Fear of childbirth and its relationship with the attitude toward child bearing: A descriptive-analytical study

Abstract

BACKGROUND AND PURPOSE:

With regard to the importance of fear of childbirth, negative consequences, its impact on fertility, and the differences in the prevalence and related factors in different regions of Iran, this study was conducted with the aim of determining the status of fear of childbirth and its relationship with attitudes toward fertility in women of childbearing age in the city of Kermanshah.

MATERIALS AND METHODS:

This descriptive-analytical study was conducted on 600 married women referring to comprehensive health service centers in Kermanshah. The sampling method was multistage random sampling. The data collection tools included a demographic profile form, a questionnaire on childbirth expectations and experiences/attitudes toward fertility and childbearing, which were completed by the participants. The data were analyzed using statistical tests.

FINDINGS:

The overall prevalence of fear of childbirth is 69.055%, and its subgroups are classified as mild (0.33), moderate (17.30), severe (66.83), and clinical (2.67) based on the fear of childbirth questionnaire scores in this study. The results also indicate an inverse relationship between the two variables of fear of childbirth and attitude toward childbearing (P < 0.05).

CONCLUSION:

According to the results of the study, there is a significant level of fear of childbirth in women of reproductive age, and it is significantly related to attitudes toward the concept of childbearing. It is suggested that strategies be developed to manage the fear of childbirth.

Introduction

Fear of childbirth is a health challenge for pregnant women that manifests as worry and anxiety before pregnancy, throughout the entire pregnancy, and during childbirth, accompanied by mild to moderate physical complications and psychological disorders.[1,2] Fear of childbirth leads to a greater perception of pain and a negative experience of childbirth.[3] When this anxiety or fear of dying during childbirth is very intense, a phobia arises known as Tocophobia.[1,2] Fear acts as a risk factor for the birth experience, so the greater the fear, the greater the risk of having a worse birth experience.[4]

Most women, especially first-time mothers, experience reasonable fear due to unfamiliarity with the birth process.[5] This fear is naturally controlled during pregnancy and childbirth.[5] The prevalence of fear of childbirth (FOC) worldwide among low-risk women has been reported at 16%[6]; furthermore, the prevalence of fear of childbirth, based on a review of 15 studies conducted in different cities of Iran from 2007 to 2021, varied between 17.3% (Talesh) and 30.89% (Toyserkan).[7] The percentage of prevalence of fear of childbirth in various articles and clinical research within the same timeframe differs, and this is the result of using different questionnaires in this field and their varying scoring criteria.[8]

The etiology of fear of childbirth is complex and multifaceted, often relating to various psych demographic and psychological factors including a history of previous sexual abuse, traumatic past childbirth experience, history of previous miscarriage, long-standing infertility history, smoking, lack of adequate social support, poor communication skills with a partner, domestic violence, unintended pregnancy, lack of trust and concern about unpleasant behaviors of the obstetric care providers, fear of being left alone in labor, mother’s noninvolvement in clinical decision-making, and lack of attention from health staff to the mother’s autonomy in her treatment and childbirth process.[9]

Maternal fear and anxiety due to the release of catecholamines result in ineffective and prolonged labor pains, poor uterine muscle function, irritability, and restlessness in the child; it has also been observed in studies that irrational fear manifests as daily anxieties, nighttime nightmares, and noticeable physical symptoms, often leading to the mother’s request for elective cesarean section.[10,11,12] Studies have shown that fear of childbirth is one of the important reasons for choosing cesarean delivery without obstetric indication.[13] Consequently, the choice of cesarean delivery to escape the fear and pain of natural childbirth can have negative effects on the mother’s health and her future pregnancies.[10,11,12] Sometimes, severe fear of childbirth leads to avoidance of pregnancy and a negative attitude toward childbearing.[14,15]

According to the theory of planned behavior, attitude is the first factor in shaping reproductive behavior and has an internal state that affects selected behavior and values; moreover, reproductive behavior is influenced by attitude toward childbearing, subjective norms regarding the desire for children, and the individual’s perception of their ability to engage in reproductive behavior.[16,17] A positive attitude toward childbearing is a prerequisite for the intention to have children.[18] Changes in attitudes toward childbearing are not solely due to economic issues and the costs of childbearing, but the complexity of various dimensions of the issue and the influencing factors create a different perspective on this topic.[19,20]

