
==== Front
Clinics (Sao Paulo)
Clinics (Sao Paulo)
Clinics
1807-5932
1980-5322
Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo

S1807-5932(24)00178-9
10.1016/j.clinsp.2024.100501
100501
Original Articles
Influence of diagnosis of gestational diabetes mellitus on fear of childbirth
Imakawa Cibele Santini de Oliveira a
Quintana Silvana Maria a
Duarte Geraldo a
Moisés Elaine Christine Dantas elainemoises@fmrp.usp.br
ab⁎
a Department of Gynecology and Obstetrics, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
b Ribeirão Preto Women's Health Reference Center, Ribeirão Preto, SP, Brazil
⁎ Corresponding author. elainemoises@fmrp.usp.br
14 9 2024
Jan-Dec 2024
14 9 2024
79 10050125 2 2024
9 7 2024
25 8 2024
© 2024 HCFMUSP. Published by Elsevier España, S.L.U.
2024
HCFMUSP
https://creativecommons.org/licenses/by/4.0/ This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Highlights

• Fear of childbirth is more prevalent in patients with gestational diabetes mellitus.

• Fear of Birth Scale score is higher in patients with gestational diabetes mellitus.

• Reasons related to vaginal birth are more associated with clinically relevant fear.

Introduction

Considering the relationship between Gestational Diabetes Mellitus and maternal and perinatal adverse outcomes, it's pertinent to investigate whether this diagnosis is a predictor of fear of childbirth. As there is little data about the fear of childbirth in Brazil, it´s necessary to understand better the population, and this way the authors can identify factors that influence this fear as well as propose public health policies to treat it.

Objective

The main goal was to compare the prevalence of fear of childbirth between the groups of low-risk pregnancy and gestational diabetes mellitus.

Material and methods

In this cohort study, the sample consisted of 319 patients divided into low-risk pregnancy group (n = 152) and gestational diabetes mellitus group (n = 167). Patients have undergone a semi-structured interview with epidemiological, obstetric, and anthropometric data and the main cause of fear of childbirth. In addition, the patients have marked an “X” on the scale into the Fear of Birth Scale to describe their fear. After delivery, data have been collected through electronic medical records.

Results

The prevalence of fear of childbirth found was higher for the gestational diabetes mellitus group (46.05%) compared to the low-risk pregnancy group (34.73%) with a cutoff score ≥ 54. In the whole sample, the main cause of fear of childbirth (score ≥ 60) was the pain of labor and delivery (31.58%).

Conclusions

The prevalence of fear of childbirth in the present study was greater than 30%, highlighting the relevance of implementing this assessment during prenatal care.

Keywords

High-risk pregnancy
Gestational diabetes mellitus
Fear of childbirth
Fear of birth scale
Parturition
==== Body
pmcIntroduction

The definitions of Fear of Childbirth (FOC), worry, and anxiety are controversial, and no standardized tools to assess FOC have been reported.1 Up to 80% of pregnant women experience concerns and fears.2,3 Tokophobia, a severe fear of childbirth, affects 7%–25% of primiparous women, 7.7%–16.25% of multiparous women, and 7%–18.6% of women with tokophobia desire an elective cesarean section.4 FOC is associated with increased anxiety and depression during pregnancy, an increased risk of premature labor, increased labor duration, and an increased risk of developing depression and post-traumatic stress disorder after childbirth. Several factors that protect against or aggravate FOC have been identified, though some factors remain controversial.5

However, the effect of the diagnosis of high-risk pregnancy on FOC has not yet been reported. Diabetes mellitus is characterized by persistent hyperglycemia caused by deficient insulin production, inadequate insulin release, and/or peripheral resistance to insulin.6, 7, 8 Hyperglycemia detected during pregnancy can be divided into GDM and diabetes in pregnancy, which can be classified as pre-gestational diabetes or diabetes diagnosed for the first time during pregnancy when it meets the criteria for non-gestational diabetes.9, 10, 11

Considering the high worldwide prevalence of GDM, affecting an average of 16.7% of pregnant women and being one of the main clinical conditions during the pregnancy-puerperal cycle, it is essential to assess whether the gestational risk resulting from the development of GDM influences fear of childbirth.12 This way, the main goal of this study was to evaluate the influence of the diagnosis of gestational diabetes mellitus on fear of childbirth.

