Academic Editor: Anca Maria Panaitescu
Background: The research on fear of childbirth and childbirth self-efficacy of pregnant women in China mainly concentrates on the late pregnancy, and there is a lack of research on the psychology of women during labor. This study aimed to investigate the correlation between fear of childbirth and childbirth self-efficacy during labor. Methods: 378 pregnant women in
labor were selected by convenience sampling. They were investigated using a
self-designed questionnaire, the Chinese version of Childbirth Attitudes
Questionnaire, and the Childbirth Self-Efficacy Inventory. Results: The
total score of fear of childbirth during labor was 31.95
Labor is a physiologic process for women as a major life event during their lifetime. Psychological and cognitive factors of pregnant women affect labor, which are considered to play a crucial role in labor outcomes . Fear of childbirth (FOC) is a psychological problem arising from the unreasonable dread of labor pain, fetal damage, labor complications, and losing control of oneself during labor , which is widespread throughout the world. The incidence of FOC is reported to be 4.5%–30% in foreign countries [3, 4, 5], and 73.06%–79.2% in China [6, 7]. Childbirth efficacy is defined as a woman’s confidence in managing labor by a variety of strategies, including analgesia . It has been shown that labor pain may induce FOC and impair childbirth efficacy. The parturients may suffer from behavioral dysfunction  due to synergistic effects of increased FOC and decreased childbirth self-efficacy, and prefer non-medically-induced cesarean delivery . Even after birth, women experiencing severe FOC may face role transition, family problems and parent-child relationship disorders, or even postpone and reject a second pregnancy . Moreover, physical and psychological adverse reactions of primiparas with FOC may occur when they are pregnant or experience labor again, which is harmful for three-child policy in China .
Previous studies primarily focus on prenatal FOC and infer the correlation between prenatal FOC and childbirth self-efficacy based on pregnant women’ imagination of labor scenarios. FOC may happen at prenatal, intrapartum, and postpartum stages. When facing labor pain in real-world scenarios, FOC of pregnant women may have a stronger negative impact on childbirth self-efficacy. Moreover, a study found that obstetricians reported their anxiety during labor of pregnant women, and FOC of pregnant women also had adverse effects on the working feelings of obstetricians . Due to the fact that the research on pregnant women’s FOC and childbirth self-efficacy in China mainly concentrates on the late pregnancy, there is a lack of research on the psychology of women during labor. Therefore, in order to improve health care services and experience of pregnant women during labor, and guarantee safe labor and mental health of pregnant women, FOC and childbirth self-efficacy of pregnant women during labor were investigated in this study, which filled a gap in the research on psychological status of pregnant women during labor.
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
The questionnaire was designed by researchers according to the literature , which mainly covered sociodemographics, parity and gestational weeks of parturients.
Wei Juan  modified the Childbirth Attitudes Questionnaire (CAQ) developed by American nursing scholar Lowe , and proposed a Chinese version. The questionnaire consisted of 16 items with a Likert response scale of 1–4, and higher scores indicated stronger fear. The total score of the questionnaire was 16–64. The scores of 16–27, 28–39, 40–51, and 52–64 indicated no, mild, moderate, and severe FOC, respectively. Cronbach’s alpha of the Chinese Version of Childbirth Attitudes Questionnaire was 0.916, and Cronbach’s alpha of each dimension was 0.678–0.853. The test-retest reliability of the questionnaire was 0.812–0.921, and the content validity index was 0.924 .
The short form of the 32-item Chinese Childbirth Self-Efficacy Inventory (CBSEI-C32) was used. This inventory consisted of two parallel sub-inventories, one related to the sense of confidence and the other related to outcome expectancy. Each sub-inventory covered 16 items, with a score of 0–10. The total score of CBSEI-32 was 32–320. The higher the score, the higher the childbirth self-efficacy would be. One domestic study found that the internal consistency coefficient of CBSEI-C32 was 0.96 , indicating good reliability and validity.
