Abstract
Background:
Fear of childbirth (FOC) during pregnancy is associated with adverse effects on mothers’ and children’s health. Factors related to FOC include physical, psychological, and social aspects. The purpose of the study is to investigate the relationship between FOC and attachment styles and to examine the factors associated with FOC.
Materials and Methods:
This analytical cross-sectional study was carried out using cluster sampling of comprehensive health centers and convenience sampling of individuals from November 21, 2023, to March 20, 2024. The participants were 330 pregnant Iranian women across different trimesters. The questionnaire included Collins and Read’s Revised Adult Attachment Scale and the Wijma Delivery Expectancy/Experience Questionnaire, which was completed online. A t-test and one-way analysis of variance were used to compare the means of variables. Tukey’s post hoc test examined pairwise comparisons. All analyses were conducted using SPSS version 23. p < 0.05 was considered significant.
Results:
The mean (SD) FOC of participants was 56.37 (27.78). The results showed that the average FOC of people with a dismissive-avoidant attachment style was 10 units higher than that of people with a fearful-avoidant attachment style (Mean difference: 10.72, 95% confidence interval [CI]: 0.96–20.49, p = 0.025). Also, FOC was significantly related to income satisfaction (F = 5.16, p = 0.006), unwanted pregnancy (t = 5.88, p = 0.013), others’ role in creating FOC (F = 11.83, p < 0.001), and the supporting person (t = −2.44, p < 0.015).
Conclusions:
Attachment style and psychosocial factors play an important role in shaping FOC. Early identification of these patterns can help healthcare providers support women and promote a positive pregnancy and birth experience.
Keywords: Attachment behavior, fear, parturition, pregnancy, risk factors
Introduction
Pregnant women experience various physical, psychological, and social changes. This enjoyable period is sometimes accompanied by fear of childbirth (FOC).[1] In a meta-analysis, the global prevalence of severe FOC (Tokophobia) in pregnant women without special care was reported as 16% (between 3.7% and 43%), and the prevalence has increased after 2015.[2] The prevalence of FOC varied in Iran from 17.3% in Talesh city to 89.3% in Tuyserkan city.[3] Approximately 30% of pregnant women in Babol city experience FOC, with education, employment, infertility, and psychiatric history as key influencing factors.[4] FOC negatively affects maternal physical and psychological health and is associated with insomnia, elevated cortisol levels, prolonged labor, postpartum depression, anxiety, and post-traumatic stress disorder, delayed or avoidance of subsequent pregnancies, increased instrumental delivery and use of epidural anesthesia, sterilization, and fear of inadequate newborn care.[5] Additionally, FOC may adversely affect infants by weakening maternal-infant bonding, increasing neonatal intensive care unit admissions, reducing birth weight, and impairing emotional and social development.[5,6] Along with factors related to labor and the prenatal period, such as the presence of domestic violence[7] and the lack of social support,[8] the hypothesis of insecure attachment was proposed as a psychological predictor of FOC.[9]
Attachment style is the first way a person communicates with the environment and others from birth and serves as a model for later relationships, shaping expectations and beliefs about oneself and others, which influence social competence and well-being. Attachment style can be secure, anxious, or avoidant. Individuals with secure attachment hold positive views of communication, communicate easily, become readily independent, and do not excessively fear abandonment or social proximity.[8,10] Many studies have examined FOC in relation to maternal-fetal attachment,[11] postpartum depression and post-traumatic stress disorder,[12] labor pain,[13] and the relationship between attachment style and infertility distress.[14] However, in Iran, no study has investigated the relationship between FOC and adult attachment styles of pregnant women, despite research on FOC and maternal-fetal attachment.[15]
The main function of adult attachment is to help maintain people’s calm in stressful situations. In fact, the positive expectations that a person has of others in stressful situations can reduce their stress levels.[6] A secure attachment style enhances women’s self-efficacy during childbirth, and since the birth process is a unique experience for each individual and is strongly influenced by social, cultural, and economic contexts, it is necessary to examine the relationship between FOC and the adult attachment style of pregnant women in Iranian culture.[16] The Turkish study found higher FOC in those with a history of miscarriage or psychiatric illness, and in women with avoidant versus secure attachment.[17] Although previous research suggests a relationship between FOC and insecure attachment style,[17] it has been conducted in other countries, and there is limited evidence on Iranian pregnant women.
