Full title: Managing the fear of childbirth, developing a care program: a multi-method study

doi:10.21203/rs.3.rs-2220461/v1

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Full title: Managing the fear of childbirth, developing a care program: a multi-method study

https://doi.org/10.21203/rs.3.rs-2220461/v1

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Background: Despite the importance of fear of childbirth and the necessity of implementing appropriate care methods to increase women's willingness to childbearing and their more tendency to perform natural childbirth, there is no clear process in this field in the care programs of the country's health system. The present study was designed with the aim of developing a guideline for managing the fear of childbirth in the current context.

Methods: This is a multi-method study which was conducted in five stages within the framework of the National Institute for Health and Care Excellence (NICE) guideline. A research committee consisting of five focal and 16 secondary members was formed. The stages included determining the scope of the study, developing guideline (a qualitative study and a systematic review, triangulation of the data, and producing a preliminary draft), consultation stage (validation of the protocol Using nominal group method), as well as revision and publication stages.

Results: The clinical guideline of Managing the fear of childbirth with 190 evidence-based recommendations was developed in seven main areas, including the Pre-pregnancy period, pregnancy period, making childbirth more pleasant, training empowerment of employees, improving the service delivery system, social support and clinical guide evaluation methods.

Conclusions: We are hoping by applying this clinical guideline in maternal health care settings to move towards an integrated care plan for fear of child birth in the context of our health system. Health care organizations should support to form multi-specialty teams to care for mothers with fear of childbirth. Through holistic care, they can constantly examine the psychological needs of pregnant mothers, including the fear of childbirth, along with their other needs, and manage them correctly.

fear of childbirth. Clinical guideline. Tokophobia. management. multi-method.

Managing the fear of childbirth during the perinatal period is an important strategy for improving pregnant women’s attitude of childbearing, childbirth and to improve the health of mothers and infants. The results of this study provide the necessary information to carry out interventions needed to promote women's health during pregnancy and postpartum period. This study has a multi-stage design that consists of several consecutive phases. At first, with a qualitative approach, the researchers explained the concept, obstacles, facilitators, and suitable strategies to deal with the fear of childbirth, then using a systematic review of clinical trial studies and guidelines, they collected evidence related to the research topic. In the second stage, the results of the qualitative study and the systematic review of related studies have been combined with each other. By combining the results of the previous two stages, the initial draft of the guideline was designed based on the prioritized guidelines by a group of experts and validated for implementation. In the quantitative phase of the study, the validation of the guideline and the evaluation of the designed recommendations have been done using the AGREE tool. Over 85% agreement was expressed in different aspects of clinical guide validation. Only in the applicability domain, it got a lower score due to the need for structural changes in the healthcare service delivery system and the necessary budget allocation. 100% of the evaluators have recommended the use of the developed clinical guide. It is expected that by conducting this multi-stage study and providing guidelines appropriate to the cultural situation and the conditions of the society, the mental health of pregnant women, including the fear of childbirth and the attitude towards childbearing, and as a result, the health of the mother and the infant will improve.

