Assessing primary Tokophobia among Lebanese childless men and nulliparous women: psychometric validation of the Arabic versions of the fathers’ fear of childbirth scale and Tokophobia severity scale

Abstract

Introduction

Tokophobia is an intense and pathological fear of pregnancy and childbirth. Despite its significance, no research in Lebanon has investigated primary tokophobia within the general population. Nevertheless, it is crucial to assess the attitudes of both women and men, as potential future parents, towards pregnancy and childbirth, particularly during these challenging times for the Lebanese population. Therefore, this study aims to evaluate the psychometric properties of the Tokophobia Severity Scale (TSS) and Fathers’ Fear of Childbirth Scale (FFCS) for assessing primary tokophobia among Lebanese nulliparous women and childless men, respectively.

Methods

This cross-sectional investigation encompassed all Lebanese governorates; 651 women and 618 men were recruited via social media platforms, using a snowball sampling technique. The questionnaire included the Tokophobia Severity Scale, the Fathers’ Fear of Childbirth Scale, the Patient Health Questionnaire, and the Lebanese Anxiety Scale.

Results

Factorial analysis of the TSS in women revealed a three-factor model: concerns related to personal complications (Factor 1), fetal well-being (Factor 2), and outward behavioral responses to fear (Factor 3). The FFCS also yielded a three-factor measurement model: emotional responses during the partner’s childbirth (Factor 1), concerns regarding the hospital environment during childbirth (Factor 2), and anxieties surrounding the perinatal health of both the partner and child (Factor 3). Both scales were internally consistent with Cronbach’s alpha > 0.9, indicating their reliability. The TSS and FFCS demonstrated statistically significant correlations with measures of anxiety and depression, thus attesting to convergent validity.

Conclusion

The results of this study provide evidence for the psychometric validity and reliability of the TSS and FFCS scales in Arabic-speaking populations. Given the previously overlooked nature of primary tokophobia in these populations, the availability of these validated instruments can significantly enhance the ability to detect and address this condition, ultimately facilitating the provision of necessary support services.

Introduction

Tokophobia, an intense and pathological fear of pregnancy and childbirth, has historically been undervalued [1]. However, its sharp rise since the year 2000 necessitates increased focus due to its significant impact on public health [2–4]. The majority of research has concentrated on childbirth fear rather than tokophobia itself, resulting in substantial knowledge gaps [1]. It is crucial to distinguish between childbirth fear and the more severe tokophobia [1], a crippling fear associated with depression and anxiety disorders and that adversely affects numerous women and men, jeopardizing their mental health, overall well-being, and potentially the well-being of their fetuses [5–7].

Notably, tokophobia presents a harrowing and debilitating condition not only for expectant mothers and fathers [8] but also hinders the formation of the father/mother-fetus bond, a well-established predictor of a child’s emotional and cognitive development; hence, acknowledging tokophobia becomes essential [9–11]. Furthermore, tokophobia has significant public health implications. This pathology compels many women to opt for unnecessary Cesarean Sects. [9, 12], thereby burdening public health resources with additional costs and increasing potential risks to both mother and child [13, 14]. Some studies indicate that women with tokophobia may even use extreme measures to avoid childbirth, such as pregnancy termination [5]. Specifically, a study showed that the most significant contributors to pathological fear of birth were the fear of episiotomy, a sense of loss of control, and the anticipation of pain. Moreover, this study found that women having tokophobia significantly preferred elective cesarean Sect. [7]. Another study demonstrated that young women with high childbirth fear are four times more likely to prefer cesarean delivery [15]. Regarding tokophobia prevalence, a study conducted among 98 French women at 36 weeks’ gestation estimated that 20.41% of pregnant women may experience the condition [4]. In addition, a significant portion of fathers, estimated at 13% based on current research, exhibit severe fear of childbirth/tokophobia [16, 17].

However, research has yet to thoroughly explore the prevalence of primary tokophobia, a condition specifically affecting childless men and nulliparous women who have never been pregnant. Ideally, primary tokophobia is defined as a condition that compels women and men to entirely avoid pregnancy and childbirth, leading to a childless life [2]; whereas secondary tokophobia specifically characterizes a pregnancy-induced anxiety state surrounding childbirth [2], potentially arising from prior childbirth trauma experienced by multiparous women or witnessed by men (i.e., fathers).