Also, attachment theory suggests that early patterns of relationships influence emotion regulation and stress coping, yet few studies have examined their role, along with social and psychosocial factors, in shaping FOC. Understanding these associations in Iranian pregnant women can provide critical cultural insights, help design targeted interventions to reduce FOC, and improve maternal and newborn health. This study was conducted to investigate the relationship between the FOC, attachment styles, and related factors of pregnant women in Iran.
Materials and Methods
This study is a cross-sectional investigation of the relationship between FOC and attachment styles, and also related factors in pregnant women. Between November 21, 2023 and March 20, 2024, the list of pregnant women registered in the electronic systems of comprehensive health service centers was obtained from midwifery experts, using an introduction letter from the research center of Babol University of Medical Sciences. The sample was drawn from comprehensive health service centers in Babol city using a cluster sampling method. Babol city has 30 rural and 10 urban comprehensive health service centers. The centers were divided into four parts: North, South, East, and West. Four densely populated centers (urban-rural) were selected from each geographical area, and finally, people were sampled from 16 urban and rural centers using the convenience method. Midwifery experts at the centers reviewed pregnant women’s electronic records and identified those who met the inclusion criteria. They were reached over the phone, and the objectives of the study were explained to them. If they agreed to participate in the research project, the researcher texted them the link to the online questionnaire (Porsline). A follow-up message was sent a week later to complete the questionnaire. The inclusion criteria for the study were pregnant women aged 18–49 who had at least basic literacy and the ability to use the Internet to complete online questionnaires. Other criteria included willingness to participate in the study, lack of special care during pregnancy or obstetric complications such as diabetes, hypertension, and preeclampsia, and not having a psychiatric illness like anxiety or depression.
The sample size was calculated based on the study objectives, and the largest feasible sample size was selected. Previous studies reported a correlation of r = −0.153 between the total attachment score and FOC. Assuming a two-tailed test, a confidence level of 95% and a study power of 80%, the required sample size was calculated using G*Power version 3. The analysis indicated that a total of 330 participants would be needed.[11]
The information collection form has been compiled in a comparative way and with a review of the literature. The variables are shown in Table 1. Collins and Read’s Revised Adult Attachment Scale (RAAS, 1996)[18] was used. This questionnaire has three subscales: DEPEND, which measures the degree of confidence and reliance of the subject on others; CLOSE, which measures the degree of intimacy and emotional closeness of the subject with others; and ANXIETY, which measures the degree of fear of rejection. The Adult Attachment Scale consists of 18 statements, with respondents indicating their agreement or disagreement on a 5-point Likert scale. Six statements are assigned to each of the subscales. In the 1996 revised version of this questionnaire, the CLOSE subscale includes six statements: 1, 6, 8, 12, 13, 17; the DEPEND subscale consists of six statements: 2, 5, 7, 14, 16, 18; and the ANXIETY subscale includes six statements: 3, 4, 9, 10, 11, 15. Scoring is reversed in statements 2, 7, 8, 13, 16, 17, and 18. To obtain the scores for each subscale, the scores for the related statements are summed and divided by six. Then, the average range of CLOSE and DEPEND is taken. Based on the results, the subjects are placed into one of four attachment style groups: secure, preoccupied, dismissing, or fearful. The retest reliability coefficients for the CLOSE, DEPEND, and ANXIETY subscales have been reported as 0.68, 0.71, and 0.52, respectively (Collins, N.L.).[19] In Iran, the anxiety subscale was the most reliable (0.74), dependence was the least reliable (0.28), and the closeness subscale was moderately reliable (0.52). The results have been consistent with retesting.[20] The Wijma questionnaire on FOC concerns pregnant women’s feelings and thoughts about childbirth and its stages. Each question was answered on a 0–5 Likert scale. The lowest and highest scores (zero and five) correspond to intense thoughts and feelings at the two extremes of the scale. The original version of the FOC questionnaire has one factor and 33 items. Total scores of 85 or higher were considered a FOC. Total scores of 100 or higher indicate a severe FOC.[21] The factors and items of this tool are specified in the narrated article of its Persian version. This study used the Persian version of the FOC Questionnaire (32 items, six factors), with a Cronbach’s alpha of 0.91.[22]
Table 1.
