Fear of child birth and associated factors among pregnant mothers who attend antenatal care service at Jinka public health facilities, Jinka town, Southern Ethiopia

Women face many challenges from conception to postpartum and fear of childbirth is one of the challenges the women encounters during pregnancy. This could have been resulted from different perspectives and it could intern lead to various pregnancy and child birth problems. Thus, understanding child birth fear and factors associated with this is of paramount importance and this study was aimed at addressing this issue. A facility base cross sectional study was done on 423 pregnant mothers who came for antenatal care services at Jinka hospital and Jinka health center. The study was conducted from June 01 to 30, 2018. Sample size was calculated using single population proportion formula and samples was taken after proportional allocation was done for the hospital and health center using proportion allocation formula. Individual participants were selected with systematic sampling technique using k- value of 2 for both the hospital and health center and the rst participant was selected by lottery method from the rst two samples. Data were entered in to epi-data version 3.1.1.and exported in to statistical packages for social sciences version 21.0 for cleaning and further analysis. Level of signicance was declared at p-value less than 0.05 in multivariable logistic regression model. Narratives, gure and tables were used to put the result. From 423 samples, two of the questionnaires were incomplete and thus 421 were used for analysis giving a response rate of 99.5%. Around a quarter of 102 (24.2%) mothers had fear of child birth and the remaining 319 (75.8%) the history of previous pregnancy previous of and delivery complications, educational status and depression status were associated with of child birth.


Introduction
Women face many challenges from conception to postpartum and fear of childbirth (FOC) is one of the challenges the women encounters during pregnancy and it can be an important source of distress for pregnant women, their family and their caregivers (1).Childbirth fear can be described as feelings of uncertainty and anxiousness before, during, or after the delivery by thinking labor and delivery (2). Fear of childbirth is common health issue for women and their caregivers when mothers are reaching to birth or are in their postpartum transition and varies from individuals ranging from negligible to extreme fear (1).
Pregnant women who fear childbirth are prone to face a lot of negative impact on physical and psychological wellbeing such as complications during pregnancy, to experience more severe pain, increased length of labor, use of anesthesia during labor and increased risk of caesarean section deliveries (3). Fear of childbirth may also associated with different psychological or clinical problems such as fear of undergoing a caesarean section, rupture, death, episiotomy, feeling helpless, lack of trust in the health workers, feeling of being alone, becoming panicked, (4,5). It also has a negative in uence on the postpartum period. Mothers with childbirth fear are more likely to have di culties with maternal adjustment(6) and mother-child bonding (7). It can also cause or worsen post-traumatic stress disorder and leads to avoidance of pregnancy, maternal and fetal stress. (4,8).
Globally, the prevalence of fear associated with childbirth is often reported to be around 20% (estimated to range from 7.5 to 27% during pregnancy (9,10). Different factors are associated with fear of childbirth like previous negative birth experience, parity, educational status, being unemployed, receiving low emotional support from husband, unwanted pregnancy (2,5,11,12).
Even though fear of childbirth is common problem with multiple consequences, most studies were conducted in high-income countries, and little is known in low-income countries including Ethiopia. Ethiopia is doing a lot to decrease maternal and neonatal morbidity and mortality and to achieve sustainable developmental goals (13). But a little concern is given on the psychological aspects of pregnancy and child birth and the possible factors associated with fear of child birth. So identi cation of women at risk of childbirth fear is essential for women's emotional well-being before and after birth. Thus, this study was aimed to assess childbirth fear and factors associated with it at Jinka public health institutions.

Study design and population
Institutional based cross-sectional study design was conducted in Jinka town public health facilities, South Omo zone from June 01 to June 30, 2018. South Omo is a zone in the Ethiopian Southern nations, nationalities and peoples region, which is bordered on the south by Kenya, on the southwest by the Ilemi Triangle, on the west by Bench Maji, on the northwest by Keffa, on the north by Konta, Gamo Gofa and Basketo, on the northeast by Dirashe and Konso, and on the east by the Oromia Region. The administrative center of south Omo zone is Jinka town. The town has two public health institutions, one health centers and one general hospital. In the hospital there are two psychiatric nurses who provide psychiatric care in outpatient for those having psychiatric problem. Pregnant women who came for antenatal care service in the study period at Jinka public health facilities were eligible to participate in the study and pregnant women who were critically ill were excluded in the study. For eligible participants who were above age 18, written consent was taken and for participants who were under the age of 18 written consent was taken from their parents.

