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. 2026 Oct 30;13(11):e70958. doi: 10.1002/nop2.70958

Association Between Intolerance of Uncertainty and Coping Behaviours Among Pregnant Women With Fear of Childbirth: A Cross‐Sectional Study

Kemeng Ji 1, Zhizhen Li 1, Hui Min 2, Liping Sun 2, Haiyue You 1, Ying Zhao 1,✉
PMCID: PMC13722801  PMID: 42963334

ABSTRACT

Aims

This study aimed to explore the associations among intolerance of uncertainty, childbirth self‐efficacy, fear of childbirth, and coping styles among primiparous women.

Design

A cross‐sectional study.

Methods

This study performed subgroup analysis based on a parent cohort of 532 primiparous women established from October 2022 to November 2023. A total of 294 pregnant women with fear of childbirth were selected from this cohort as participants. Participants completed the Childbirth Attitude Questionnaire (CAQ), Revised Prenatal Coping Inventory (NuPCI), Intolerance of Uncertainty Scale‐9 (IUS‐9), Childbirth Self‐Efficacy Inventory (CBSEI‐C32), and a sociodemographic data sheet. Kruskal–Wallis tests and Mann–Whitney U tests were used to analyse differences in prenatal coping scores across demographic characteristics. Spearman correlation analysis was used to examine the relationships among fear of childbirth, intolerance of uncertainty, childbirth self‐efficacy, and prenatal coping. Finally, Mplus 8.3 was used to test the mediating roles of fear of childbirth and childbirth self‐efficacy in the relationship between intolerance of uncertainty and prenatal coping.

Results

Structural equation modelling showed that intolerance of uncertainty was positively associated with avoidance coping (B = 0.202, β = 0.228, 95% CI [0.068, 0.355]), with fear of childbirth mediating the relationship between intolerance of uncertainty and avoidance coping (B = 0.186, β = 0.210, 95% CI [0.132, 0.314]). Intolerance of uncertainty was not directly associated with planning‐preparation coping but was indirectly negatively associated with planning‐preparation coping through fear of childbirth and childbirth self‐efficacy (B = −0.042, β = −0.040, 95% CI [−0.093, −0.014]). Intolerance of uncertainty was not directly associated with spiritual‐positive coping but was indirectly positively associated with spiritual‐positive coping through fear of childbirth (B = 0.033, β = 0.088, 95% CI [0.009, 0.181]).

Conclusions

No direct association was observed between intolerance of uncertainty and either planning‐preparation coping or spiritual ‐positive coping among pregnant women with fear of childbirth. Pregnant women with higher levels of intolerance of uncertainty exhibited more severe fear of childbirth and greater use of avoidance coping and spiritual‐positive coping.

Implications for the Profession and/or Patient Care

Nurses should focus on the perception of uncertainty regarding childbirth and the coping behaviours adopted by pregnant women with fear of childbirth, assess their cognition about childbirth, and guide them to view childbirth positively, thereby reducing fear of childbirth and enhancing their coping ability for childbirth.

Reporting Method

This study adheres to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for cross‐sectional studies.

Patient or Public Contribution

Pregnant women were surveyed to collect relevant data.

Keywords: coping styles, fear of childbirth, intolerance of uncertainty, pregnant women, self‐efficacy

Abbreviations

CFI

Comparative Fit Index

CI

Confidence Interval

M[IQR]

Medians and Interquartile Ranges

RMSEA

Root Mean Square Error of Approximation

SRMR

Standardized Root Mean Square Residual

TLI

Tucker–Lewis Index

1. Introduction

Women's experiences of pregnancy, labor and birth are multidimensional and can range from joy to anxiety (Wigert et al. 2020). Some pregnant women may experience fear of childbirth as the delivery date approaches, which can have negative impacts on their well‐being (Nieminen et al. 2017). In 1981, Swedish coined the term ‘fear of childbirth’ to describe this anxiety that can impair daily functioning and wellbeing for pregnant women (Areskog et al. 1981). Fear of childbirth is a common mental health issue for pregnant women, characterized by anxiety and fear related to childbirth, such as delivery success, labor pain, perinatal events, medical interventions, maternal and infant health (Dai et al. 2020; Huang et al. 2021; Saisto and Halmesmäki 2003). The prevalence of fear of childbirth varies widely worldwide due to different measurements and cultures. For example, in Australia (Toohill et al. 2014), the prevalence of fear of childbirth in the second trimester was 24.00%, and in Sweden (Persson et al. 2020), it was 28.80% in the third trimester. While in China, using the Childbirth Attitudes Questionnaire, the prevalence was 66.22% (Zhao 2019). In addition to emotional suffering, fear of childbirth during pregnancy is linked to negative birth experiences, worse postpartum psychological status and medical complications such as prolonged delivery time higher rates of birth interventions and caesarean delivery (Adams et al. 2012; Handelzalts et al. 2015; Molgora et al. 2020; Sieber et al. 2006). Therefore, focusing on pregnant women's fear of childbirth and reducing their anxiety about childbirth is essential to promoting maternal mental health and facilitating natural childbirth.