Quantifying any form of tokophobia has long been a challenge due to the lack of a standardized, reliable, and internationally accepted measurement tool. While the Wijma Delivery Expectancy/Experience Questionnaire (WDEQ) [18] benefits from widespread use, other researchers rely on scoring a single question about fear of childbirth [19]. This inconsistency in measurement makes comparisons across studies difficult due to the ambiguity and multifaceted nature of tokophobia’s definition [19]. Researchers highlighted the limitations of these existing measures, emphasizing the need to validate a concise and more convenient tool compared to the lengthy WDEQ (33 items) [19, 20]. Furthermore, the WDEQ is explicitly pregnancy-centered [18]. Therefore, this instrument’s focus on anxieties directly related to the childbirth experience within the context of pregnancy renders it unsuitable for evaluating primary tokophobia.

To this end, in a recent surge of research, attempts have been made to develop and validate instruments specifically designed to assess primary tokophobia in both men and women from the general population, independent of pregnancy status. One such example is the Tokophobia Severity Scale (TSS), which was constructed using a sample of nulliparous women (those who have never given birth) of childbearing age [21]. This scale has been established as a brief, unidimensional, reliable, and valid tool with the potential to identify women with tokophobia in future clinical settings [21]. Remarkably, a recent clinical evaluation identified the TSS as the most preferred available instrument for assessing tokophobia in women [5]. Similarly, the Fathers’ Fear of Childbirth (FFCS) scale is a recently developed and validated self-report measure demonstrating strong psychometric properties for evaluating this fear in expectant fathers [22]. This scale demonstrated a bidimensional structure, distinguishing the fear of childbirth process from the fear of hospital. Reliability was evidenced by internal consistencies greater than 0.70 for both factors [22]. This measure was also validated in the Chinese [23] and Turkish [24] languages. While the Turkish validation study maintained the two-factor structure of the scale, the Chinese study shed light on its potential tridimensional nature [23, 24].

Despite the significance of this topic, no research in Lebanon has investigated this phenomenon within the general population. Nevertheless, it is crucial to assess the attitudes of both women and men, as potential future parents, towards pregnancy and childbirth, particularly during these challenging times for the Lebanese population. The country faces multiple hardships, including financial, healthcare, social, and political crises, compounded by the ongoing regional war [25]. These multifaceted challenges facing Lebanon have created a climate of uncertainty and anxiety that can significantly influence attitudes towards pregnancy and childbirth. Moreover, the recent disaster of August 4, 2020, left hundreds of people emotionally traumatized, having lost loved ones and children [26]. This collective trauma may exacerbate these fears, hence discouraging Lebanese individuals from starting families. In a nation where life feels constantly under threat, the prospect of bringing a child into the world can be overwhelming, leading to a heightened sense of vulnerability and anxiety. In addition, the historical context of enduring wars and conflicts in Lebanon can further contribute to a deep-rooted fear of the unknown and the potential risks associated with pregnancy and childbirth.

Therefore, this study aims to evaluate the psychometric properties of the Tokophobia Severity Scale and Fathers’ Fear of Childbirth Scale for assessing primary tokophobia among Lebanese nulliparous women and childless men, respectively. We aim to validate these scales in the Arabic language among the Lebanese population, in order to establish a suitable method for assessing primary tokophobia, a condition that has been underestimated and deserves greater attention within our community. We hypothesized that the Arabic Tokophobia Severity Scale and Fathers’ Fear of Childbirth Scale would: (1) replicate the originally proposed factor structures (unidimensionality for TSS and two-factor structure for FFCS), (2) show good reliability, and (3) demonstrate adequate patterns of correlations with measures of depression and anxiety.