Fear of childbirth (FOC) is an extreme state of anxiety from phobia about childbirth(1). FOC in pregnant women revolves around concerns such as the well-being of the child, pain, loss of control, medical interventions and the medical environment, unfamiliar healthcare providers during childbirth, and lack of support(2, 3). Results have shown that these fears are a source of anxiety in women, affect their everyday activities, lead to C-section, or prevent further pregnancies(4, 5). Some studies have suggested that a strong fear of Normal Vaginal Delivery (NVD) is an important factor in a pregnant mother's desire to have a cesarean section. Also, fear of pain, fear for the health of the baby, and fear of the situation not being controlled by the caregiver are the factors influencing the choice of cesarean section on normal delivery(6, 7). Reported incidence of FOC in pregnant women ranges from 8% in Europe to 24% in Australia(8), 25% in Asia, and 26.9% in the United States(9), with a recent systematic review reporting a global incidence of severe FOC of 6–10%(4). Previous studies have found several risk fac tors for FOC in pregnant women, including maternal age, low educational level, parity, gestational age, depression, lack of social support, low self-esteem and low childbirth self-efficacy(10–12). Some studies about planned measures to reduce the fear or anxiety of pregnant women have shown that a variety of counseling, support, and personal care programs with the presence of one or more members of the health care team such as midwives, psychologists, psychiatrists, counselors, and other specialists is effective in reducing mothers' fears and anxieties and reducing mothers' requests for cesarean section(13).The purpose of interventions designed to reduce the fear of childbirth is to help control the anxiety associated with pregnancy and childbirth so that pregnant mothers can accept the doubts associated with it and reduce the stressors following the treatments to make better adaptations in pregnancy and refuse to request a cesarean section(14). An integrative meta-diagnostic approach to reduce stress, which includes mental and physical exercises and appropriate behavioral interventions in the prenatal period, helps pregnancy health and reduces birth complications and can lead to the promotion of healthy parenting(15). The evidence shows that developing special guidelines for health sector employees to properly manage the fear of childbirth is one of the priorities of care and support. Because it has been seen in various researches that proper treatment of fear in mothers can show its effect in reducing anxiety and depression, increasing self-efficacy and creating good pregnancy outcomes(16). Providing clinical guidelines as a key component can be effective by presenting evidence-based care and thereby optimizing the care consequences and improving effective use of the healthcare system resources(17, 18). A review of the evidence in this regard shows that various clinical guidelines have been designed for mental health during pregnancy(19–22), but only one of them specifically addresses the fear of childbirth(23). The authors have prepared this guideline based on their field of expertise by mentioning the general headings and have refrained from addressing the details and the path of the interventions. On the other hand, these guideline recommendations were not graded based on the level of evidence. However, this is a general guideline and does not take into account the mental health care team, settings and human resources to provide care in cases of fear of childbirth based on our health system. A review of the literature about developing a clinical guideline of mental care shows that development of a clinical guideline should capture the complexities of healthcare provider organizations as well as ethical, legal, cultural, and economic aspects in any organization and country.

In other words, the clinical guideline of a country may not be completely applicable for another context. Therefore, healthcare systems and organizations need standardization of their care policies in order to manage their resources and promote the care. Therefore, having a clinical guideline based on evidence-based recommendations, taking into account the needs of pregnant women and clinical expertise, is necessary to provide coherent mental health care, especially to deal with fear of childbirth. Based on this, the present study was designed for midwives with the aim of developing a clinical practice guide in Iran for the managing of fear of childbirth.

This multi-method design study was conducted in five stages within the framework of the National Institute for Health and Care Excellence (NICE) guideline(24). This research was conducted from January2020 to June 2022. First, a research committee consisting of five members (the first author and research team) was created for performing qualitative study and searching the available reference in databases. Furthermore, 16 secondary members were added. Then 9 specialists in the Related scientific fields investigated the content validity of the clinical practice guideline. The NICE guide consists of six stages, but in this study, the last stage (updating phase) was not applicable(24).

1) The stage of determining the scope: In our study in the first stage, the scope of the study and its objectives were determined in the research committee with focal members. Then, a decision was made on the following issue: “Which clinical questions should be addressed through the clinical practice guideline of management fear of childbirth?”

2) The stage of development: this stage was performed through discussion and decision-making in the research committee for conducting a qualitative study phase involving interpreting the understanding of managing of fear of childbirth concept, the needs of pregnant women, expectations, and skills of beneficiaries in the culture context as well as a systematic review phase (scoping search). In the qualitative study phase, 40 unstructured interviews were made with the participants in the study, including pregnant women, healthcare team members, and Health policy makers through conventional content analysis method. Writing of the qualitative phase of the study was based on the COREQ (consolidated criteria for reporting qualitative research) checklist. In the next step, by a systematic review, the available evidence on the literature and existing guidelines was extracted during an extensive search in databases. The systematic review was done based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2009. In the process of systematic review, first the research question was designed based on the study objectives through PIPOH method (Population, Intervention(s) (or diagnostic test) of interest, Professionals, Expected Outcomes, Healthcare setting and context). Through this method, the clinical question was designed as “What evidence-based interventions do health care providers and other members of the health care team use to reduce expectant mothers' fear of childbirth and promote their mental health?”. After designing the clinical question, three members (the first author and one member of the reproductive health group and finally one person with librarian expertise) searched the literature related to the topic. The search was carried out in the electronic databases, PubMed, Scopus, Embase, Web of Science, Clinical Key, Cochrane Library, and in specialized databases for guidelines, Agency for Healthcare Research and Quality & National Guideline Clearinghouse (NGC), Guideline International Network (G-I-N), National Institute for Health and Care Excellence, New Zealand Guidelines Group, National Health and Medical Research Council (NHMRC), The Scottish for Clinical Guidelines Network (SIGN), Clinical Trials.gov. At first, the title and summary of the extracted articles were independently screened by two authors according to the inclusion and exclusion criteria. In the next step, the full text of the selected articles was thoroughly studied by two authors. Eventually, 62 studies remained in the study (Fig. 1).