Socio-demographic, psychological, and fertility-related medical history in pregnant participants
| Variable | Group | n (%) |
|---|---|---|
| Age (year) | <35 | 261 (79.10) |
| ≥35 | 69 (20.90) | |
| Educational status | Pre-academic education | 196 (59.40) |
| Academic education | 134 (40.60) | |
| Husband’s Educational status | Pre-academic education | 202 (61.21) |
| Academic education | 128 (38.79) | |
| Occupation | Housewife | 298 (90.29) |
| Employee | 32 (9.69) | |
| House place | Rural | 175 (53.03) |
| Urban | 155 (46.97) | |
| Income satisfaction | Satisfied | 109 (33.03) |
| Relative satisfied | 166 (50.30) | |
| Not satisfied | 55 (16.67) | |
| Duration of marriage (year) | ≤2 | 46 (13.90) |
| 3–5 | 87 (26.40) | |
| ≥6 | 197 (59.70) | |
| Marriage to first pregnancy age (year) | <5 | 262 (79.40) |
| ≥5 | 68 (20.60) | |
| Current Pregnancy age (week) | First trimester | 51 (15.50) |
| Second trimester | 143 (43.30) | |
| Third trimester | 136 (41.20) | |
| Number of child | 0 | 141 (42.73) |
| 1 | 123 (37.27) | |
| >1 | 66 (20.00) | |
| Abortion history | Without abortion | 238 (72.12) |
| with abortion | 92 (27.88) | |
| Delivery history | Without history | 141 (42.73) |
| Normal vaginal delivery | 104 (31.51) | |
| Cesarean section | 85 (25.76) | |
| Pregnancy history | Wanted pregnancy | 259 (78.49) |
| Unwanted pregnancy | 71 (21.51) | |
| Participation in physiological childbirth classes | Yes | 77 (23.30) |
| No | 253 (76.70) | |
| Previous childbirth experience | Without child | 141 (42.70) |
| Good experience | 103 (31.20) | |
| Bad experience | 61 (18.50) | |
| No idea | 25 (7.60) | |
| Role of others in creating your fear of childbirth | Yes | 49 (14.80) |
| No | 168 (50.90) | |
| I do not pay attention | 113 (34.30) | |
| Supportive person | Husband | 167 (50.60) |
| Others | 163 (49.40) | |
| Attachment style | Secure | 79 (23.96) |
| Insecure | 251 (76.14) | |
| Insecure attachment style | Preoccupied | 39 (11.81) |
| Dismissive-avoidant | 104 (31.51) | |
| Fearful-avoidant | 108 (32.72) | |
| FOC | Without FOC | 281 (85.15) |
| With FOC | 49 (14.84) | |
| With FOC | Low FOC | 29 (8.78) |
| Sever FOC | 20 (6.06) |
FOC=Fear of childbirth
To describe the patients’ characteristics using statistical indicators, for quantitative variables with normality assumptions, central indexes (mean and median) and dispersion indexes (standard deviation, minimum, and maximum) were used. Qualitative variables were presented as frequencies (percentages). First, the data were checked for normality using the Kolmogorov–Smirnov test to determine the appropriate statistical tests. The independent samples t-Test was used to compare the equality of two means between qualitative variables with the assumption of the equality of variances. Also, to compare the means of qualitative variables with more than two categories, an analysis of variance (ANOVA) test (one-way ANOVA) was used. Tukey’s post hoc test was used to examine pairwise comparisons. This study used the mean difference and 95% CI to show the effect size and investigate the relationships. Collected data were entered and analyzed using IBM SPSS Statistics for Windows, version 23 (IBM Corporation, Armonk, NY, USA). The significance level was p < 0.05.
