With increasing global efforts made to decrease the rate of cesarean sections and increase the popularity of natural childbirth among women, psychological issues, such as fear of childbirth, should be addressed more than ever before (1). Fear of childbirth (FOC) is an unpleasant and prevalent condition that negatively affects a part of pregnant women’s emotions and undermines the normal process of physical and mental changes that occur during this period. Fear is usually accompanied by stress and emotional maladjustments (2). This type of fear may be rooted in many factors like fear of labor pain and fear of harming the infant or may have a psychological origin, such as anxiety or fear of becoming a mother (3). Studies conducted in different countries have investigated the fear of childbirth in pregnant women and reported various figures (e.g., the FOC was reported to be 50%, 10%, and 5% in the US, Finland, and Switzerland, respectively) (1). In Iran, according to a study done by Matinnia et al., 48.2% of women had a severe fear of childbirth, 62% of whom asked for a cesarean section due to this fear (4). Avoiding natural childbirth and asking for a cesarean section (5,6), anxiety (7), sleep disorder (1), postpartum depression (8), and a reduction in breastfeeding (9) are among the complications of fear of childbirth.
Furthermore, while good mental well-being has a positive impact on people’s performance, poor mental well-being leads to emotional problems and a decrease in quality of life. Maternal prepartum and postpartum depression and anxiety are the most common mental disorders in the period (10). A systematic review has shown that the prevalence of depression in pregnant women has increased from 6.5% to 12.9% (11). Anxiety was prevalent among 39% of these women (12). Preterm labor, a decrease in breastfeeding, and mother-infant communication disorder can be mentioned among the complications of depression and anxiety (13).
Fatigue is another prevalent complaint (87-96%) among pregnant women, especially from month 7 till month 9 of pregnancy (14). It may be caused by sleep disturbances, particularly in the third trimester, and can be associated with problems, such as heartburn, fetal movements or discomfort at night (15). Some evidence suggests that fatigue is correlated with stress, depression, anxiety, and impaired quality of life and these complications may be associated with preterm labor or fetal or mental development (16,17). Fatigue is also one of the predisposing factors for cesarean section (18).
Given the importance of having a healthy pregnancy for mothers to promote maternal and neonatal health, considering the physical and mental conditions of mothers seems essential. Fatigue and mental well-being are two important issues in the field of pregnant women’s health. Few studies have examined the relationships of the mentioned factors with fear of childbirth. Fenwick states that a decrease in maternal emotional health is related to an increase in FOC (19). On the other hand, despite the prevalence of fatigue in pregnancy, except for a study conducted by Hall et al. (1), no other studies reported the relationship between fatigue and fear of childbirth. Moreover, fatigue may be a factor in the occurrence or intensification of fear of childbirth. In this regard, this study aimed to examine the severity of fatigue and the level of mental well-being in pregnant women and their relationships with fear of childbirth.
Materials and Methods
This descriptive cross-sectional study was carried out following by a correlational design. It had a statistical population including all pregnant women referred to Sabzevar healthcare centers and related health bases in 2017. The sample consisted of 525 pregnant women who referred to Sabzevar comprehensive healthcare centers. Sampling and performing the current study initiated after being confirmed by the Research Ethics Committee of the Sabzevar University of Medical Sciences, explaining the main objectives of carrying out this study, and obtaining written consent from the pregnant women. A cluster sampling method was applied; as a result, Sabzevar was divided into 4 districts considering the 16 healthcare centers and bases in this city. Two centers were randomly selected from each district. Then, samples were chosen from each center according to the number of pregnant women referred to that center and based on the Integrated Health System (known as SIB in Persian).
Inclusion criteria were Persian language, residency of Sabzevar, maternal age of 18 to 35 years, pregnant women with healthy, alive, and single fetus, mental health (their mental health statuses were examined by asking about the history of psychiatric drug use in the demographic characteristics form), and literacy. Exclusion criteria included current or previous medical illnesses, obvious fetal abnormalities, substance, psychotropic drug use, and stimulant abuse, drug addiction, alcohol consumption, exposure to adverse events and stressful situations 6 months before carrying out the study, and history of infertility.