(Fig. 1 here)

Then, the information required for the studies was extracted and recorded in a designed form by the research team. At stage of development, the preliminary draft of the guideline was also developed in the research team through combining evidence-based recommendations from the results of the qualitative study phase and the systematic review.

3) Consultation stage: A panel group consisting of the specialists, i.e., the researchers and practitioners of the reproductive and mental health field, evaluated the draft of guidelines in terms of content validity using the nominal group technique. The specialists of the expert panel consisted of 16 scholars in the area of reproductive health and midwifery, gynecology and obstetrics, clinical psychology and psychiatry, health policy and university faculty members who had adequate skills and knowledge to comment on the studied subject, and expressed their interest to participate in the study. Based on the available sources, first the guide table of clinical components was designed in seven areas, and based on the opinions of people in each area, detailed descriptions of the relevant measures were included. Specific areas in this table include: the target group for the development of the clinical guide, the implementers of the implementation of the clinical guide, the necessary services for the development of the clinical guide (including educational services and individual and group counseling, psychological interventions and interventions related to Improving childbirth experiences), empowering the health team, improving the system of providing health services to pregnant women, social support for women suffering from fear of childbirth, forming peer groups, and monitoring indicators and evaluating the results of service implementation. Each of the areas of this table included different options that were the result of integration the results of the qualitative stage and the systematic review of articles. Based on the scores given by the panel members for each item, options were prioritized in each section. The results of prioritization were used in the compilation of recommendations related to different parts of the clinical guideline.

The clinical guide for the management of fear of childbirth was developed with the aim of designing evidence-based recommendations based on the expectations and needs of expectant mothers and health team members in the context of Iranian culture. The recommendations of the clinical guidelines for the management of fear of childbirth in pregnant women (190 recommendations) were formed in seven main areas. Subsequently, this version of the guideline was provided to 12 scholars to evaluate the guideline by the AGREE-II reporting checklist (Appraisal of Guidelines for REsearch & Evaluation-II)(25).

4) Revision stage: After critical appraisal of the descriptive comments in the research team, the necessary modifications were made. Then, the final version of the clinical practice guideline of management the fear of childbirth was produced.

5) Publication stage: Guideline recommendations are published in the first author’s Doctoral Thesis, alongside all evidence reviews, tables’ results, and methods.

6) Updating stage: The formal process for updating will begin three years after publication. When important changes are made, there will be a stakeholder consultation. The updated guideline will then be published, along with a list of changes from the previous version of it. As we were in the development stage, this stage was not included in our study.

In the qualitative part of this study 40 participants including 15 pregnant women and 25 health care providers were included. From the analysis of the data obtained from the interviews, three themes emerged concerning the needs of mothers to properly manage the fear of childbirth: "Need to provide awareness and empowerment of mother and family", and "The need to pay attention to the mental health of pregnant women" and "Supporting needs (seeking support)". Overall, 1000 codes, 40 subcategories, 11 categories, and 3 themes were extracted from the text of the interviews (Table 1).