Methods

Study design

This cross-sectional investigation, encompassing all Lebanese governorates, was conducted over a two-month period from February to March 2024. The target demographic comprised nulliparous women and childless men residing in Lebanon, aged 18 years and above. The primary objective was to evaluate the construct of primary tokophobia within this population. Inclusion criteria for women stipulated the absence of prior pregnancy experiences. Additionally, men with no prior exposure to childbirth, including first-time expectant fathers, were also eligible to participate. Adhering to the validation recommendations outlined by Comrey and Lee [27], a minimum sample size of 130 women and 170 men was established, based on ten observations per scale’s item for the exploratory factor analysis; whereas a minimum sample between 260 women and 340 men was needed, based on 3–20 times the number of scale’s items for the confirmatory factor analysis [28]. Ultimately, the study successfully recruited 651 women (mean age: 24.41 ± 7.06 years; 86.9% with a university education level, and a mean household crowding index (i.e., number of people in the house divided by the number of rooms in the house, excluding the kitchen and bathrooms; which reflects the socioeconomic status) [29] of 1.13 ± 0.50 person/room) and 618 men (mean age: 26.58 ± 7.62 years; 85.4% with a university education level, and a mean HCI of 1.04 ± 0.51 person/room).

Participant recruitment employed a snowball sampling technique, leveraging social media platforms such as WhatsApp and Facebook. The self-administered questionnaire, designed in Arabic, was disseminated via a Google Forms link. To ensure participant confidentiality, anonymity was guaranteed throughout the study. The snowball sampling strategy was chosen due to the sensitive nature of the topic and the difficulty of recruiting participants using traditional methods. By starting with a small group of initial participants and asking them to recommend others who might be interested, this approach allowed us to reach a diverse group of women who had experienced tokophobia. However, while snowball sampling can be effective, it may introduce bias and limit the sample’s representativeness. To mitigate this issue, we ensured initial participants had various backgrounds. Established exclusion criteria disqualified individuals with prior experiences of pregnancy or childbirth. All methodologies employed were conducted in strict accordance with relevant ethical guidelines and regulations. Notably, the study protocol received thorough review and approval by the institutional review board of the ethics committee of the School of Pharmacy at the Lebanese International University (reference # 2024ERC-004-LIUSOP).

Translation procedure for the TSS and FFCS

The instrument translation adhered to established international guidelines for the cultural adaptation of self-report measures [30, 31] and the International Test Commission Guidelines for Translating and Adapting Tests [32]. Initially, the original English versions were meticulously translated into Arabic by two bilingual healthcare professionals. These individuals were native Arabic speakers with demonstrably high fluency in English. Subsequently, a rigorous back-translation process was implemented, whereby the Arabic versions were translated back into English by separate bilingual healthcare professionals. This meticulous approach ensured the preservation of the original instrument’s meaning and construct validity within the target Arabic-speaking population. The resulting two English versions – the original and the back-translated version – were then meticulously reviewed by an expert committee comprised of psychologists and psychiatrists. This review process aimed to identify and eliminate any potential discrepancies or intellectual inconsistencies that may have arisen during the translation process. Following this comprehensive evaluation, the final Arabic versions were deemed linguistically and conceptually equivalent to the original English instruments, as no significant incongruities were detected.

Scales description and scoring procedures

The scales used in the current study were:

The Tokophobia Severity Scale (TSS)

(For women only)

The Tokophobia Severity Scale (TSS) functions as a 13-item instrument designed to comprehensively assess tokophobia in women. The scale encompasses both the cognitive and behavioral dimensions of this fear. Cognitive aspects are evaluated through items that capture worry and negative appraisals, such as “I worry about medical complications during pregnancy and/or childbirth.” Conversely, behavioral avoidance tendencies are measured through questions like “I check excessively to determine if I am pregnant.” Each item on the TSS utilizes a 4-point Likert scale, ranging from 0 (“not at all”) to 3 (“always”), to quantify the frequency or intensity of the experience. Total scores are derived by summing the individual item responses. Consequently, higher scores on the TSS reflect a greater severity of tokophobia [21].

The Fathers’ Fear of Childbirth Scale (FFCS)

(For men only)

The Fathers’ Fear of Childbirth Scale (FFCS) was specifically designed to evaluate the construct of tokophobia within the male population. This instrument comprises 17 items scored using a five-point Likert scale, ranging from “I do not agree at all” (1) to “I completely agree” (5). The scale captures a nuanced spectrum of tokophobia-related anxieties in men, encompassing concerns for their child’s well-being during childbirth (e.g., “I am afraid that my child’s health will be endangered due to childbirth”) and partner’s delivery (e.g., “During my spouse’s childbirth, I will feel helpless”). Higher total scores on the FFCS correspond to a greater severity of tokophobia in men [22].