Participants, ethics and methods

This cohort study was approved by the Research Ethics Committee (REC) of the Clinics Hospital of the School of Medicine of Ribeirão Preto, University of São Paulo (Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo; HCFMRP-USP) and did not interfere with the obstetric management of the women (approval n° 3,712,476). The present study adhered to the STROBE guidelines (Strengthening the Reporting of Observational Studies in Epidemiology).13

Women aged 18 years or older with a single pregnancy at gestational age ≥ 34 weeks who were undergoing prenatal follow-up care at the Reference Center for Women's Health of Ribeirão Preto or at the HCFMRP-USP from January 2020 to October 2022 were included in this study. The women were divided into the Low-Risk Pregnancy Group (LRP) and the GDM group.

The diagnosis of GDM was established when one or more blood glucose values were altered in the oral glucose tolerance test, according to the following parameters: fasting blood glucose, one and two hours after an overload of 75g of anhydrous glucose, respectively, greater than or equal to 92 and less than or equal to 125 mg/dL, greater than or equal to 180 mg/dL, greater than or equal to 153 and less than or equal to 199 mg/dL.14,15 The LRP was the control group and consisted of women without maternal comorbidities and without fetal and/or placental attachment changes.

All women provided informed consent and were literate. The interviews were conducted during the women's third-trimester prenatal follow-up visits at the research centers. In-person interviews based on a semi-structured questionnaire regarding the epidemiological, obstetric, and anthropometric data of the women were conducted. Subsequently, the women answered the instruments of the Brazilian Economic Classification Criteria, the Fear of Birth Scale (FOBS), and the specific question about the main cause of FOC.

The FOBS included the item, “How do you feel about the upcoming childbirth now?” The women were instructed to place a mark on two 100 mm Visual Analog Scales (VASs) that have the anchor words calm/concern and no fear/great fear. The FOBS score is calculated as the mean score of those two scales about concern and fear16 (Fig. 1). According to previous studies, the cutoff of mean ≥ 54 mm and ≥ 60 mm was considered clinically significant.1,16, 17, 18Fig. 1 Fear of childbirth scale.19, 20, 21

Fig 1

After childbirth, the women's obstetric data were retrospectively obtained from electronic medical records. The data were collected from January 2020 to November 2022. Intending to guarantee the confidentiality of the information, the main researcher was the only one who had access to the database with the identification of the women. After obtaining the obstetric data, the numbers of the women's medical records were replaced by a code containing the classification between the control and study groups, in addition to the sequential numbering of inclusion, which was maintained in the definitive database.

This is the first study regarding the risk of FOC in women with GDM. Thus, the necessary sample size was calculated according to the risk of FOC in women with uncomplicated pregnancies (80%).2,3 Assuming a 15% increase in fear of childbirth-related to GDM as a clinically significant difference and a test power of 80%, the necessary sample size was calculated using SAS software (version 9.4, SAS Institute, North Carolina) using the proc power procedure. In this cohort study, a total of 304 women are necessary, including 152 in each group. As some women were predicted to be lost due to giving birth at another institution, a safety margin of 10% was added for the phase two analysis, increasing each group to 167 women to allow for an analysis of secondary variables.

Boxplot and histogram graphs were performed to verify the distribution of quantitative variables in relation to groups (LRP and GDM). Qualitative variables were summarized considering absolute and relative frequencies.

To verify if there is a statistical relevance of the quantitative variables in relation to the study groups, the Wilcoxon test for independent samples was applied. This test was chosen due to data distribution.

The Chi-Square test was applied to verify if there is an association between the qualitative variables in relation to the study groups.

The reliability of the Fear of Birth Scale was estimated considering Cronbach's alpha coefficient. This coefficient ranges from zero to one, with measures close to one indicating greater reliability of the scale.

Pearson's coefficient was calculated to verify the correlation between worry and fear.

Statistical analyses were implemented in the SAS version 9.4 program.

Results

A total of 319 women underwent a semi-structured interview and completed the FOBS, including 167 women in the LRP group and 152 in the GDM group (Fig. 2).Fig. 2 Woman flowchart.

Fig 2

The mean women's age was 25.69 ± 5.33 years in the LRP group and 28.92 ± 6.25 years in the GDM group (p = 0.0001). The mean gestational age at the time of the interview was higher in the LRP group (36.83 ± 1.25 weeks) than in the GDM group (36.47 ± 1.46 weeks) (p = 0.0402) (Table 1). women in the GDM group had significantly more pregnancies (2.47 ± 1.41 pregnancies) than those in the LRP group (1.97 ± 1.11 pregnancies) (p = 0.0008). The mean parity was 1.26 ± 1.33 in the GDM group and 0.80 ± 0.96 in the LRP group (p = 0.0007). The number of abortions was not significantly different between the groups. While the woman's height was not significantly different between the groups, the pre-gestational weight (p = 0.0001), pre-gestational Body Mass Index (BMI) (p = 0.0001), gestational weight (p = 0.0004), and gestational BMI (p = 0.0003) were higher in the GDM group.Table 1 Women characteristics.