Fear significantly influences an individual's coping styles, defined as behavioural patterns employed to manage stressors (Folkman and Moskowitz 2004). Research (Shackman et al. 2011) indicates that fear can impact attention, problem‐solving abilities and decision‐making, leading to diverse coping responses. Pregnant women experiencing fear of childbirth often adopt different coping strategies (Nilsson et al. 2018). In China, three primary types of childbirth coping styles have been identified: plan‐preparation, avoidance and spiritual‐positive coping (Li 2019). The plan‐preparation coping involves activities such as developing a birth plan, purchasing infant supplies and discussing labor procedures for psychological readiness. The avoidance coping utilizes distraction techniques or topic avoidance to alleviate negative emotions. The spiritual‐positive coping involves seeking spiritual support through practices like prayer (YF, L 2019).

Prior cross‐sectional evidence has documented that adaptive coping strategies are correlated with better cognitive‐emotional responses and higher psychological resilience, which may co‐occur with attenuated stress‐related health concerns among pregnant women (Austenfeld and Stanton 2004). In contrast, maladaptive coping behaviours have been observed to correlate with elevated psychological distress and increased likelihood of poor mental health outcomes (Aldao et al. 2010). Accordingly, exploring the correlational patterns of coping responses in the context of childbirth fear is meaningful for informing targeted clinical intervention strategies that aim to improve maternal psychological status and maternal–infant health.

Intolerance of uncertainty refers to an individual's negative beliefs and reactions toward uncertain situations (Odacı et al. 2022). It has been repeatedly documented to correlate with a range of internalizing psychopathologies, including social anxiety disorder, generalized anxiety disorder, panic disorder, depression, obsessive‐compulsive disorder and eating disorders (Brown et al. 2017; McEvoy and Mahoney 2012). Intolerance of uncertainty significantly influences fear of childbirth (Ji et al. 2023). Childbirth involves numerous unpredictable scenarios for pregnant women, which are often accompanied by negative cognitive appraisals, such as worries about severe labor pain, adverse delivery outcomes, fetal distress, or fetal death (Christiaens and Bracke 2007). These negative cognitions fuel fear of childbirth. Furthermore, intolerance of uncertainty is differentially correlated with distinct coping patterns (Mishel 1990). Existing empirical evidence supports cross‐sectional associations of intolerance of uncertainty with both proactive and passive coping tendencies (Wang et al. 2023). The Uncertainty in Illness Theory proposes that individuals who appraise uncertainty as threatening tend to display avoidant behavioural tendencies, whereas those who interpret uncertainty as challenging or opportunistic are more likely to adopt approach‐oriented coping responses (Mishel 1990). In addition, intolerance of uncertainty is closely correlated with self‐efficacy beliefs (Ji et al. 2023). Previous study has reported that higher intolerance of uncertainty levels co‐occur with lower childbirth self‐efficacy (Luo et al. 2026). Primiparas with low uncertainty tolerance tend to endorse catastrophic appraisals of unknown childbirth‐related scenarios, which are correlated with reduced confidence in labor management (Ji et al. 2023).

Self‐efficacy describes individuals' subjective beliefs regarding their ability to accomplish specific tasks and cope with challenging situations (Salles 2017). Self‐efficacy is closely correlated with coping patterns and behavioural decision‐making in stressful contexts (Jacobs et al. 2020). Individuals with higher self‐efficacy tend to report stronger perceived control over potential threats, greater confidence in problem‐solving and more proactive coping tendencies (Bandura 2001). Childbirth self‐efficacy specifically reflects pregnant women's perceived competence in managing the childbirth process (Lowe 1993). Empirical studies have observed childbirth self‐efficacy is associated with positive and negative emotions during pregnancy: higher childbirth self‐efficacy tends to co‐occur with more positive emotions and fewer negative emotions (Minamida et al. 2020). Consistent with prior findings, there is a negative cross‐sectional association between fear of childbirth and childbirth self‐efficacy; that is, pregnant women with higher fear of childbirth tend to concurrently show lower levels of childbirth self‐efficacy (Dwiarini et al. 2022).

In summary, exploring correlational patterns regarding pregnant women's coping responses to fear of childbirth requires a comprehensive examination of the cross‐sectional associations among intolerance of uncertainty, childbirth self‐efficacy, childbirth fear and coping behaviours. Accordingly, this study proposes the following hypotheses:

Hypothesis 1

Fear of childbirth is associated with intolerance of uncertainty and coping styles. Fear of childbirth accounts for an indirect association between intolerance of uncertainty and coping styles.

Hypothesis 2

Childbirth self‐efficacy is associated with intolerance of uncertainty and coping styles. Childbirth self‐efficacy accounts for an indirect association between intolerance of uncertainty and coping styles.

Hypothesis 3

Fear of childbirth and childbirth self‐efficacy together account for the serial indirect cross‐sectional association between intolerance of uncertainty and coping behaviours.