The patient health questionnaire (PHQ-9)

This instrument functions as a concise, 9-item depression screener. Each item aligns with a corresponding criterion from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) for major depressive disorder [33]. The scale utilizes a 4-point Likert format, ranging from 0 (“not at all”) to 3 (“nearly every day”), to assess the frequency of depressive symptomatology. Sample items include “feeling tired or having little energy,” “little interest or pleasure in doing things,” and “trouble falling or staying asleep, or sleeping too much.” Scores are derived by summing the individual item responses. Consequently, higher scores reflect a greater severity of depressive symptoms. Notably, the Arabic adaptation of this scale has been demonstrably effective in detecting depression within the Lebanese adult population [34].

The Lebanese anxiety scale (LAS-10)

The LAS-10 serves as a concise, 10-item screening instrument designed to assess anxiety in the Lebanese adult population. Administered in Arabic, the scale incorporates items capturing various facets of anxiety, encompassing both cognitive aspects (e.g., “I have an anxious mood.“) and somatic (physical) symptoms (e.g., “I have somatic [muscular] problems.“). Scores are obtained by summing the responses across all items, with higher scores reflecting a greater degree of anxiety. The LAS-10 has been demonstrably effective in prior validation studies conducted within the Lebanese population [35].

Statistical analysis

First, a confirmatory factor analysis (CFA) was conducted to test the original 2-factorstructure of the Fathers’ Fear of Childbirth Scale among men (N = 618) and the unidimensional structure of the Tokophobia Severity Scale (TSS) among women (N = 651), respectively. The CFA was performed using RStudio (Version 1.4.1103 for Macintosh) [36], the Lavaan [37], and the SemTools [38] packages. As these scales use continuous scores (Likert scales), we used Weighted Least Squares with Mean and Variance (WLSMV) estimation method, which is known to be more appropriate for ordinal data [39]. The following fit indices were reported: Comparative Fit Index (CFI), Goodness of Fit Index (GFI), Tucker Lewis index (TLI), Root Mean Square Error of Approximation (RMSEA), and the Standardized Root Mean Square Residual (SRMR). Values closer to 0.90 for the CFI and TLI, and those at or below 0.08 for RMSEA and SRMR indicate better model fit. Scales’ reliability was assessed via the Cronbach’s alpha. Convergent validity was evaluated by Pearson correlations between the TSS/FFCS scores and both depression and anxiety scores.

Results

Exploratory and confirmatory factor analyses

The confirmatory model displayed poor fit for both the FFCS (a CFI of 0.794, a TLI of 0.762, RMSEA of 0.081, a SRMR of 0.065) and the TSS (CFI of 0.658, a TLI of 0.658, a RMSEA of 0.114 and a SRMR of 0.077).

To improve these original models, which yielded inadequate fit, we examined the modification index (MI), as recommended. The MI provides an estimate increase in the chi-square for each parameter if it were to be freed.

The MI outlined a positive covariance (i.e., of 19.76) between items 16 and 17 for the FFCS, and a strong positive covariance (i.e., of 53.90) between items 7 and 11 for the TSS. Accordingly, modified models considering these covariances were created. However, these modified versions also failed to display significant improvements, as they yielded poor model estimates for both FFCS (CFI: 0.811, TLI: 0.780, RMSEA: 0.078, SRMR: 0.062) and the TSS (CFI: 0.765, TLI: 0.714, RMSEA: 0.105, and SRMR: 0.070).

Therefore, an EFA-to-CFA strategy was employed to both data (FFCS in men and TSS in women) [40]. A significant Bartlett’s test of sphericity and the Kaiser-Meyer- Olkin (KMO) of 0.96 for the FFCS and 0.93 for TSS, ensured the adequacy of both samples. On the basis of the scree test, the appropriate number of factors underlying the TSS items in women and those underlying the FFCS items in men was found to be equal to three for both scales. Factor loadings and variance accounting for by these three factors can be found in Table 1 (Table 1).

Table 1.

