https://orcid.org/0000-0002-4642-164X
Figures
Abstract
Background
Childbirth is a normal physiological process that transit women to motherhood, and it is a major event in women’s life. Women face many challenges from conception to the childbirth process and during the postpartum period. Childbirth fear is one of the problems women encounter during pregnancy and it is associated with a wide range of negative outcomes on the health of the woman and her fetus. Even though childbirth fear has had negative health outcomes studies on the prevalence and its associated factors are scares in developing countries including Ethiopia.
Methods
An institutional based cross-sectional study was conducted among 453 pregnant women from February 15–28/2022. Data were collected using a pretested, interviewer administered questionnaire, and a systematic sampling technique was employed to select the study participants. Epi Data version 4.6 and SPSS 25 were used for data entry, cleaning and, analysis, respectively. A binary logistic regression (bi- and multivariable) model was fitted to identify factors associated with childbirth fear. The level of significant association was declared using the adjusted odds ratio (AOR) with its 95% confidence interval (CI) and a p-value of ≤ 0.05.
Results
Childbirth fear among pregnant women was 23.8% (95% CI: 20.1–28.0). Being rural residence (AOR = 6.24, 95% CI: 3.05, 12.80), having moderate social support (AOR = 0.54, 95% CI: 0.29, 0.99), anxiety during pregnancy (AOR = 2.82, 95% CI: 1.52, 5.23), and intimate partner violence (AOR = 4.95, 95% CI: 2.78, 8.81), were significantly associated with childbirth fear.
Conclusion
The study showed that the magnitude of childbirth fear is high in the study area. Policymakers should develop strategies or screening tools for the early identification of women with pregnancy-related anxiety and childbirth fear, and it is important to give special attention and counseling to pregnant women in rural areas and victims of intimate partner violence.
Citation: Temesgan WZ, Aklil MB, Anteneh TA, Desalegn SY (2025) Childbirth fear and its associated factors among pregnant women attending antenatal care at Gondar city public health institutions, northwest Ethiopia, 2022. PLoS One 20(7): e0328819. https://doi.org/10.1371/journal.pone.0328819
Editor: Addis Eyeberu, Haramaya University, ETHIOPIA
Received: December 14, 2022; Accepted: July 7, 2025; Published: July 23, 2025
Copyright: © 2025 Temesgan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: “All relevant data are within the paper and its Supporting Information files.”
Funding: The authors received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Abbreviations: ANC, Antenatal Care; AOR, Adjusted Odds Ratio; CI, Confidence Interval; COR, Crude Odds Ratio; EPDS, Edinburgh Postnatal Depression Scale; HRQoL, Health related quality of life; SPSS, Statistical Package for Social Science; WHO, World Health Organization; W-DEQ, Wijma Delivery Expectation/ Experience Questionnaire
Introduction
Childbirth is a normal physiological process that transit women to motherhood and it is a major life event [1]. Women face many challenges from conception to the childbirth process and during the postpartum period. Childbirth fear is one of the problems women encounter during pregnancy and can be a source of distress for the women, their family, and their caregivers [2]. It is described as feelings of uncertainty and anxiousness before, during, or after delivery by thinking about the future labor and delivery or experiencing others’ fearful responses to childbirth and labor pain. Childbirth fear ranges from minor worth and anxieties about giving birth to severe fear of childbirth that has a considerable impact on women’s life, causing distress and affecting their mental well-being [3,4].
The prevalence of childbirth fear increases from time to time. According to a systemic review and meta-analysis report in 2022, FOC affects 16% of women globally [5]. Evidence showed that the prevalence of severe childbirth fear in Africa ranges from 8%−20% [6,7]. According to studies conducted in Arba Minch, Ethiopia, and Wollega zone, Ethiopia, 24.5% and 28.9% of pregnant women are affected by childbirth fear respectively [8,9].