Table 1

Main and subcategories obtained from the analysis of participants' interviews
Theme	Categories	Subcategories
Need to provide awareness and empowerment of mother and family	The lack of awareness of mothers about pregnancy and childbirth	Mother's ignorance of the pregnancy and childbirth process
		Inadequate maternal information on the advantages and disadvantages of NVD and C/S
		Lack of knowledge of preparation methods for childbirth
		Need to learn about pain relief methods
	The need to achieve more knowledge in reducing the fear of childbirth	Need to know the facts of childbirth in different ways
		Lack of sensitivity of the couple to the specific conditions of pregnancy
		Improve the situation and reduce fear seeking more cognition
		Conscious choice of delivery method following cognition increase
	Educating and informing mothers and families	The effect of education on the mother's physical and mental preparation
		Need to train spouse and family
		Continuous improvement of the training process taking into account the training needs
Need to pay attention to the mental health of pregnant women	The effect of maternal attitude on the process of pregnancy and childbirth	The role of positive perceptions and thoughts in reducing the fear of childbirth
		The role of beliefs, previous experiences and negative mentality of the mother towards childbirth
		The importance of the impact of psychological factors and thoughts on pregnancy acceptance
		The influence of previous beliefs, experiences and indoctrination of others in choosing the method of delivery
	The psychological burden of experiencing fear in mother and family (healthy transition anxiety)	Persistence of previous experiences of fear in life (rooted phobia from childhood to adulthood)
		Fear experience in the first sexual intercourse (wedding night experience)
		Unpleasant experience of previous delivery and experiences of others (family and friends)
	Experience of psychological trauma in pregnant women	Experience coping with fear
		Consequences of fear of childbirth
		Threat to married life
	The need for maternal psychological support during pregnancy	The need to pay attention to the mental and psychological condition of pregnant women
		Lack of support and lack of proper counseling services
		Use of effective methods on fear and anxiety
Supporting needs (seeking support)	Pay attention to the role of the husband in supporting the mother	Psychological and emotional support and sympathy from the husband
		Husband's inattention to wife
		Husband's companionship and attention to the mother's needs
	The importance of family support	Need for family support
		The need for family presence during childbirth
		The importance of empathy and family companionship
	The importance of supporting medical staff (health team)	Need support from health care providers and midwives
		Need to support the midwifery team during delivery
		The importance of maternal support by obstetricians
	The need for social support	Cultural and welfare activities to support pregnant women in society
		The importance of using communication media
		The impact of using cyberspace

In the extensive search of electronic databases, 4831 articles were obtained. After removing duplicate and irrelevant studies in the screening and selection stages, eventually, 62 articles were included in the study. In the search phase in the dedicated databases of clinical guidelines, at first 1651 primary studies were extracted, after removing duplicate and unrelated cases, 12 clinical guidelines published between 2011 and 2021 were included in the final review. In the search for evidence and clinical guidelines, criteria such as relevance to the subject of the research, year of compilation, language and credibility of the compiler of the clinical guide were considered.

The clinical guideline of management the fear of childbirth was developed with 190 evidence-based recommendations in seven main areas: the pre-gestational period (12 recommendations), the pregnancy period (80 recommendations), the improving childbirth experiences (49 recommendations), the educational empowerment of health providers (9 recommendations), the improving the system of providing health services to pregnant women (26 recommendations), the social support and formation of peer groups (9 recommendations), and evaluation methods of clinical guideline (5 recommendations) ) Table 2).

Table 2

The main areas and recommendations of the clinical guideline the management of fear of childbirth.
Areas	Evidence-based recommendations
pre-gestational period (12 recommendations)	3 recommendations for education and counseling, 4 recommendations for screening and diagnosis, and 5 recommendations for interventions.
Pregnancy period (80 recommendations)	34 recommendations for the prevention of fear of childbirth (14 items for general actions, 4 items for educational content of pregnant women, 7 items for the method of providing education to pregnant women, 5 items for the educational content of women's families and spouses, and 4 items for the method of teaching to spouses) 14 recommendations for screening and diagnosis, 24 recommendations for interventions and care, and 8 recommendations for measures related to spiritual health.
Improving childbirth experiences (49 recommendations)	20 recommendations for providing respectful care to mothers in the hospital, 15 recommendations for the first stage of labor, 6 recommendations for the second stage of labor, and 8 recommendations for the postpartum stage.
Educational empowerment of health providers ) 9 recommendations)	9 recommendations for educational programs necessary to improve the performance of midwifery health providers and students.
Improving the system of providing health services to pregnant women (26 recommendations)	7 recommendations for reforming the structure of health services, 5 recommendations for motivating employees and 14 recommendations for policy making in the field promote normal vaginal delivery.
Social support and formation of peer groups (9 recommendations)	9 recommendations for social support of women suffering from fear of childbirth, forming and setting up peer groups for pregnant women
Evaluation methods of clinical guideline (5 recommendations)	5 recommendations for Indicators for monitoring and evaluating the results of interventions.

Based on the standard score of AGREE-II checklist, the minimum and maximum scores were related to the domains of Applicability (80/86%) and Scope and Purpose (93/21%), respectively. The scores given by specialists to the clinical practice guideline in other domains ranged between 86/57 and 92/06%. In the end, in the final evaluation of the clinical guide, the evaluators declared their judgment about the quality of the guide and 100% of them recommended the use of the clinical guide. 72.2% strongly recommended the use of the clinical guide and 27.8% conditionally recommended the use of the clinical guide. (Minor changes in parts of the clinical guide were recommended based on the suggestions provided by the evaluators). Overall, the quality of the clinical practice guideline of managing the fear of childbirth was estimated as desirable.