Factor loadings of the TSS and FFCS items deriving from the exploratory and confirmatory factor analyses among women and men, respectively

Model 1: Among Women (TSS)
	EFA			CFA
	F1: Fear of Personal Complications During Pregnancy and Childbirth	F2: Fear of Fetal Complications During Pregnancy and Childbirth	F3: Behavioral Responses to Fear	Loading factor	Standard error	p
1-I worry about medical complications during pregnancy and/or childbirth	0.64			0.62	0.030	< 0.001
2- I worry about the type of delivery that I will have a baby	0.71			0.61	0.029	< 0.001
3- I worry that something terrible will happen to me during my pregnancy and/or childbirth	0.70			0.69	0.025	< 0.001
4- I worry that something terrible will happen to my baby during my pregnancy and/or childbirth		0.61		0.65	0.028	< 0.001
5- I worry that I will not be able to cope with the pain of pregnancy and/or childbirth	0.77			0.67	0.026	< 0.001
6-I worry about the medical procedures required during pregnancy and/or childbirth	0.59			0.61	0.027	< 0.001
7-I avoid talking about pregnancy, children and childbirth because of my fears			0.67	0.64	0.030	< 0.001
8- I worry that I will not be in control of the medical procedures during my pregnancy and/or delivery			0.56	0.78	0.027	< 0.001
9-I worry that pregnancy and/or childbirth will be too painful	0.78			0.68	0.026	< 0.001
10-I check excessively to determine if I am pregnant			0.47	0.18	0.045	< 0.001
11-I have nightmares about being pregnant and/or delivering a child			0.79	0.53	0.036	< 0.001
12- I worry that something dangerous will happen to me during pregnancy or the delivery (e.g., a ruptured uterus, preeclampsia, emergency interventions, death)		0.58		0.71	0.025	< 0.001
13- I worry that something dangerous will happen to my child during pregnancy or the delivery (e.g., injury or death)		0.73		0.68	0.027	< 0.001
Variance explained	0.31	0.16	0.16	-	-	-

Model 2: Among males (FFCS)
	EFA			CFA
	F1: Emotional Responses During Partner’s Childbirth	F2: Hospital Concerns During Childbirth	F3: Perinatal Partner and Child’s Health Concerns	Loading factor	Standard error	p
1-I worry about the quality of sex with my spouse after childbirth	0.65			0.66	0.040	< 0.001
2-As the time of childbirth approaches, my worries increase	0.64			0.69	0.039	< 0.001
3-I am afraid that dangerous medical interventions will be needed during childbirth	0.59			0.80	0.036	< 0.001
4-During my spouse’s childbirth, I will feel helpless	0.77			0.75	0.036	< 0.001
5-During my spouse’s childbirth, I will feel fear	0.62			0.87	0.032	< 0.001
6-During my spouse’s childbirth, I will feel restless	0.63			0.85	0.032	< 0.001
7-Because of my spouse’s fear of childbirth, I feel fear	0.65			0.80	0.033	< 0.001
8-I am afraid that I am not capable enough to support my spouse during childbirth	0.62			0.74	0.038	< 0.001
9-I am afraid that my spouse’s childbirth will be risky			0.64	0.85	0.031	< 0.001
10-I will feel fear because of my spouse ‘s pain			0.63	0.85	0.033	< 0.001
11-I am afraid that my spouse’s health will be endangered due to childbirth			0.73	0.86	0.037	< 0.001
12-I am afraid that my child’s health will be endangered due to childbirth			0.60	0.83	0.035	< 0.001
13-I am afraid that the hospital staff will not take enough care of my spouse		0.70		0.90	0.032	< 0.001
14-I am afraid the hospital staff will not treat me and my spouse respectfully		0.71		0.82	0.035	< 0.001
15-I am afraid that my child will be hospitalized in the neonatal intensive care unit after birth		0.63		0.88	0.034	< 0.001
16-I am afraid that the hospital staff will not have enough skills to perform a safe childbirth		0.79		0.89	0.034	< 0.001
17-I am afraid that the hospital will not have enough facilities and equipment for a safe childbirth		0.81		0.86	0.034	< 0.001
Variance explained	0.25	0.23	0.20			< 0.001

Note: in both models, the structure outlined in the EFA is replicated in the CFA

Compared to previously reported confirmatory models, the CFA conducted on the basis of the EFA results, yielded more satisfactory model fit for both the FFCS (CFI: 0.894, TLI: 0.876, RMSEA: 0.056, SRMR: 0.040) and the TSS (CFI: 0.847, TLI: 0.808, RMSEA: 0.086, and SRMR: 0.056).

