Fear of child birth and its associated factors among pregnant women in Ethiopia: systematic review and meta-analysis

Abstract

Background

Fear of childbirth (FOCB) significantly contributes to labor abnormalities, needless caesarean sections, and postpartum psychotic illnesses that occur throughout pregnancy, childbirth, and the postpartum period. This directly or indirectly increases unfavorable maternal and neonatal outcomes. However, there was a paucity of data regarding the scope and contributing factors of birthing fear in Ethiopia.

Objective

To assess the pooled prevalence of fear of childbirth and its associated factors among pregnant women in Ethiopia.

Methods

This systematic review and meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 checklist. A comprehensive search was conducted using PubMed, Cochrane Library, Scopus, Web of science and African Journals Online databases and search engines like Google Scholar. The quality of the included studies was assessed using the Joanna Briggs Institute (JBI) quality assessment tool for cross-sectional studies. Heterogeneity among the studies was evaluated using the I² statistic, while publication bias was assessed with funnel plot, and Egger’s test. A fixed-effects model was applied to calculate the pooled prevalence and odds ratios, with results presented as 95% confidence intervals.

Result

A total of six studies, involving 2,579 pregnant women, were included in this review. The pooled prevalence of FOCB was found to be 25.48% (95% CI: 23.77–27.16). In Ethiopia unplanned pregnancy (AOR: 4.45, 95% CI: 2.68–7.38), a previous history of pregnancy complications (AOR: 6.43, 95% CI: 2.43–16.98), and a previous history of labor and delivery complications (AOR: 6.05, 95% CI: 3.65–10.01) were significantly associated with FOCB.

Conclusion

The prevalence of FOCB in Ethiopia is higher than in other countries. Key factors contributing to FOCB include unplanned pregnancies, a history of pregnancy complications, and past labor or delivery issues. To reduce FOCB, reducing unplanned pregnancies through various strategies and offering preconception counseling, especially for women with prior obstetric complications, is recommended.

Prospero registration number

CRD42024538215.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40748-025-00228-5.

Introduction

Pregnancy is a significant and memorable milestone in a woman’s life; While it often brings positive emotions [1], it can also be a highly stressful experience [2, 3]. Pregnancy has been referred to as an emotional crisis for some women; and if not properly managed, it can lead to maternal and neonatal complications [3]. Fear of childbirth (FOCB) is a health concern for women and their caregivers when pregnant mothers are approaching to birth [4]. FOCB exists on a continuum from normal worries and fears, to severe fear [5]. FOCB is an important clinical issue observed in all pregnant women, leading to consequences for their health, and implications for labor, delivery and the postpartum period [6]. Due to poor consensus on definition and to various methods of measuring FOCB the magnitude of childbirth fear were differ across the country; however it was common in both pregnant and postpartum women in both developed and developing countries [7]. The prevalence of FOCB varies globally, ranging from 8 to 45.4% in different regions [4–6, 8–15]. The estimated global pooled-prevalence of FOCB among pregnant women were14% [16]. In Ethiopia, 21% of pregnant women are affected by FOCB; the issue is more prevalent among women with poor social support and those who experienced unfavorable birth outcomes in previous pregnancies [11, 17, 18].

FOCB has been associated with an increased rate of cesarean delivery worldwide especially elective cesarean delivery [19, 20]. It is also linked prolonged second stage of labor, increased intensity of labor pain, a higher risk of labor disorder, postpartum psychiatric disorder, posttraumatic stress disorder and sterilization [21]. Furthermore, a woman’s FOCB may hinder her ability to communicate effectively with the medical team, and this lack of communication can complicate clinical decision-making and delay in obstetric procedures, this contributed with unfavorable birth outcomes [7, 20–22]. While these women are willing to have a baby, they consider themselves unable to cope with their FOCB; Consequently, some women resort to unsafe termination of pregnancy, leading to related complications [22].

Different scholars suggests that demographic characteristics, obstetrics related factors, social related factors of the pregnant women were significantly contributed with FOCB. Younger women, unemployed and illiterate pregnant mothers were more fearful for childbirth compared to their counterpart. Being nulliparous, unplanned pregnancy, outcome of previous pregnancy, current pregnancy related complication and previous mode of delivery were significant determinants of severe FOCB [4–6, 9, 11]. The existing research on the prevalence and factors associated with fear of childbirth among Ethiopian women shows considerable variability and inconclusiveness at the national level. To address this gap and provide the necessary evidence for best practices, a systematic review is proposed. This review aimed to assess and consolidate the available data to estimate the overall magnitude of FOCB and identify its contributing factors among Ethiopian women.