In a study that examined the willingness to have children in Iran, only 31.8% of participants expressed a desire for childbearing, and the results indicate a significant decline in fertility rates compared to the past five decades.[21] The issue of declining fertility rates in various regions of the world depends on various demographic factors and women’s attitudes toward childbearing in that society.[22] One of the most important influential factors in this regard is the presence of social and religious beliefs in that society; such that one of the factors that can play a positive role in individuals’ attitudes toward reproductive behavior is religiosity, which can lead to an increase in the population trend among different ethnicities.[23] In recent years, the decline in fertility rates in several countries, including Iran, has become one of the demographic problems that has drawn the attention of policymakers in the field of reproductive health, and all population policies have been focused on promoting childbearing; however, it seems that despite the reform of reproductive policies compared to past decades, there has not been a significant change in women’s attitudes toward childbearing.[24]

Despite the fact that fear of childbirth and its negative consequences on pregnancy can be a significant barrier to women’s childbearing, studies conducted in Iran on women of reproductive age have identified social and economic factors as the most important barriers to childbearing[25]; while individual and obstetric factors, particularly fear of childbirth, have been less emphasized in such research or have not been specifically addressed, and in cases where they were studied, they led to contradictory results. Furthermore, the studies conducted so far have not been updated based on demographic differences in society and their resulting impacts. Therefore, considering the importance of fear of childbirth, its multiple negative consequences, and its effect on women of reproductive age’s attitudes toward childbearing, as well as the differences in the prevalence and related factors in different regions of Iran,[7] this study was conducted with the aim of determining the status of fear of childbirth and its relationship with attitudes toward childbearing among women of reproductive age in Kermanshah city in 2023–2024.

Materials and Methods

Study design and setting

The present study is descriptive-analytical in nature. The research population included married women of childbearing age (15–49 years) who had visited comprehensive health service centers in Kermanshah city in 2023–2024.

Study participants and sampling

In this study, a multistage random sampling method was used. First, Kermanshah city was divided into three areas based on the information obtained from the Kermanshah health center: low-income (4 health centers), semiaffluent (14 health centers), and affluent (6 health centers) in social and economic terms. Then, the number of health care centers in each area was determined, and the sample size was taken proportionally to the population covered in each area. To this end, two centers each were randomly selected through a lottery method from the low-income and affluent areas, and 4 centers from the semiaffluent area (a total of 8 centers) from the list of comprehensive health centers in Kermanshah city. After visiting the selected centers, the researcher extracted the list of married women aged 15–49 who met the study criteria using the information from the Health Electronic Information system, and with the help of health monitors, and systematically selected eligible individuals. They were invited to the health center by phone to complete the questionnaire and enter the study.

The inclusion criteria for the study included informed consent to participate in the study, married women of childbearing age (15–49 years), no known previous mental illness, having fertility capability (no infertility), and literacy adequate for reading and writing. The exclusion criterion was incomplete completion of the questionnaires.

To determine the sample size based on previous studies,[7] considering a prevalence of fear of childbirth at 50%, an error of 5%, and a precision of 4%, a sample size of 600 individuals was needed for estimating the outcome of interest. According to the health center information of Kermanshah County, the population of married women of reproductive age between 15 and 49 years in the underprivileged area was 18,077, in the semiprivileged area 71,063, and in the privileged area 30,179. Therefore, the sample size proportionate to the population was estimated to be 74 individuals in the underprivileged area, 403 individuals in the semiprivileged area, and 123 individuals in the privileged area.

d = 0/04

P = 0/050 × 0/04

Data collection tools and technique

1. Individual Information Form: This form includes individual and demographic questions about participants such as the age of the woman and her partner, education level of the woman and her partner, household monthly income, employment status of the woman and her partner, number of pregnancies, number of live children, number of deliveries, children’s gender, type of delivery, duration of marriage, and housing status.