Therefore, this cross‐sectional study aimed to explore the associations among intolerance of uncertainty, fear of childbirth, childbirth self‐efficacy and prenatal coping styles in pregnant women. The findings may provide valuable insights for developing targeted antenatal counselling interventions.

2. Methods

2.1. Aims

This study aimed to explore the associations among intolerance of uncertainty, childbirth self‐efficacy, fear of childbirth, and coping styles among primiparous women.

2.2. Design

A cross‐sectional study was conducted from October 2022 to March 2023. The STROBE checklist was used to guide the reporting of this study.

2.3. Samples and Setting

A convenience sample of pregnant women was recruited from a local tertiary hospital in Shanghai, China. Potential participants were approached during their clinic visits and invited to join the study. Inclusion criteria were: (1) singleton, primiparous pregnancy; (2) gestational age of 13 weeks or more; (3) a score of ≥ 28 on the Childbirth Attitude Questionnaire (CAQ); and (4) willingness to participate, confirmed through written informed consent. Exclusion criteria included a history of schizophrenia or intellectual disability, severe physical illness, pregnancy complications, or comorbidities during pregnancy.

2.4. Data Collection

This study performed subgroup analysis based on a parent cohort of 532 primiparous women established from October 2022 to November 2023 (Ji et al. 2024). Instead of re‐analysing the full cohort data, we strictly screened and included 294 primiparas with childbirth fear as the exclusive study sample for the current research. Sample size was determined via a formal a priori power analysis conducted using G*Power 3.1. This power analysis was based on the multiple regression rather than specifically powering the indirect effect (Faul et al. 2009). With a medium effect size (f 2  = 0.15), an alpha level of 0.05, a statistical power of 0.80 (Cohen 1988) and 16 independent variables, the calculated minimum sample size was 143 participants. Therefore, the sample of 294 pregnant women with fear of childbirth is sufficient for the data analyses of this study.

2.5. Instruments

2.5.1. Sociodemographic Data

The sociodemographic data sheet included age, gestational week, educational level, marital status, work status, average monthly household income, unplanned pregnancy or not, pregnancy with complications or not, take medication during pregnancy or not and sources of childbirth information.

2.5.2. Fear of Childbirth

Fear of childbirth was assessed using the 16‐item Childbirth Attitude Questionnaire. Each item is scored on a scale from 1 to 4, with total scores ranging from 16 to 64. Higher scores indicate more severe fear of childbirth. The scale is divided into four dimensions: fear of baby safety, fear of labor pain, fear of losing control and fear of environment. Total scores are categorized as follows: none (16–27), mild (28–39), moderate (40–51) and severe (52–64). The Chinese version has demonstrated good reliability and validity, with Cronbach's α of 0.88 (Zhang 2016).

2.5.3. Prenatal Coping Style

Prenatal coping style was assessed using the 30‐item Chinese version of the Revised Prenatal Coping Inventory (NuPCI) (Li 2019). Each item is scored on a scale from 0 to 3, with higher scores indicating more frequent use of the coping style. The scale is divided into four dimensions: planning‐preparation‐psychology (7 items), planning‐preparation‐knowledge (7 items), avoidance (12 items) and spiritual‐positive coping (4 items). The Cronbach's α of the revised total scale was 0.92, and each dimension was 0.77–0.93. In accordance with the three dimensions defined in the original scale (Hamilton and Lobel 2008) and other translated versions (Penengo et al. 2020; Shobeiri et al. 2018), the present study combined the dimensions of planning‐preparation‐psychology and planning‐preparation‐knowledge into a single dimension of planned‐preparation to facilitate subsequent data analysis and result interpretation. Internal consistency of NuPCI in this survey also showed good (Cronbach's α = 0.87), planned‐preparation was 0.85, avoidance was 0.77 and spiritual‐positive coping was 0.60.

2.5.4. Intolerance of Uncertainty

The study assessed intolerance of uncertainty by the 9‐item Intolerance of Uncertainty Scale (IUS‐9) (H. P. Wang 2021). Each item scores on a 5‐point scale of 1 to 5, with a total score ranging from 9 to 45. Higher scores indicate greater intolerance of uncertainty. The Chinese version of the IUS‐9 has demonstrated good internal consistency and construct validity, with a Cronbach's α of 0.91 in this study.

2.5.5. Childbirth Self‐Efficacy

This study assessed childbirth self‐efficacy by the 32‐item Childbirth Self‐Efficacy Inventory (CBSEI‐C32) (Ip et al. 2008). Each item scores on a 10‐point scale of 1 to 10, with a total score ranging from 32 to 320. Higher scores indicate greater perceived childbirth self‐efficacy. The scale demonstrated good reliability (Cronbach's α = 0.92–0.97), with subscales showing strong internal consistency (Cronbach's α = 0.98 for the total scale, 0.97 for Outcome Expectancy, and 0.97 for Efficacy Expectancy).