Methods

Systematic review registration and search strategies

This systematic review was designed to estimate the pooled prevalence of FOCB and associated factors among Ethiopian women. A research protocol was developed and registered in PROSPERO, University of York PLOS ONE Center for Reviews and Dissemination, with a registration number of PROSPERO 2024 CRD42024538215 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024538215. All published articles were searched in major international databases such as PubMed, Cochrane Library, Scopus, Web of science and African Journals Online databases and search engines like Google Scholar. Onwards, a search of the reference lists of the identified studies was done to retrieve additional articles. For this review, the Condition, Context, Population (CoCoPop) search strategy was used. Conditions: FOCB, Populations: pregnant women, Context: Ethiopia. FOCB among pregnant women in Ethiopian was the outcome of interest. For each selected CoCoPop component, the electronic databases were searched using keywords and the medical subject heading [MeSH] terms. The search terms included combinations of the following: prevalence OR magnitude OR burden; childbirth fear OR fear of childbirth OR tokophobia OR fear of labor; and predictors OR determinants OR associated factors OR contributors, combined with Ethiopia. The Boolean operators “OR” and “AND” were used to structure the search effectively (S1). The outcome of interest was fear of childbirth and its associated factors, assessed using the Wijma Delivery Expectation/Experience Questionnaire (W-DEQ) [23]. The primary outcome was the prevalence of FOCB among pregnant women in Ethiopia. The secondary outcomes included the associated factors or determinants of FOCB, such as unplanned pregnancy, previous pregnancy-related complications, and prior labor and delivery-related complications.

Eligibility criteria and study selection

This systematic review included studies conducted in Ethiopia that reported either the prevalence or magnitude of fear of childbirth or its determinants/associated factors. Only studies published in English up to the end of the search period (May 15, 2024) were considered. Excluded from the review were case reports, surveillance data (e.g., demographic health surveys), conference abstracts, and articles without full-text access. All identified articles from the databases and search engines were exported into EndNote 20 for management to identify and eliminate duplicate records, and to screened articles based on their titles. The study selection process involved an initial screening of titles and abstracts. Subsequently, full-text screening was conducted for articles deemed eligible. Two independent reviewers (TNK and BTT) carried out the screening process to ensure accuracy and minimize bias. Any disagreements between the reviewers were resolved through discussion. Articles meeting the eligibility criteria were included in the final review. We had planned to contact the corresponding author via email for any missing data. However, we did not find any missing data during our review.

Quality assessment and data abstraction

The Joanna Briggs Institute (JBI) quality assessment tool was employed to evaluate the quality of the included studies [24]. Specifically, the JBI critical appraisal checklist for analytical cross-sectional studies consisted of eight clearly defined criteria aimed at assessing methodological and overall quality of the studies. Each criterion provided four distinct options: “yes,” “no,” “unclear,” and “not applicable.” The maximum score achievable with the JBI tool was 8 points (based on the sum of “yes” responses). To assess the quality of each study, two reviewers (TNK and LAM) independently evaluated the included studies. Disagreements between the reviewers were resolved through discussion. Articles achieving the maximum score were included in the review; however, no articles were found with a quality score below 7. As a result, only primary studies classified as good quality with higher scores were included to ensure the validity and reliability of the systematic review findings. (Table 1). Data extraction was performed independently by two reviewers (TNK and BTT) using a pre-piloted, standardized form prepared in Microsoft excel. Any disagreements were resolved by discussion or by consulting a third reviewer. Data entries were cross-verified for accuracy. The data extraction format included primary author, publication year, type of the study (community based or institutional based), study setting, study period, sample size, prevalence, and the selected determinant of child birth fear (adjusted odds ratio with confidence interval) were taken based on the available articles. Then it was exported to STATA version 14.2 for analysis.

Table 1.

