Fear of childbirth in Iran: A systematic review of psychological intervention research


Background: Due to the fear of childbirth (FOC) and failure to provide painless delivery in Iran, the prevalence rate of elective cesarean section (C-section) performed on request by pregnant women is on the rise. However, no systematic review assessing the results of studies in this respect has been thus far developed.

Objective: To systematically review published psychological intervention research reflecting on FOC in Iran.

Materials and Methods: In this systematic review, the databases of PubMed, MEDLINE, PsycINFO, Wiley, ISI Web of Science, Scopus, Science Direct, Cochrane Library, Google Scholar, and Scientific Information Database were searched to retrieve the relevant studies. Manual searches were performed to find the relevant articles and finally 21 intervention studies were reviewed.

Results: Based on the modified Jadad Scale, a methodological quality (risk of bias) assessment tool, 14 and 7 studies had acceptable or good and low quality, respectively. The included articles covered fear, fear of childbirth, pregnancy, and psychological intervention in Iran. Cognitive behavioral therapy, relaxation techniques, psychological counseling, childbirth preparation classes (CPCs), mindfulness programs, and psychoeducation had been also practiced as the main types of psychological interventions for reducing FOC in pregnant women.

Conclusion: There was no clear evidence to establish the most effective method for minimizing levels of FOC in pregnant women. Based on the assessment tool and since most of the studies had moderate or low quality, conducting standard and high-quality randomized controlled trials focusing on FOC in pregnant women is of most importance in Iranian population.

Key words: Fear, Childbirth, Pregnancy, Psychological intervention, Iran.

[1] Taheri Z, Khorsandi M, Amiri M, Hasanzade A. [Investigating the causes of fear of childbirth in Shahrekord pregnant women, in 2013: A short report.] J Rafsanjan Univ Med Sci 2015; 14: 345–350. (in Persian)

[2] Nilsson C, Bondas T, Lundgren I. Previous birth experience in women with intense fear of childbirth. J Obstet Gynecol Neonatal Nurs 2010; 39: 298–309.

[3] Lukasse M, Schei B, Ryding EL, Group BS. Prevalence and associated factors of fear of childbirth in six European countries. Sexual & Reproductive Health 2014; 5: 99–106.

[4] Haines H, Pallant JF, Karlström A, Hildingsson I. Cross-cultural comparison of levels of childbirth-related fear in an Australian and Swedish sample. Midwifery 2011; 27: 560–567.

[5] Sydsjö G, Sydsjö A, Gunnervik C, Bladh M, Josefsson A. Obstetric outcome for women who received individualized treatment for fear of childbirth during pregnancy. Acta Obstet Gynecol Scand 2012; 91: 44–49.

[6] Serçekuş P, Başkale H. Effects of antenatal education on fear of childbirth, maternal self-efficacy and parental attachment. Midwifery 2016; 34: 166–172.

[7] Hildingsson I, Nilsson C, Karlström A, Lundgren I. A longitudinal survey of childbirth‐related fear and associated factors. J Obstet Gynecol Neonatal Nurs 2011; 40: 532–543.

[8] Heimstad R, Dahloe R, Laache I, Skogvoll E, Schei B. Fear of childbirth and history of abuse: Implications for pregnancy and delivery. Acta Obstet Gynecol Scand 2006; 85: 435–440.

[9] Waldenström U, Hildingsson I, Ryding EL. Antenatal fear of childbirth and its association with subsequent caesarean section and experience of childbirth. BJOG 2006; 113: 638–646.

[10] Fenwick J, Gamble J, Nathan E, Bayes S, Hauck Y. Pre‐and postpartum levels of childbirth fear and the relationship to birth outcomes in a cohort of Australian women. J Clin Nurs 2009; 18: 667–677.

[11] Toohill J, Fenwick J, Gamble J, Creedy DK. Prevalence of childbirth fear in an Australian sample of pregnant women. BMC Pregnancy Childbirth 2014; 14: 275–285.

[12] Størksen HT, Garthus-Niegel S, Adams SS, Vangen S, Eberhard-Gran M. Fear of childbirth and elective caesarean section: A population-based study. BMC Pregnancy Childbirth 2015; 15: 221–231.