2. Wijma Delivery Expectancy/Experience Questionnaire: This questionnaire contains 33 questions and 6 factors, including lack of positive prediction, fear, lack of self-efficacy, loneliness, fear of fetal injury, and lack of control, which are measured using a six-option Likert scale (never to always). To calculate the score of each subscale, the scores of each item related to that subscale are summed up, and to calculate the overall score of the questionnaire, all item scores are summed together. The score range for this questionnaire was between 0 and 165. A score of 37 or less indicates “mild fear”, a score of 38–65 indicates “moderate fear”, and a score of 66–84 indicates “severe fear”. In studies conducted, the reliability of the fear of childbirth tool during pregnancy was reported as 0.78, and the Cronbach’s alpha coefficient was calculated in the study by Andaroon et al.[26] for this questionnaire was estimated to be above 0.7. In Mortazavi’s study, which examined the validity and reliability of this tool, the reliability of this tool was 0.925, with reliability reported as equal to or above 0.869 in all domains.[27]

3. Questionnaire “Scale of Attitude Towards Fertility and Childbearing”: The Attitude Scale Towards Fertility and Childbearing (AFCS) has three constructs (the importance of fertility for the future, childbearing as an obstacle in the present, and social identity) and 27 items that are scored on a five-point Likert scale ranging from “strongly agree” to “strongly disagree”. A higher score indicates a more positive attitude toward fertility and childbearing. The psychometrics of this tool were carried out by Ba’ezat et al.[28] in 2015. The Persian version of this tool contains 23 items and four constructs, named as the first construct “child as a cornerstone of life”, the second “child as an obstacle”, the third “postponing fertility to the future”, and the fourth “fertility requiring the realization of prerequisites”. The reliability of the subscales, measured using Cronbach’s alpha coefficient, ranged between 0.74 and 0.76, and the overall reliability of the scale was obtained as 0.79, indicating the desirable reliability of the Persian version of this questionnaire and its factors. Scoring of this questionnaire is based on a five-point Likert scale from strongly agree (5), agree (4), neutral (3), disagree (2), to strongly disagree (1), with a higher score indicating a more positive attitude toward fertility and childbearing. The minimum and maximum scores are 23 and 115, respectively.

Data analysis

The data were analyzed using STATA software version 14. For descriptive analysis of quantitative variables, the indices of mean and standard deviation, as well as qualitative and grouped data, were reported in terms of frequency and percentage. To determine the prevalence of fear of childbirth, the ratio of the number of women identified based on the Wijma Delivery Expectancy/Experience Questionnaire to the total number of women studied was calculated. Considering that attitude was examined quantitatively, linear regression was used at a significance level of 0.05 to determine the relationship between fear of childbirth and other variables with attitude (the dependent variable under study).

Ethical consideration

This study was approved by the ethics review board of the Vice-chancellor for Research Affairs of Kermanshah University of Medical Sciences (IR.KUMS.REC.1402.246), and all the methods were used according to the relevant guidelines and regulations or the Declaration of Helsinki. The informed consent form was obtained from all the subjects and/or their legal guardian(s).

Results

In this study, 600 eligible married women with an average age of 31.50 ± 7.35 years participated. The average fear of childbirth was estimated to be 69.55 ± 8.021 based on the classification of the childbirth fear questionnaire and the expectations of childbirth according to the Wijma Delivery Expectancy/Experience Questionnaire, with the status of fear of childbirth as follows: mild (0.33), moderate (30.17), severe (66.83), and clinical (2.67).

According to the research findings, there is no significant correlation between the quantitative demographic variables of the age of the woman and her spouse, monthly income, and duration of marriage with the fear of childbirth (P > 0.05) [Table 1].

Table 1.

Frequency distribution of fear of childbirth based on demographic and fertility variables of the study

Variables		Average (standard deviation)								Statistical test		P
		Mild 0–37		Moderate 38–65		Severe 66–84		Clinical 85<
Women’s age		38 (9.89)		36.12 (8.06)		31.61 (7.01)		31.93 (7.31)		0.72		0.540
Husband’s age		41 (7.07)		36.12 (8.20)		36.18 (7.56)		36.87 (7.24)		0.30		0.824
Monthly income		10 (14.14)		15.17 (8.82)		15.53 (9.15)		18.5 (10.17)		0.90		0.440
Duration of marriage		11 (12.72)		10 (7.35)		9.99 (6.55)		10.25 (6.84)		0.02		0.995

