The relationships of spiritual health, pregnancy worries and stress and perceived social support with childbirth fear and experience: A path analysis

Saeideh Hosaini; Mansoureh Yazdkhasti; Farnoosh Moafi Ghafari; Farima Mohamadi; Seyed Hamid Reza Kamran Rad; Zohreh Mahmoodi

doi:10.1371/journal.pone.0294910

. 2023 Dec 7;18(12):e0294910. doi: 10.1371/journal.pone.0294910

The relationships of spiritual health, pregnancy worries and stress and perceived social support with childbirth fear and experience: A path analysis

Saeideh Hosaini ¹, Mansoureh Yazdkhasti ², Farnoosh Moafi Ghafari ³, Farima Mohamadi ⁴, Seyed Hamid Reza Kamran Rad ⁵, Zohreh Mahmoodi ^2,^*

Editor: Zemenu Yohannes Kassa⁶

PMCID: PMC10703247 PMID: 38060610

Abstract

Background

Given maternal health is a major health indicator, the present research aimed at determining the causal relationships of spiritual health, worries, stress and perceived social support with the fear and experience of childbirth in pregnant women.

Methods

The present longitudinal prospective research recruited 352 pregnant women presenting to selected health centers in Qazvin, Iran in 2021. The data were collected using the Childbirth Experience Questionnaire-2 (CEQ-2), the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ), the Multidimensional Scale of Perceived Social Support (MSPSS), the Persian version of the Pregnancy Worries and Stress Questionnaire (PWSQ), the Spiritual Health Questionnaire, the Socioeconomic Status (SES) questionnaire and a sociodemographic checklist, and were analyzed in SPSS-25 and Lisrel-8.8.

Results

The mean age of the participants was 28.1±6.8 years. According to the results of the path analysis, among the variables related to fear of childbirth, childbirth experience (B = -0.37, CI:-0.44;-0.22) in the direct path and perceived social support (B = -0.51, CI:-0.58;-0.43) in both direct and indirect paths demonstrated the most significant negative relationship. Among the variables related to childbirth experience, pregnancy worries and stress had a negative causal relationship (B = -0.06, CI:-0.079;-0.043) in the direct path, spiritual health showed the highest significant positive relationship (B = 0.01, CI: 0.008; 0.012) in the indirect path, and perceived social support (B = 0.112, CI: 0.092; 0.131) and the number of children (B = 0.32,CI: 0.30; 0.34) demonstrated the highest significant positive relationship in both direct and indirect paths. In other words, childbirth experience becomes more desirable as spiritual health, social support, and the number of children increases, and it becomes less desirable as pregnancy worries and stress rise.

Conclusion

According to the present findings, various psychological, social, and spiritual factors are associated with childbirth fear and experience. It is thus necessary to utilize appropriate methods and promote training and support to reduce the adverse outcomes of childbirth.

1. Background

The maternal mortality rate is one of the key health indicators of any country directly or indirectly affected by pregnancy and childbirth [1] Moreover, these two experiences constitute the most important events in a woman’s life [2], as a mother’s experiences of pregnancy and childbirth can have desirable or undesirable short- or long-term effects on her own, her family’s, and the newborn’s life. The most commonly-reported health concerns in pregnancy relate to childbirth, neonatal health and parenting [3,4].

Childbirth is a process that is not wholly predetermined, and its outcomes cannot be predicted. It is multidimensional and can include all kinds of feelings from happiness and satisfaction to anxiety. The differences are related to mothers perceived of the situations, culture, and religion, emotional well-being and staffs behavior. Uncertainty about the birth process seems to be a reason for fear of childbirth [5]. A quarter of mothers experience different levels of childbirth fear due to their fear of episiotomy, losing control, and pain [6], which can affect the mother and the newborn [7,8]. These two concepts are so closely related that high fear of childbirth can lead to an unpleasant childbirth experience for the mother. Conversely, an unpleasant previous childbirth experience can cause higher fear in the mother in the recent birth [2,9,10]. According to the literature, the prevalence of undesirable experiences and fear of childbirth varies in different countries and cultures [11]. For instance, 19.8% of the mother assessed in a study in Turkey and 6.1% of those in a study in Iran experienced a severe fear of childbirth [4,12].

Numerous factors, such as demographic, psychosocial, and spiritual characteristics, are associated with adverse experiences and fear of childbirth. Some researchers found that psychological and social factors have an effective role in causing these issues [13]. Also, according to the Fear-Tension-Pain theory, fear of childbirth, maternal tension, and the amount of pain experienced are cyclically related and can affect each [14].

In a conceptual model developed in 2015, Siddall stated the role of spiritual, physiological, social, and psychological factors on labor pain. According to this model, pain is a multidimensional concept, and modifying or reinforcing each of its dimensions can change the mother’s perception of it. For instance, mothers’ social support and higher spiritual health lead to better tolerance of labor pain, followed by less fear and a better experience of childbirth (Fig 1) [15].

In addition, spiritual health and perceived social support can help as a coping mechanism to control oneself in difficult and stressful situations and show better adaptation [16,17]. Although the results of various studies show the positive effect of spirituality on mental health, we should consider that religious beliefs may lead to negative outcomes by encouraging people to quit treatment or delaying theirtimely referral to prevent diseases [18]. For example, in a study by Beery et al. with 250 patients in England, they found that patients with stronger spiritual beliefs had a worse prognosis and worse condition than other patients during nine months of continuous follow-up [19].

To the best of the authors’ knowledge, perceived social support, spiritual and psychological variables, and fear and experience of childbirth have not been addressed yet in a single model. The present research thus aimed at determining the causal associations of spiritual health, worries, stress and perceived social support with the experience and fear of childbirth in pregnant women.

The questions raised were as follows:

What is the effect of spiritual well-being, perceived social support and pregnancy worries and stress (direct/indirect) on fear of childbirth in pregnant mothers?
What is the effect of spiritual well-being, perceived social support and pregnancy worries and stress (direct/indirect) on childbirth experience in pregnant mothers?
What is the childbirth experience (direct/indirect) on fear of childbirth in pregnant mothers?
What is the effect of demographic factors (age, education) on pregnancy worries and stress, fear of childbirth and childbirth experience in pregnant mothers?
Do pregnancy worries and stress mediate the effect of fear of childbirth on childbirth experience?

2. Methods

2.1. Study design and participants

This longitudinal (prospective) study was performed in 2021 on 352 eligible pregnant mothers presenting to the selected health centers in Qazvin, Iran. Qazvin is the largest city and the capital of Qazvin Province in the central part of Iran.

Based on the previous study results [20], the minimum required sample size considering the first type error 0.05 for a two-way test (α = 0.05), the second type error 0.2 (β = 0.2) (test power 0.8) and considering the correlation coefficient between the social support and fear and experience of childbirth, at least 0.16 and using the below formula; the minimum sample size was 302 mothers. Therefore, the final sample size was 352 mothers considering 15% loss.

n = \frac{{(z_{1 - \frac{α}{2}} + z_{(1 - β)})}^{2}}{r^{2}} + 3

Inclusion criteria

Iranian pregnant mothers who were in the last four weeks of their pregnancy; not having high-risk pregnancies, such as multiple pregnancies, preeclampsia, and gestational diabetes; not having a mental illness according to the self-reports or health records, and not taking antidepressants and anti-anxiety medications according to the self-reports or health records, not having negative birth and abortion experiences and pregnancies were planned and desired.