2.6. Data Analysis

Data analyses were conducted using SPSS version 27.0 and Mplus version 8.3. First, participants' demographic characteristics were summarized as frequencies and percentages. Second, scores for fear of childbirth, intolerance of uncertainty, childbirth self‐efficacy and prenatal coping were presented as medians and interquartile ranges (M[IQR]). As the prenatal coping scores were not normally distributed, differences in prenatal coping scores across demographic characteristics were analysed using the Kruskal–Wallis test and Mann–Whitney U test. Spearman correlation analysis was used to examine the relationships among the four variables: fear of childbirth, intolerance of uncertainty, childbirth self‐efficacy and prenatal coping. Finally, Mplus version 8.3 was employed to assess the mediating roles of fear of childbirth and childbirth self‐efficacy in the relationship between intolerance of uncertainty and prenatal coping. The study utilized maximum likelihood estimation with a bootstrap sample size of 5000. Bootstrapped confidence intervals (CIs) were used to determine the significance of indirect effects, with significance inferred when the upper and lower bounds of the CIs did not include zero. The bootstrap method approximates the population distribution using the empirical distribution, allowing for parameter estimation and confidence interval construction without relying on data normality assumptions, making it particularly suitable for handling skewed or non‐normal distributions (M. C. Wang 2014). The statistical significance level was set at α = 0.05.

3. Results

3.1. Descriptive and Bivariate Statistics

As shown in Table 1, 82.99% of the pregnant women were under 34 years of age, while 17.01% were 35 years or older. Regarding gestational age, 36.05% were less than 28 weeks pregnant, and 63.95% were at or beyond 28 weeks of gestation. The majority of the women had a bachelor's degree (52.04%) and were married (98.99%). Additionally, 65.65% were employed, and 40.81% had a monthly household income of ¥15,000 (approximately US $2500) or higher (per capita). Among the pregnant women who experienced fear of childbirth, 217 cases (73.81%) had mild fear, 61 cases (20.75%) had moderate fear of childbirth, and 16 cases (5.44%) had severe fear of childbirth. The medians and interquartile ranges for intolerance of uncertainty, fear of childbirth, childbirth self‐efficacy, planning‐preparation coping, avoidance coping and spiritual‐positive coping were 17.00 (8.00), 35.00 (9.00), 221.50 (72.00), 29.00 (8.00), 18.00 (7.00) and 10.00 (4.00), respectively. Statistically significant differences in planning‐preparation coping scores were found across different gestational weeks (p = 0.040), and spiritual‐positive coping scores differed significantly by work status (p = 0.039).

TABLE 1.

Differences in coping scores across demographic characteristics (N = 294).

Variables n(%) Planning‐preparation coping Avoidance coping Spiritual‐positive coping
M(IQR)
Age(years)
< 34 244 (82.99) 29.00 (8.00) 18.00 (8.00) 10.00 (4.00)
≥ 35 50 (17.01) 30.50 (8.25) 19.00 (6.00) 11.00 (3.00)
p 0.130 0.358 0.223
Gestational Week
< 28 106 (36.05) 28.00 (7.25) 18.00 (8.00) 10.00 (4.00)
≥ 28 188 (63.95) 30.00 (8.75) 18.00 (7.00) 10.00 (4.00)
p 0.040 0.675 0.997
Education
Below bachelor 64 (21.77) 28.50 (9.75) 19.00 (8.00) 10.00 (4.00)
Bachelor 153 (52.04) 30.00 (8.00) 18.00 (7.00) 10.00 (4.00)
Master degree or above 77 (26.19) 30.00 (10.50) 17.00 (7.00) 10.00 (4.00)
p 0.329 0.375 0.545
Relationship
Unmarried 3 (1.02) 33.00 (/) 29.00 (/) 12.00 (/)
Married 291 (98.99) 29.00 (8.00) 18.00 (7.00) 10.00 (4.00)
p 0.122 0.154 0.092
Work status
Employed 193 (65.65) 30.00 (8.00) 18.00 (8.00) 10.00 (3.00)
Not employed 101 (34.35) 29.00 (8.50) 18.00 (7.00) 10.00 (4.00)
p 0.617 0.574 0.039
Per capita monthly household income (RMB)
5000–9999 93 (31.63) 28.00 (10.00) 18.00 (7.00) 10.00 (4.00)
10,000–14,999 81 (27.55) 30.00 (7.00) 19.00 (7.00) 10.00 (3.00)
≥ 15,000 120 (40.81) 30.00 (8.00) 17.00 (9.00) 10.00 (4.00)
p 0.150 0.313 0.710
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Note: Bold values indicate statistical significance (p < 0.05).

3.2. Relationships Between Fear of Childbirth, Intolerance of Uncertainty, Childbirth Self‐Efficacy and Prenatal Coping

Among the women, fear of childbirth was negatively correlated with childbirth self‐efficacy (r = −0.184, p < 0.01) and positively correlated with intolerance of uncertainty (r = 0.412, p < 0.001), planning‐preparation coping (r = 0.116, p < 0.05), and avoidance coping (r = 0.408, p < 0.001). Furthermore, significant correlations were observed between intolerance of uncertainty and both childbirth self‐efficacy (r = −0.134, p < 0.05) and avoidance coping (r = 0.360, p < 0.001). Additionally, the study identified significant associations between childbirth self‐efficacy and both planning‐preparation coping (r = 0.230, p < 0.001) and spiritual‐positive coping (r = 0.168, p < 0.001) (Table 2).

