378 pregnant women in labor were selected using convenience sampling at a tertiary obstetrics and gynecology hospital in Guangzhou from April to October 2020. Inclusion criteria: singleton pregnancy with head downward position of the fetus; voluntary for vaginal delivery without contraindication; parturiency or already in labor; gestational age $\ge$36 weeks; maternal age of 20–40 years; able to read Chinese characters; able to communicate in Mandarin or Cantonese. Exclusion criteria: severe pregnancy complications or comorbidities; abnormal fetal growth and development; mental disorders. The protocol was approved by Ethics Committee of Guangzhou Women and Children Medical Center (Guangzhou Ethical Approval for Scientific Research Involving Women and Children [2021] No. 113A01). The present study conformed to the Declaration of Helsinki. Among 378 parturients selected, 347 (91.8%) parturients completed the questionnaire survey.

There were 183 primiparas and 186 multiparas. The baseline information of these parturients is shown in Table 1.

The total score of FOC during labor was 31.95 $\pm$ 9.01, indicating mild FOC. Among all participants, 123 participants (35.4%) experienced no FOC at all; 147 participants (42.4%) experienced mild FOC; 77 participants (22.2%) experienced moderate to severe FOC. The total score of childbirth efficacy was 212.03 $\pm$ 59.64 (Table 2).

The total score of FOC was negatively correlated with the total score of childbirth efficacy (R${}^2$ = –0.302, p 0.01). Each dimension of FOC was significantly correlated with that of childbirth self-efficacy (p 0.01) (Table 3).

Our results showed that the incidence of FOC during labor was 66.6%. The total score of FOC was 31.95 $\pm$ 9.01, indicating mild FOC. Compared with the previous studies on FOC during labor, the total score of FOC in the participants in our study was significantly lower than that reported by Deng et al. [17]. This difference may be explained by the discrepancy in the educational background of parturients. In the present study, 80.03% of the participants had an education level of junior college and above, which was higher than that in the study by Deng et al. [17] Besides, 68.59% of the parturients in our study had already gained some knowledge related to labor, and 62.25% of the parturients had been informed of the methods to relief labor pain. The higher the education level, the greater the ability of the parturients to acquire new knowledge related to labor. And the more the labor-related knowledge acquired, the greater the parturients’ ability to assuage their FOC [18]. The total score of FOC among parturients in our study was also higher than that before labor in the studies by Gao et al. [6] and Wei et al. [7]. Many previous surveys on FOC [6, 7, 8] focused on parturients before labor, and FOC was largely based on imagination. In the present study, labor had already begun, and FOC was recorded in the real world. This fact may explain the difference in FOC. Furthermore, the parturients surveyed in our study came from the obstetrics ward in a tertiary maternal and child health care hospital in Guangzhou, China, which was on evidence-based practice for non-pharmacological analgesia. The evidence-based nursing program in this hospital has noticeably improved the quality of obstetric care services. The parturients included in our survey also already acquired some knowledge on childbirth. After admission, videos about labor-related health education and non-pharmacological analgesia were delivered to parturients via the electronic health education system. The nurses in charge provided parturients and their family members one-to-one guidance on non-pharmacological labor analgesia. Labor pain was assessed regularly, and the non-pharmacological analgesia strategy was based on personal preference and adaptability. The professional and individualized support above may greatly boost parturients’ sense of safety and help relieve labor pain. The parturients would be more confident about natural childbirth and experience weaker FOC [19]. It is indicated that FOC during labor should arouse our attention, which should be evaluated after the parturient enters labor, and targeted strategies are recommended to alleviate fear and pain of childbirth according to the parturients, such as non-pharmacological analgesia knowledge and skills (such as relaxation breathing, massage, acupoint pressing, warm water shower, music therapy, free position), how to cooperate during labor, etc. [20]. Moreover, health education for parturients may be enhanced, including newborn health, labor pain management, cooperation during labor, and introduction about available resources of the hospital and department. Using the electronic platform, education can be directly delivered to the maternal mobile phone, and the content of education can also be shown in animated short films, which are vivid and intuitive; the childbirth tips can be taught using scenario simulation; non-pharmacological analgesia can be educated by one-to-one guidance. The most important point is to evaluate outcomes, that’s to evaluate whether pregnant women can manage labor using methods learnt from nurses, and ask whether FOC is alleviated and confidence of pregnant women in labor is enhanced. Family members are required to support the parturients; the labor partners are also instructed on how to support the parturients in thoughts, language, and action to reduce their FOC [15, 21].

In the present study, the total score of childbirth self-efficacy during labor was 212.03 $\pm$ 59.64. The average score of outcome expectancy was 106.78 $\pm$ 29.82, and that of confidence was 105.24 $\pm$ 31.02. These scores were higher than those reported in the study by Sun et al. [21]. Such a difference may be explained by a higher percentage of multiparas in the present study. Multiparas are more experienced in childbirth and, therefore, more confident than primiparas [22]. Besides, parturients with an education level of junior college and above accounted for a higher proportion and had a more accurate understanding of delivery methods [23]. Generally speaking, the higher the education level, the higher the ability to acquire new knowledge, including the knowledge on childbirth. Sun et al. [24] focused on late pregnancy before labor. Parturients’ confidence in childbirth varies with the environment, the ability to manage childbirth, and labor pain management after labor begins. Prenatal education can reduce FOC and improve childbirth self-efficacy [24]. Alternatively, childbirth simulation education [25], peer education, and perinatal health education can be combined [26] to help improve parturients’ childbirth self-efficacy and promote natural childbirth. After admission, the parturients’ awareness of childbirth-related knowledge and skills is assessed, and bedside guidance is provided accordingly.

As indicated in previous studies [7, 27], parturients’ FOC was negatively correlated with childbirth self-efficacy. However, the correlation coefficient for the total score of FOC and childbirth self-efficacy during labor was higher in our study [7, 27]. This is probably because the previous studies are generally concerned with late pregnancy before labor. But during labor, FOC affected childbirth self-efficacy more strongly, highlighting psychological support for parturients during labor to reduce FOC and boost their confidence in childbirth. One systematic review of FOC-targeted interventions [28] has shown that cognitive-behavioral therapy, relaxation, psychological counseling, childbirth class, mindfulness program, and psychological education as the main psychological interventions can effectively reduce FOC among parturients. Munkhondya et al. [29] conducted companion-integrated childbirth preparation based on structured childbirth education, which reduced FOC and improved childbirth self-efficacy. Midwife-dominated group prenatal care can also help reduce FOC [30] and boost parturients’ confidence and childbirth self-efficacy. Therefore, in the future health care about pregnancy, the intervention measures for FOC should not be limited to FOC itself, and childbirth self-efficacy should also arouse attention of medical staffs. Midwifery service [16], peer education [26], music therapy during labor [31], and companion-nursing integration scheme are also recommended to improve parturients’ childbirth self-efficacy.

However, there are also some limitations in this study. First, the research was only conducted in a single center, and the sample cannot represent the whole population. Our findings remain to be further verified by well-designed multi-center studies. Second, interventions for FOC were not investigated in this study.