Exclusion criteria

Not having a phone number and lack of access to the parturient to complete the questionnaires in the second stage of the study; delivery in a center other than the selected centers; returning incomplete questionnaires, and withdrawing from the study.

2.2. Data collection and definition of terms

Data were collected by a sociodemographic checklist and the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ), Childbirth Experience Questionnaire 2 (CEQ-2), Multidimensional Scale of Perceived Social Support (MSPSS), Spiritual Health Questionnaire, the Persian version of the Pregnancy Worries and Stress Questionnaire (PWSQ), and Ghodratnama Socioeconomic Status (SES) questionnaire.

2.2.1. Demographic checklist

This checklist included items on the couple’s age, education, gravidity, the number of children, and Pregnancy-Childbirth History.

2.2.2. Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ)

Wijma K. et al. designed a specific questionnaire known as the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) to assess fear of childbirth [21]. In 2017, Mortazavi translated the W-DEQ for use in Iran and examined its validity and reliability. They reported a reliability of 0.91 for this scale [20]. The W-DEQ has 33 items, which are scored based on a six-point Likert scale from 0 to 5. The total score for W-DEQ is between 0 and 165. Higher scores denote greater fear of childbirth in the mothers. A score above 100 indicates severe fear in the mother [22].

2.2.3. Childbirth Experience Questionnaire 2 (CEQ-2)

The participating mother’s childbirth experience was examined using a specific questionnaire, namely the Childbirth Experience Questionnaire 2 (CEQ-2). The CEQ-2 was developed by Dencker et al. [23]. In Iran, midwifery researchers translated this tool into Persian, validated it in 2020 and reported a reliability of 0.91, indicating that the tool is suitable for being implemented in Iranian society. CEQ-2 has 23 items divided into four domains: own capacity, professional support, perceived safety, and participation. Twenty of its items are scored based on a four-point Likert scale from strongly agree (4 points) to strongly disagree (1 point). Three items are scored based on a ruler from 0 to 100. The score of these three items is also converted to a score from 1 to 4 (i.e., 0–40 = 1 point, 41–60 = 2 points, 61–80 = 3 points, 80–100 = 4 points). A higher final score indicates the mother’s more positive experience, and a lower score shows a more negative experience [24].

2.2.4. MSPSS

The 12-item MSPSS developed by Zimet et al [25]. Helps measure the support provided by the friends family and significant others on a seven-point Likert scale, ranging from “strongly disagree” to “strongly agree”. In 2013, Bagherian et al. confirmed the reliability and validity of this scale by calculating a Cronbach’s alpha of 0.84 [26]. Similarly, the present research confirmed the reliability by obtaining a Cronbach’s alpha of 0.82.

2.2.5. Spiritual health questionnaire

The 20-item Spiritual Health Questionnaire (Palutzian & Ellison) was used to evaluate spiritual health [27]. Ten items measured existential health and ten items measured religious health on a scale of 10–60. Given the lack of definite religious and existential health subgroups, judgments were made on the basis of the scores obtained. The higher the score, the better the religious and existential health. The spiritual health score was obtained as 20–120, i.e. the sum of the scores of these two subscales. The spiritual health therefore positively related to the total score of this tool. The items were scored on a six-point Likert scale, ranging from “strongly disagree” to “strongly agree”. Rezaei et al. confirmed the reliability and validity of this instrument by calculating a reliability coefficient of 0.79 [28].

2.2.6. PWSQ

The 25-item PWSQ constitutes a combination of the 10-item scale designed by Hoysing et al. [29] and certain personal/family factors addressed in the original version of the Van den Berg questionnaire [30]. This questionnaire comprises six subscales, i.e. maternal health (6 items), neonatal health (5 items), mother-newborn bonding (2 items), experience of childbirth and motherhood (4 items), personal-occupational (3 items) and personal-family (5 items). This tool was scored on a five-point Likert scale defined as 0: never, 1: rarely, 2: sometimes, 3: often and 4: always, with a total score of 0–100. Despite the lack of cut-off points in the PWSQ, the score showed the level of worry and its effective factors in pregnancy. Identifying these factors and offering solutions can help lower worries and anxiety in pregnant women and prevent the harmful effects of stress. The validity of the PWSQ was confirmed by Navidpour et al. (2015) in Iran using the face, content and construct validity. The criterion validity assessments also showed significant correlations between this questionnaire and the Spiel Berger State-Trait Anxiety Inventory (r = 0.739, P<0.001) [31].

2.2.7. Socioeconomic status questionnaire

Four dimensions of socioeconomic status, i.e. housing status, income level, education and economic class, were evaluated using the socioeconomic status questionnaire (Ghodratnama, 2013) consisting of five main items and six demographic items. The items were scored on a five-point scale ranging from 1: very low to 5: very high. In Iran, Eslami et al. approved the face and content validity of this questionnaire and confirmed its reliability through calculating a Cronbach’s alpha of 0.83 [32].

2.3. Procedures

The present research began after obtaining the necessary permission and approval of the Ethics Committee of Alborz University of Medical Sciences, Karaj, Iran. After presenting to the health centers, the researcher identified the eligible individuals, briefed them on the study objectives and asked them to sign informed consent forms for participation in the study.

Data were collected in two stages in this study from 2021/3/3 to 2021/9/2.

The first stage was performed during the last four weeks when the mothers visited the selected centers for periodic examinations. Information related to their spiritual health, pregnancy worries and stress, and fear of childbirth were collected during these visits. After completing the questionnaires, the mothers gave the researcher their telephone numbers to contact after their delivery. If the mother could not complete the questionnaires in one meeting, the researcher would set the next time to complete the questionnaires

The second stage was performed after the delivery. At this stage, one week before the estimated date of delivery, the mother was contacted via a phone call and asked to inform the researcher when they attended the hospital. The researcher then visited the hospital to collect information on the mother’s childbirth experience and perceived social support when she went to the postpartum ward and was in a more stable condition. If a mother’s clinical condition were not suitable for any reason, the completion of the questionnaires would be postponed until the mother’s condition stabilized. If the mother gave birth earlier than the scheduled date, which was based on the date of the first day of her last menstruation, she was contacted, and arrangements were made for her to complete the delivery experience and perceived support questionnaires at the time of her subsequent referral to the select center for postpartum care (i.e., 3 to 5 days after the delivery).

Ethical approval and consent to participate

Informed consent was obtained from all the participants. All the methods were employed based on the relevant guidelines and regulations. The Ethics Committee of Alborz University of Medical Sciences approved all the experimental protocols (IR. ABZUMSREC.1399.273).

After briefing the eligible candidates on the study objectives, they signed written informed consent forms. They were assured of the confidentiality of their information and their right to withdraw from the study at their own discretion without being deprived of health services.

2.4. Statistical analysis

According to Fig 2, the present study investigated the fit of a conceptual model of the relationships of spiritual health, worries, stress and perceived social support with the fear and experience of childbirth in pregnant women. The Kolmogorov-Smirnov test was employed to examine the distribution normality of the quantitative data. The path analysis was performed as an extension of conventional regression to show both direct and indirect effects of the individual variables on the dependent variables. The results of this analysis were used to interpret the relationships and correlations. The data were analyzed in SPSS-25 [33] and Lisrel-8.8 [34]. The Pearson’s correlation coefficient was also used to express the correlations and the beta coefficient to report the path analysis. The level of statistical significance was adjusted at T>1.96.