Table 1		LRP (n = 167)	GDM (n = 152)	p-value	
Obstetric history and parity	Maternal age (years)	25.69 (± 5.33)	28.92 (± 6.25)	0.0001	
GA (weeks)	36.83 (± 1.25)	36.47 (± 1.46)	0.0402	
Number of pregnancies	1.97 (± 1.11)	2.47 (± 1.41)	0.0008	
Parity	0.80 (± 0.96)	1.26 (± 1.33)	0.0007	
Number of abortions	0.17 (± 0.44)	0.20 (± 0.47)	0.5710	
Anthropometric data	Height (meters)	1.62 (± 0.07)	1.62 (± 0.06)	0.7630	
Pre-gestational weight (kg)	65.46 (± 13.84)	73.94 (± 17.42)	0.0001	
Pre-gestational BMI (kg/m2)	24.86 (± 4.71)	28.09 (± 6.09)	0.0001	
Gestational weight (kg)	77.70 (± 13.85)	83.81 (± 16.18)	0.0004	
Gestational BMI (kg/m2)	29.52 (± 4.58)	31.85 (± 5.62)	0.0003	
Data are presented as mean ± standard deviation.

GDM, Gestational Diabetes Mellitus; LRP, Low Risk Pregnancy; GA, Gestational Age; kg, Kilograms; BMI, Body Mass Index; m2, Square meter.

*p-value referring to the Wilcoxon test for independent samples.

The demographic and socioeconomic variables were similar between the groups (Table 2). The history of fetal death was less than 5% in both groups and the majority of women reported not planning their current pregnancy.Table 2 Qualitative women characteristics.

Table 2	LRP (n = 167)	GDM (n = 152)	p-value	
Race	Non-white	65 (38.92%)	59 (38.82%)	0.9845	
White	102 (61.08%)	93 (61.18%)	
Profession	Unpaid	92 (55.09%)	88 (57.89%)	0.6138	
Paid	75 (44.91%)	64 (42.11%)	
MS	Without partner	27 (16.17%)	14 (9.21%)	0.0637	
With partner	140 (83.83%)	138 (90.79%)	
Years of study	< 8 years	20 (11.98%)	23 (15.13%)	0.2153	
8 years	11 (6.59%)	6 (3.95%)	
> 8 and < 11 years	42 (25.15%)	40 (26.32%)	
11 years	70 (41.92%)	50 (32.89%)	
> 12 years	24 (14.37%)	33 (21.71%)	
PFD	No	162 (97.01%)	151 (99.34%)	0.1250	
Yes	5 (2.99%)	1 (0.66%)	
PP	No	107 (64.07%)	89 (58.55%)	0.3118	
Yes	60 (35.93%)	63(41.45%)	
PH	No	155 (92.81%)	135 (88.82%)	0.2147	
Yes	12 (7.19%)	17 (11.18%)	
PF	No	11 (91.67%)	15 (88.24%)	0.7651	
Yes	1 (8.33%)	2 (11.76%)	
GDM, Gestational Diabetes Mellitus; LRP, Low Risk Pregnancy; MS, Marital Status; PFD, Previous Fetal Death; PP, Planned Pregnancy; PH, Psychiatric History; PF, Psychiatric Follow-up.

*p-value referring to the Chi-Square test.

The most prevalent economic class in the LRP group was C2, in which the monthly household income is USD 330.55, comprising 35.93% of the group. The most prevalent economic class in the GDM group was C1, in which the monthly household income is USD 583.27, comprising 35.53% of the group (Table 3).Table 3 Socioeconomic classification.

Table 3	Household income (USD)	LRP (n = 167)	GDM (n = 152)	p-value	
A	4.830.69	1(0.60%)	2 (1.32%)	0.8790	
B1	2.132.16	4 (2.40%)	2 (1.32%)	
B2	1.066.47	25 (14.97%)	21 (13.82%)	
C1	583.27	54 (32.34%)	54 (35.53%)	
C2	330.55	60 (35.93%)	49 (32.24%)	
D‒E	136.07	23 (13.77%)	24 (15.79%)	
Modified ABEP (Associação Brasileira de Empresas de Pesquisa ‒ Brazilian Association of Market Research Companies).