TABLE 2.

Correlations between fear of childbirth, prenatal coping, intolerance of uncertainty and childbirth self‐efficacy (N = 294).

Variables M(IQR) 1 2 3 4 5 6
1. Fear of Childbirth 35.00 (9.00) 1
2. Intolerance of Uncertainty 17.00 (8.00) 0.412*** 1
3. Childbirth Self‐Efficacy 221.50 (72.00) −0.184** −0.134* 1
4. Planning‐Preparation Coping 29.00 (8.00) 0.116* 0.011 0.230*** 1
5. Avoidance Coping 18.00 (7.00) 0.408*** 0.360*** −0.040 0.339*** 1
6. Spiritual‐Positive Coping 10.00 (4.00) 0.101 0.036 0.168** 0.442*** 0.322*** 1
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*p < 0.05, **p < 0.01, ***p < 0.001.

3.3. Mediation Analysis

In this study, the coping styles of pregnant women were categorized into three groups: planning‐preparation coping, avoidance coping and spiritual‐positive coping. Structural equation models were constructed to examine the effects of intolerance of uncertainty, fear of childbirth and childbirth self‐efficacy on these coping styles. Demographic factors showing significant differences in coping scores (gestational week, work status) were included as control variables. The model fit indices were as follows: RMSEA = 0.054, SRMR = 0.057, CFI = 0.966, TLI = 0.948, χ2/df = 1.851, indicating acceptable model fit.

As shown in Figure 1, intolerance of uncertainty was positively correlated with fear of childbirth (B = 0.068, β = 0.525, p < 0.001) and avoidance coping (B = 0.202, β = 0.228, p = 0.001). Fear of childbirth was negatively correlated with childbirth self‐efficacy (B = −7.117, β = −0.264, p = 0.002), and positively correlated with spiritual‐positive coping (B = 0.484, β = 0.168, p = 0.033) and avoidance coping (B = 2.737, β = 0.400, p < 0.001). Childbirth self‐efficacy was positively correlated with planning‐preparation coping (B = 0.087, β = 0.287, p < 0.001). Intolerance of uncertainty had no significant correlation with planning‐preparation coping (B = 0.018, β = 0.017, p = 0.824), spiritual‐positive coping (B = 0.012, β = 0.031, p = 0.668), or childbirth self‐efficacy (B = −0.246, β = −0.071, p < 0.368). Fear of childbirth was not correlated with planning‐preparation coping (B = 1.460, β = 0.178, p = 0.052). Childbirth self‐efficacy showed no correlation with spiritual‐positive coping (B = 0.015, β = 0.138, p = 0.104) and avoidance coping (B = 0.011, β = 0.042, p = 0.500).

FIGURE 1.

FIGURE 1

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Serial Multiple Mediation Role of Intolerance of Uncertainty and Prenatal Coping in The Association Between Childbirth Self‐Efficacy and Fear of Childbirth. Solid lines represent statistically significant paths, whereas dashed lines represent statistically non‐significant paths. Standardized Beta Values Are Reported.

The structural equation model showed that the total (B = 0.380, β = 0.428, 95% CI [0.295, 0.548]), direct (B = 0.202, β = 0.228, 95% CI [0.068, 0.355]), indirect (B = 0.178, β = 0.201, 95% CI [0.129, 0.298]) effect of intolerance of uncertainty on avoidance coping was statistically significant. The indirect effect of intolerance of uncertainty on avoidance coping was statistically significant through fear of childbirth (B = 0.186, β = 0.210, 95% CI [0.132, 0.314]). Although the total, direct and indirect effects of intolerance of uncertainty on planning‐preparation coping and spiritual‐positive coping were not statistically significant, intolerance of uncertainty was statistically significantly associated with planning‐preparation coping through the serial mediation of fear of childbirth and childbirth self‐efficacy (B = −0.042, β = −0.040, 95% CI [−0.093, −0.014]), and was statistically significantly associated with spiritual‐positive coping through fear of childbirth (B = 0.033, β = 0.088, 95% CI [0.009, 0.181]). Standardized path coefficients are shown in Figure 1, and the direct, indirect and total effects are presented in Table 3.

TABLE 3.

Estimates of the direct structural paths.