3. Results

The present study examined the data from 352 pregnant mother presenting to the selected centers in Qazvin, Iran. The mean age of the mother was 28.1±6.8 years and that of their husbands 33.6±6.2. Most mother were housewives, and most of their husbands were self-employed (95.5%). The mean score of spiritual health was 103.12±15.8, pregnancy worries and stress 37.2±20.8, perceived social support 66.3±15.2, fear of childbirth 59.6±26.8, and childbirth experience 61.2±10.4 (Table 1).

Table 1. The sociodemographic character of participants.

quantitative
Variables		Mean ± sd	Variables		Mean ± sd
Age mother (year)		8/1±6/28	Spiritual health		103.12 ±15.8
Age men		2/6±6/33	Perceived social support		66.3±15.2
Education mother(year)		9.8±3.5	Fear of birth		59.6±26.8
Pregnancy’s Worries and Stress		37.2±20.8	Childbirth experience		10.4 61.2±
Education men (year)		9.4±3.7	Gestational age		2/0±2/38
Socioeconomic status		6/2±3/12	Gestational age		2/0±2/38
qualitative
Variables		F (%)	Variables		F (%)
Number of Family	<2	163(57)	JOB mother	House keeper	336(95.5)
Number of Family	≥2	119(41.6)		Worker	7(2)
Number of children	Zero	132(37.5)		Employment	9(2.6)
	1	124(35.2)
	2	67(19)
	3 and more	29(8.3)

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According to the results of Pearson’s correlation test, the score of childbirth experience had a positive correlation with the number of children, spiritual health score, and perceived social support and a negative correlation with mother’s education, fear of childbirth, and pregnancy worries and stress. Among those variables, the number of children had the highest positive correlation (r = 0.149) and fear of childbirth with the highest negative correlation (r = -0.459) with childbirth experience. In other words, the chances of a desirable childbirth experience decreased as fear of childbirth grew (Table 2).

Table 2. The correlation matrix of childbirth fear and experience in relation to personal-social variables, spiritual health, pregnancy worries and stress, and perceived social support.

		1	2	3	4	5	6	7	8	9	10
1	Mother’s education	1
2	Husband’s education	0.513^*	1
3	Gravidity	-0.247^**	-0.302^**	1
4	Number of children	-0.283^**	-0.335^**	0.861^**	1
5	Socio-economic status score	0.055	0.230	-0.143	-0.155^**	1
6	Spiritual health score	0.009	0.025	0.039	0.014	0.027	1
7	Perceived social support score	0.105^*	0.185^**	-0.046	-0.042	0.092	0.203^**	1
8	Fear of childbirth score	0.105^*	0.053	-0.118^*	0.182^**	-0.120^*	-0.200^**	-0.183^**	1
9	Pregnancy worries and stress score	0.034	-0.039	-0.225^**	-0.225^**	-0.036	-0.216^**	-0.165^**	0.484^**	1
10	Childbirth experience score	-0.133^*	-0.097	0.84	0.149^**	0.078	0.108^*	0.134^*	-0.459^**	-0.272^**	1

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* P<0.05

** P<0.01.

According to the findings, female education and the number of children had a positive correlation, and socioeconomic status, social support and spiritual health had a negative and significant correlation with fear of childbirth, among which the number of children had the highest positive correlation (r = 0.182) and spiritual health had the highest inverse correlation. Furthermore, with the fear of childbirth (r = -0.200), In other words, increasing the score of spiritual health is associated with reducing fear of childbirth.

Based on the results of the path analysis, after examining the paths that were significant due to a T-value ≥1.96 (Fig 2), the variables of spiritual health (B = -0.14), childbirth experience (B = -0.37), and socioeconomic status (B = -0.1) in the direct path, and pregnancy worries and stress (B = 0.022) in the indirect path, were associated with fear of childbirth, while perceived social support (B = -0.51) and the number of children (B = -0.334) had a significant negative causal relationship with fear of childbirth in both direct and indirect paths. In other words, the score of fear of childbirth decreases as the score of the noted variables increases.

Based on the findings, the variable of pregnancy worries and stress had a negative and significant causal relationship (B = -0.06) with childbirth experience in the direct path; in the indirect path, the variable of husband’s education (B = 0.007), gravidity (B = 0.01), socioeconomic status (B = 0.002), and spiritual health (B = 0.01) had a positive and fear of childbirth (B = -0.02) has negative and significant causal relationship with childbirth experience; meanwhile, the variables of perceived social support (B = 0.112) and the number of children (B = 0.32) had a positive and significant causal relationship with childbirth experience in both direct and indirect paths. That is to say; the childbirth experience becomes more desirable as spiritual health, socioeconomic status, social support, and the number of children increase. In contrast, it becomes less desirable as pregnancy worries and stress rise. According these finding pregnancy worries and stress was mediator between fear of child birth and childbirth experience (Fig 3) (Table 3).

Fig 3 — Single-headed arrow means regression coefficient, Standardized Beta. SES = Socio-Economic Statues, GR = Gravid, CN = child number, EDUM = Education mother EDUH = Education Husband, SP = Spiritual well-being, SS = Social support, FE = Fear of childbirth, TEN = Pregnancy’s Worries and Stress, EX = Childbirth experience.

Table 3. The direct and indirect effects of personal-social variables, spiritual health, pregnancy worries and stress, and perceived social support on childbirth fear and experience.

Variables		Direct effects	Indirect effects	Total effect	R²
Fear of childbirth	Mother’s education	0.04	-	0.04	0.30
	Husband’s education	0.00	-	0.00
	Gravidity	0.1	0.066	0.166
	Number of children	-0.22*	-0.114*	-0.334*
	Socio-economic status	-0.1*	-0.033	-0.1*
	Perceived social support	-0.1*	-0.041*	-0.51*
	Spiritual health	-0.14*	0.0259	-0.14*
	Childbirth experience	-0.37*	-	-0.37*
	Pregnancy worries and stress	-	0.022*	0.022*
Childbirth experience	Mother’s education	-	-0.001	-0.001	0.40
	Husband’s education	^-	0.007*	0.007*
	Gravidity	-0.18	0.01*	0.01*
	Number of children	0.31*	0.01*	0.32*
	Socio-economic status	0.09	0.002*	0.002*
	Perceived social support	0.11*	0.002*	0.112*
	Spiritual health	0.07	0.01*	0.01*
	Fear of childbirth	-	-0.02*	-0.02*
	Pregnancy worries and stress	-0.06*	-	-0.06*

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The results of the model fit indices indicated the desirability and high fit of the model and the rationality of the adjusted relationships between the variables based on the conceptual model. Accordingly, the fitted model does not differ significantly from the conceptual model (Table 4).

Table 4. Goodness of fit indices for the model.

Fitting Index	X²	df	X²/df	CFI	GFI	NFI	RMSEA
Model Index	91/5	2	9/2	1	1	1	03/0
Acceptable Range	X2/df < 5			> 0.9	> 0.9	> 0.9	< 0.05

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NFI = Normed-fit index, GFI = Goodness-of-fit statistic, RMSEA = Root mean square error of approximation, X² = chi-square.