Quality assessment of included studies using the JBI critical appraisal checklist for analytical cross-sectional studies

Author	Criteria for inclusion in the sample clearly defined?	Study subjects and the setting described in detail	Exposure (determinant factors) measured in a valid and reliable way	Were objective, standard criteria used for measurement of the condition	Were confounding factors identified	Were strategies to deal with confounding factors stated	Were the outcomes measured in a valid and reliable way	Was appropriate statistical analysis used	Total
Aynalem, et al.	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
Dereje, et al.	Unclear	Yes	Yes	Yes	yes	Yes	Yes	Yes	7
Robera, et al.	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
Chekol, et al.	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
Tiruset, et al.	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8
Abebe et al.	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	8

Publication bias and, statistical analysis

The publication bias was assessed using the funnel plot and Egger’s tests with a p-value of less than 0.05 declared as publication bias [25, 26]. I² statistic was employed to assess heterogeneity among studies and a p-value less than 0.05 was used to declare heterogeneity. As a result of the absence of heterogeneity, the fixed-effects model was used as a method of analysis to estimate the pooled effect. Publication bias was assessed by funnel plot egger`s test, we declared if p- value was statically significant (< 0.05) The effect of selected determinant variables was analyzed using separate categories of meta-analysis. The findings of the meta-analysis were presented using forest plot and Odds Ratio (OR) with its 95% CI. Additionally, we performed a sensitivity analysis to assess whether the pooled prevalence estimates were influenced by individual studies.

Results

Study identification and characteristics of included studies

This systematic review and meta-analysis included published studies on the prevalence of FOCB and its determinants in Ethiopia using international electronic databases. The review found a total of 3,671 published articles. From those, 827 duplicated records were removed and 2,807 articles were excluded through screening of the title and abstracts. After that, a total of 37 full-text papers were assessed for eligibility based on the inclusion and exclusion criteria. Of these, 31 studies were excluded by, primarily because they focused on depression rather than FOCB or were conducted outside of Ethiopia. Ultimately, 6 studies met the criteria and were included in the final quantitative meta-analysis (Fig. 1).

Fig. 1.

Flowchart of study selection for systematic and metanalysis of fear of childbirth and associated factors in Ethiopia

Characteristics of the included studies

Regarding the design of the included studies, all were cross-sectional studies, all of them reported both the prevalence and its determinants of FOCB. The review was conducted among 2,579 women to estimate the pooled prevalence of FOCB. The largest sample size (575) was observed in Amhara region [27] and the study with smallest sample (304) was conducted at west Wellega, Oromia region [18]. All studies were conducted in five regions of Ethiopia. Of these studies, one were from Amhara region [27], two from Southern Nations, Nationalities and Peoples region (SNNPR) [10, 11], one from Addis Ababa [28], one from Oromia [18], and the remained one was from Harar [9] (Table 2).

Table 2.

Characteristics of the included studies on FOCB and its determinants in Ethiopia

Author	Year of publication	Study setting	Type of study	Sample size	Prevalence of FOCB
Tiruset et al.	2020	SNNPR	Institutional based	401	24.5%
Chekol et al.	2024	Amhara	Community based	575	25.5%
Robra et al.	2022	Oromia	Institutional based	304	28.9%
Abebe et al.	2021	Addis Ababa	Institutional based	400	28.25%
Dereje et al.	2023	Harar	Community based	476	23.3%
Aynalem et al.	2020	SNNPR	Institutional based	423	24.2%

Prevalence of fear of childbirth

The meta-analysis of six studies showed that the pooled prevalence of FOCB in Ethiopia was 25.48% (95% CI: 23.77, 27.16). A fixed-effect model was used due to the absence of significant heterogeneity (I² = 1.9%, p-value = 0.404). This suggests that the differences in effect sizes across the studies were minimal and likely attributable to random variation rather than substantial differences in study populations, methodologies, or other factors (Fig. 2).

Fig. 2.

The pooled prevalence of fear of childbirth in Ethiopia

Publication bias

A funnel plot and Egger’s test were employed to assess the presence of potential publication bias. The funnel plot appeared symmetrical, suggesting no significant publication bias. This observation was further statistically confirmed by Egger’s test, which showed a p-value greater than the threshold of 0.05 (p = 0.127). This indicates that there was no evidence of publication bias in the studies included in the meta-analysis (Fig. 3).

Fig. 3.