GDM, Gestational Diabetes Mellitus; LRP, Low Risk Pregnancy.

*p-value referring to the Chi-Square test.

The worry and total FOBS scores were higher in the GDM group while the fear score was not significantly different between the groups (Table 4).Table 4 FOBS scores.

Table 4	LRP (n = 167)	GDM (n = 152)	p-value	
Mean ± SD	Median (interquartile range)	Range	Mean ± SD	Median (interquartile range)	Range		
Worry	41.57±33.28	41.5 (8.5‒69.0)	0-100	49.38±33.27	50 (17.5‒78.75)	0‒100	0.0440	
Fear	48.13±33.53	47 (16–80)	0.5‒100	53.23±31.20	54 (28.5‒82)	1‒100	0.2094	
Total score	44.85±31.30	46.63 (17.75–68.75)	0.75‒100	51.30±28.90	51.13 (28.25‒75.38)	1.25‒100	0.0489	
GDM, Gestational Diabetes Mellitus; LRP, Low Risk Pregnancy; SD, Standard Deviation.

*p-value referring to the Wilcoxon test for independent samples.

More women in the GDM group met the cutoff value of 54 for the worry VAS (45.39%), fear VAS (50%), and total score VAS (46.05%) than in the LRP group (32.34%, 38.92%, and 34.73%, respectively; p = 0.0167, p = 0.0466, and p = 0.0393, respectively). More women in the GDM group met the cutoff value of 60 for worry VAS (GDM = 41.25%, LRP = 29.34%, p = 0.0237) (Table 5).Table 5 Clinically significant concern and fear regarding fear of childbirth.

Table 5Fear of childbirth Scale	Cutoff point	LRP (n = 167)	GDM (n = 152)	p-value	
Worry	≥ 54	No	113 (67.66%)	83 (54.61%)	0.0167	
Yes	54 (32.34%)	69 (45.39%)	
≥ 60	No	118 (70.66%)	89 (58.55%)	0.0237	
Yes	49 (29.34%)	63 (41.45%)	
Fear	≥ 54	No	102 (61.08%)	76 (50%)	0.0466	
Yes	65 (38.92%)	76 (50%)	
≥ 60	No	110 (65.87%)	87 (57.24%)	0.1131	
Yes	57 (34.13%)	65 (42.76%)	
Total score	≥ 54	No	109 (65.27%)	82 (53.95%)	0.0393	
Yes	58 (34.73%)	70 (46.05%)	
≥ 60	No	114 (68.26%)	91 (59.87%)	0.1181	
Yes	53 (31.74%)	61 (40.13%)	
GDM, Gestational Diabetes Mellitus; LRP, Low Risk Pregnancy.

*p-value referring to the Chi-Square test.

The relative risk of FOC (measured using a cutoff value of 54) in women with GDM is 1.33 (95% Confidence Interval: 1.0124–1.7368). The relative risk of FOC (measured using a cutoff value of 60) in women is 1.26 (95% CI: 0.9412–1.6989).

The two main reasons for FOC in the groups were fear regarding fetal death and suffering and fear regarding labor and childbirth (Table 6).Table 6 Reasons for FOC.

Table 6	LRP (n = 167)	GDM (n = 152)	p-value	
Fetal death/suffering	48 (28.74%)	52 (34.21%)	0.3737	
Pain of labor and childbirth	39 (23.35%)	40 (26.32%)	
Not being able to give birth	14 (8.38%)	17 (11.18%)	
Not being able to deal with the lack of control	11 (6.59%)	6 (3.95%)	
Unable to raise the child	3 (1.80%)	2 (1.32%)	
Lack of trust in the team	2 (1.20%)	3 (1.97%)	
Going through an unwanted procedure or situation	28 (16.77%)	18(11.84%)	
Having another bad experience	9 (5.39%)	10 (6.58%)	
No fear of childbirth	13 (7.78%)	4 (2.63%)	
FOC, Childbirth Fear; GDM, Gestational Diabetes Mellitus; LRP, Low Risk Pregnancy.

*p-value referring to the Chi-Square test.

Clinically significant FOC (measured using a cutoff value of 60) was associated with the white race (Table 7, Table 8). There were no differences in obstetric outcomes between women with and without FOC (Table 9).Table 7 Characteristics of women with and without clinically significant fear of childbirth.