4. Discussion

Pregnancy and childbirth are events that change a woman’s worldview and affect her health, emotions, and social roles [35]. Fear is a normal emotion that can be an appropriate response to danger or threat [36].

The path analysis revealed the most significant and negative causal relationship between childbirth experience and fear of childbirth. Research suggests an unpleasant history of childbirth raises the fear of the following childbirth in the mother [2,9,10]. When someone experiences an unpleasant event, this memory or experience is stored in a different brain region as primary sensory memory. Therefore, it can lead to later understandings of disturbing images and thoughts [37]. In their qualitative study, Rodríguez-Almagro et al. (2019) found that childbirth complications, obstetric problems, and prenatal problems can affect a mother’s childbirth experience [38]. Korukcu et al. (2017) and Viirman et all (2022) also found that fear of childbirth results from a previous unfavorable pregnancy and childbirth experience and Primary contributing factors to negative childbirth experiences appear to be labour- and birth-related [39,40].

Perceived social support was also mostly associated with the fear of childbirth along both direct and indirect paths. Social support functions as an intermediary between stress and its manifestations. This variable is negatively related to anxiety and positively to adaptation [17]. According to Dolatian et al. (2014), perceived social support affects gestational age and prevents preterm delivery by influencing worries and stress in pregnancy [41]. Research suggests the key role of perceived support provided by the husband, family and friends in lowering the fear of childbirth [12,42,43].

Based on the present study findings, pregnancy worries and stress had the most destructive relationship with childbirth experience in the direct path and fear of childbirth in indirect path. In other word this variable was mediator between fear of childbirth and childbirth experience. Studies have shown a correlation between stress and stressful events during pregnancy and adverse pregnancy outcomes [13,38,44]. Stress can affect the childbirth process and lead to adverse pregnancy outcomes such as preterm delivery through the hypothalamic-pituitary-endocrine axis. In this way, it is related to an undesirable pregnancy experience [45].

Spiritual health was another variable that was indirectly, positively, and significantly related to pregnancy experience. Spirituality is the most critical guide in problem-solving behaviors. Studies have shown that people with high levels of spirituality cope better with problems and life circumstances. Spiritual health helps reduce fear of childbirth and leads to a more pleasant pregnancy and childbirth experience by controlling stress and promoting psychosocial health [46]. Bilgiç et al. (2021) found a negative correlation between spiritual health and fear of childbirth [4]. Foruzandeh Hafshejani et al. (2018) found a linear relationship between spiritual health and stress coping styles [47].

Perceived social support and the number of children had a positive and significant relationship with pregnancy experience in both paths. As stated earlier, perceived social support significantly affects fear, adverse pregnancy outcomes, and pregnancy experience by controlling worries and stress [43,48].

The number of children was another variable that was positively correlated with pregnancy experience. In nulliparous mothers, fear of childbirth may be due to the lack of information and receiving incorrect information from others. Nonetheless, some studies have reported the relationship of multi-parity with fear of birth and poor pregnancy experience [39]. This disparity can also be due to the differences in the cultural context and, subsequently, the spiritual health of individuals [46]. Moreover, some studies have suggested a relationship between having previous childbirth experience and increased self-confidence in the mother. This history can significantly impact the mother’s experience during the next pregnancies [49].

5. Limitation

One of the limitations of the present research is that we used questionnaires to collect and record the data, and the number of questions can affect individual’s accuracy. Furthermore, we assessed pregnant mothers presenting to selected health centers, not the ones who went to other private centers. Also, some women did not present to health care centers during the COVID-19 pandemic due to social distancing rules. These could have affected our sampling; therefore, now that the conditions are changed and more mothers can be examined, it is suggested that more extensive research be conducted even in private centers.

6. Conclusion

Our study showed that spiritual health, and perceived social support is related to childbirth fear and experience in pregnant mothers. Accordingly, using appropriate programs to improve spiritual and family support can reduce fear and adverse outcomes of childbirth and make positive childbirth experience. Other findings were the relationship between childbirth experience, fear of childbirth and the media role of pregnancy worries and stress so health systems must have attention to these subjects to prepare programs to aware mothers about pregnancy and delivery for decreasing their fear and pregnancy worries and stress, also prepare programs for health workers to make well childbirth experience for mothers.

Supporting information

S1 Checklist. STROBE statement—checklist of items that should be included in reports of observational studies.

(DOCX)

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Acknowledgments

The present research was extracted from a master’s dissertation on midwifery counselling. The authors would like to express their gratitude to the participants and the authorities of the Research Deputy and Education Deputy of Alborz University of Medical Sciences for their support.

Abbreviations

SES: Socio-Economic Statues
GR: Gravid
CN: child number
EDUM: Education mother
EDUH: Education Husband
SP: Spiritual well-being
SS: Social support
FE: Fear of childbirth
TEN: Pregnancy’s Worries and Stress
EX: Childbirth experience

Data Availability

working link to dataset are as follows: TARGET URL: (https://doi.org/10.5281/zenodo.10183716) https://zenodo.org/records/10183716.

Funding Statement

The author(s) received no specific funding for this work.

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PLoS One. 2023 Dec 7;18(12):e0294910. doi: 10.1371/journal.pone.0294910.r001

Author response to previous submission

24 Mar 2023

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PLoS One. doi: 10.1371/journal.pone.0294910.r002

Decision Letter 0

Zemenu Yohannes Kassa

20 Jun 2023

PONE-D-23-08753The relationship of spiritual health, pregnancy worries and stress, and perceived social support with childbirth fear and experience: A path analysisPLOS ONE

Dear Dr. Zohreh Mahmoodi,

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Shadabi, N., Saeieh, S. E., Qorbani, M., Babaheidari, T. B., & Mahmoodi, Z. (2021). The relationship of supportive roles with mental health and satisfaction with life in female household heads in Karaj, Iran: a structural equations model. BMC public health, 21, 1-9.

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# Abstract: Your only show us the β -value. However, you should show us a confidence interval.

Did you conduct a multivariable analysis? if yes, which domains show statistically significant? If not, why?

Conclusion and recommendations

The conclusion and recommendations are given based on your pertinent findings while you recommended physical aspects, there are no findings in your result part related to physical domains.

#Introduction

You should use the words mother or women across the document to clarify the reader.

In Paragraph 2, you expected to demonstrate the women’s fear during childbirth and its outcome, which makes the reader more interested in your ideas follow.

You did not clearly explain the research gaps rather, listing research questions. You should remove research questions and add what makes your findings differ from the existing articles.

#Result

The mean score of spiritual health was 104.3±14.9 out of ________?

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Reviewer #2: Partly

**********

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Reviewer #1: I Don't Know

Reviewer #2: No

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Reviewer #2: Yes

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Reviewer #2: No

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Reviewer #1: The relationship of spiritual health, pregnancy worries and stress, and perceived social support with childbirth fear and experience: A path analysis

1. What about related studies? In addition, what is gap of the previous studies in these issues?

2. Why researchers used general social support scale for pregnant women? The study needs specific scale in this issue.

3. Considering the questionnaire length in this study and in pregnant women? What about arrangements in the study to prevent the accuracy decrease?

4. Why researchers used online consent form?

5. "Assuming the correlation between the social support and fear and experience of childbirth, at least 0.16"author express reference?