Ethical considerations
After obtaining permission to conduct the research from the Deputy of Research and Technology of Babol University of Medical Sciences, obtaining the code of ethics IR.MUBABOL.HRI.REC.1402.112, and by issuing a letter of introduction to the comprehensive health service centers in Babol city, all participants were informed of the research’s purpose and asked to complete an online questionnaire. Informed consent was obtained from those who volunteered to participate in the study.
Result
Demographic features of the participants, fear of childbirth, and attachment style
The mean (SD) of 330 pregnant women was 28.74 (6.28) [Table 1]. The mean (SD) of FOC was 56.37 (27.78). FOC was observed in 49 (14.84%) participants, with 20 (6.06%) experiencing severe fear. A total of 79 (23.96%) of participants had a secure attachment style, and 251 (76.14%) participants had an insecure attachment style. The prevalence of preoccupied, dismissive-avoidant and fearful-avoidant attachment styles of participants were 39 (11.8%), 104 (31.51%), and 108 (32.72%), respectively [Table 1].
The relationship between attachment style and fear of childbirth
This research showed a significant relationship between the FOC and the attachment style of pregnant women (p = 0.029; Table 2). Also, a statistically significant difference was observed between the FOC by comparing dismissive-avoidant and fearful-avoidant attachment styles. The average FOC of people with a dismissive-avoidant attachment style was reported to be 10 units higher than that of people with a fearful-avoidant attachment style (Mean difference: 10.725, 95% Confidence interval [CI]: 0.96–20.49, p = 0.025); [Table 2].
Table 2.
Relationship between FOC score and attachment styles in double comparisons of attachment
| Attachment style | n (%) | Mean (SD) | 95% confidence interval for mean | Value of F | p one-way ANOVA | |
|---|---|---|---|---|---|---|
|
| ||||||
| Lower bound | Upper bound | |||||
| Secure | 79 (23.96) | 58.24 (26.46) | 52.31 | 64.17 | 3.04 | 0.029 |
| Preoccupied | 39 (11.81) | 52.64 (30.63) | 42.71 | 62.57 | ||
| Dismissive-avoidant | 104 (31.51) | 61.82 (28.07) | 56.36 | 67.28 | ||
| Fearful-avoidant | 108 (32.72) | 51.09 (26.57) | 46.02 | 56.16 | ||
|
| ||||||
| Pairwise comparisons | ||||||
|
| ||||||
| Mean difference | 95% Confidence interval | p | ||||
|
| ||||||
| Dismissive–Secure | 3.57 | −7.03 | 14.19 | 0.820 | ||
| Dismissive–Fearful | 10.72 | 0.96 | 20.49 | 0.025 | ||
| Dismissive–Preoccupied | 9.17 | −4.17 | 22.52 | 0.287 | ||
| Secure–Fearful | 7.14 | −3.38 | 17.67 | 0.298 | ||
| Secure–preoccupied | 5.59 | −8.31 | 19.51 | 0.726 | ||
| Preoccupied–fearful | 1.54 | −11.73 | 14.83 | 0.991 | ||
p-value based on ANOVA (One-Way ANOVA) and Tukey’s Post Hoc test for pairwise comparisons. ANOVA=analysis of variance; FOC=fear of childbirth
The relationship between fear of childbirth and demographic/fertility variables
The relationship between FOC and socio-demographic variables is examined in Table 3. The results showed that the average FOC among pregnant women was significantly related to dissatisfaction with income (F = 5.16, p = 0.006), unwanted pregnancy (t = 5.88, p = 0.013), the role of others in creating FOC (F = 11.83, p = < 0.001), and a supportive person in a crisis event (t = −2.44, p = 0.015; Table 3).
Table 3.