In the study of the relationship between qualitative demographic variables and fear of childbirth, the findings showed that there was no significant relationship between qualitative demographic variables, such as women’s education and occupation, as well as their spouse’s education and housing status, with fear of childbirth (P > 0.05). However, there was a significant relationship between the qualitative variable of spouse›s occupation and fear of childbirth (P < 0.05). Additionally, a significant relationship existed between qualitative fertility variables like the number of childbirths, number of living children, and their gender with fear of childbirth (P < 0.05), while no significant relationship was found between the type of childbirth, history of abortion, and number of pregnancies with fear of childbirth (P > 0.05)

Based on the simple linear regression model regarding the number of children, the relationship between not having children and having two or more children, with the variable of fear of childbirth, is significant. However, it should be noted that the average fear of childbirth among mothers who have no children or are single is less than that of mothers with two or more children. Additionally, the fear of childbirth in individuals who had a cesarean delivery was, on average, 0.02 higher than that of individuals with a natural delivery, although this is not significant. With an increase in the number of pregnancies (b = −0.43) and also with an increase in women’s educational level (b = +0.66), the average fear of childbirth decreases and increases, respectively, although the relationship is not significant [Table 2].

Table 2.

Determining the relationship between fertility and demographic variables with the variable fear of childbirth based on the simple linear regression model

Variables		Average Difference		Average Difference		P		Confidence interval 95%
								Lower limit		Lower limit
Women’s employment		−0.756		0.519		0.146		−1.777		0.63
Women’s education		0.667		0.416		0.110		−0.151		1.485
Number of pregnancies		−0.435		0.355		0.221		−1.134		0.263
Number of living children
Not having children		−6.625		2.265		0.004		−11.074		−2.176
Only child		−0.986		0.996		0.323		−2.942		0.970
Two or more children		−2.044		1.017		0.045		−4.042		−0.046
Type of delivery
Natural delivery		4.931		2.180		0.024		0.649		9.213
Cesarean section		0.024		0.729		0.973		−1.409		1.475

Based on the simple linear regression model, considering other variables in the model, the average attitude toward childbearing and fertility among individuals whose spouse had a freelance job was higher than that of employees’ spouses, although this correlation was not statistically significant. On the other hand, with the increase in the average income of the samples, the attitude score toward childbearing and fertility decreased and became negative. With the increase in the average age and education of the women studied, the level of attitude toward fertility and childbearing decreased, although this relationship was not statistically significant for the variable of women’s education level [Table 3].

Table 3.

Determining the relationship between fertility and demographic variables with the scale of attitudes toward fertility and childbearing based on the simple linear regression model

Variables		Average Difference		Average Difference		P		Confidence interval 95%
								Lower limit		Lower limit
Women’s age		−0.422		0.220		0.056		−0.856		0.010
Husband’s age		0.215		0.208		0.303		−0. 194		0.625
Women’s education		−1.158		1.136		0.309		−3.390		1.074
Monthly income		−1.183		0.082		0.570		−5.724		2.906
Marriage duration		−1.413		2.245		0.529		−5.824		2.997
Husband’s job
General work		14.676		6.271		0.020		2.359		26.999
Employee		13.076		6.608		0.048		0.0975		26.054

According to the findings of the Pearson correlation analysis of demographic quantitative variables, there was a significant relationship between the age of women and monthly income with regard to childbearing (P < 0.05). However, there was no significant relationship between the two quantitative variables of the duration of marriage and the spouse›s age with regard to childbearing (P > 0.05).

The analysis of variance test shows that there was no significant relationship between variables such as education level and women’s occupation, as well as education level and spouse’s occupation, and housing status with attitudes toward childbearing (P > 0.05). There was also a significant relationship between the number of pregnancies, number of births, number of living children, gender of children, and type of delivery with attitudes toward childbearing (P < 0.05), but no significant relationship was found between the history of miscarriage and attitudes toward childbearing (P > 0.05) [Figure 1].

Figure 1.

Determining the relationship between the prevalence of fear of childbirth and the attitude scale toward childbearing in women of childbearing age in Kermanshah city in 2023

This scatter plot shows that there is an inverse relationship between the two independent and dependent variables of the study (fear of childbirth and attitude toward childbearing and fertility), such that as the level of fear of childbirth increases, the attitude scale toward childbearing becomes more negative, to the extent that as the fear of childbirth score increases, the score on the attitude toward fertility and childbearing decreases (P < 0.05).