Childbirth fear has negative outcomes on the health of the women and their fetuses such as prolonging the time to subsequent delivery, prolonging the active phase of labor, increasing the risk of operative delivery, use of epidural anesthesia, increasing the presence of post-traumatic stress syndrome and postpartum depression, and reduces mother to child bonding after delivery. It also has bad obstetric outcome including abortion, still birth, uterine rupture and preterm labor, [4,10,11]. The women’s fear is related to an inability to cope with labor pain, intervention during labor, fear of harm to self in labor and postnatal, fear of harm or stress to the baby, fear of not having a voice in decision making, fears about their body’s ability to give birth and fear of being abounded and alone [3]. Even though there is no definitive treatment for childbirth fear, studies suggested that cognitive behavioral therapy, hypnotherapy, antenatal education, psychoeducation, enhancing midwifery care, and intervention during labor are effective in reducing childbirth fear [4,12]. evidences showed that being nulliparous, having unplanned pregnancies, not having living children, pregnancy-related anxiety, depression, and perceived low levels of health related quality of life are some of the predictive factors for childbirth fear [6,8,13,14].
Nowadays, maternal and neonatal mortality reduction is a global priority. One of the Sustainable Development Goal (SDG) targets is to reduce the global maternal mortality ratio (MMR) to less than 70 maternal deaths per 100, 000 live births and neonatal mortality rate to at least 12 per 1,000 live births by 2030 [15]. Similarly, the Ethiopian government planned to reduce the MMR from 401 to 279 maternal deaths per 100,000 live births by 2024/25 [16], and doing a lot to decrease maternal and neonatal morbidity and mortality. But a little concern is given on the psychological aspects of pregnancy and childbirth. Even though childbirth fear is a common problem with multiple consequences, little is known in low-income countries including Ethiopia. Therefore, this study aimed to assess the childbirth fear and its associated factors among pregnant women attending ANC at Gondar city public health facilities in northwest Ethiopia. It could also provide input for stakeholders to design strategies for improving maternal and neonatal health.
Methods and materials
Study design, period, and setting
An institutional based cross-sectional study was conducted from February 15–28, 2022 in Gondar city public health institutions.
The city is found in Amhara regional state, Central Gondar Zone. It is located 166 km from Bahir Dar, the capital city of Amhara regional state, and 750 km northwest of Addis Ababa (the capital city of Ethiopia). According to the Population projection of Ethiopia for all regions at the woreda level from 2014–2017, the total population of the city was estimated to be 306,246. Among these 156,276 were females [17].
There are one governmental specialized hospital, eight governmental health centers, twenty-two health posts, one private primary hospital, and one general private hospital serving the community. All public health institutions in the city are providing ANC services.
Study population and eligibility criteria
The study population was all pregnant women who had ANC follow-up at public health institutions in Gondar city, and Women who were seriously ill during the data collection period were excluded from the study.
Sample size determination and sampling procedure
The single population proportion formula was used to calculate the sample size for this study by considering the following assumptions: the proportion of childbirth fear among pregnant women as 24.5% [8], level of confidence-95%, and margin of error-4%.
Therefore,
After considering a non-response rate of 5%, we obtained a total sample size of 466.
In Gondar city, there is one specialized referral hospital and eight public health centers. First, all public health facilities in Gondar city were considered. Then, the calculated sample size was proportionally allocated to each health facility based on the number of pregnant women who visited health facilities during the preceding two weeks before data collection. The sampling interval was calculated for each health institution, which was 3. The first case in each facility was selected randomly using a lottery method. Finally, a systematic random sampling technique was used to select all eligible pregnant women (Fig 1).
Variables of the study
Dependent variable: Childbirth fear.
Independent variables: women’s age, residence, religion, women educational status, women occupation, marital status, husband’s educational status, husband’s occupation, age at first marriage, gravidity, gestational age, planned current pregnancy, wanted current pregnancy, mode of delivery of the preceding child, previous pregnancy complication, previous adverse pregnancy outcome, the preferred mode of delivery, preconception care, history of mental illness, history of chronic illness, social support, anxiety during pregnancy, depression during pregnancy, intimate partner violence and perceived health-related quality of life (HRQoL) were the independent variables.