Internal consistency/reliability

The Cronbach’s alpha of the TSS was 0.917 in the total sample of 651 women (Cronbach’s alpha for 3 factors of the TSS were 0.91, 0.86, and 0.76 respectively). Furthermore, the Cronbach’s alpha of the FFCS was 0.958 in the total sample of 618 men (Cronbach’s alpha for 3 factors of the FFCS were 0.92, 0.93 and 0.91 respectively); thus, attesting to internal validity/reliability of both scales.

Convergent validity

The Tokophobia Severity Scale (TSS) and Fathers’ Fear of Childbirth Scale (FFCS) exhibited modest positive correlations with measures of depression (r = 0.376 for women, r = 0.362 for men) and anxiety (r = 0.397 for women, r = 0.336 for men). However, these correlations were statistically significant (p < 0.01 for all). Notably, the significant correlations between the tokophobia scales (i.e., TSS and FFCS) and depression/anxiety scores support the convergent validity of these scales.

Discussion

In this study, we aimed to address the dearth of validated instruments for assessing primary tokophobia in Lebanon. We investigated the psychometric properties of the Arabic translations of the TSS and FFCS within a sample of Lebanese nulliparous women and childless men, respectively. The findings provided encouraging support for the validity of both scales in the Arabic language. Both scales were internally consistent with Cronbach’s alpha > 0.9, indicating their reliability. The TSS and FFCS demonstrated statistically significant correlations with measures of anxiety and depression, thus attesting to convergent validity.

Factorial analysis of the Tokophobia Severity Scale (TSS) in women revealed a three-factor model (refer to Table 1 for details). Factor 1 predominantly loaded with items reflecting the fear of personal complications during pregnancy and childbirth. Factor 2 specifically captured concerns related to fetal complications during pregnancy and childbirth. Finally, Factor 3 encompassed behavioral responses associated with fear. These findings deviate from the original instrument, which was conceptualized as a unidimensional measure [21]. However, our three-factor model might offer a more nuanced and comprehensive understanding of tokophobia in women, as it differentiates between concerns related to personal complications (Factor 1), fetal well-being (Factor 2), and outward behavioral responses to fear (Factor 3). This multidimensional perspective aligns with the multifaceted nature of tokophobia, encompassing both cognitive aspects (fears) and behavioral tendencies (avoidance). Lending further credence to our results, a recent study independently verified the analysis employed in the initial validation study of the TSS. This investigation identified a three-factor model that exhibited a statistically significant improvement in data fit compared to the unidimensional model [41]. This observation provides further support to the multidimensionality of the construct observed in the current study. Power analysis conducted by the subsequent researchers suggested that the initial study might have been underpowered, potentially impacting the generalizability of its conclusions due to insufficient sample size [41]. Our findings also contribute valuable insights into the scale’s potential for cross-cultural application. Consistent with the findings of the present study, the original TSS demonstrated high internal consistency (Cronbach’s alpha = 0.93) and a significant correlation with scores on the PHQ-9 [21].

In addition, our analysis of the Fathers’ Fear of Childbirth Scale (FFCS) also yielded a three-factor measurement model (Table 1). Factor 1 grouped items pertaining to emotional responses during the partner’s childbirth. Factor 2 focused on concerns regarding the hospital environment during childbirth. Lastly, Factor 3 assessed anxieties surrounding the perinatal health of both the partner and child. While the original FFCS and its Turkish adaptation proposed a two-dimensional structure encompassing “Fear of Childbirth Process” and “Fear of Hospital” [22, 24], our analysis delves deeper, differentiating emotional responses from anxieties concerning fetal and maternal well-being. This granular approach aligns with the findings from the Chinese study [23], which identified a three-factor model specific to their population. These observations collectively underscore the cross-cultural variability in the tokophobia experience among fathers. Importantly, all versions of the FFCS demonstrate high reliability, solidifying its foundation as a robust assessment tool [22–24]. Our analysis of the FFCS has also helped us further explore the concept of men’s tokophobia, represented by the fears and anxieties experienced by fathers during their partner’s pregnancy and childbirth. The FFCS, which was originally developed and tailored for use in fathers, has since then provided valuable insights into their unique phobic experiences of childbirth: from anxious emotional responses during the partner’s childbirth to the importance of the physical setting in shaping fathers’ fear experiences, not to neglect fathers’ deep-seated concerns for the well-being of their family. In sum, while the concept of men’s tokophobia has not been thoroughly underlined in the literature up until this point, our findings suggest that the FFCS can serve as a valuable tool for understanding this complex phobia experienced by Lebanese fathers during the significant life event of childbirth.