Discussion

In the present study, the results showed that the average fear of childbirth in the surveyed women was 69.055 ± 8.021, which was categorized into subgroups based on the scoring of the fear of childbirth questionnaire used in the study as follows: mild (0.33), moderate (30.17), severe (66.83), and clinical (2.67). Meanwhile, in the systematic review study by Moradi et al.[7] (2022), aimed at determining the prevalence of fear of vaginal childbirth in Iran, the results indicated that the prevalence of fear of childbirth varied between 17.3% and 89.30%, with the lowest prevalence of fear of childbirth reported in Talesh (17.3%) and the highest in Tuyserkan (89.30%). Furthermore, the prevalence of fear of childbirth with mild intensity ranged from 22% to 39.07%, the prevalence with moderate intensity ranged from 19.6% to 54%, and the prevalence with high intensity ranged from 6% to 59%, which is somewhat different from the results of the present study. This discrepancy is more evident in clinical fear of childbirth, where only 2.67% of women in our study fell into this group. In the study by Shahbakhti et al.,[1] aimed at determining the prevalence of tokophobia worldwide, the prevalence of tokophobia among 18 different countries was reported to be 14%, which shows a significant difference compared to the global statistics and the findings of the present study. In another cross-sectional study conducted in Eastern Ethiopia by Dereje et al.[29] on 476 participating pregnant women, the results indicated that 25% of them had fear of childbirth. The results obtained from the searched studies do not align with the present study. Perhaps the unique social and cultural characteristics of the communities, the differing methodologies of the two mentioned studies, the age distribution of the sampling, and also the differences in the time frame of the studies conducted compared to the present research are among the important reasons for this discrepancy in the estimated prevalence of fear of childbirth.

Based on the research findings, there is a significant and inverse relationship between demographic variables such as the number of births, the number of living children, the gender of the children, and the occupation of the spouse with the level of fear of childbirth. It was reported that as the number of births and living children in the research samples increased, the fear of childbirth scores decreased. The current study also showed that there was no significant relationship between the age of the woman, the level of education of the woman and her spouse, the woman’s occupation, history of miscarriage, and fear of childbirth. The study by Taheri et al.,[30] which aimed to investigate the causes of fear of childbirth among 130 women in Shahrekord, demonstrated that fear of childbirth had a significant inverse relationship with the number of births, such that as the number of births in women increased, their fear of childbirth scores decreased. Furthermore, there was no significant relationship between the variables of the woman’s age, the level of education, and her occupation, which aligns with the current study. In this regard, a study by Isbir et al. (2024), which examined the causes of fear of childbirth among 2025 pregnant women in Turkey, showed that there was a significant inverse relationship between the economic status and employment of the family, particularly the spouse, and the fear of childbirth.[31] It was found that the more stable and higher the spouse’s employment status was reported, the lower the fear of childbirth in women, which is consistent with the current study.[31] Meanwhile, in the review study by Donnell (2019), which investigated the causes of tokophobia, the results indicated that having a history of miscarriage is one of the main causes of tokophobia,[9] which contradicts the findings of the current research. It is expected that having a history of repeated miscarriages would naturally create particular concern and fear regarding the health of the current fetus for pregnant women. However, the relationship between the independent and dependent variables of fertility status, fear of childbirth, and history of miscarriage may be meaningless, depending on the target group of the study and the questionnaire used. In this study, among married women who were not pregnant, the variable of miscarriage did not act as a factor creating fear of childbirth. In the current study, there was a significant relationship between the gender of the children and fear of childbirth, such that women who had a son had a higher average fear of childbirth score, whereas this aspect has not been examined or mentioned in any of the studies conducted on the causes of fear of childbirth so far.