Evidence-based recommendations and expectations of pregnant women and healthcare team members developed the clinical guideline for managing the fear of childbirth. One hundred and ninety recommendations within seven areas in the Iranian culture context were made. Recommendations in the first three areas, regarding education, counseling, diagnosis, and treatment, are specifically designed for clients. The next two areas contain recommendations for empowering health providers and the health service delivery system. 14 recommendations of the clinical guide in two other areas are related to social services and evaluation methods. This guideline is applicable based on the levels of health care in the health system. The health system of our country functions as a coherent network at three levels and the Ministry of Health and Medical Education stands at the top level. The first level includes sectors in which the first and largest level of contact between the society and healthcare system occur. These sectors include health houses and rural and urban health centers, in addition to health posts. The second level includes sectors which are able to provide healthcare services at a more specialized level. They include district health centers as well as district general hospitals under the supervision of medical sciences universities. Healthcare services at specialized levels occur at the third level of the health system of the country. This level includes the province health center and specialized hospitals under the supervision of medical sciences universities (26). Concerning the structure of the health system of the country and access to resources, this guideline can be applied at all three levels. That is, it can be implemented in primary care, intermediate care, and finally, hospitals (emergency departments, delivery, postpartum and palliative care), as well as hospital-integrated services to community-based home care. Considering the negative effects of the fear of childbirth on the attitude of women of reproductive age to the issue of having children, attention has been paid to the needs of women before pregnancy. So that the first field is dedicated to training, counseling, screening and necessary interventions in the pre-pregnancy period. Mycroft et al also emphasize in the guide to tokophobia and Traumatic Experience of Childbirth on identifying and providing educational and counseling services to non-pregnant women with a negative attitude towards childbirth(23). Several clinical guidelines have mentioned the issue of providing mental health services to pregnant mothers during the perinatal period and have provided specific recommendations for the diagnosis and management of cases with mental health disorders(20–22). This is despite the fact that the issue of fear of childbirth has only been addressed in the guide to fear of childbirth (tokophobia)(23). In the third area, providing respectful services to mothers during admission, in the first and second stage of childbirth and postpartum are mentioned as recommendations related to making childbirth pleasant. Increasing the mother's participation, self-confidence, independence of action and satisfaction in the process of physiological childbirth can make childbirth pleasant for the mother and the family and reduce the desire of the mother to perform a cesarean section. By the World Health Organization, the intrapartum care clinical guideline for a positive childbirth experience was published in 2018 with 56 recommendations. WHO recommends respectful maternal care (RMC), effective communication, companionship during labor, and continuity of care for a positive birth experience(27). The recommendations of this clinical guideline are classified into three-time stages for providing care (peripartum, intrapartum and postpartum). In other studies, interventions to increase self-confidence or improve women's childbirth conditions have had positive results regarding making childbirth more pleasant(28–30). In order to improve the structure of providing services to pregnant women in health systems, recommendations have been designed in the next two areas of the guideline. Educational empowerment of health providers and improving the system of providing health services to pregnant women are issues that were raised due to the low quality of health service provider systems. It is necessary to reform the service delivery system in order to improve the quality of care in the field of women's health, and the current structure should be revised and the performance procedure should be modified. Some studies in Iran have shown that the low quality of health services for women and the lack of proper education for them leads to a lack of belief in health services. It not only causes a decrease in the motivation of service providers, but also creates unmet needs of clients and their dissatisfaction with health services(31). Regarding the educational empowerment of the health team, some studies stated that the necessary capacities to enable them to play the role they are responsible for in the system with high efficiency and effectiveness should be created by using appropriate training(32). For this reason, paying attention to the educational needs of employees in order to improve the quality of training courses was brought up. The lack of a specific screening protocol for the fear of childbirth and its administration in pregnancy is an important factor in the low performance of the health team in this field. The establishment of new regulations by health system policymakers with the aim of changing the approach of identifying high-risk cases and operational solutions to remove obstacles to NVD will lead to a change in the service path for pregnant women. Researchers have suggested that protocols based on theories of health education be designed, implemented and evaluated in healthcare systems(33). In these protocols, women who receive psychoeducation along with usual care methods will experience more positive pregnancy and birth experiences. Psychologically based interventions can play an effective role in reducing FOC during pregnancy and even childbirth. Therefore, creative and counseling-based methods should be used to improve women's psychological conditions by health care teams(34, 35). Social support and the formation of peer groups is another area of clinical guidance for the management of fear of childbirth. Considering the special conditions of pregnancy, women need multifaceted support, including family and community support in the form of cultural and welfare services. These supports reduce the psychological burden caused by pregnancy and with companionship, empathy and attention to the woman's needs from other people, are effective in reducing fears during pregnancy. In studies, increasing social support leads to a decrease in the fear of childbirth in primiparous women and an increase in their satisfaction with childbirth(36, 37). In addition to positive effects during pregnancy and childbirth, social support also has beneficial effects after childbirth. Studies have shown that women who received supportive measures during pregnancy had less depression than others in the postpartum period(38, 39). In recent years, more emphasis has been placed on that a significant part of health behaviors is the result of learning from others, and in particular, the effects of peer groups. Thus, the use of a peer education approach, which is considered a behavior change strategy, can be applied in this regard(40).In a peer education approach, the peers communicate with other peers and transfer the information effectively thus affecting their counterparts(41).The results of studies have shown that peer education has an effect on reducing the FOC in pregnant women. The mean scores of mothers’ fear in the peer education group after the intervention decreased compared to their mean scores before the intervention(42). Considering the positive effect of peer groups in reducing fear of childbirth, recommendations were designed on this basis in this clinical guide. Considering the importance of evaluation in determining the positive performance of a process and the degree of success in achieving the goals, recommendations for its evaluation methods were designed in the last area of the clinical guide.