6. Persian Version of the Pregnancy Worries and Stress Questionnaire (PWSQ)

7. This tools generally was used in assessing anxiety ?

8. "The second stage was performed after the delivery. At this stage, one week before the probable date of the delivery, the mother was contacted via a phone call and asked to inform the researcher when they attended the hospital. The researcher then visited the hospital to collect information on the mother's childbirth experience and perceived social support when she went to the postpartum ward and was in a more stable condition. If a mother's clinical condition were not suitable for any reason, the completion of the questionnaires would be postponed until the mother's condition stabilized". If women did 9.Which kind of social support (instrumental support-emotional – information- appraisal) had the highest negative causal relationship with fear in pregnant women?

Reviewer #2: 1. The first aim of the current study is to examine the effect of spiritual well-being, perceived social support and pregnancy's worries and stress on fear of childbirth. However, little information about pregnancy's worries and stress can be found in the Introduction part. Furthermore, what kind of variable is pregnancy's worries and stress? An independent variable of fear of childbirth? Or a mediating variable between fear of childbirth and childbirth experience? In Figure 2, the path analysis revealed a potential mediation model among PE, TEN, and EX. Therefore, from my humble point, the results of the study do not fit the aims. The authors should explain clearly the relationships of the five variables (spiritual well-being, perceived social support, pregnancy's worries and stress, fear of childbirth, and childbirth experience) in the Introduction part.

2. From the Introduction part, perceived social support might be an independent variable of fear of childbirth. However, in Method part, fear of childbirth was measured in the first stage, while perceived social support was measured in the second stage. It is very confusing and the authors should explain it.

3. The minimum required sample size (352) is equal to actual sample size (352)?

4. There are some obvious limitations in the study. However, the Limitation part is short and non-professional. The authors should re-write this part.

5. The Conclusion part is less related to the findings of the study. For example, countries have always considered mothers' health as one of the most important groups in society. One of the most important health indicators of a country is its maternal mortality rate. Is it the conclusion from the results of the current study? The authors should re-write this part and conclude what we can get from the findings of the current study.

6. In Table 3, pregnancy worries and stress was included in the model of childbirth experience but excluded in the model of fear of childbirth. It is not consistent with the aims of the study. The authors should explain the reason.

7. The format of tables is not standard, such as Table 1. Moreover, the format of fonts is inconsistent, such as Table 1 and Table 2. The authors should uniform it.

**********

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Reviewer #1: No

Reviewer #2: No

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PLoS One. 2023 Dec 7;18(12):e0294910. doi: 10.1371/journal.pone.0294910.r003

Author response to Decision Letter 0

3 Jul 2023

Dear Editor

Thank you for your valuable comments. We corrected and answered all of them as follows:

Journal Requirements:

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming

Answer: Thank you. We checked it.

2. We noticed you have some minor occurrence of overlapping text with the following previous publication, which needs to be addressed:

Answer: Thank you. We checked and corrected it.

3.Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified (1) whether consent was informed and (2) what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information.

Answer: Thank you for your attention. The eligible people explained the study objectives to them and asked them to read and sign a written informed consent form if they wished to participate in the study. This is explained in the ‘Ethics approval and consent to participate’ section.

Additional Editor Comments from academic editor:

Abstract: Your only show us the β -value. However, you should show us a confidence interval.

Answer: Thank you for your attention. It was added as per your comments.

Did you conduct a multivariable analysis? If yes, which domains show statistically significant? If not, why?

Answer: Thank you for your attention. Yes, path analysis is an extension of multiple regression that allows us to examine more complicated relations among the variables. It is used to answer research questions about the effect of a given independent (X1) variable on the dependent variable (Y) in the model. (1) In this study, we assessed the direct/ indirect effects of some independent variables: mother’s education, father’s education, gravidity, number of children, socioeconomic statues, perceived social support, spiritual health and pregnancy worries and stress on fear of childbirth and childbirth experience. In the analysis, we used the total number of questionnaires (socioeconomic statues, perceived social support spiritual health and pregnancy worries and stress) not their domains. And as we wrote in Methods, the paths are significant if T ≥ 1.96 (Figur-2). The paths coefficients -direct /indirect- are shown in Table 3 and Figur-3.

Conclusion and recommendations

the conclusion and recommendations are given based on your pertinent findings while you recommended physical aspects, there are no findings in your result part related to physical domains.

Answer: Thank you for your attention. Sorry for the mistake. We corrected it.

#Introduction

you should use the words mother or women across the document to clarify the reader.

Answer: Thank you for your attention. We corrected it. We replaced women with mothers.

In Paragraph 2, you expected to demonstrate the women’s fear during childbirth and its outcome, which makes the reader more interested in your ideas follow.

You did not clearly explain the research gaps rather, listing research questions. You should remove research questions and add what makes your findings differ from the existing articles.

Answer: Thank you for your attention. It was added this in two paragraphs.

#Result

the mean score of spiritual health was 104.3±14.9 out of ________?

Answer: Thank you for your attention. It is 103.12 ±15.8. Sorry for the typo. As we explained in Methods section, spiritual health total score lies between 20-120. Most participants scored higher than 90.

Reviewer 1:

1. What about related studies? In addition, what is gap of the previous studies in these issues?

Answer: Thank you for your comments. We added some studies to the Introduction section as per reviewer comments. For further explanation, we did not find the models that assess all of these factors together with fear and childbirth experience. As explained, we wrote a conceptual model developed in 2015 about labor pain. So it needs to assess the factors that are effective on these variables to find the suitable approach.

2. Why researchers used general social support scale for pregnant women? The study needs specific scale in this issue.

Answer: Thank you for your comments. In our study, we did not use general social support (Vaux et al., 1986). We assessed the Perceived Social Support (Zimet et al.). The Multidimensional Scale of Perceived Social Support (MSPSS) is a short and reliable instrument that assesses perceived social support from the social network of an individual (family, friends and significant others). This questionnaire was assessed in pregnant women too and its reliability and validity during pregnancy in pregnant women were confirmed: “Psychometric Validation of the Multidimensional Scale of Perceived Social Support during Pregnancy in Rural Pakistan. 2021 (2)

3. Considering the questionnaire length in this study and in pregnant women? What about arrangements in the study to prevent the accuracy decrease?

Answer: Thank you for your attention. As written in the Method section in 2.3. Procedures, questionnaires were collected in two phases:

The first phase was during the last four weeks of pregnancy when the spiritual health, pregnancy worries and stress, and fear of childbirth questionnaire were collected. If a mother could not complete the questionnaires in one meeting, the researcher would set the next time to complete the questionnaires.

The second phase was after delivery. The childbirth experience and perceived social support were collected when the mother went to the postpartum ward and was in a more stable condition. If a mother's clinical condition was not suitable for any reason, the completion of the questionnaires would be postponed until the mother's condition stabilized.

We explained this more in the Methods section. But it is our limitation and we mentioned it in the limitation section.

4. Why researchers used online consent form?

Answer: Thank you for your comments. We did not use online consent form. As written in 2.3. Procedures, the eligible people explained the study objectives to them, and asked them to read and sign an informed consent form if they wished to participate in the study. We used a written consent form.

5. "Assuming the correlation between the social support and fear and experience of childbirth, at least 0.16"author express reference?

