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IMR Press / CEOG / Volume 49 / Issue 11 / DOI: 10.31083/j.ceog4911258
Open Access Original Research
Correlation between Fear of Childbirth and Childbirth Self-Efficacy during Labor
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1 Guangzhou Women and Children's Medical Center Guangdong Provincial Clinical Research Center for Child Health, 510623 Guangzhou, Guangdong, China
*Correspondence: xiaoqiao00195@163.com (Qiaozhu Chen)
Clin. Exp. Obstet. Gynecol. 2022, 49(11), 258; https://doi.org/10.31083/j.ceog4911258
Submitted: 28 May 2022 | Revised: 5 July 2022 | Accepted: 18 July 2022 | Published: 18 November 2022
This is an open access article under the CC BY 4.0 license.
Abstract

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 $\pm$ 9.01, and the total score of childbirth self-efficacy was 212.03 $\pm$ 59.64. The total score of fear of childbirth and the score of each dimension were significantly negatively correlated with those of childbirth self-efficacy (R${}^{2}$ = –0.354 to –0.155, p $<$ 0.01). Conclusions: Fear of childbirth during labor should arouse attention of medical staffs. It is necessary to enhance psychological support and childbirth self-efficacy during labor to reduce the fear of childbirth.

Keywords
during labor
pregnant women
fear of childbirth
childbirth self-efficacy
correlation
1. Introduction

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 [1]. 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 [2], 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 [8]. It has been shown that labor pain may induce FOC and impair childbirth efficacy. The parturients may suffer from behavioral dysfunction [9] due to synergistic effects of increased FOC and decreased childbirth self-efficacy, and prefer non-medically-induced cesarean delivery [10]. 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 [11]. 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 [12].

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 [13]. 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.

2. Subjects and Methods
2.1 Subjects

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 $\geq$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.

2.2 Methodology
2.2.1 Research Tools

The questionnaire was designed by researchers according to the literature [14], which mainly covered sociodemographics, parity and gestational weeks of parturients.

2.2.2 Childbirth Attitudes Questionnaire

Wei Juan [15] modified the Childbirth Attitudes Questionnaire (CAQ) developed by American nursing scholar Lowe [8], 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 [15].

2.2.3 Childbirth Self-Efficacy

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 [16], indicating good reliability and validity.

2.2.4 Research Methodology

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.

2.2.5 Statistical Analysis

All data were analyzed statistically using the SPSS Statistics version 20.0 (IBM, Chicago, IL, USA). Measurement data were expressed as ($\bar{x}$ $\pm$ S. Enumeration data were expressed as counts and percentages. Measurement data were analyzed by t-test, and count data were analyzed by chi-square test. Spearman’s correlation coefficient was calculated to measure the correlation between FOC and childbirth self-efficacy during labor. p $<$ 0.05 indicated a significant difference.

3. Results
3.1 Baseline Information of Parturients

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

Table 1.Baseline data of pregnant women (n = 347).
 Cases Ratio, % Age 20–34 years old 289 83.29 $\geq$35 years old 58 16.71 Gestational age $<$37 weeks 14 4.03 $\geq$36 weeks 333 95.97 First pregnancy or not Yes 150 43.23 No 197 56.77 Primipara/pluripara Primipara 183 52.74 Pluripara 164 47.26 With or without a labor partner Yes 288 83.00 No 59 17.00 Educational background 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 Occupation None 50 14.41 Civil servant/staffs at public institutions 69 19.89 Employee 150 43.23 Self-employed 26 7.50 Other 52 14.99 Family monthly income per capita (CNY) $\leq$6000 115 33.14 6001–10,000 117 33.71 $\geq$10,001 115 33.14 Any labor-related knowledge or not No 109 31.41 Yes 238 68.59 Adequately prepared or not No 76 21.90 Yes 271 78.10 Spousal relationship Excellent 276 79.54 Good 63 18.16 Average 5 1.44 Below average 3 0.86 Poor 0 0 Knowing about any ways to relieve labor pain or not No 131 37.75 Yes 216 62.25
3.2 Scores of FOC and Childbirth Self-Efficacy

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).

Table 2.Scores of FOC and childbirth self-efficacy during labor (n = 347).
 Variable Number of items Total score Maximum Minimum Mean $\pm$ standard deviation FOC 16 64 63 16 31.95 $\pm$ 9.01 Fear of child’s health 5 20 20 5 11.41 $\pm$ 3.49 Fear of labor pain 4 16 16 4 7.84 $\pm$ 2.57 Fear of losing control 4 16 16 4 8.40 $\pm$ 2.67 Fear of hospital intervention and environment 3 12 11 3 4.30 $\pm$ 1.62 Childbirth self-efficacy 32 320 320 39 212.03 $\pm$ 59.64 Sense of confidence 16 160 160 23 105.24 $\pm$ 31.02 Outcome expectancy 16 160 160 16 106.78 $\pm$ 29.82 FOC, fear of childbirth.
3.3 Correlation Between FOC and Childbirth Self-Efficacy During Labor

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).

Table 3. Correlation between FOC and childbirth self-efficacy during labor (R${{}^{2}}$).
 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 p $<$ 0.01 for all. FOC, fear of childbirth.
4. Discussion
4.1 Incidence of FOC During Labor

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].

4.2 Childbirth Self-Efficacy During Labor

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.

4.3 Correlation Between FOC and 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 [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.

5. Conclusions

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.

Author Contributions

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.

Ethics Approval and Consent to Participate

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). Each subject has signed an informed consent form.

Acknowledgment

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.

Funding

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).

Conflict of Interest

The authors declare no conflict of interest.

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Publisher’s Note: IMR Press stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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