Models’ modification criteria were respected in terms of goodness-of-fit statistics, without the need to add correlation between residuals, which also respects the principle of parsimony. We also confirmed that the EFA-CFA strategy is not sample-dependent via ensuring an adequate sample size for both EFA and CFA, by splitting our data into a development sample for the EFA and a validation sample for the CFA; the latter strategy ensured that the model derived from the EFA performed well on a second independent sample. It is of note that each factor obtained from the EFA had a low variance; this might be due to the nature of the construct. Tokophobia is a specific and potentially complex construct, thus, low variance in individual factors might indicate that the factors are capturing more nuanced aspects of the construct rather than explaining a broad amount of variance. The low variance can also be explained by the low number of items per factor; therefore, the factor might not fully capture the contrast it is intended to represent.

Clinical implications

Previous research suggests that psychoeducational interventions, delivered either in group or individual settings, hold promise in empowering nulliparous women (those who have never given birth) and reducing unnecessary caesarean deliveries stemming from tokophobia [42]. Similarly, the implementation of non-pharmacological interventions has the potential to mitigate anxiety, stress, and apprehension surrounding childbirth in expectant fathers, consequently enhancing their overall childbirth experience [43]. Therefore, the routine use of validated assessment tools is crucial to identify tokophobia in both women and men. Our study provides a means for early detection of this condition, which would allow for the provision of appropriate expert support, potentially improving maternal well-being and birth outcomes.

Limitations

This study has some limitations. The employed cross-sectional design precludes the establishment of test-retest validity. Additionally, the snowball sampling technique inherent to the data collection process introduces a potential selection bias. Furthermore, the self-reported nature of tokophobia symptomatology, absent of formal clinical diagnosis, renders the results susceptible to information bias. The possibility of residual confounding bias cannot be entirely discounted, as factors potentially associated with tokophobia, such as those pertaining to the cognitive and emotional domains, were not incorporated into the current study. Future research endeavors should be directed towards elucidating other psychometric properties of the TSS and FFCS, including test-retest reliability and convergent validity with different scales. In addition, future multinational studies are essential to enhance the global understanding and management of tokophobia, where collaborative efforts between researchers and clinicians should focus on establishing internationally recognized and reliable cutoff points for the existing tokophobia scales. Aligning assessment methods across various populations and clinical settings may thus provide a more standardized and consistent approach to diagnosing and treating this condition worldwide.

Conclusion

The results of this investigation provide evidence for the psychometric validity and reliability of the TSS and FFCS scales. These findings suggest their potential utility as valid measures for the identification of primary tokophobia in Arabic-speaking populations, applicable to both women (TSS) and men (FFCS). Given the previously overlooked nature of tokophobia in these populations, the availability of these validated instruments can significantly enhance the ability to detect and address this condition, ultimately facilitating the provision of necessary support services. The development of psychometrically robust Arabic versions of the TSS and FFCS holds the potential to unlock a new frontier in cross-cultural research on primary tokophobia. This initiative would facilitate the inclusion of underrepresented populations from non-Western, non-developed countries, thereby enriching our understanding of this critical phenomenon.

Author contributions

SG and SH designed the study. EY and SH performed the statistical analysis and data interpretation. SG wrote the manuscript. FS and MD collected the data. SO reviewed the paper. All authors reviewed the manuscript and approved the final version.

Funding

None.

Data availability

All data generated or analyzed during this study are not publicly available due to restrictions from the ethics committee. The dataset supporting the conclusions is available upon request to the corresponding author.

Declarations

Ethics approval and consent to participate

The ethics approval was obtained from the ethics committee of the School of Pharmacy at the Lebanese International University (reference # 2024ERC-004-LIUSOP). A written informed consent was considered obtained from each participant upon submission of the online form.

Consent to Publish

Not applicable.

Competing interests

The authors declare no competing interests.