Answer: Thank you for your comments. Yes, the reference is correct. Given the correlation coefficient of 0.16 between social support and experience of childbirth, and using the following formula and considering 15% loss, we determined the sample size.

6. Persian Version of the Pregnancy Worries and Stress Questionnaire (PWSQ)

7. This tools generally was used in assessing anxiety?

Answer: Thank you for your comments. No, this questionnaire assesses mothers' concern in six subcategories: mother's health, newborn’s health, experience of childbirth and motherhood, mother–newborn bonding, personal-family and personal-occupational. It does not assess anxiety.

Answer: Thank you for your comments. I did not quite understand your question. Do you mean that this process was done or not? If so, I should say yes. One of the researchers did it and set the time and mothers collaborated with her.

9. Which kind of social support (instrumental support-emotional – information- appraisal) had the highest negative causal relationship with fear in pregnant women?

Answer: Thank you for your comments. The mentioned domains are related to General social support but, as explained before, we used Multidimensional Scale of Perceived Social Support (MSPSS), it measures support from three sources, including the family, friends, and significant others with 12 items on a seven-point Likert scale, from strongly disagree to agree strongly. Perceived social support is the individual's evaluation of the availability of support when necessary and required and is a qualitative-mental and measurable concept. The total score of MSPSS is the sum of the scores of all its items (3) and we use its total score in path analysis.

Reviewer #2:

1. The first aim of the current study is to examine the effect of spiritual well-being, perceived social support and pregnancy's worries and stress on fear of childbirth. However, little information about pregnancy's worries and stress can be found in the Introduction part.

Answer: Thank you for your comments. We added some papers in the Introduction section as per reviewer comments.

Furthermore, what kind of variable is pregnancy's worries and stress? An independent variable of fear of childbirth? Or a mediating variable between fear of childbirth and childbirth experience? In Figure 2, the path analysis revealed a potential mediation model among PE, TEN, and EX. Therefore, from my humble point, the results of the study do not fit the aims.

Answer: Thank you for your comments. Pregnancy worries and stress (TEN) is endogenous for variables of mother’s education, father’s education, gravidity, number of children, socioeconomic status, perceived social support, spiritual health, and fear of childbirth and exogenous for childbirth experience. Endogenous variables are variables that are diagrammed as being influenced by other variables in the model. The variables diagrammed as independent of any influence are the exogenous variables. Dependent variables are always endogenous, but some independent (or predictor) variables can be endogenous if they are themselves being influenced by other independent variables in the model (1). Fear of childbirth is endogenous for all variables except TEN, and endogenous for TEN.

It is correct that TEN is a mediator between childbirth experience and fear of childbirth. It was one of our aims, but we did not write it in our questions in the end of the introduction. So, we added a questions at the end of Introduction: “Do pregnancy worries and stress mediate the effect of fear of childbirth on childbirth experience?.

The book ‘MUNRO’S Statistical Methods for Health Care Research’ (2013) explained that, in general, the research questions for path analysis relate to the testing of relationships that are hypothesized to exist between and within a dependent variable and a set of predictor variables. In general, path analysis helps us address the following questions:

1. Are the paths in the model supported by the data?

2. What is the total effect (direct plus indirect) of a predictor variable?

3. Does one of the independent variables mediate the effect of another variable on the dependent variable?

Path analysis is literally an analysis of the paths or lines in a model that represent the influence of one variable on another. It is used to answer research questions about the effect of a given independent (X1) variable on the dependent variable (Y) in the model and path analysis is an extension of conventional regression that shows not only the direct effects but also the indirect effects of each variable on the dependent variables, and the results can be used to provide a rational interpretation of the relationships and correlations observed (1) , so because we assessed direct and indirect effects of all variables as well as pregnancy worries and stress (TEN), we considered mediator effect on childbirth fear and experience in the present study. All path coefficient show in Table 3.

. The authors should explain clearly the relationships of the five variables (spiritual well-being, perceived social support, pregnancy's worries and stress, fear of childbirth, and childbirth experience) in the Introduction part.

Answer: Thank you for your comments. We added some papers as per reviewer comments:

“Numerous factors, such as demographic, psychosocial, and spiritual characteristics, are associated with adverse experiences and fear of childbirth [13]. Also, according to the Fear-Tension-Pain theory, fear of childbirth, maternal tension, and the amount of pain experienced are cyclically related and can affect each [14]. In addition, spiritual health and perceived social support can help as a coping mechanism to control oneself in difficult and stressful situations and show better adaptation [16,17]. Even if the results of various studies show the positive effect of spirituality on mental health,but we have to considered that Religious beliefs may bring In case of negative results by encouraging to quit or Get out of treatment, without timely referral to prevent diseases[16]

Answer: Thank you for your comments. In our manscript, the aim was to assess perceived social support during pregnancy until delivery and its effect on chilbirth experience too, not only after delivery or childbirth fear. So we assessed it after delivery. According to the litreature, social relations, the unofficial support networks of pregnant women, and strong support by midwives can strengthen women's perception of childbirth as a physiological and controllable processes (4). Social support is also a predictor of postpartum depression and maternal role competence. So it has to start before pregnancy until after delivery (5).

Furthermore, in our study, we wanted to assess childbirth experience. Childbirth experience and fear of childbirth mutually affect each other, so it was important to assess each variable first and remove its confounding effect on the other variables because fear of childbirth is an important issue during pregnancy and during and after childbirth. (4) For omiting this interventional effect, our team decided to assess fear of childbirth in the first phase (last 4 weeks) and childbirth experience in the secound phase (after delivery).

3. The minimum required sample size (352) is equal to actual sample size (352)?

Answer: Thank you for your comments. The researchers tried to collect all of the sample size determined.

4. There are some obvious limitations in the study. However, the Limitation part is short and non-professional. The authors should re-write this part.

Answer: Thank you for your comments. It was added as per reviewer comments.

Answer: Thank you for your comments. We corrected it as per reviewer comments.

Answer: Thank you for your comments. Sorry for the mistake. It was added.

7. The format of tables is not standard, such as Table 1. Moreover, the format of fonts is inconsistent, such as Table 1 and Table 2. The authors should uniform it.

Answer: Thank you for your comments. We corrected all.

Regards

Researchers Team

1. Plichta SB, Kelvin EA, Munro BH. Munro's statistical methods for health care research: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2013.

2. Sharif M, Zaidi A, Waqas A, Malik A, Hagaman A, Maselko J, et al. Psychometric validation of the Multidimensional scale of perceived social support during pregnancy in rural Pakistan. Frontiers in Psychology. 2021;12:601563.

3. Zimet GD, Dahlem NW, Zimet SG, Farley GK. The multidimensional scale of perceived social support. Journal of personality assessment. 1988;52(1):30-41.

4. Fisher C, Hauck Y, Fenwick J. How social context impacts on women's fears of childbirth: a Western Australian example. Social science & medicine. 2006;63(1):64-75.

5. Saeieh SE, Rahimzadeh M, Yazdkhasti M, Torkashvand S. Perceived social support and maternal competence in primipara women during pregnancy and after childbirth. International journal of community based nursing and midwifery. 2017;5(4):408.