Funnel plot assessing publication bias for fear of childbirth in Ethiopia

Sensitivity analysis

The sensitivity analysis using the fixed-effects model showed that no single study had an undue influence on the overall estimate of FOCB among Ethiopian women. When each study was individually omitted from the meta-analysis, the pooled prevalence of FOCB remained consistent, ranging from 24.99 to 25.98%. This stability across different scenarios indicates that the overall estimate is robust and not significantly affected by the exclusion of any one study (Table 3).

Table 3.

The sensitivity analysis report of fear of childbirth in Ethiopia

Study omitted	Estimate	95% confidence interval
Tiruset et al. (2020)	25.639713	23.80798 27.471447
Chekol et al. (2024)	25.446341	23.541779 27.350901
Robra et al. (2022)	25.038746	23.259714 26.817778
Abebe et al. (2021)	24.985107	23.168732 26.801481
Dereje et al. (2023)	25.983088	24.110367 27.855806
Aynalem et al. (2020)	25.714792	23.871908 27.557674
Combined	25.458267	23.778659 27.137875

Sub group analysis

A subgroup analysis was conducted to examine the prevalence of FOCB across different regions of Ethiopia. The results of Cochran’s Q statistics support the reliability of the meta-analysis, indicating that the studies were consistent and the effect estimates can be interpreted with confidence interval (p-value between groups = 0.279). There is minimal variation in FOCB prevalence between regions. However, Oromia (28.9%) and Addis Ababa (28.25%) show slightly higher prevalence rates compared to other regions (Fig. 4).

Fig. 4.

Subgroup analysis of fear of childbirth in Ethiopia by region

Determinants of fear of child birth in Ethiopia

This meta-analysis identified three significant factors that contribute to FOCB in Ethiopia (i.e. unplanned pregnancy, previous pregnancy complications and previous labor and delivery complications). These factors are statistically significant in influencing the prevalence of FOCB among Ethiopian women, highlighting the importance of addressing both medical and psychological aspects in maternal care to reduce childbirth-related fears.

Unplanned pregnancy and fear of childbirth

Women with unplanned pregnancies were over four times more likely to experience a higher level of fear of childbirth (AOR = 4.45; 95% CI: 2.68–7.38) compared to those with planned pregnancies (Fig. 5). This suggests that preventing unplanned pregnancies through comprehensive family planning coverage, along with targeted counseling and emotional support, is essential. Such interventions can help women accept their pregnancies and reduce the occurrence of FOCB.

Fig. 5.

The association between unplanned pregnancy and fear of childbirth in Ethiopia

History of previous pregnancy complications and fear of childbirth

Women who experienced complications in previous pregnancies are significantly more likely to develop a fear of childbirth, with over six times (AOR: 6.43, 95%CI: 2.43, 16.98) compared to those with favorable past pregnancy outcomes (Fig. 6). This finding implies that specialized counseling and ongoing emotional support should be provided to pregnant women who faced complications in previous pregnancies. Addressing women’s concerns starting from the first antenatal care visit may be crucial in minimizing FOCB and improving outcomes in the current pregnancy.

Fig. 6.

The association between history of previous pregnancy omplications and fear of childbirth in Ethiopia

History of previous labor and delivery complications and fear of childbirth

A history of complications during labor and delivery markedly increases the likelihood of developing fear of childbirth, with affected women being over six times more likely to experience FOCB compared to those whose previous deliveries were uncomplicated (AOR: 6.05, 95%CI: 3.65, 10.01) (Fig. 7). This finding emphasizes that women who experience unfavorable outcomes in previous pregnancies require special attention throughout their pregnancy journey and during labor and delivery. Providing such support may reduce FOCB and boost women’s confidence in their ability to give birth.

Fig. 7.

The association between history of previous labor and delivery complications and fear of childbirth in Ethiopia

Discussion

This systematic review and meta-analysis found that the pooled prevalence of FOCB was 25.48% (95% CI: 23.77–27.16). This figure aligns with findings from cross-sectional studies conducted in other countries, including Iran, Slovenia, and Australia with reported burden of 25.7%, 25%, and 24%, respectively [29–31]. These consistent findings across these diverse regions highlight that FOCB is a widespread concern for many women. This underscores the importance of developing targeted interventions and conducting further cross-national research to better understand the underlying factors contributing to FOCB and identify effective strategies for treatment.