[13] Adams SS, Eberhard‐Gran M, Eskild A. Fear of childbirth and duration of labour: A study of 2206 women with intended vaginal delivery. BJOG 119: 1238–1246.

[14] Fenaroli V, Saita E. Fear of childbirth: A contribution to the validation of the Italian version of the wijma delivery expectancy/experience questionnaire (WDEQ). TPM Test Psychom Methodol Appl Psychol 2013; 20: 131–154.

[15] Rouhe H, Salmela‐Aro K, Gissler M, Halmesmäki E, Saisto T. Mental health problems common in women with fear of childbirth. BJOG 2011; 118: 1104–1111.

[16] Elyasi F, Khani S, Azizi M. The effect of tokophobia on mother and child's health: A literature review. J Pediatr Rev 2019; 7: 17–17.

[17] Nieminen K, Andersson G, Wijma B, Ryding EL, Wijma K. Treatment of nulliparous women with severe fear of childbirth via the Internet: A feasibility study. J Psychosom Obstet Gynecol 2016; 37: 37–43.

[18] Ryding EL, Persson A, Onell C, Kvist L. An evaluation of midwives' counseling of pregnant women in fear of childbirth. Acta Obstet Gynecol Scand 2003; 82: 10–17.

[19] Larsson B, Karlström A, Rubertsson C, Hildingsson I. The effects of counseling on fear of childbirth. Acta Obstet Gynecol Scand 2015; 94: 629–636.

[20] Fenwick J, Gamble J, Creedy DK, Buist A, Turkstra E, Sneddon A, et al. Study protocol for reducing childbirth fear: A midwife-led psycho-education intervention. BMC Pregnancy Childbirth 2013; 13: 190–199.

[21] Byrne J, Hauck Y, Fisher C, Bayes S, Schutze R. Effectiveness of a mindfulness‐based childbirth education pilot study on maternal self‐efficacy and fear of childbirth. J Midwifery Womens Health 2014; 59: 192–197.

[22] Rouhe H, Salmela-Aro K, Toivanen R, Tokola M, Halmesmäki E, Ryding EL, et al. Group psychoeducation with relaxation for severe fear of childbirth improves maternal adjustment and childbirth experience-a randomised controlled trial. J Psychosom Obstet Gynecol 2015; 36: 1–9.

[23] Ahmadi L, Karami S, Faghihzadeh S, Jafari E, Dabiri Oskoei A, Kharaghani R. Effect of couples counseling based on the problem-solving approach on the fear of delivery, self-efficacy, and choice of delivery mode in the primigravid women requesting elective cesarean section. Prevent Care Nurse Midwife J 2018; 7: 32–40.

[24] Khorsandi M, Vakilian K, Nasir zadeh Masooleh M. [Investigating different factors of fear in normal delivery among pregnant women, in arak: A cross sectional study.] Journal of Fasa University of Medical Sciences 2014; 4: 161–167. (in Persian)

[25] Masoumi SZ, Kazemi F, Oshvandi K, Jalali M, Esmaeili-Vardanjani A, Rafiei H. Effect of training preparation for childbirth on fear of Normal vaginal delivery and choosing the type of delivery among pregnant women in Hamadan, Iran: A randomized controlled trial. J Family Reprod Health 2016; 10: 115–121.

[26] Masoumi M, Elyasi F. Tokophobia in fathers: A narrative review. Iran J Psychiatry Behav Sci 2021; 15: e104511.1–10.

[27] Ghaffari SF, Elyasi F, Mousavinasab SN, Shahhosseini Z. A systematic review of clinical trials affecting anxiety, stress and fear of childbirth in expectant fathers. Nursing Open 2020: 1–11.
[28] Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: Explanation and elaboration. JCE 2009; 62: e1–e34.

[29] Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: Elaboration and explanation. BMJ 2015; 349: g7647.

[30] Halpern S, Douglas M. Jadad scale for reporting randomized controlled trials. Evidence-Based Obstetric Anesthesia 2005; 5: 237–238.