From other results of the study, the average attitude toward parenthood (59.237) with a standard deviation of 20.269 and a minimum score of 23 and a maximum of 112 can be mentioned. In the present study, there was a significant relationship between demographic variables such as type of delivery, gender of children, age of women, income, number of pregnancies, number of deliveries, and number of living children with attitude toward parenthood. The results also showed that there was no significant relationship between variables such as the level of education and occupation of women, history of miscarriage, as well as the education and occupation of the spouse, housing status, and duration of marriage. However, the results of the study by Mobasheri et al.[32] aimed at investigating the most important factors affecting the fertility pattern of families with only one child or no children conducted on 180 married women in Kord city indicated that there was a direct significant relationship between the attitude score toward parenthood and age, age at marriage, duration of cohabitation, and education, which contradicts the present study. This aligns with the findings of the present study. In addition, the study by Dabiri et al., conducted in 1401 with the aim of determining the relationship between mothers’ satisfaction with prenatal and intrapartum care and their willingness to have more children, which was performed on 423 eligible women referring to comprehensive health service centers in Bandar Abbas city, showed that there is a positive correlation between the variables of willingness to have children, the woman’s age, and the gender of the children, and these results are also consistent with the present study.[33] One of the main reasons for this discrepancy in results can be attributed to the changing attitudes of women over different times and the demographic differences in the samples studied in the two studies. In the study by Motlagh et al.,[34] which examined the factors affecting fertility preferences among Iranian ethnic groups, the findings indicated that gender and number of children had a significant relationship with individuals’ attitudes toward parenthood, such that individuals had a greater tendency to have a male child in their subsequent pregnancies, and also, the more the number of living children in a family increased, the lesser the women’s tendency toward subsequent pregnancies became, which aligns with the findings of the present study. In the present research, women with a single male child (28.50%) showed less desire for future fertility, while women with a single female child (31%) showed more inclination, indicating the presence of a nearly uniform cultural pattern among different Iranian ethnic groups.

In the study by Miyata et al. (2017) that investigated the phenomenological scale of attitudes toward fertility and childbearing in Japanese women, results showed that income levels and economic factors are among the most important factors influencing attitudes toward childbearing, in such a way that individuals with low to moderate income levels had less desire for future pregnancies.[19] Various domestic studies have also pointed to economic and family income factors as significant barriers to childbearing,[32] while in the present study, individuals with high income and stable economic and employment conditions (54.90%) had less desire for fertility and childbearing in the future. These results may be due to a shift in individuals’ lifestyles toward modernity and the emergence of new thought patterns in the post-modern world, leading to changes in women’s and society’s attitudes toward fertility and childbearing.

The results of the present study showed that there is an inverse and significant relationship between the level of fear of childbirth and women’s attitudes toward childbearing, such that the higher the fear of childbirth, the lower the score of attitude toward childbearing. In this regard, the study by Xu et al.,[35] which aimed to determine the relationship between fear of childbirth and attitudes toward fertility and childbearing among graduate students at Central China College, found that only 38.8% of the total students expressed their desire to have children, and also students who did not want or were uncertain about having children showed higher levels of fear of childbirth compared to other students. In 2013, Stoll et al.[36] conducted a study aimed to determine the attitudes and preferences of young women with low and high fear of childbirth in Canada, the results of their study showed that students with high fear of birth described childbirth as a frightening and painful ordeal and viewed midwifery interventions as a means to further manage labor and birth. Students with low fear framed birth as a natural event and viewed interventions more critically. The results of this study align with the present study and have the most content consistency among the reviewed studies, despite the fact that the target groups of the two studies are different. However, they had relatively similar results, and it is also worth mentioning that other research conducted on this topic has not directly addressed the relationship between these two significant variables, and this aspect is considered one of the strengths of the present research and one of the reasons for its innovation.

Conclusion

The results of the present study indicate a direct relationship between the level of fear of childbirth in women of childbearing age and their attitudes toward childbearing and fertility. Considering these results, reducing the level of fear of childbirth in the group of women of childbearing age could lead to an improvement and enhancement of their attitudes toward childbearing in the future. Therefore, utilizing the findings of the present study in designing interventions by reproductive health specialists and senior midwifery consultants could be effective in reducing and managing fear, as well as increasing the pleasantness of the childbirth process. This, in turn, would lead to an increase in population growth and fertility rates, as well as an improvement in women’s attitudes toward childbearing in the future society. The design of these interventions could also play a role in planning and providing maternity services in this area and assist specialists in the field of midwifery counseling in enhancing effective, specialized counseling services for women of childbearing age.

Ethical statement

The Ethics Committee of Kermanshah University of Medical Sciences (IR.KUMS.REC.1402.246) approved the protocol of this study. All participants gave written informed consent to participate in the study. All methods were performed in accordance with the guidelines and regulations.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

This research was conducted with financial support from Kermanshah University of Medical Sciences, Kermanshah, Iran (4020480). The funder had no role in the study design, data collection, analysis, interpretation of data, writing of the manuscript, or in the decision to submit the article for publication.