The prevalence of fear of FOCB found in this study is higher compared to several other countries. For example, a study in Sri Lanka reported a prevalence 16.8% [13], systematic review from nine countries in Europe, Australia, Canada and the United States varied from 6.3 to 14.8% [12],the global estimate of FOC 16.8% [32], in Europe, FOC rates ranging from 4.5% in Belgium to 15.6% in Estonia, and from 7.6% in Iceland to 15.2% in Sweden [33], in Northwest of China 22% [34], in Brazil 12% [35], in Malawi 20% [4], in Sudan 11.1% [36], Portuguese 10% [37]. The higher prevalence of FOCB in our study may be attributed to differences in the study population, geographical factors, and healthcare infrastructure [38–40]. Many of the countries mentioned above provide comprehensive preconception care, which plays a crucial role in preparing women psychologically, economically, and physically for pregnancy and childbirth. This support can help reduce FOCB [41–43]. In contrast, Ethiopia does not yet provide preconception care in a comprehensive manner. Only prenatal care is offered to pregnant women, which may be a key factor contributing to the higher burden of FOCB observed in this study [40].

On the other hand, the prevalence of FOC in our study is lower compared to findings from several other countries. For instance, a systematic review in Turkey reported a prevalence of 62.3%, while another study in Turkey found a rate of 42.4% [44, 45], Similarly, higher rates have been observed in Iran (80.8%) [46], Saudi Arabia 55.33% [47], in Ireland 44.1% [5], Kenya in two different studies (30.1%,58.6%) [48, 49], in India 45.4% [50] and in Changsha, China 43.76% [51]. The variation in FOCB prevalence between our study and the above studies could be due to differences in study populations and settings. For example, the study in China focused on women who had previously given birth via caesarean section (CS), which may contribute to a heightened FCB in the next time. These women might be more concerned about complications related to repeated CS or the possibility of attempting a vaginal delivery after a previous CS, leading to a higher prevalence of FOC compared to our study [6, 38, 52, 53].

This systematic review and meta-analysis revealed that FOCB are four times more common among women with unplanned pregnancies compared to those with planned pregnancies. This finding is consistent with studies conducted in Poland, Iran, Turkey, and in Northwest of China [6, 34, 45, 46]. The reason might be because of, The uncertainty and lack of preparedness associated with an unplanned pregnancy can contribute to increased anxiety and fear about the childbirth process [54, 55].

Women who experienced complications in a previous pregnancy are six times more likely to develop FOCB during their current pregnancy. This finding is supported by studies conducted in Tanzania and India [50, 56]. The increased fear may stem from the anxiety and concern that previous complications could recur or lead to more severe issues in the current or future pregnancies [57]. This review also found that women who experienced complications during labor and delivery are more likely to develop FOCB in subsequent pregnancies. This finding is consistent with studies from Brazil, India, Turkey, Saudi Arabia, Tanzania, and Kenya [35, 47, 50, 56, 58]. The reason for this may be that, traumatic or difficult childbirth experiences can lead to fear of repeating such experiences, resulting in anxiety during subsequent pregnancies [57].

Limitation of the review

The main limitation of this systematic review is that it includes only six studies conducted across five regions of the country. This limited sample size may affect the representativeness of the findings and restrict the generalizability of the conclusions at a national level. Consequently, the results should be interpreted with caution, taking into account the potential for regional variability and the fact that not all areas of the country are represented.

Conclusion

The pooled prevalence of FOCB in Ethiopia is higher compared to reports from other countries. Unplanned pregnancy, a history of pregnancy complications, and previous labor and delivery complications are identified as key factors contributing to FOCB in the country. To reduce FOCB, it is recommended to prevent unplanned pregnancies using multiple strategies, and to provide comprehensive preconception counseling and care, particularly for women who have experienced adverse obstetric outcomes.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Abbreviations

AOR

Adjusted odds ratio

FOCB

Fear of childbirth

CI

Confidence interval

CS

Caesarean section

Author contributions

TNK played a significant part in the protocol development, and conception. TNK and BTT extracted the important data from the eligible papers. Each author contributes to the formal analysis as well as the initial draft’s writing. Then equally contributed to the preparation, editing, and approval of the paper for submission for publication.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.