Table 7	< 60 (n = 205)	≥ 60 (n = 114)	p-value	
Mean ± SD	Median (interquartile range)	Range	Mean ± SD	Median (interquartile range)	Range	
Age (years)	26.96 ± 6.04	26 (22‒30)	18‒43	27.72 ± 5.92	28 (23‒32)	18‒41	0.1852	
GA (weeks)	36.77 ± 1.40	37 (36‒38)	34‒41	36.46 ± 1.29	36 (36‒37)	34‒40	0.0480	
Number of pregnancies	2.14 ± 1.25	2 (1 ‒3)	1‒7	2.32 ± 1.33	2 (1‒3)	1‒8	0.2110	
Childbirths	0.98 ± 1.15	1 (0 ‒1)	0‒6	1.09 ± 1.22	1 (0‒2)	0‒7	0.4211	
Number of Abortions	0.16 ± 0.39	0 (0)	0‒2	0.24 ± 0.54	0 (0)	0‒3	0.2999	
Pre-gestational weight (kg)	68.35 ± 15.12	66 (58‒76)	32.60‒130	71.56 ± 17.83	69.5 (60‒80)	39‒144	0.1925	
Height (m)	1.62 ± 0.06	1.62 (1.57 ‒1.65)	1.40‒1.82	1.63 ± 0.07	1.62 (1.57‒1.68)	1.48‒1.81	0.3485	
Pre-gestational BMI (Kg/m2)	26.09 ± 5.33	25.10 (22.64–29.05)	13.39‒48.33	26.96 ± 6.12	26.49 (22.77‒30.43)	15.05‒47.02	0.2098	
Gestational weight	79.66 ± 14.54	79 (70 – 88)	42.40‒143	82.31 ± 16.48	79 (70 – 90)	45‒136.80	0.2274	
Gestational BMI (kg/m2)	30.43 ± 5.04	29.97 (26.45‒33.53)	18.84‒53.17	30.99 ± 5.55	30.94 (27.24 – 34.81)	17.36‒47.90	0.3224	
SD, Standard Deviation; GA, Gestational Age; BMI, Body Mass Index.

*p-value referring to the Wilcoxon test for independent samples.

Table 8 Qualitative characteristics of women with and without clinically significant childbirth fear.

Table 8		< 60 (n = 205)	≥ 60 (n = 114)	p-value	
Race	Non-white	70 (34.15%)	54 (47.37%)	0.0203	
White	135 (65.85%)	60 (52.63%)	
Maternal Age	19 years	17 (8.29%)	11 (9.65%)	0.9071	
≥ 19 e < 35	163 (79.51%)	90 (78.95%)	
≥ 35	25 (12.20%)	13 (11.40%)	
BMI	< 25	98 (47.80%)	44 (38.60%)	0.1128	
≥ 25	107 (52.20%)	70 (61.40%)	
Abortion	No	174 (84.88%)	92 (80.70%	0.3369	
Yes	31 (15.12%	22 (19.30%)	
Profession	Unpaid	115 (56.10%)	65 (57.02%)	0.8738	
Paid	90 (43.90%)	49 (42.98%)	
Marital status	Without partner	27 (13.17%)	14 (12.28%)	0.8199	
With partner	178 (86.83%)	100 (87.72%)	
Years of study	< 8 years	27 (13.17%)	16 (14.04%)	0.8089	
8 years	11 (5.37%)	6 (5.26%)	
> 8 and < 11 years	57 (27.80%)	25 (21.93%)	
11 years	76 (37.07%)	44 (38.60%)	
> 12 years	34 (16.59%)	23 (20.18%)	
PFD	No	201 (98.05%)	112 (98.25%)	0.9013	
Yes	4 (1.95%)	2 (1.75%)	
PP	No	125 (60.98%)	71 (62.28%)	0.8185	
Yes	80 (39.02%)	43 (37.72%)	
PH	No	191 (93.17%)	99 (86.84%)	0.0595	
Yes	14 (6.83%)	15 (13.16%)	
PF	No	13 (92.86%)	13 (86.67%)	0.5844	
Yes	1 (7.14%)	2 (13.33%)	
Socioeconomic classification (USD)	4.830.69	2 (0.98%)	1 (0.88%)	0.9964	
2.132.16	4 (1.95%)	2 (1.75%)	
1.066.47	31 (15.12%)	15 (13.16%)	
583.27	69 (33.66%)	39 (34.21%)	
330.55	70 (34.15%)	39 (34.21%)	
136.07	29 (14.15%)	18 (15.79%)	
BMI, Body Mass Index before pregnancy; PFD, Previous Fetal Death; PP, Planned Pregnancy; PH, Psychological History of depression; PF, Psychiatric Follow-up for women with a history of depression

*p-value referring to the Chi-Square test.