Effect pathway B SE 95% CI p β
Planning‐Preparation Coping Intolerance of Uncertainty → Fear of Childbirth→ Planning → Preparation Coping 0.099 0.052 0.005, 0.210 0.072 0.093
Intolerance of Uncertainty → Childbirth Self‐Efficacy → Planning‐Preparation Coping −0.022 0.024 −0.076‐0.018 0.390 −0.020
Intolerance of Uncertainty → Fear of Childbirth→ Childbirth Self‐Efficacy → Planning‐Preparation Coping −0.042 0.018 −0.093, −0.014 0.026 −0.040
Total 0.053 0.062 −0.067, 0.173 0.419 0.050
Direct 0.018 0.074 −0.126, 0.165 0.824 0.017
Total indirect 0.035 0.052 −0.065, 0.141 0.520 0.033
Avoidance Coping Intolerance of Uncertainty → Fear of Childbirth→Avoidance Coping 0.186 0.045 0.132, 0.314 < 0.001 0.210
Intolerance of Uncertainty → Childbirth Self‐Efficacy →Avoidance Coping −0.003 0.008 −0.036, 0.004 0.071 −0.003
Intolerance of Uncertainty → Fear of Childbirth→ Childbirth Self‐Efficacy → Avoidance Coping −0.005 0.010 −0.031, 0.008 0.542 −0.006
Total 0.380 0.065 0.295, 0.548 < 0.001 0.428
Direct 0.202 0.071 0.068, 0.355 0.001 0.228
Total indirect 0.178 0.042 0.129, 0.298 < 0.001 0.201
Spiritual Coping Intolerance of Uncertainty → Fear of Childbirth→ Spiritual‐Positive Coping 0.033 0.044 0.009, 0.181 0.043 0.088
Intolerance of Uncertainty → Childbirth Self‐Efficacy → Spiritual‐Positive Coping −0.004 0.016 −0.061, 0.007 0.533 −0.010
Intolerance of Uncertainty → Fear of Childbirth→ Childbirth Self‐Efficacy → Spiritual‐Positive Coping −0.007 0.014 −0.059, 0.000 0.161 −0.019
Total 0.034 0.058 −0.024, 0.199 0.118 0.090
Direct 0.012 0.072 −0.109, 0.175 0.668 0.031
Total indirect 0.022 0.043 −0.020, 0.149 0.168 0.059
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Note: Bold values indicate statistical significance (p < 0.05).

Abbreviations: β, standardized path coefficient; B, unstandardized path coefficient; CI, confidence interval; SE, standard error.

4. Discussion

This study included 294 pregnant women with fear of childbirth and found that these women reported higher levels of intolerance of uncertainty and avoidance coping, and lower childbirth self‐efficacy, than the general pregnant population (Ji et al. 2024). This finding is consistent with previous studies. Rondung et al. (Rondung et al. 2019) reported that intolerance of uncertainty were correlates of fear of childbirth. Han et al. (Han et al. 2022), in a study of Chinese pregnant women, similarly reported that intolerance of uncertainty and negative coping styles were significant risk factors for fear of childbirth, whereas women who adopted positive coping strategies had lower levels of fear of childbirth. In the present study, planning–preparation coping scores differed significantly across gestational weeks (p = 0.040).This finding is consistent with the temporal dynamics of psychosocial adaptation during pregnancy reported in previous studies (Lin and Chou 2008). The gestational difference in planning–preparation coping may reflect adjustments in pregnant women's cognitive investment in childbirth preparation as childbirth approaches. Another finding of this study was that positive spiritual coping scores differed significantly by employment status (p = 0.039), with employed pregnant women scoring higher on positive spiritual coping. Previous research (Peñacoba‐Puente et al. 2013) has also shown that employment status is associated with coping behaviours. Research indicates (Jannah et al. 2026), that spiritual resources help individuals cope with stressful life events by providing a sense of meaning, hope and support; during pregnancy, these resources may help women reframe their experiences of uncertainty, thereby reducing emotional distress. For women who simultaneously take on occupational and pregnant roles, spiritual coping may help them maintain psychological stability amid the intersection of work stress and childbirth uncertainty. Therefore, antenatal care services should prioritize the early identification of the psychological and behavioural characteristics of pregnant women with fear of childbirth. Tailored support strategies may be considered for women at different gestational weeks and with different employment statuses to guide them toward appropriate coping behaviours and help maintain their psychological adjustment.

In this study, intolerance of uncertainty was not directly associated with positive coping styles among pregnant women. However, intolerance of uncertainty was indirectly and negatively associated with positive coping behaviours through fear of childbirth and childbirth self‐efficacy. This finding is consistent with previous research (Ji et al. 2024). Nevertheless, possibly because other indirect pathways did not reach statistical significance, neither the total effect nor the total indirect effect of intolerance of uncertainty on positive preparation coping was significant. However, the non‐significant total effects should not obscure the mediating roles of fear of childbirth and childbirth self‐efficacy in the relationship between intolerance of uncertainty and positive preparation coping behaviours. The intolerance of uncertainty theoretical framework proposed by Carleton et al. (Carleton 2012) emphasizes that intolerance of uncertainty does not directly produce specific emotions or behaviours; rather, it exerts its effects indirectly by influencing individuals' cognitive appraisals of uncertain situations, such as threat perception and worry beliefs. These findings suggest that nurses should pay attention to pregnant women with cognitive vulnerability. By correcting their cognitions regarding uncertainty, nurses may alleviate fear of childbirth, enhance childbirth self‐efficacy and help pregnant women reinterpret childbirth uncertainty as a challenge that can be prepared for and managed rather than an inevitable threat. Specific strategies include childbirth rehearsal (Şimşek Çetinkaya et al. 2026), digital storytelling of peers' childbirth experiences (Mahdavi et al. 2025).

