Moreover, we calculated the sensitivity, specificity, and Cohen’s Kappa statistics of the newly proposed cut-off value as calculated by Calderani et al. [20] to determine its concordance with the other threshold values described in the literature.
Several other research proposed different cut-off values to categorize FOC previously. Threshold values as 66 and 71 were proposed by Zar et al [21] and Fenwick et al [18] for Swedish and Australian populations respectively, using the same method as our study i.e. fourth quartile of the distribution of WDEQ-A Scores. Moreover, Rouhe et al [22] took the highest fifth percentile and proposed 100 as a new threshold value for the Finnish population. Ryding et al. [23] proposed 85 as a cut-off value for the Swedish population, by taking the highest 10th percentile of scores of participants. Even though there are various threshold values defined in the literature, the optimal cut-off value was proposed as 85 for different populations in various studies [14,16-17].
The proposed cut-off value as 69 FOC score in the current study was found lower compared to other cut-off values defined in the literature. This result also shows that the threshold of fear of the Turkish pregnant population was lower, suggesting they are less fearful about childbirth. The reason for this lower threshold and less fearfulness might be the results of having previous birth experiences, participating in psychotherapy programs for the preparation of delivery, etc.
In the current study, no association was observed between FOC levels and sociodemographic characteristics of the pregnant population, such as maternal age, educational level, occupation, and gestational age. Similar results have been published previously [12,15,24,25]. In contrast, it was found that women who have a low education level and those who are unemployed are likely to have high levels of FOC, while maternal age was not associated with FOC [26]. The high levels of FOC were reported to be associated with educational levels and unemployment in several studies [27,28]. Unemployment was defined as a sociodemographic risk factor related to FOC by Saisto et al. [29]. Employed women were reported to be likely to have a higher level of FOC by Toohill et al. 2014 [25]. It was revealed that higher maternal age was associated with higher levels of FOC [30]. However, educational level and occupation were not reported to be significant risk factors for maternal cesarean preference, while age was a significant factor in this regard [31]. In the present study, effects of economic or socioeconomic status on FOC were not investigated directly, occupation and educational levels and their relationship with FOC were analyzed instead. Previous studies identified their relationship with delivery mode preferences. Buyukbayrak et al. reported that higher monthly income was observed to be related to a cesarean delivery preference [31], while high or unspecified socioeconomic status was reported to be associated with first-time mothers (the nulliparous group) by Räisänen et al. [32].
In the current study, FOC levels were found to be associated with social (social-media effect) and obstetric-related (concern for disorder in the baby) risk factors for the formerly cesarean group; sociodemographic (educational level) and obstetric-related (fear of bleeding during delivery) risk factors for the vaginal delivery group; while social (social-media effect and fear of not able to return to the former social life) and obstetric-related (unplanned pregnancy, concern for disorder in baby after the delivery, and fear of bleeding during delivery) risk factors were the determinants of the FOC levels for the nulliparous group. In contrast, cesarean delivery preference was found to be associated with FOC and educational level between 10 and 13 years in the primiparous and multiparous groups; age over 35 years and depressive symptoms in the primiparous group; and previous cesarean delivery and negative birth experience in the multiparous group by Løvåsmoen et al. [33]. Similarly, regardless of mode of delivery groups, Konar et al. have found parity and a concern of disorder in the baby after delivery as the significant factors for FOC for unselected Turkish pregnant sample [34]. In addition, medical risk factors and previous negative birth experiences were previously recorded to be associated with elective cesarean delivery [1]. Furthermore, increasing parity was reported to be related to cesarean delivery preference in an earlier study [31]. On the other hand, having depression was found to be related to first-time mothers (the nulliparous group) by Räisänen et al. [32]. Undergoing training programs regarding pregnancy and delivery processes were not found to affect FOC levels in our study. Contrary to our results, women who did not receive training regarding pregnancy and delivery processes had two times higher FOC scores than the women who received this training [24]. In a previous study, nulliparous women were reported to be likely to have a higher level of FOC compared to multiparous women [25]; however, in contrast, we did not find any such association for the entire study population in our study.
Numerous studies have investigated the relationship between FOC and delivery mode preferences [2,5]. Moreover, several studies have contributed to the literature by analyzing the effects of FOC on cesarean delivery [1,15,17]. This study differs from the previous studies by constructing study groups with actual mode of delivery rather than the preferred one. Thus, this study is unique since risk factors were determined based on the actual mode of delivery for each study group.
This study has some limitations. Firstly, part of this study was questionnaire-based; therefore, bias arising from this kind of study design cannot be ignored. Secondly, it was a single-center study; hence, these results cannot be generalized to the entire pregnant population of Turkey. Moreover, a limited discussion could be made for this current research since the risk factors studied are different compared to the existing literature. Therefore, the most similar risk factors were reviewed, matched with the current risk factors, and attempted to be discussed.
In the current study, the focus was on the statistical evaluation of newly-proposed cut-off value rather than its clinical relevance. Therefore, other tools for measuring FOC, such as the Fear of Birth Scale (FOBS), Tilburg Pregnancy Distress Scale, etc. were not utilized for comparison and determination of clinic usefulness. A new threshold value was proposed via the most common tool for FOC, W-DEQ, and its statistical concordance was assessed primarily. Hence, this present study should be considered as having a mainly statistics-based approach.
Conclusions
In conclusion, a comprehensive study, including the research of a wide range of multi-level factors of FOC, was conducted for evaluating the relationship between FOC and mode of delivery. Both sociodemographic and obstetric-related risk factors were observed to be associated with each study group. Furthermore, having the information regarding the highest prevalence of severe FOC in the previously cesarean groups training programs regarding delivery and pregnancy process are recommended to be organized to lower the FOC and increase the knowledge regarding these processes for the entire pregnant population, especially for pregnant who prefer cesarean delivery. It’s also planned to apply this scale for each unselected pregnant woman who was admitted to polyclinic right before the medical examination and specify the most fearful group via the newly proposed cut-off value for the Turkish population. Other than training programs, the most fearful group is being aimed directed to some therapy programs which are planned to be provided in the collaboration with the Psychiatry Department and psychological counselor of the hospital to help reduce the fear. Even online therapy programs and telephone-based counseling are considered to be conducted under pandemic conditions. Furthermore, couple-based therapy programs could also be organized in an attempt to reduce fear with the father's support. Moreover, we recommend the proposed cut-off value to be utilized for the Turkish population as it yielded effective diagnostic and concordance values with the previously proposed thresholds. Additionally, multi-center studies must determine the relationship between mode of delivery and FOC more precisely. Moreover, only Turkish pregnant women were included in this study. The inclusion of pregnant women of other nationalities would enable us to analyze the differences in various populations. Therefore, it can be seen as a future research option to investigate such a comparison of different populations.
Abbreviations
FOC: Fear of Childbirth WDEQ-A: Wijma Delivery Expectancy Questionnaire AOR: Adjusted Odds Ratio FOBS: Fear of Birth Scale
Institutional Review Board Statement
Any aspect of the work covered in this manuscript has been conducted with the ethical approval of all relevant bodies and that such approvals are acknowledged within the manuscript.
Conflicts of Interest
There are no known conflicts of interest in the publication of this article. The manuscript was read and approved by all authors.
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