Operational definitions and measurement
Childbirth fear: Wijma Delivery Expectation/Experience Questionnaire (W-DEQ) Version A was used to measure childbirth fear. This 33-item rating scale has a 6-point Likert scale as a response format, ranging from ‘ not at all’ (= 0) to ‘ extremely’ (= 5) yielding a score range between 0 and 165, pregnant women who scored ≥ 85 were considered as having childbirth fear [8,18])
Antenatal Depression: The Edinburgh Postnatal Depression Scale (EPDS) was used to detect depression. The EPDS is a 10 item questionnaire, scored from 0 up to 3 (a higher score indicating more depressive symptoms), pregnant women who scored 12 and above were categorized as depressed women while pregnant women who scored below 12 were considered as none depressed [19].
Anxiety during pregnancy: was measured using a revised version of the 10-item pregnancy-related anxiety Questionnaire (PRA-Q). Each item was on a 4-point Likert scale of 0–3 and Participants who scored above 13 were considered as having pregnancy-related anxiety [20].
Social support: is defined as the physical and psychological comfort provided by other people. It was measured using the Oslo three-item social support scale. The respondents who scored 3–8 on the Oslo three-item social support scale were categorized as having poor support, 9–11 were categorized as having moderate support, and 12–14 were categorized as having strong support [21].
Intimate partner violence: An intimate partner is considered as a current spouse, co-habited, current boyfriend, former partner, or spouse. If the respondent said “Yes” to any one of the ranges of sexual, psychological, physical, or any combination of the three coercive acts regardless of the legal status of the relationship with the current/former intimate partner, it was considered as intimate partner violence [22].
Health-related quality of life: was measured using short version of WHO quality of life (WHOQOL-BREF) questionnaire. It contains a total of 26 items from which 24 items are categorized into four domains (physical, psychological, social relationships, and environmental). The remaining two questions were scored individually to assess the perception of a person about their quality of life and overall health. The respondents who scored above the mean for the transformed score were considered as having high HRQoL [23].
Preconception care utilization: If women get at least one type of intervention, either treatment or advice and lifestyle modification care at least once before pregnancy to 3 months after pregnancy [24].
Data collection tool and procedures
The data collection tool was developed by reviewing related literature [18,21,22,25]. Data were collected using semi-structured, pretested questionnaires through face-to-face interview. The questionnaire contains socio-demographic characteristics, obstetric-related variables, intimate partner violence-related questions, and questions assessing social support, antenatal depression, anxiety during pregnancy, health related quality of life, and childbirth fear. Nine BSc midwives and one MSc clinical midwife were recruited for data collection and supervision respectively.
Data quality control measures
The data collection tool was prepared
in English and then translated into the local language, Amharic, and then translated back to English to maintain consistency. Before the actual data collection, the questionnaire was pretested on 5% of the total sample size at Koladiba Primary Hospital. One-day training was provided for data collectors and supervisor about the aim of the study, contents of the tool, sampling technique, and also how to give clarification and adequate description for the participants. During data collection, data collectors were supervised for any difficulties. The consistency and completeness of the data were checked by the data collectors and supervisor and the incomplete data were discarded before data entry.
Data processing and analysis
Data were checked, coded, and entered into Epi Data version 4.6 and then exported to SPSS version 25 for analysis. Bivariable logistic regression was done to identify variables candidates for multivariable logistic regression, and variables having a p-value less than 0.2 were entered into multivariable logistic regression analysis. Adjusted odds ratio with 95% CI and a p-value of ≤ 0.05 was used to determine the level of significance. The variance inflation factor (VIF) was checked for multicollinearity and was acceptable with a value of <10, in our analysis the maximum value was 1.806. Moreover, the Hosmer Lemeshow goodness of fit was done to check the model fit and it was 0.085.