The present study also found that intolerance of uncertainty was not directly associated with positive spiritual coping, consistent with previous research. Previous studies have found (Howell et al. 2018), that positive spiritual coping was not significantly associated with intolerance of uncertainty, whereas negative spiritual coping (e.g., feeling abandoned by God or dissatisfaction with one's religious community) was significantly positively associated with intolerance of uncertainty. This suggests that when spiritual coping manifests as ‘struggle’ or ‘doubt’, it is associated with higher intolerance of uncertainty. Other studies also support (Aryeh et al. 2021), that the associations of negative beliefs about God with intolerance of uncertainty and anxiety mainly stem from such negative cognitions. Furthermore, fear of childbirth mediated the relationship between intolerance of uncertainty and positive spiritual coping; that is, intolerance of uncertainty was positively associated with pregnant women's positive spiritual coping behaviours through fear of childbirth. A qualitative study of Iranian primiparous women directly corroborates this: among the identified coping strategies, ‘resorting to spirituality’ was explicitly listed as one of the strategies used by pregnant women to overcome fear of childbirth (Yoosefi Lebni et al. 2021). This may be because fear of childbirth is a highly aroused state of emotional distress that may prompt pregnant women to adopt spiritual coping strategies to seek meaning or relieve distress (Öçal and Çetinkaya 2026). In other words, positive spiritual coping is not directly driven by uncertainty; rather, it is mobilized after fear is aroused as an attempt to cope with distress, seek comfort and restore a sense of control.

Although this study did not observe direct associations of intolerance of uncertainty with positive preparation coping or positive spiritual coping among pregnant women with fear of childbirth, it found that intolerance of uncertainty was directly associated with negative coping, with fear of childbirth mediating this relationship. This finding is consistent with previous research on the relationship between intolerance of uncertainty and negative coping (Han et al. 2022). A study has shown (Carnahan et al. 2022), that elevated intolerance of uncertainty is closely associated with subsequent avoidance coping and anxiety. Research has also shown (Sahib et al. 2024), that intolerance of uncertainty is often accompanied by higher threat perception and lower perceived control, making problem‐focused coping less likely to be adopted, while negative strategies such as avoidance and emotion‐focused coping are more heavily relied upon to temporarily alleviate anxiety. For pregnant women, childbirth involves both high uncertainty and low perceived control, making those with higher levels of intolerance of uncertainty more likely to report greater fear of childbirth; the distress triggered by fear may further reinforce avoidance behaviours, making avoidant coping appear to be a viable coping strategy.

These findings suggest that clinical nurses should attend to intolerance of uncertainty in pregnant women with fear of childbirth and assess the specific content of their concerns about childbirth uncertainty and their threat appraisals. Intolerance of uncertainty may prompt pregnant women to adopt predominantly emotion‐focused coping strategies, such as avoidance and prayer. Although such strategies may provide temporary emotional relief, they are unlikely to resolve practical childbirth‐related problems. Therefore, based on this assessment, nurses should help pregnant women identify their core problems and psychological difficulties, mobilise available resources and implement interventions targeting the stressors, thereby reducing their uncertainty and fear of childbirth.

5. Limitations

Despite these significant contributions, it is necessary to acknowledge several limitations of the present study. First, the dataset used in this study was obtained through convenience sampling, which may introduce selection bias and limit the generalizability of the findings. Second, all data were collected via self‐reported questionnaires at a single time point, which may lead to common‐method bias. Third, the cross‐sectional study design prevents the determination of temporal ordering among variables; therefore, all identified associations should be interpreted as correlational rather than causal, and no causal inferences or mechanistic explanations can be drawn. Additionally, the study did not include multiparous women, who differ significantly from primiparous women in terms of childbirth experience and psychological state. This omission may affect the comprehensiveness of the study results. Future research should adopt longitudinal designs to verify potential temporal and causal relationships, employ random sampling to reduce selection bias and expand the sample coverage to include multiparous women and pregnant women with pregnancy complications, so as to further validate the generalizability of the findings. Nevertheless, considering that primiparae account for the majority of Chinese parturient women and childbirth fear is a prevalent psychological concern during pregnancy that closely correlates with maternal mental health and childbirth outcomes, the results of this study can still provide valuable references for primiparous maternal health management and lay a foundation for subsequent related research and clinical practice.

6. Conclusions

This study examined the current status of intolerance of uncertainty, childbirth self‐efficacy and coping styles among pregnant women with fear of childbirth. The results showed that pregnant women with fear of childbirth generally exhibited higher levels of intolerance of uncertainty and avoidance coping, as well as lower levels of childbirth self‐efficacy. In addition, planning‐preparation coping differed across gestational weeks; employed pregnant women had significantly higher levels of spiritual‐positive coping than non‐employed pregnant women. Structural equation modelling showed that pregnant women's intolerance of uncertainty was not directly associated with planning‐preparation coping or spiritual‐positive coping. However, higher levels of intolerance of uncertainty were associated with more avoidance coping. Furthermore, intolerance of uncertainty also influenced pregnant women's avoidance coping and spiritual‐positive coping through fear of childbirth. Therefore, assessing pregnant women's uncertainty about childbirth and correcting erroneous childbirth‐related cognitions are important for promoting maternal mental health and improving coping behaviours.