One of the data collection tools used in this study was a demographic characteristics form that consisted of items examining demographic and midwifery characteristics. Moreover, the Delivery Expectancy Questionnaire (WDEQ-A) designed by Wijma et al. was used to assess fear of childbirth (20). This questionnaire has 33 items and the answers to these items are scored based on a 6-point Likert-type scale. The answers vary from 0 (completely disagree) to 5 (completely agree). The minimum score is 0 and the maximum score is 165. A score lower than 85 indicates no significant childbirth fear, a score between 85-100 shows a moderate level of childbirth fear and a score above 100 shows a severe level of childbirth fear (21). The validity and reliability of the Persian version of the Wijima Delivery Expectancy Questionnaire (WDEQ-A) were confirmed by Mortazavi (2017). The reliability of this questionnaire was examined by Cronbach’s alpha coefficient and was 0.93 (22).
The 5-item World Health Organization Well-Being Index (WHO-5; 1998) was used to evaluate a subject’s well-being and mental health status. This index measures positive well-being over the past 2 weeks by asking 5 self-reported items and based on a Likert-type scale ranging from 0 (never) to 5 (always). The final score is in the range of 0 (minimum well-being) to 100 (maximum well-being). Scores equal to or greater than 50 indicate positive well-being and scores lower than 50 reveal a state of depression (23).
The original version of this index has been translated into several languages including Persian by the WHO Psychological Research Center. Using Cronbach’s alpha coefficient, Mortazavi et al. examined the validity and reliability of this questionnaire (α=0.85) in pregnant women (24).
Besides, the Multidimensional Assessment of Fatigue (MAF) scale was used to measure fatigue. This scale was first designed and introduced by Belza (1990) (25). The MAF scale has 14 items that examine the degree of fatigue (item 1), the severity of fatigue (item 2), the level of distress caused by fatigue (item 3), the level of interference with daily activities (items 4-14), and the frequency of fatigue (items 15-16). The items 1 to 14 are scored based on a 10-point Likert-type scale ranging from never (0) to very high (10) and the items 15 and 16 are designed in four options. The final score, i.e., the overall fatigue index, is calculated from 1 (minimum fatigue) to 50 (maximum fatigue). The validity of the Persian version of this scale was examined by Mortazavi et al. A study determined the convergent construct validity of this scale with the Fatigue Severity Scale (r=0.74) and the Mental Well-Being Index and assessed its reliability in pregnant women using Cronbach’s alpha coefficient (α=0.93) (26). Its internal consistency was calculated by Cronbach’s alpha coefficient which was 0.93. After entering the data into SPSS 16 (SPSS Inc., Chicago, Illinois, USA), the data were analyzed and described by using descriptive statistics, independent t-test, and Pearson correlation coefficient.
These pregnant women’s mean age was 27.3±5.5 years. 8.4% of these women were younger than 20 years old and 29.5% were older than 30 years old. 42.4% of the pregnant women who participated in the current study were nulliparous. 41.7% of these women were in their first trimester and 36.8% of them were in their second trimester. 80% of the subjects scored less than 85 on the Wijima questionnaire, 19% of them scored higher than 85, and 6% of them scored above 100. 24.8% of these women scored lower than 50 on the Well-being index and the mean fatigue index was 20.3±12.7.
The results indicated that the mean scores of overall fatigue and mental well-being were calculated and then their relationships with severe and very severe levels of fear were assessed. The independent t-test showed a significant difference between the mean scores of fatigue in the two groups of fear with a cut-off point of 85 (P<0.001) and severe pain with a cut-off point of 100 (P=0.001). Furthermore, there were significant differences between the mean scores of well-being at the two cut-off points of fear of childbirth (i.e., 85 and 100) introduced by Wijma (P=0.003 and P=0.019, respectively). Table 1 represents the distribution of means and standard deviations of fatigue and mental well-being scores in terms of fear and severe fear.