Description and comparison of FOC regarding different socio-demographic groups in 330 pregnant cases
| Variable | Mean (SD) | 95% confidence interval for mean | Value of F/t/U | p | |
|---|---|---|---|---|---|
|
| |||||
| Lower bound | Upper bound | ||||
| Age (year) | |||||
| 18–35 | 56.74 (26.83) | 53.47 | 60.01 | 0.47 | 0.636 |
| ≥35 | 54.96 (31.27) | 47.44 | 62.47 | ||
| Educational status | |||||
| Pre-academic | 57.84 (27.38) | 53.84 | 61.84 | 1.16 | 0.244 |
| Academic | 54.21 (26.83) | 49.62 | 58.79 | ||
| Occupation | |||||
| Housewife | 56.19 (27.99) | 53.00 | 59.38 | 0–35 | 0.727 |
| Employee | 58.00 (26.07) | 48.60 | 67.40 | ||
| Husband education | |||||
| Pre-academic | 57.38 (27.49) | 53.57 | 61.20 | 0.83 | 0.405 |
| Academic | 54.77 (28.25) | 49.82 | 59.71 | ||
| House place | |||||
| Rural | 57.21 (26.58) | 53.24 | 61.18 | −0.58 | 0.558 |
| Urban | 55.41 (29.12) | 50.79 | 60.03 | ||
| Income satisfaction | |||||
| Satisfied | 49.47 (26.25) | 44.48 | 54.45 | 5.16 | 0.006 |
| Relative satisfied | 59.58 (26.08) | 55.58 | 63.58 | ||
| Not satisfied | 60.35 (33.18) | 51.37 | 69.32 | ||
| Current pregnancy age | |||||
| First trimester | 53.94 (23.58) | 47.31 | 60.57 | 0.300 | 0.741 |
| Second trimester | 56.20 (28.85) | 51.43 | 60.96 | ||
| Third trimester | 57.46 (28.21) | 52.67 | 62.24 | ||
| Number of child | |||||
| 0 | 56.67 (24.86) | 52.36 | 60.81 | 0.64 | 0.524 |
| 1 | 54.47 (28.96) | 49.30 | 59.64 | ||
| >1 | 59.24 (31.39) | 51.53 | 66.96 | ||
| Abortion history | |||||
| Without abortion | 57.39 (27.53) | 53.87 | 60.91 | 1.07 | 0.282 |
| With abortion | 53.72 (28.38) | 47.84 | 59.60 | ||
| Delivery history | |||||
| Without history | 56.65 (25.41) | 52.42 | 60.88 | 0.70 | 0.497 |
| Normal vaginal delivery | 58.30 (31.11) | 52.25 | 64.35 | ||
| Cesarean section | 53.53 (27.31) | 47.64 | 59.42 | ||
| Pregnancy history | |||||
| Planned pregnancy | 54.37 (26.07) | 51.18 | 57.56 | 5.88 | 0.013 |
| Unplanned pregnancy | 63.63 (32.46) | 55.95 | 71.32 | ||
| Duration of marriage (year) | |||||
| ≤2 | 61.07 (23.09) | 54.21 | 67.92 | 0.98 | 0.375 |
| 3–5 | 53.97 (26.82) | 48.25 | 59.68 | ||
| ≥6 | 56.33 (29.14) | 52.23 | 60.43 | ||
| Distance between marriage to first pregnancy (year) | |||||
| <5 | 55.89 (27.02) | 52.61 | 58.18 | −0.60 | 0.544 |
| ≥5 | 58.19 (30.67) | 50.77 | 65.62 | ||
| Participation in physiological childbirth classes | |||||
| Yes | 51.87 (24.13) | 46.39 | 57.35 | 1.62 | 0.105 |
| No | 57.74 (28.70) | 54.18 | 61.29 | ||
| Previous birth experience | |||||
| Without child | 56.69 (25.23) | 46.34 | 67.18 | 0.11 | 0.954 |
| Good experience | 56.92 (29.44) | 51.17 | 62.68 | ||
| Bad experience | 54.52 (31.50) | 46.46 | 62.59 | ||
| No idea | 56.76 (25.23) | 46.34 | 67.18 | ||
| Role of others in creating your FOC | |||||
| Yes | 73.41 (31.98) | 64.22 | 82.59 | 11.83 | 0.000 |
| No | 54.40 (26.89) | 50.31 | 58.50 | ||
| I do not pay attention | 51.89 (24.43) | 47.34 | 56.45 | ||
| Supportive person | |||||
| Husband | 52.69 (25.86) | 48.74 | 56.65 | −2.44 | 0.015 |
| Others | 60.13 (29.22) | 55.61 | 64.65 | ||
FOC=fear of childbirth
Discussion
The results showed that 49 (14.84%) people had a FOC, and 6% of the participants experienced a severe FOC. Additionally, this research indicated that the average FOC among individuals with a dismissive-avoidant attachment style was reported to be 10 units higher than that of people with a fearful-avoidant attachment style. Factors such as income satisfaction, unwanted pregnancy, the role of others in creating FOC, and the supportive person were identified as related to FOC.