7. Implications for Nursing Practice

Based on the findings of this study, the maladaptive coping styles exhibited by pregnant women with fear of childbirth are closely related to their intolerance of uncertainty regarding childbirth and the severity of fear of childbirth. Nursing staff can provide stratified and individualized psychological care according to pregnant women's uncertainty tolerance status, gestational stage and employment status. In clinical practice, attention should be paid to the uncertainty‐related cognitive characteristics and negative coping tendencies of pregnant women with fear of childbirth, and intolerance of uncertainty, childbirth self‐efficacy and fear of childbirth should be incorporated into routine prenatal psychological assessment to enable early identification of high‐risk pregnant women with poor psychological adjustment. Nurses should consider the dynamic changes during pregnancy and provide stage‐specific childbirth preparation guidance for pregnant women at different gestational weeks, tailored to their current cognitive status and preparation needs. For employed pregnant women, their favourable spiritual coping resources can be fully utilized to guide them in combining problem‐focused positive coping strategies to stabilize their psychological state during pregnancy. For pregnant women with poor uncertainty tolerance and a tendency toward avoidant coping, nursing interventions should focus on correcting negative avoidance behaviours, reducing purely emotional coping and strengthening actual childbirth preparation behaviours and adaptive coping skills. In addition, differentiated prenatal psychological support programs should be implemented in clinical practice, with targeted health guidance and psychological interventions based on individual characteristics, to improve the overall psychological adjustment of pregnant women with fear of childbirth and enhance the quality of prenatal psychological care.

Author Contributions

Kemeng Ji: writing – original draft, investigation, methodology, writing – review and editing. Zhizhen Li: data curation, writing – original draft, investigation. Hui Min: investigation, supervision, resources. Liping Sun: investigation, supervision, resources. Haiyue You: investigation, writing – original draft. Ying Zhao: conceptualization, methodology, writing – original draft, writing – review and editing, funding acquisition, resources, supervision.

Funding

This study was funded by the office of global partnerships (key projects development fund). The funder had no role in study design, data collection, data analysis, or the decision to publish or prepare the manuscript.

Disclosure

Statistical Statement: One of the authors (Kemeng Ji) has received formal training in statistics and was responsible for the statistical analysis in this study. The authors confirm that the statistical methods used were appropriate for the study design and data, and that the results were correctly interpreted.

State Statement: This study conducted a subgroup analysis based on a parent cohort of 532 primiparous women recruited from October 2022 to November 2023. Rather than re‐analysing the full cohort data, the present study strictly screened 294 primiparas with childbirth fear as the exclusive research sample. A previously published study utilized the full 532‐participant dataset to perform latent class analysis on the coping patterns of childbirth fear among primiparas, examining both women with and without childbirth fear. In contrast, the current study only focused on the coping behaviours of primiparas with childbirth fear. Structural equation modelling was adopted to explore the influencing pathways of intolerance of uncertainty, childbirth fear, and childbirth self‐efficacy on coping behaviours among pregnant women with childbirth fear. Therefore, the present study is completely distinct from the previously published work in terms of research objectives, study population, statistical methods, and research conclusions. No duplicate publication exists in this manuscript.

Ethics Statement

This study was formally approved by the Ethics Committee of Obstetrics and Gynaecology Hospital of Fudan University (Approval No.: 2022101, approval date: August 1, 2022). Prior to formal investigation, all eligible pregnant women were fully informed of the study purpose, research procedures, voluntary participation principle, and the right to refuse participation or withdraw from the study at any time without any penalty. Strict anonymity and confidentiality of personal information were guaranteed for all participants. Written informed consent was obtained from each participant before questionnaire data collection.

Consent

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Appendix S1: STROBE Statement—Checklist of items that should be included in reports of cross‐sectional studies.

NOP2-13-e70958-s001.docx (31.1KB, docx)

Acknowledgements

The authors would like to thank all the pregnant women who participated in this study and the medical staff who assisted with data collection. We also acknowledge the support from the Obstetrics departments of the participating hospitals.

AI Statement: During the manuscript preparation, auxiliary language polishing and grammatical optimization were performed with the assistance of artificial intelligence tools. All study design, statistical analysis, result interpretation, and core manuscript writing were independently completed by the authors. The authors take full responsibility for the integrity, accuracy, and originality of all content in the final manuscript.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request. The data are not publicly available due to privacy or ethical restrictions.

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Associated Data

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

Supplementary Materials

Appendix S1: STROBE Statement—Checklist of items that should be included in reports of cross‐sectional studies.

NOP2-13-e70958-s001.docx (31.1KB, docx)

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request. The data are not publicly available due to privacy or ethical restrictions.

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