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PLoS One. doi: 10.1371/journal.pone.0294910.r004

Decision Letter 1

Zemenu Yohannes Kassa

15 Aug 2023

PONE-D-23-08753R1The relationships of spiritual health, pregnancy worries and stress and perceived social support with childbirth fear and experience: A path analysisPLOS ONE

Dear Dr. Mahmoodi,

Please submit your revised manuscript by Sep 29 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Zemenu Yohannes Kassa

Academic Editor

PLOS ONE

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #2: Partly

Reviewer #3: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #2: No

Reviewer #3: Yes

**********

6. Review Comments to the Author

Reviewer #2: 1. There are some conflicting statements in the manuscript. For example, in Limitation section, authors said “Another limitation was the cross-sectional nature of the study that deprives the researcher from the opportunity to follow up ideas.” However, in Methods section, this longitudinal (prospective) study was performed in 2021 on eligible pregnant mothers presenting to the selected health centers in Qazvin, Iran. What is the kind of this study design actually? Besides, in Limitation section, part of the study was done after delivery, which may have tired mothers and affected their responses. But in Methods section, if a mother's clinical condition were not suitable for any reason, the completion of the questionnaires would be postponed until the mother's condition stabilized. Limitation section is very important for the current study and future research. Authors should take more efforts to improve it.

2. The Conclusion section can hardly cover main findings of this study. It is very simple and unspecific. For example, in Conclusion section, our study showed that spiritual health, and perceived social support is related to childbirth fear and experience in pregnant mothers. However, if authors want to get this finding, it is not necessary to conduct a path analysis. On the other hand, the third aim of this study is to explore what is the childbirth experience (direct/indirect) on fear of childbirth in pregnant mothers? The fifth aim is to explore if pregnancy worries and stress mediate the effect of fear of childbirth on childbirth experience? These research questions are not reflected well in the subsequent sections, such as Results section, Discussion section, and Conclusion section. In other words, these sections seem like they come from different researches and different authors. Authors should try to make different sections of the manuscript become closely related.

Reviewer #3: Dear Editor,

I want to thank you for providing the opportunity to review this revised manuscript, ““The relationships of spiritual health, pregnancy worries and stress and perceived social support with childbirth fear and experience: A path analysis?”

Fear of childbirth is defined as the fear experienced before, during and after birth. While fear of childbirth affects the mother, fetus and newborn in many ways, it also causes negativities in the relations between parents. It is important to define the fear of childbirth by the health personnel, to determine the factors causing the fear and to plan the appropriate interventions. For this reason, the results of the related study will make significant contributions to the existing literature.

My evaluation notes:

The manuscript includes a current and very interesting subject. Therefore, I congratulate the authors

Referee suggestions were carried out significantly on the text. However, there are a couple of points that are not fully understood.

1. What is the total number of pregnant women followed in the center where the study was conducted?

2. It would be appropriate to indicate the dates of the study and the duration of the study.

3. Were there any cases not included or excluded from the study? How many and why?

4. Women who have fear of childbirth are often affected by their “delivery choice”. It is stated that the fear of childbirth increases the rate of cesarean section and that a large part of women prefer cesarean delivery instead of vaginal delivery. Was the mode of delivery examined in this study?

5. Were the pregnancies of the pregnant women included in the study planned and desired pregnancies?

6. Another factor that causes fear of birth is previous negative birth and abortion experiences. Was it evaluated in this study?

7. How the study was carried out is not fully understood. Were the cases included in the study evaluated twice, before and after birth? Were these interviews conducted face-to-face or over the phone? Were the scales and questionnaires given to the subjects and asked to be filled in at home? In this case, erroneous results may occur.

8. It is recommended to expand the discussion section with the results of studies conducted in different cultures on the subject. The following studies can be used.

Chválna Zuzana, Dominová Natália, Ostatníková Michaela, et al. Prevalence and risk factors for serious birth concerns in unselected population of mothers. Prevalencia a rizikové faktory závažných obáv z pôrodu u neselektovanej populácií rodičiek. Ceska Gynekol. 2023;88(2):80-85. doi:10.48095/cccg202380

Nieminen K, Stephansson O, Ryding EL. Women's fear of childbirth and preference for cesarean section--a cross-sectional study at various stages of pregnancy in Sweden. Acta Obstet Gynecol Scand. 2009;88(7):807-813. doi:10.1080/00016340902998436

Viirman F, Hesselman S, Wikström AK, et al. Negative childbirth experience - what matters most? a register-based study of risk factors in three time periods during pregnancy. Sex Reprod Healthc. 2022;34:100779. doi:10.1016/j.srhc.2022.100779

Räisänen S, Lehto SM, Nielsen HS, Gissler M, Kramer MR, Heinonen S. Fear of childbirth in nulliparous and multiparous women: a population-based analysis of all singleton births in Finland in 1997-2010. BJOG. 2014;121(8):965-970. doi:10.1111/1471-0528.12599

Smith KB, Zdaniuk B, Ramachandran SO, Brotto LA. A longitudinal case-control analysis of pain symptoms, fear of childbirth, and psychological well-being during pregnancy and postpartum among individuals with vulvodynia. Midwifery. 2022;114:103467. doi:10.1016/j.midw.2022.103467

9. It seems that the study was conducted during the period when the most important effects of COVID-19 were seen. The cases participating in the study may have been affected by this situation. It can be stated in the limitations of the study.

10. Do the cases participating in the study have a previous history of psychiatric disorder and treatment?

11. Superiority and dissimilarity of this study from the other studies have not been emphasized enough. What is the difference should be emphasized

12 .What is the recommendation for further studies?

In my opinion, this study is publishable after minor revision in your journal.

Best regards,

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

Reviewer #3: No

**********

PLoS One. 2023 Dec 7;18(12):e0294910. doi: 10.1371/journal.pone.0294910.r005

Author response to Decision Letter 1

27 Aug 2023

Dear Editor

Thank you for your valuable comments. We corrected and answerd all of them as follows:

Answer: Thank you for your attention. This study was longitudinal and we corrected. We rewrite limitation part, and highlighted.

Answer: Thank you for your attention. If we only wanted to determine the relationship between this variables, yes it wasn’t need to use path analysis, but, we wanted to understand the direct effect and indirect effect of these variables, so we had to do the powerful analysis like path analysis.About third and fifth questions, we added them in result ,discussion and conclusion parts and highlighted.

Thanks

Reviewer #3: Dear Editor,

1. What is the total number of pregnant women followed in the center where the study was conducted?

Answer: Thank you for your attention. In this study Two Referral Center of Qazvin were selected) Kowsar and shafa hospitals) and 352 eligible pregnant mothers were assessed. We added it in methods part and highlighted.

2. It would be appropriate to indicate the dates of the study and the duration of the study.

Answer: Thank you for your comment. This study was conducted from 2021/3/3 to 2021/9/2 .we added in methods part and highlighted.

3. Were there any cases not included or excluded from the study? How many and why?

Answer: Thank you for your comment. We didn’t have any case that not included or excluded from study.

Answer: Thank you for your comment.in this study we assessed all variable in path analysis. Path analysis requires the same type of data as linear multiple regression. In other words, you need a dependent variable that is continuous and normally distributed. ( Munro's statistical methods for health care research: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2013) Accordingly, we couldn't assess the mode of delivery. Because of that, we only entered the mothers who wanted to have a vaginal delivery and did it.