Sample size determination and Sampling technique
To get the actual sample size, different sample sizes were calculated based on the objectives.
The required sample size was determined using a formula for single population proportion n = (Zα/2)2p (1-p)/d2, as shown in the table below.
Where; n = Minimum sample size for a statistically signi cant survey, z= is the signi cance level (at 5% signi cance level its value is 1.96), p= 0.5, d= is the margin of error (It has been taken as 5%). Sample size was allocated proportionally to the hospital and the health center using population proportion formula. i.e. ni=Ni*n/N , where , ni=sample for the speci c proportion, Ni=total population of a speci c proportion, n=total samples to be included in the study and N=total source population. Hence, samples from the hospital= 600*423/900=282. Samples from the health center=300*423/900=141. Finally 423 pregnant women were included in the study.
Regarding to the sampling technique, there are two public health institutions in Jinka town, one health center and one general hospital. According to their last year June 01 to June 30 ANC service report, 600 pregnant mothers get ANC service in the hospital and 300 pregnant women in health center. Samples were allocated to each public health institutions based on proportional allocation to sample size. By considering last year June 01 to June 30 report as a sample frame (N) which is 900 pregnant women, Systematic sampling technique was used to identify the study unit to participate in the study. The eligible attending respondents were recruited in order of their coming for antenatal service during each day. The rst study participant was selected by lottery method using their card number, then every k value (k=N/n=900/423=2, where N is sample frame, n is sample size for this study and k is regular interval between study participants) were selected based on their order of entry for ANC follow up until reach 423 samples. Fear of Childbirth -Feelings of uncertainty and anxiousness arise from the woman's anticipation or experience of being captured in a situation where she faces the approaching delivery, which is unknown, uncontrollable and lead the woman to distress; and WDEQ scores more than 84 (2,14) Antenatal care attended: Pregnant women who had attended antenatal clinics during the recent pregnancy at least once.
Antenatal depression: A pregnant women who have mood disorder and scoring 16 or more in beck depression inventory scale(15).
Beck's Depression Inventory: Is a tool which contains 21 questions each with four possible responses.
Each response assigned a score ranging from 0 to 3. The overall value of the scale ranges from 0 to 63, and a pregnant mother with a score of 15 and less was considered as normal while a mother with BDI score of 16 and more was considered as depressed (15,16).

Data collection method and instruments
Data was collected using semi-structured and pretested questionnaire through face to face interview.
Questionnaire was rst prepared in English language and translated into Amharic (the local language in the study area) and then translated back to English in order to ensure its consistency. The Amharic version was used for data collection. The questionnaire includes socio demographic characteristics, obstetric history, depression history, substance use, psychosocial and Beck Depression Inventory (BDI) which is a depression screening tool for assessment of depression condition. Four diploma and two Bachelor Science (BSc) nurse professionals who didn't work in the ANC clinic were selected for data collection and supervision respectively. One day training was given for both data collectors and supervisors about the methodology and questionnaire by the investigators. Data was collected after study participants got ANC services.

Data quality assurance
Data quality was assured before, during and after data collection. Prior to actual data collection, the questionnaire was rst prepared in English language and translated into Amharic and then translated back to English in order to ensure its consistency. Pretest was done on 5 %( 22) of the sample size in Arba Minch general hospital to determine clarity, adequacy, and e ciency of the questionnaire and corrections and modi cations taken according to the result and one day training was given for data collectors and supervisors about the methodology and questionnaire by the investigator.
During data collection period the purpose of data collection and importance of the study was informed to the participants in order to generate quality data and the collected data were checked for completeness and consistencies by trained supervisors and investigator through close follow up and necessary corrective action were taken accordingly. In addition data collectors were always check participants appointment date on the participant's card to avoid repeated visit. After data collection, the collected data were rechecked for completeness and consistencies by investigator.

Data processing and analysis
Data was entered in to Epi data version 3.3.1 software after coding and checking their completeness and exported to statistical package for social science (SPSS) version 20.0 for analysis. Descriptive analysis (frequencies, percentage, means and standard deviations) was computed to explore socio-demographic, obstetric and other health related characteristics, depression history, substance use and psychosocial characteristics of study participants. Binary Logistic regression was used to nd out association between fear of child birth and explanatory variables. Explanatory variables which had P-value less than 0.25 and ful ll the assumption of logistic regression from bi-variable logistic regression were considered for the multi-variable logistic regression model. The model goodness of t was tested by using Hosmer-Lemeshow and Omnibus test and p-value was 0.447 and 0.000 respectively. Strength of association was evaluated using odds ratio at 95% con dence interval and P-value < 0.05 was considered to declare signi cant associations.