In summary, applying this clinical guideline can help caregivers of the health system to move towards an integrated mental health care plan for pregnant women in our healthcare system. midwives can be in the core of the Maternal mental health team. Maternal mental health team consists of qualified healthcare providers who are all working under supervision of the Reproductive health specialist. Through holistic view, they can constantly examine the psychological needs of mothers, including fear of childbirth alongside their other needs and provided standard care to pregnant women by focusing on the process of identification, psychoeducation, follow-up and referral.

Benefiting from the NICE guideline, grading the evidence, and critical appraisal of the clinical practice guideline by the AGREE-II have been the strong points of this study.

The guideline obtained from this research with regards to fear of childbirth can be employed for management, policymaking, educational, and research purposes, and be effective in enhancing the quality of services provided to pregnant mothers. Considering the increasing rate of C-section caused by fear of childbirth in Iran it is expected that with implementing of guideline, women would have greater tendency to undergo natural delivery. Further, implementation of the guideline will help gain awareness about the benefits and obstacles of executing this guideline across the Iranian population. Indeed, we could also provide this guideline to policymakers and planners, so that they would use it as a standard for Promotion of natural childbirth. Nevertheless, in this regard the grounds for implementing national protocols of management fear of childbirth such as human and financial resources as well as hospitalization environment should be provided. Since there is no comprehensive guideline in WHO or presented by other countries for management fear of childbirth, this study was designed to compose guideline in Iran based on a multiphase study. Tis guideline can be also considered in other parts of the world as well.

NICE

National Institute for Health and Care Excellence

FOC

Fear of childbirth

NVD

Normal Vaginal Delivery

COREQ

Consolidated criteria for Reporting Qualitative research

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

NGC

National Guideline Clearinghouse

G-I-N

Guideline International Network

NHMRC

National Health and Medical Research Council

SIGN

The Scottish for Clinical Guidelines Network

AGREE

Appraisal of Guidelines for REsearch & Evaluation

WHO

World Health Organization

RMC

Respectful Maternal Care.

Ethics approval and consent to participate

Ethical approval to conduct this study (IR.SHMU.REC.1399.135) was granted by the Ethics Committee of Shahroud University of Medical Sciences, Iran. Written informed consent will take from each participant.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests

Availability of data and materials

The dataset supporting the conclusions of this article is available from the corresponding author upon reasonable request.

Funding

None.

Authors’ contributions

All the authors contributed to the conception and design of the study. AB drafted the first version of the manuscript. ZM, NJ, and MK revised the manuscript. MR critically reviewed the manuscript for important intellectual content. All authors approved the final version.

Acknowledgements

This paper was extracted from a reproductive health PhD thesis, approved by the research session of Shahroud University of Medical Sciences with code 873. Therefore, I would like to thank the Vice Chancellor for Research of Shahroud University of Medical Sciences.

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No competing interests reported.

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Full title: Managing the fear of childbirth, developing a care program: a multi-method study

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