Ethical consideration
Ethical clearance was obtained from the University of Gondar ethical review committee (VP/RTT/05/336/2021). Support letters were submitted to the health facilities, and permission for facilities was obtained from administrates. Written informed consent was taken from each study participant after a clear explanation of the aim of the study. Study participants were also informed that they had the full right to withdraw from the interview at any time.
Results
Socio-demographic characteristics of study participants
In this study, a total of 453 pregnant women were involved with a response rate of 97.21%. The age of the participants ranges from 20 to 40 years with a mean age of 27.2(± 4.23 SD) years. Most of the study participants (85.7%) were urban residents. The majority of the respondents (91.6%) and (98%) were orthodox Christian in religion and married in their marital status respectively (Table 1).
Obstetrics-related characteristics of study participants
Of the study participants, 242 (53.4%) were multigravida. Regarding the gestational age, more than half (58.1%) were greater than 28 weeks of gestation. More than three-fourths (85.4%) of study participants had planned pregnancy. The majority (89.9%) of the study participants preferred vaginal delivery and more than one-fourth (28.7%) of women’s had preconception care. The Majority (98.7%) of the respondents’ current pregnancy is wanted and about 95.4% and 96.2% of study participants had no history of mental and chronic illness respectively (Table 2).
Psychosocial related variables
More than one-third (35.3%) of the study participants experience anxiety during pregnancy. Also, nearly one-fourth (24.3%) of women faced intimate partner violence during this pregnancy (Table 3).
Childbirth fear and its associated factors
In this study, about 23.8% (95% CI: 20.1, 28.0) of women have experienced childbirth fear. In the multivariable logistic regression, factors such as residence, social support, intimate partner violence, and anxiety during pregnancy were significantly associated with childbirth fear.
Study participants who lived in rural areas were 6.24 times more likely to develop childbirth fear as compared to urban dwellers (AOR = 6.24, 95% CI: 3.05, 12.80). On the other hand, women who got moderate social support were 46% less likely to have childbirth fear as compared with those women who got poor social support (AOR = 0.54, 95% CI: 0.29, 0.99). The study also revealed that respondents who experienced intimate partner violence during this pregnancy were 4.95 times more likely to have childbirth fear as compared to their counterparts (AOR = 4.95, 95% CI: 2.78, 8.81). Similarly, the odds of childbirth fear among women who had anxiety during pregnancy were 2.82 times higher as compared to their counterparts (AOR = 2.82, 95% CI: 1.52, 5.23) (Table 4).
Discussion
This institution-based cross-sectional study tried to assess the childbirth fear and associated factors among pregnant women who were attending antenatal care at Gondar city public health institutions, northwest Ethiopia, 2022. This study showed that the prevalence of childbirth fear was 23.8% (95%CI: 20.1, 28.0). This finding is in line with previous studies conducted in turkey (20.5%) [26] and Arba Minch (24.5%) Ethiopia [8].
This study was also higher than studies conducted in Malawi-20% [6], Polish-18.4% [27], and Slovakia-9.6% [28]. The possible explanation for the variation might be due to the difference in culture and characteristics of the study participants. For instance, a study in Malawi showed that 77% of study participants had high social support. However, only 7.9% of the participants get high social support in this study. It has been evidenced that women who get high social support during pregnancy have experienced a low level of childbirth fear [29]. In addition to this, a study conducted in Malawi showed only 19.7% and 15.8% of women are primiparous and illiterate in their educational level respectively, whereas in our study, nearly half (46.6%) of study participants were primiparous and 19.8% of study participants had no formal education. Evidence supports that being primiparous and lower educational level increases the experience of childbirth fear [30–32]. In the other hand, the reason for lower prevalence of childbirth fear in Polish and Slovakia might be due to the quality of antenatal care. This may address the needs of the pregnant women in preparing them for childbirth [33].