Before the survey began, the informed consent was signed by all participants, and the researchers guided participants on how to fill out the questionnaire. All copies of the questionnaire were retrieved on site. Then it was checked whether there were unanswered items and answers not meeting the requirements. Timely corrections and clarifications were made if there were any. A total of 378 copies of the questionnaire were distributed, and 347 (91.8%) copies were valid.
All data were analyzed statistically using the SPSS Statistics version 20.0 (IBM, Chicago, IL, USA). Measurement data were
expressed as (
There were 183 primiparas and 186 multiparas. The baseline information of these parturients is shown in Table 1.
|20–34 years old||289||83.29|
|First pregnancy or not|
|With or without a labor partner|
|Junior high school||28||8.10|
|Senior high school or technical secondary school||41||11.82|
|Junior college or bachelor’s degree||248||71.47|
|Master’s degree or doctoral degree||30||8.65|
|Civil servant/staffs at public institutions||69||19.89|
|Family monthly income per capita (CNY)|
|Any labor-related knowledge or not|
|Adequately prepared or not|
|Knowing about any ways to relieve labor pain or not|
The total score of FOC during labor was 31.95
|Variable||Number of items||Total score||Maximum||Minimum||Mean |
|Fear of child’s health||5||20||20||5||11.41 |
|Fear of labor pain||4||16||16||4||7.84 |
|Fear of losing control||4||16||16||4||8.40 |
|Fear of hospital intervention and environment||3||12||11||3||4.30 |
|Childbirth self-efficacy||32||320||320||39||212.03 |
|Sense of confidence||16||160||160||23||105.24 |
|Outcome expectancy||16||160||160||16||106.78 |
|FOC, fear of childbirth.|
The total score of FOC was negatively correlated with the total score of
childbirth efficacy (R
|Variable||Total score of childbirth self-efficacy||Confidence||Outcome expectancy|
|Total score of FOC||–0.302||–0.274||–0.320|
|Fear of children’ health||–0.223||–0.196||–0.241|
|Fear of labor pain||–0.290||–0.268||–0.302|
|Fear of losing control||–0.341||–0.316||–0.354|
|Fear of hospital intervention and environment||–0.177||–0.155||–0.194|
Our results showed that the incidence of FOC during labor was 66.6%. The total
score of FOC was 31.95
In the present study, the total score of childbirth self-efficacy during labor
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  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.  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  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 , peer education , music therapy during labor , 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.
It was found that FOC and childbirth self-efficacy were closely related to each other. Stronger FOC caused lower childbirth self-efficacy, and lower childbirth self-efficacy resulted in increased FOC. Therefore, FOC during labor should be evaluated by medical staffs, and timely intervention is recommended.
YH and YFD designed the study. YH performed the research. YH, YHZ and HQZ analyzed the data. YH and QZC wrote the manuscript. JZ supervised the project. All authors have read and approved the final manuscript.
The protocol was approved by Ethics Committee of Guangzhou Women and Children Medical Center (Guangzhou Ethical Approval for Scientific Research Involving Women and Children  No. 113A01). Each subject has signed an informed consent form.
The successful completion of this research relied on a cast of people to whom we are obliged. Chiefly, we wish to thank all the women who participated in this study and our partners, the field researchers (Yue Huang and Yongfang Deng), for their thorough and trustworthy determination in the field. We also extend our sincere appreciation to Qiaozhu Chen, Head of Obstetric Department at Guangzhou Women and Children’s Medical Center, whose valuable contributions to this research are from beginning to end. Thanks to the head nurseYuehua Zhong for her administrative support and trust throughout. Last but not least, the authors are indebted to the reviewers and editors for their insights and comments which only served to improve the paper’s rigor and readability.
The present study was supported by the grants from Ministry of Science and Technology of People’s Republic of China (2019YFC0121905) and Guangzhou Medical Science and Technology General Guidance Project (No.20221A011025).
The authors declare no conflict of interest.
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