[31] Berger VW, Alperson SY. A general framework for the evaluation of clinical trial quality. Reviews on Recent Clinical Trials 2009; 4: 79–88.

[32] Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJM, Gavaghan DJ, et al. Assessing the quality of reports of randomized clinical trials: Is blinding necessary? Control Clin Trials 1996; 17: 1–12.

[33] Oremus M, Wolfson C, Perrault A, Demers L, Momoli F, Moride Y. Interrater reliability of the modified Jadad quality scale for systematic reviews of Alzheimer’s disease drug trials. Dement Geriatr Cogn Disord 2001; 12: 232–236.

[34] Aminolroayaee M, Aghaei A. The effectiveness of cognitive therapy based on mindfulness on fear of delivery in primiparous women. Knowledge Res App Psychol 2019; 19: 56–65.

[35] Baleghi M, Mohamadian E, Zahedpasha Y. The effect of relaxation on childbirth and an increase in natural childbirth. JBUMS 2016; 18: 14–19.

[36] Boryri T, Navidian A, Marghzari N. Comparison of the effect of muscle relaxation and guided imagery on happiness and fear of childbirth in primiparous women admitted to health care centers. IJWHR 2019; 7: 490–495.

[37] Bouzari B, Fatahi A. Effect of behavioral group therapy on childbirth fear and anxiety in pregnant women. MEJDS 2018; 8: 37–42.

[38] Rastegari L, Mohebbi P, Jafari E, Mazloumzadeh S. Effects of child birth preparation classes on parous womens’attitude toward child birth. PCNM 2016; 6: 36–44.

[39] Mahmoudjanlou M, Ahadi H, Nazarpour S, Kraskian Moujembari A. [The effectiveness of reducing the fear of labor pain in the way of the reality therapy on the choice of vaginal delivery in pregnant women.] J Res Behav Sci 2019; 17: 68–76. (in Persian)

[40] Momeni E, Alidostishahraki K, Taebi M, Hoseini M, Dehesh T. Effectiveness of group psychological counseling on the pregnancy anxiety and fear of vaginal delivery in the pregnant women: A quasi-experimental study. Crit Care Nurs J 2018; 11: e74212.1–6.

[41] Ghazaei M, Davodi I, Neysi A, Mehrabizadeh Honarmand M, Basak Nejad S. [Effectiveness of cognitive behavioral therapy and psycho-education on fear of natural childbirth and its related variables.] Journal of Applied Psychology 2018; 12: 103–125. (in Persian)

[42] Pour-Edalati M, Moghadam NK, Shahesmaeili A, Salehi-Nejad P. Exploring the effect of mindfulness-based stress reduction on childbirth fear among single-child mothers in the city of kerman, iran (2017): A clinical trial study. Med Surg Nurs 2018; 7: e90247.1–7.

[43] Jamali F, Olfati F, Oveisi S, Ranjkesh F. [Effects of spouses’ involvement in pregnancy on fear of childbirth in nulliparous women.] J Qazvin Univ Med Sci 2018; 22: 38–47. (in Persian)

[44] Andaroon N, Kordi M, Kimiaei SA, Esmaeily H. The effect of individual counseling program by a midwife on fear of childbirth in primiparous women. J Edu Health Promot 2017; 6: 97–103.

[45] Khorsandi M, Ghofranipour F, Heydarnia A, Faghih Zadeh S, Vafaei M, Rousta F, et al. The effect of relaxation on childbirth fear and normal delivery among primiparous women. J Arak Uni Med Sci 2008; 11: 29–36.

[46] Soltani F, Eskandari Z, Khodakarami B, Parsa P, Roshanaei G. The effect of self-efficacy oriented counselling on controlling the fear of natural delivery in primigravida women. J Int J Pharm Sci Res 2017; 9: 1757–1761.

[47] Sharifzadeh M, Haghighi N, Keramat A, Goli M, Motaghi Z. Effectiveness of midwifery counseling based on solution-focused approaches on fear of childbirth. Koomesh 2018; 20: 375–383.