Table 9 Obstetric characteristics of women with and without clinically significant childbirth fear.

Table 9Variable	< 60 (n = 179)	≥ 60 (n = 102)	p-value	
Childbirth mode	Vaginal	121 (67.60%)	64 (62.75%)	0.4095	
Cesarean section	58 (32.40%)	38 (37.25%)	
Start of labor	Spontaneous	88 (49.16%)	551 (50.49%)	0.9961	
Induced	71 (39.66)	39 (38.61%)	
Cesarean section without induction	20 (11.17)	11 (10.89%)	
Indication for Cesarean section	No	120 (67.04%)	68 (66.67%)	0.9491	
Yes	59 (32.96%)	34 (33.33%)	
CSR	No	174 (97.20%)	97 (95.10%)	0.3600	
Yes	5 (2.80%)	5 (4.90%)	
Analgesia	No	127 (70.95%)	64 (62.75%)	0.1765	
Yes	52 (29.05%)	38(37.25%)	
CSR, Cesarean Section Request.

*p-value referring to the Chi-Square test.

The internal consistency of the FOC scale was measured by α-Cronbach's Coefficient was good (α-Cronbach's Coefficient = 0.8164). The scales used to measure concern and FOC were correlated (Pearson's correlation coefficient = 0.69).

Discussion

This is the first study to report the association between the gestational risk of GDM and FOC. The International Federation of Gynecology and Obstetrics estimates that one in six pregnant women has some type of hyperglycemia during pregnancy, including 84% of those with GDM.22

The sample consisted of women with higher pre-gestational and gestational weight and BMI; maternal age and parity in the study group, characteristics classically considered risk factors for the development of GDM.23

There is no widely used cutoff value of the FOCQ to represent clinically significant FOC. An Australian study used a cutoff value of 54,20 while other studies used a cutoff value of 60.17,18 Rondung et al. also used a cutoff value of 60 in a Swedish study and reported a prevalence of clinically significant FOC of 24.6%.1 As no single cutoff value has been accepted, both previously reported cutoff values were used in this study. A previous cross-cultural study used the FOCQ to compare the prevalence of FOC among pregnant women living in Sweden and Australia.16 While the prevalences of FOC were similar between the groups, a cutoff value of 50 was used in the previous study based on the results of a Finnish study that used a single-item VAS that was the starting point to establish the standard values of the FOCQ.24 Other previous studies reported an FOC prevalence of 22% when a cutoff value of 60 was used.17 The prevalence of FOC found in this study was higher than previously reported values, regardless of the cutoff value used.

The causes of FOC can be classified as relating to the infant's well-being; procedures and complications throughout the childbirth process; personal issues including insecurity and fear of losing control; and external issues related to the healthcare team.5,25,26 In this study, the main causes of FOC were fears of fetal death/suffering, labor pain, and experiencing unwanted procedures. Among women with clinically significant FOC, the main causes of concern were labor and childbirth pain (31.58%), fetal death/suffering (26.32%), and not being able to give birth (14.91%). Nearly half (46.49%) of the women with clinically significant FOC in this study had fears related to a vaginal birth.

The association between FOC and elective cesarean section procedures has been studied. In 2022, a systematic review reported that the prevalence of tokophobia ranged from 7%–25% in primiparous women and from 7.7%–16.25% in multiparous women and that approximately 7%–18.6% of women with tokophobia requested elective cesarean sections.4. The World Health Organization recommends cesarean section rates between 10%–15%.27 However, the cesarean section rate in Brazil is 55% among women of the Unified Health System and 90% among the private sector. A cesarean section is the preferred route of childbirth in 27% of women in the public sector and 44% in the private sector in Brazil.28. The maternal preference for cesarean childbirth in Brazil is based on maternal convenience and fear of labor pain,28 which are similar to the factors affecting maternal preference in other countries.29,30 Tokophobia is the primary cause of cesarean section requests.26,31 Women who report high FOC are more likely to request a cesarean section.24,32,33 FOC was associated with a preference for a cesarean section in a previous study.34 When this fear is not treated in a timely manner, the chance of a cesarean section is increased five-fold,35 resulting in cesarean sections without medical indications and exposing the women to unnecessary risks.24,35 In this study, FOC did not affect the obstetric outcomes, which may be due to the fact that this study was conducted at an accredited public institution that follows the principles of Hospital Amigo da Criança e da Mulher.