On the other hand, the result of this study is lower than the finding reported from Wollega, Ethiopia-28.9% [9]. This variation could be related to the difference in tools used to measure the degrees of fear and the different educational status of the women. The study conducted in Wollega, Ethiopia used 12-item questions with a cutoff point mean score to declare childbirth fear. However, in this study, Wijma delivery expectation/experience questionnaire version A with a cutoff point ≥85 was used. Moreover, 26.5% of study participants in Wollega have no formal education. Evidence shows that poor educational attainment increases the level of childbirth fear during pregnancy [6].
This study revealed that study participants who lived in rural areas were 6.24 times more likely to develop childbirth fear as compared to urban dwellers. Women from urban areas may have better access to media and have a better understanding and acceptance of health-related information [34]. Women who had better health-seeking behavior and service utilization could have the opportunities to communicate with health care providers about the common physiological changes during pregnancy and birth preparedness and complication readiness plan [35]. This in turn reduces the childbirth fear [36].
The finding of this study also indicates that pregnant women who received moderate social support during pregnancy were less likely to have childbirth fear than women who received poor social support during pregnancy. The odds of childbirth fear were decreased by 46.3% among pregnant women who had moderate social support compared to their counterparts. This finding is supported by the previous studies conducted in Norway [37], Turkey [25], Thailand [38], Arba Minch town, southern Ethiopia [8], and West Wollega Zone, Ethiopia [9]. The possible explanation might be social support, especially from their family, partner, neighbor, and friends are very important for the maintenance of mental health, increasing an individual’s capacity of coping with stressful situations. Moreover, pregnant women may get information, confidence, and assistance during social support so these all may decrease their childbirth fear [39]. In addition evidence showed that social support played a mediating role between depressive symptoms and childbirth fear [40]. In our study, moderate social support has a protective effect against childbirth fear, but not strong social support. This difference may be due to frequency variation between strong and moderate social support (7.9% vs 45%), variables which have high frequencies will have a high chance to significantly associate with the outcome variable.
The current study also found that intimate partner violence was a significant predicting factor for childbirth fear. Thus, Women who experienced intimate partner violence during the current pregnancy were 4.92 times more likely to experience childbirth fear than their counterparts. This finding is supported by a study conducted in Turkey and Iran [41,42]. The possible reason might be intimate partner violence during pregnancy affects a woman’s physical and mental health, pregnant women experiencing IPV reported high levels of anxiety and depression. This psychological problem and lack of support from the partner may lead the women to childbirth fear [43,44].
This study also revealed that the odds of developing childbirth fear were 2.82 times higher among women who had pregnancy-related anxiety as compared with their counterparts. This finding is supported by a previous study conducted in Turkey [45]. evidence showed that comorbidity (anxiety, depression, and childbirth fear) is very common [46].
This study collects data on the childbirth fear and related factors. The finding implies that, childbirth fear among pregnant women is high. It emphasizes the need for addressing factors related with childbirth fear with appropriate intervention is crucial to reduce childbirth fear and to improve maternal and neonatal outcome. It guides policymakers to design and implement routine screening for childbirth fear and other mental health conditions during antenatal visit to improve maternal and fetal outcome. Health care providers can also use the identified factors to develop person centered intervention to reduce childbirth fear.
Conclusion
In this study, the magnitude of childbirth fear is high. Rural residents, intimate partner violated women, and women who experience anxiety have increased odds of childbirth fear whereas women who get moderate support have decreased odds of childbirth fear. Therefore, policymakers should develop strategies or a screening tool for early identification of women with pregnancy-related anxiety and childbirth fear and the need to give psychological support. Healthcare providers also should pay special attention and counseling for pregnant women living in rural areas and victimized by their intimate partners. Lastly, we suggest for researchers community based study for generalizability and a longitudinal study for better detection of childbirth fear throughout pregnancy.
Acknowledgments
We would like to thank the University of Gondar for providing Ethical clearance. We would also like to extend our gratitude to each health facility’s administrative, data collectors, supervisor, and study participants.
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