[48] Gerami G, Makvand Hoseini Sh, Sedaghat M, Moazedian A. [The effectiveness of individual cognitive behavioral therapy on fear of delivery in Extroverted & Neuroticism women.] Applied Psychological Research Quarterly 2018; 9: 125–141. (in Persian)

[49] Gerami G, Makvand Hoseini Sh, Sedaghat M, Moazedian A. [Compare the effectiveness of cognitive- behavioral therapy with Relaxation therapy on Delivery process in Primipara.] Applied Psychological Research Quarterly 2017; 7: 203–217. (in Persian)

[50] Ghazaie M, Davoodi I, Neysi A, Mehrabizadeh Honarmand M, Bassak Nejad S. The effectiveness of cognitive-behavioral therapy on fear of childbirth, fear of pain, self-efficacy of childbirth and tendency to caesarean in nulliparous women. Iran J Obstet 2016; 19: 1–12.

[51] Kordi M, Bakhshi M, Masoudi S, Esmaily H. Effect of a childbirth psychoeducation program on the level of fear of childbirth in primigravid women. Evid Bas Ca 2017; 7: 26–34.

[52] Navaee M, Abedian Z. Effect of role play education on primiparous women's fear of natural delivery and their decision on the mode of delivery. Iran J Nurs Midwifery Res 2015; 20: 40–46.

[53] Rondung E, Ternström E, Hildingsson I, Haines HM, Sundin Ö, Ekdahl J, et al. Comparing internet-based cognitive behavioral therapy with standard care for women with fear of birth: Randomized controlled trial. JMIR Mental Health 2018; 5: e10420.

[54] Ternström E, Hildingsson I, Haines H, Karlström A, Sundin Ö, Ekdahl J, et al. A randomized controlled study comparing internet-based cognitive behavioral therapy and counselling by standard care for fear of birth – A study protocol. Sex Reprod Health 2017; 13: 75–82.

[55] Nieminen K, Malmquist A, Wijma B, Ryding EL, Andersson G, Wijma K. Nulliparous pregnant women's narratives of imminent childbirth before and after internet‐based cognitive behavioural therapy for severe fear of childbirth: A qualitative study. BJOG 2015; 122: 1259–1265.

[56] Uçar T, Golbasi Z. Effect of an educational program based on cognitive behavioral techniques on fear of childbirth and the birth process. J Psychosom Obstet Gynecol 2019; 40: 146–155.

[57] Lilliecreutz C, Josefsson A, Sydsjö G. An open trial with cognitive behavioral therapy for blood-and injection phobia in pregnant women-a group intervention program. Arch Womens Ment Health 2010; 13: 259–265.

[58] Duncan LG, Cohn MA, Chao MT, Cook JG, Riccobono J, Bardacke N. Benefits of preparing for childbirth with mindfulness training: A randomized controlled trial with active comparison. BMC Pregnancy Childb 2017; 17: 140–151.

[59] Saisto T, Toivanen R, Salmela‐Aro K, Halmesmäki E. Therapeutic group psychoeducation and relaxation in treating fear of childbirth. Acta Obstet Gynecol Scand 2006; 85: 1315–1319.

[60] Salmela-Aro K, Read S, Rouhe H, Halmesmäki E, Toivanen RM, Tokola MI, et al. Promoting positive motherhood among nulliparous pregnant women with an intense fear of childbirth: RCT intervention. J Health Psychol 2012; 17: 520–534.

[61] Najafi F, Abouzari-Gazafroodi K, Jafarzadeh-Kenarsari F, Rahnama P, Gholami Chaboki B. [Relationship between attendance at childbirth preparation classes and fear of childbirth and type of delivery.] Hayat 2016; 21: 30–40. (in Persian)

[62] Bergström M, Kieler H, Waldenström U. Effects of natural childbirth preparation versus standard antenatal education on epidural rates, experience of childbirth and parental stress in mothers and fathers: A randomised controlled multicentre trial. BJOG 2009; 116: 1167–1176.

[63] Mehdizadeh A, Roosta F, Chaichian S, Alaghehbandan R. Evaluation of the impact of birth preparation courses on the health of the mother and the newborn. Am J Perinatol 2005; 22: 7–9.