5. Were the pregnancies of the pregnant women included in the study planned and desired pregnancies?

Answer: Thank you for your comment. Yes, all pregnancies were planned and desired, and for this subject, first, we asked women about their pregnancy, and if it was wanted, they entered the study. We added it to the inclusion criteria, and highlighted.

6. Another factor that causes fear of birth is previous negative birth and abortion experiences. Was it evaluated in this study?

Thank you for your comment. Yes, it was our inclusion criteria.

Answer: Thank you for your comment. Yes, as we wrote in the 2.3. Procedures: Data were collected in two stages in this study; the first stage was performed during the last four weeks of the pregnancy, and the second stage was performed after the delivery. The questionnaires were given to the participants to complete; if they could not complete the questionnaires in one meeting, the researcher would set the next time to complete the questionnaires, which means they came back to the center and completed, so all questionnaires were completed face-to-face and not at home.

8. It is recommended to expand the discussion section with the results of studies conducted in different cultures on the subject. The following studies can be used.

Answer: Thank you for your comment; we added and highlighted two references per your recommendation in the Discussion part.

Answer: Thank you for your comment; we added it in the limitation part, and highlighted

10. Do the cases participating in the study have a previous history of psychiatric disorder and treatment?

Answer: Thank you for your comment. No. they didn’t have. This was our inclusion criteria as we wrote in inclusion criteria part:” not having a mental illness according to the self-reports or health records, and not taking antidepressants and anti-anxiety medications according to the self-reports or health records.”

11. Superiority and dissimilarity of this study from the other studies have not been emphasized enough. What is the difference should be emphasized

Answer: Thank you for your comment. As we wrote in the end of background:” To the best of the authors’ knowledge, perceived social support, spiritual and psychological variables, and fear and experience of childbirth have not been addressed yet in a single model.” It means this model can be first model that show casual paths between these variables.

12 .What is the recommendation for further studies?

Answer: Thank you for your comment. We wrote in the limitation part: “This study assessed pregnant mothers presenting to the selected health centers. Mothers who did not refer to the health center or offered in other specific centers did not set so that it could be another limitation. We recommended that in further research, they consider.” and also “The study was conducted during COVID-19 so the participating cases may have been affected by this situation” so ut can be done in another time.

Regards

Researchers Team

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PLoS One. doi: 10.1371/journal.pone.0294910.r006

Decision Letter 2

Zemenu Yohannes Kassa

26 Sep 2023

PONE-D-23-08753R2The relationships of spiritual health, pregnancy worries and stress and perceived social support with childbirth fear and experience: A path analysisPLOS ONE

Dear Dr. Mahmoodi,

Please submit your revised manuscript by Nov 10 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Zemenu Yohannes Kassa, Msc

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #2: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Reviewer #2: 1. Limitation section is very important for the current study and future research. However, the Limitation section in the manuscript is still not professional and specific. For example, “we recommended that in further research, they consider.” Consider what? How to consider? Besides, “The study was conducted during COVID-19 so the participating cases may have been affected by this situation.” Affect what? Reporting bias? Or sampling procedure? How to handle it in future research? Authors should pay more attention to improve scientific writing quality of the whole manuscript.

Reviewer #3: Dear Editor,

I want to thank you for providing the opportunity to review this revised chapter ‘The relationships of spiritual health, pregnancy worries and stress and perceived social support with childbirth fear and experience: A path analysis”

I have re-reviewed the study. I determined that the authors made the suggested changes to the text.

In my opinion, this study is publishable in your journal.

Best regards,

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

Reviewer #3: No

**********

PLoS One. 2023 Dec 7;18(12):e0294910. doi: 10.1371/journal.pone.0294910.r007

Author response to Decision Letter 2

15 Oct 2023

Answer: Thank you. We checked and corrected it

Attachment

Submitted filename: Response to Reviewers.docx

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PLoS One. doi: 10.1371/journal.pone.0294910.r008

Decision Letter 3

Zemenu Yohannes Kassa

13 Nov 2023

The relationships of spiritual health, pregnancy worries and stress and perceived social support with childbirth fear and experience: A path analysis

PONE-D-23-08753R3

Dear Dr. Zohreh Mahmoodi,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Zemenu Yohannes Kassa

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Authors should check punctuation for example, put full stop after reference citation.

Revised the following sentences, as follows Qazvin is the administrative city of the province, I think in Iran there is one capital city, which is Tehran.

Qazvin is the largest city and the capital of Qazvin Province in the central part of Iran.

.......experience. (Figure 3) (Table 3). please put full stop after figure or table.

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0294910.r009

Acceptance letter

Zemenu Yohannes Kassa

29 Nov 2023

PONE-D-23-08753R3

The relationships of spiritual health, pregnancy worries and stress and perceived social support with childbirth fear and experience: A path analysis

Dear Dr. Mahmoodi:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at customercare@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Zemenu Yohannes Kassa

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Checklist. STROBE statement—checklist of items that should be included in reports of observational studies.

(DOCX)

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Data Availability Statement

working link to dataset are as follows: TARGET URL: (https://doi.org/10.5281/zenodo.10183716) https://zenodo.org/records/10183716.

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The relationships of spiritual health, pregnancy worries and stress and perceived social support with childbirth fear and experience: A path analysis

Saeideh Hosaini

Mansoureh Yazdkhasti

Farnoosh Moafi Ghafari

Farima Mohamadi

Seyed Hamid Reza Kamran Rad

Zohreh Mahmoodi

Roles

Abstract

Background

Methods

Results

Conclusion

1. Background

Fig 1. The model presented by Siddall based on the role of spiritual, physiological, social and psychological factors in labor pain in pregnant mother [15].

2. Methods

2.1. Study design and participants

Inclusion criteria

Exclusion criteria

2.2. Data collection and definition of terms

2.2.1. Demographic checklist

2.2.2. Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ)

2.2.3. Childbirth Experience Questionnaire 2 (CEQ-2)

2.2.4. MSPSS

2.2.5. Spiritual health questionnaire

2.2.6. PWSQ

2.2.7. Socioeconomic status questionnaire

2.3. Procedures

2.4. Statistical analysis

Fig 2. Full empirical path model between spiritual health, pregnancy worries and stress, and perceived social support with childbirth fear and experience according T-Value ≥1.96.

3. Results

Table 1. The sociodemographic character of participants.

Table 2. The correlation matrix of childbirth fear and experience in relation to personal-social variables, spiritual health, pregnancy worries and stress, and perceived social support.

Fig 3. Full Empirical Path Model between spiritual health, pregnancy worries and stress, and perceived social support with childbirth fear and experience.

Table 3. The direct and indirect effects of personal-social variables, spiritual health, pregnancy worries and stress, and perceived social support on childbirth fear and experience.

Table 4. Goodness of fit indices for the model.

4. Discussion

5. Limitation

6. Conclusion

Supporting information

Acknowledgments

Abbreviations

Data Availability

Funding Statement

References

Author response to previous submission

Decision Letter 0

Zemenu Yohannes Kassa

Roles

Author response to Decision Letter 0

Decision Letter 1

Zemenu Yohannes Kassa

Roles

Author response to Decision Letter 1

Decision Letter 2

Zemenu Yohannes Kassa

Roles

Author response to Decision Letter 2

Decision Letter 3

Zemenu Yohannes Kassa

Roles

Acceptance letter

Zemenu Yohannes Kassa

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

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RESOURCES

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