Among other investigations conducted in this study was examining the relationship of the subscales of the Persian version of the Wijma Delivery Expectancy Questionnaire (WDEQ-A) with the scores of fatigue and mental well-being, the results of which are shown in Table 2 in the form of correlation coefficients. Pearson’s correlation coefficient was calculated by calculating the correlation matrices between the subscales of the Persian version of this questionnaire with the fatigue and mental well-being scores. The correlation coefficient of the fatigue score with all the subscales of fear was positive and it was significant for all the subscales except for control loss (P<0.5). Additionally, the correlation coefficient of the score of well-being with all the subscales of fear was negative and significant (P<0.5).
Table 1. The distribution of means and standard deviations of the scores of fatigue and mental well-being in terms of fear and sever fear in the subjects.
Table 2. The correlation matrices of the subscales of the Persian version of the Wijma questionnaire with the overall fatigue index and mental well-being of the subjects
In The present study was conducted to examine the severity of fatigue and the level of mental well-being in pregnant women and their relationships with fear of childbirth. The main findings of the current study indicated that the fear of childbirth among pregnant women was related to their overall fatigue index. The results of this study showed that the FOC had a relative prevalence among pregnant women. In the case of severe fear (tokophobia), for reducing which interventional measures should be taken (27), 4.4% of the women displayed very severe and phobic fear. This finding is consistent with the results of a study carried out by Nieminen which used the same measurement tool and revealed that 5.5% of the samples experienced a very severe level of fear (the cut-off point>100).
When examining the relationship between the scores of fear and fatigue, the results demonstrated a significant relationship between them. Therefore, the more a subject’s fear of childbirth, the more she is likely to experience fatigue. When assessing the relationship of the subscales of fear with the overall fatigue index, the results of Pearson’s correlation coefficient showed that there was a direct relationship between all the subscales of fear and fatigue. That is, the increase in each fear-related subscale, except for the subscale of control loss, led to an increase in the severity of fatigue. Although fatigue has been reported as a common symptom in pregnancy in many studies (17,28), so far only Hall et al.’s study (1) has examined the association between fatigue and fear of childbirth. Their results, which obtained by employing the Wijma Delivery Expectancy Questionnaire (WDEQ) and the Multidimensional Assessment of Fatigue (MAF) scale, were similar to the present study. Since this was a cross-sectional study, determining the relationship between these two variables and figuring out their cause and effect relationship were not possible. Accordingly, it is recommended that future longitudinal studies address whether FOC causes or exacerbates fatigue in pregnant women or conversely fatigue exacerbates fear in pregnant women.
Evaluating the relationship between mental well-being and fear showed that as the fear of childbirth increased in pregnant women, the state of their mental well-being decreased. Pearson’s correlation coefficient indicated a significant diverse relationship between all the subscales of fear and mental well-being. In line with the results of the current study, Rouhe et al. reported that mental well-being disorders, such as mood disorder and anxiety, were highly prevalent among pregnant women who were experiencing fear of childbirth (29). Based on the results of the present study, conducting a longitudinal study aimed at investigating the cause and effect relationship between the mentioned variables is recommended.
In general, insufficient evidence in investigating the correlation between fear of childbirth and mental well-being highlights the importance of carrying out further studies. In the current study, the correlation of fear with an increase in fatigue and a decrease in well-being was determined. It seems that women experience the fear of childbirth with varying degrees during pregnancy. This phenomenon is of great importance since it is accompanied by several risks for the mother and infant, such as depression, decreased couple relationships, tendency to have a cesarean section, difficult childbirth, trauma at birth, and reduced maternal-infant interaction (19). Finally, providing mental support for pregnant women and using psychological techniques aimed at reducing the fear of childbirth during pregnancy are highly recommended. Screening and providing special measurement for women with severe fear by controlling the effects of fear will lead to a healthy pregnancy in this group of mothers.
The authors would like to express their sincere thanks to the Research Vice-Chancellor of the Sabzevar University of Medical Sciences, all the mothers who participated in this study, and all midwives who helped them in carrying out this study.
Conflicts of Interest
The authors declared that there are no conflicts of interest.