This study provided appropriate information about the prevalence of FOC in Babol. Also, in Turkey, the prevalence of Tokophobia (severe FOC) was reported to be 8.5% in 2024. Consistent with this study, a meta-analysis article reported the prevalence of FOC in women without special care conditions as 16%.[2] In Babol city, the FOC was reported to affect 30% of women during 2019–2020, which may be due to the use of different tools to assess this condition.[4] Similar to this study, another study also found that unintended pregnancy was associated with FOC.[23] Women with unintended pregnancies cite a wide range of reasons for the unwanted pregnancy and are more vulnerable psychologically.[24] Women with unplanned pregnancies were also found to have weaker maternal-fetal attachment.[25]
One factor associated with FOC in this study is people’s satisfaction with their economic conditions. Consistent with this study, other studies have shown that satisfaction with income conditions is related to FOC.[26] Given recent changes in the country’s population policies and lack of access to contraceptive methods, unplanned pregnancies are more likely in women with low household income levels.[27]
This study shows that people who identified their husband as a supportive person have less FOC than those who identified others as supportive. The meta-analysis identified poor social support as a factor associated with FOC.[28] But the fact that the husband was examined separately from others is a strength of this study. This may be because people with better marital adjustment tend to have better psychological stability and less FOC.[29]
In this study, the average FOC of people with a dismissive-avoidant attachment style was reported to be 10 units higher than that of people with a fearful-avoidant attachment style. This relationship may result from insufficient support and a lack of willingness to engage in emotional communication in people with an avoidant attachment style.[29] Contrary to this study, it was stated that people with avoidant attachment styles have more pain tolerance and prefer to use methods such as distraction to reduce labor pain due to their aversion to receiving emotional support. People with the fearful-avoidant attachment style show more distress during times of stress.[30] Consistent with this study, the dismissive–fearful-avoidant attachment style is more prone to depression, post-traumatic stress disorder, and the perception of pain during labor. Increased perception of pain during labor is a risk factor for postpartum depression.[31] It can be hypothesized that the defensive mechanisms of individuals with a fearful-dismissive attachment style may lead to greater perceived psychological support during times of stress. Moreover, since a pregnant woman’s avoidance score can influence her partner’s stress level as a support provider, it is also important to examine the relationship between the partner’s attachment style and the pregnant woman’s FOC.[32] Consistent with this study, a Turkish study showed that people with avoidant attachment had more FOC than other styles. However, in the Turkish study, based on Ainsworth’s Adult Attachment Style Questionnaire, three attachment styles were examined: avoidant, secure, and anxious.[17] In this study, using the Collins Attachment Style Questionnaire, avoidant attachment style was divided into two categories (dismissive and fearful), and attachment style was categorized into four categories (secure, preoccupied, dismissive-avoidant, and fearful-avoidant). Although the researchers of this study aimed to include all urban and rural pregnant women registered in the Babol electronic health system, a limitation was the use of an online method, which excluded individuals without Internet access from participating.
Conclusion
The results of this study indicate a positive relationship between FOC and spousal support; this potential can be harnessed by strengthening the marital and emotional bonds of couples, thus enhancing the health of pregnant women. Therefore, considering the connections between pregnant women’s attachment styles and the supportiveness of their spouses in relation to the FOC, exploring the attachment style of the husband and the pregnant woman’s FOC is a valuable avenue for further research in this area.
Conflicts of interest
Nothing to declare.
Acknowledgments
This project was approved by Babol University of Medical Sciences, Babol, Iran (approval code: 724134586). We thank the participating pregnant women and the midwifery staff at comprehensive health centers for their valuable collaboration in this study.
Funding Statement
Babol University of Medical Sciences, Babol, Iran
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