It is also important to highlight that even though it is a public university and reference hospital in the state of São Paulo, cesarean section rates are around 20% above that recommended by the WHO and therefore it is essential to begin debating and implementing public health policies to identify and assess women's fear of childbirth, as this way they will be less afraid of vaginal birth and it would be possible to reduce cesarean section rates.

Conclusion

This is the first study to determine the prevalence of FOC by using the Fear of Birth Scale in Brazil and the effects of gestational risk factors, such as GDM, on FOC. The prevalence of FOC is higher in Brazil than in other countries. A diagnosis of GDM is associated with an increased prevalence of FOC. The main causes of FOC include the fear of labor pain and childbirth, the fear of fetal death/suffering, and the fear of not being able to give birth. Therefore, public policies to educate the women about risks and benefits of the route of birth and to assess and treat FOC should be discussed and created.

Authors’ contributions

Cibele Santini de Oliveira Imakawa: Conceptualization; methodology; validation; formal analysis; investigation; data curation; writing-original draft, writing-review & editing, visualization.

Silvana Maria Quintana: Resources; writing-review & editing; funding acquisition. geraldo duarte: resources; writing-review & editing; funding acquisition.

Elaine Christine Dantas Moisés: Conceptualization; methodology; validation; formal analysis; resources; writing-original draft, writing-review & editing, visualization; supervision; project administration; funding acquisition.

Declaration of competing interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments

The authors thank the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) for the financial support.
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References