Socio demographic characteristics
A total of 423 pregnant women were considered to be involved in this study. But, there were two incomplete questionnaires giving a response rate of 99.5%. The mean age of the study participants was 24.16 ± 4.43 SD years. Regarding family size 296(70.5%) of participants had small family size and 35(8.3%) had large family size while other 89 (21.2%) participant had average family size with minimum 1, maximum 9 and mean 3.8 ± 1.68 SD. The rest socio-demographic characteristics are listed in table one below.

Discussion
In this study, the prevalence of child birth fear was 24.2%. Almost similar ndings were obtained with studies done in Australia (24%) (5) and Iran(25.7%) (18). However the prevalence of this study is lower than study done in Egypt (49.3%) (19), India (45.4%) (20) and United States (39.4%) (21). This difference may be due to difference in socio-demographic characteristics, screening tool used and sample size. On the contrary, lower child birth fear was obtained with studies conducted in Estonia and Sweden (21). This variation might be due to socio-demographic variations, methodological difference and time of study as there could be improvements in health service systems and literacy level of mothers over time.
Moreover, a previous pregnancy complication was signi cantly associated with fear of childbirth. i.e.
pregnant women who had previous pregnancy complication were 5.6 times more likely to have fear of childbirth than those who hadn't previous pregnancy complication (AOR = 5.60, 95% CI (1. 12-28.29). This study is supported by study done in Australia(5) and China (22). The possible justi cation for this might be due to fear of the recurrence of previous pregnancy related complication and posttraumatic feeling of those previous complication.
Previous history of labor and delivery complications was signi cantly associated with fear of childbirth. Study participants who had previous labor and delivery complications were 6.59 times more likely to have fear of childbirth than participants who hadn't previous labor and delivery complication(AOR = 6.59, 95% CI (1.09-39.62).. This study is supported by study done in Malawi (12), Australia(5), Sweden (11) and Turkey (23). The possible reason might be due to poor reproductive health counseling, fear of previous labor and delivery complication recurrence, posttraumatic feeling of the previous negative birth experience and poor pregnancy and child birth knowledge.
Educational status was another explanatory variable which had signi cant association with fear of child birth. Study participants with primary level of educational only were 10.89 times more likely to develop fear of child birth than those whose educational status is college or university(AOR = 10.89, 95% CI (1.72-69.53). Why only primary schooling had association is it is the category with which the highest number of mothers fails. Thus, it considered that educational level in general had association with mother's fear of child birth. This is in line with study done in Malawi (12) and Iran (20). The possible reason may be due to those participants with their educational status fall in primary level may have inadequate knowledge on maternal health service.
In addition, fear of child birth was also signi cantly affected with depression status of mothers. Study participants who had antenatal depression history were 10.46 times more prone to have fear of child birth than those mothers who hadn't antenatal depression (AOR = 10.46, 95% CI (4.32-25.33). A similar nding was obtained with a study conducted in Australia (5). This could be resulted as depressive symptoms can exacerbate physiological changes which occur during pregnancy, labor and delivery and leads to anxiety and childbirth fear.

Conclusion
In this study, a considerable gure of mothers has fear of child birth. Even though it is physiological to have some fear, the result obtained is relatively higher. Previous pregnancy and child birth complications as well as depression together with educational status of mothers signi cantly lead mothers to have fear of child birth. Improving literacy, providing adequate health information on different obstetric histories and their real risk to pregnant mothers as well as integrating psychiatric assessments particularly depression assessment with maternal health services is recommended to prevent mother's child birth University, College of Health Sciences. Additional permission was obtained from Jinka public health facilities. Moreover, the purpose of the study was explained to the study participants and verbal informed consent was taken before data collection started. Verbal consent was taken as there is no harm to the study participants as a result of participating in the study and this was approved by the ethical review board of Arba Minch University. To keep the con dentiality of the participants, personal identi ers like name of the participant was not included in the data collection format and ensured throughout the research process. Again the information obtained was utilized only for research purposes. Participation was entirely voluntary.

Consent for publication
Not applicable Availability of data and materials The datasets used for this study could be deposited in publicly available repositories where appropriate and upon reasonable request. All relevant raw data supporting the ndings and conclusions of this study can also be freely available from the corresponding author through email ''enemelkamu@gmail.com'' or with other means to any scientist wishing to use them for non-commercial purposes without breaching participant con dentiality upon reasonable request. There will not be any concern on ethical aspect for this as participant data was de-identi ed

Competing interests
The authors declare that they have no competing interest