1 Rondung E Ekdahl J Sundin Ö. Potential mechanisms in fear of birth: The role of pain catastrophizing and intolerance of uncertainty Birth 46 1 2019 61 68 29954044
2 Szeverenyi P Poka R Hetey M Torok Z. Contents of childbirth-related fear among couples wishing the partner's presence at delivery J Psychosom Obstet Gynaecol 19 1 1998 38 43 9575467
3 Melender HL. Experiences of fears associated with pregnancy and childbirth: a study of 329 pregnant women Birth 29 2 2002 101 111 12051188
4 Kanellopoulos D Gourounti K. Tocophobia and women's desire for a caesarean section: a systematic review Maedica 17 1 2022 186 193 35733734
5 Dencker A Nilsson C Begley C Jangsten E Mollberg M Patel H Causes and outcomes in studies of fear of childbirth: a systematic review Women Birth 32 2 2019 99 111 30115515
6 World Health Organization. Classification of diabetes mellitus [Internet]. Iris.who.int. World Health Organization; 2019. Available from: https://iris.who.int/handle/10665/325182.
7 American Diabetes Association Professional Practice Committee. 2. Diagnosis and classification of diabetes: standards of care in diabetes-2024 Diabetes Care 47 Suppl 1 2024 S20 S42 38078589
8 American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins – Obstetrics. ACOG Practice Bulletin N° 201: Pregestational Diabetes Mellitus Obstet Gynecol. 132 6 2018 e228 e248 Dec 30461693
9 Hod M Kapur A Sacks DA Hadar E Agarwal M Di Renzi GC The international federation of ginecology and obstetrics (FIGO) initiative on gestational diabetes mellitus: a pragmatic guide for diagnosis, management, and care Int J Gynaecol Obstet 131 Suppl 3 2015 S173 S211
10 World Health Organization Diagnostic criteria and classification of hyperglycaemia first detected in pregnancy: a World Health Organization Guideline Diabetes Res Clin Pract 103 3 2014 341 363 24847517
11 Colagiuri S Falavigna M Agarwal MM Boulvain M Coetzee E Hod M Strategies for implementing the WHO diagnostic criteria and classification of hyperglycaemia first detected in pregnancy Diabetes Res Clin Pract 103 3 2014 364 372 24731475
12 ElSayed NA Aleppo G Aroda VR Bannuru RR Brown FM Bruemmer D Classification and diagnosis of diabetes: standards of care in diabetes-2023 Diabetes Care 46 Suppl 1 2023 S19 S40 36507649
13 von Elm E Altman DG Egger M Pocock SJ Gotzche PC Vandenbroucke JP. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies Ann Intern Med 147 8 2007 573 577 17938396
14 American College of Obstetrician and Gynecologists” Committee on Practice Bulletins – Obstetrics. ACOG Practice Bulletin N°. 190: gestational diabetes mellitus Obstet Gynecol. 131 2 2018 e49 e64 29370047
15 Haines H Pallant J Karlström A Hildingsson I. Cross cultural comparison of levels of child-birth related fear in an Australian and Swedish sample Midwifery 27 4 2011 560 567 20598787
16 Ternström E Hildingsson I Haines H Rubertsson C. Higher prevalence of childbirth related fear in foreign born pregnant women-findings from a community sample in Sweden Midwifery 31 4 2015 445 450 25529841
17 Ternström E Hildingsson I Haines H Rubertsson C. Pregnant women's thoughts when assessing fear of birth on the Fear of Birth Scale Women Birth 29 3 2016 e44 e49 26710973
18 Richens Y Campbell M Lavender T. Fear of birth – a prospective cohort study of primigravida in the UK Midwifery 77 2019 101 109 31306998
19 Haines H Pallant JF Fenwick J Gamble J Creedy D Toohill J Identifying women are afraid of giving birth: a comparison of the fear of birth scale with the W-DEQ A in a large Australian cohort Sex Reprod Healthc 6 4 2015 204 210 26614602
20 Hildingsson I. Swedish couples’ attitudes towards birth, childbirth fear and birth preferences and relation to mode of birth – a longitudinal cohort study Sex Reprod Healthc 5 2 2014 75 80 24814442
21 International Federation of Gynecology ans Obstetricas (FIGO) Initiative on gestational diabetes mellitus: a pragmatic guide for diagnosis, management, and care Int J Gynaecol Obstet 131 3 2015 173 211
22 Zhang Y Xiao C Zhang Y Chen Q Zhang X Li X Factors associated with gestational diabetes mellitus: a meta-analysis J Diabetes Res 2021 2021 6692695
23 Rouhe HK Salmeal-Aro E Halmesmäki T Saisto T. Fear of childbirth according to parity, gestational age and obstetric history BJOG 116 1 2009 67 73 19055652
24 Wijma K Alehagen S Wijma B Development of the Delivery Fear Scale J Psychosom Obstet Gynaecol 23 2 2002 97 107 12189903
25 Saisto T Halmesmäki E. Fear of childbirth: a neglected dilemma Acta Obstet Gynecol Scand 82 3 2003 201 208 12694113
26 World Health Organization. Caesarean sections should only be performed when medically necessary says WHO. 2015 [cited 2023 feb 26]. Available from: https://www.who.int/news/item/09-04-2015-caesarean-sections-should-only-be-performed-when-medically-necessary-says-who.
27 Reiter M Betrán AP Marques FK Torloni MR. Systematic review and meta-analysis of studies on delivery preferences in Brazil Int J Gynaecol Obstet 143 1 2018 24 31 29920679
28 Mazzoni A Althabe F Gutierrez L Gibbons L Liu NH Bonotti AM Women's preferences and mode of delivery in public and private hospitals: a prospective cohort study BMC Pregnancy Childbirth 16 2016 34 26857448
29 Stoll K Edmonds JK Hall WA. Fear of childbirth and preference for cesarean delivery among young american women before childbirth: a survey study Birth 42 3 2015 270 276 26104997
30 Larsson B Karlstrom A Rubertsson C Ternstrom E Ekdahl J Segebladh B Birth preference in women undergoing treatment for childbirth fear: a randomised controlled trial Women Birth 30 6 2017 460 467 28495462
31 Wax JR Cartin A Pinette MG Blackstone J. Patient choice caesarean: an evidence-based review Obstet Gynecol Surv 59 8 2004 601 616 15277895
32 Dweik D Girasek E Toreki A Meszaros G Pal A. Women's antenatal preferences for delivery route in a setting with high cesarean section rates and a medically dominated maternity system Acta Obstet Gynecol Scand 93 4 2014 408 415 24575805
33 Storksen 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 15 2015 221 26382746
34 ydsjö G Angerbjörn L Palmquist S Bladh M Sydsjö A Josefsson A. Secondary fear of childbirth prolongs the time to subsequent delivery Acta Obstet Gynecol Scand 92 2 2013 210 214 23066797
35 Wiklund I Edman G Ryding EL Andolf E. Expectation, and experiences of childbirth in primiparae with caesarean section BJOG 115 3 2008 324 331 18190368
