Fear of Childbirth in Chinese Pregnant Women and Their Preferred Mode of Delivery: Validation Study of the Chinese Version of Wijma Delivery Expectancy/experience Questionnaire Version A

Fear of childbirth causes signicant distress and impact on women’s wellbeing. It also contributes to the rising trend of non-medically indicated Caesarean sections worldwide. The Wijma Delivery Expectancy/Experience Questionnaire (Version A) (W-DEQ-A) is a comprehensive instrument for the assessment of fear of childbirth among antenatal women. Hong Kong Chinese women at the antenatal booking clinic completed the translated questionnaire, Edinburgh Postpartum Depression Scale, State-trait Anxiety Inventory and indicated their preferred mode of delivery. The validity and reliability of the translated questionnaire were analysed using Cronbach’s alpha coecient and intraclass correlation coecient respectively. The subscales of the questionnaire were determined using exploratory factor analysis. The relationship between demographic data, preferred mode of delivery and the W-DEQ-A score were analysed using student’s t test, Mann-Whitney test or Pearson’s correlation. rst visit was dened as women having FOC, while score of ≥ 100 indicated severe FOC. Data were presented as mean and standard deviation (SD) for continuous data or n and percentage for categorical data. Differences according to demographic or obstetric characteristics were analysed by student’s t test or Mann-Whitney test for continuous data and chi-square test for categorical data. Exploratory factor analysis was conducted to analyse the factor validity. Principal component analysis with varimax rotation was performed on 33 items, and the number of factors were dened by the use of scree plots.

Globally, the rate of Caesarean section is increasing in both developed and developing countries. In a secondary analysis of the two World Health Organization multi-country surveys, a rising trendof Caesarean section rates up to an overall of 31.2% was noted (1), even though Caesarean section rates above 10-15% are known to not be associated with reductions in maternal and neonatal mortality rates (2). Caesarean section can be associated with short and long term complicationsfor the women and their children (3). Non-medically indicated Caesarean sections, i.e. for social reasons, maternal request or maternal anxiety,have been viewed as one of the top contributory factors for the high rates of Caesarean sections at term in China (4), where the rate of Caesarean section rates is increasing by 1.0% annually (1). This is also a serious problem in Hong Kong, where the rate of Caesarean section for social reasons have increased from 9% to 15.1% between 2004 and 2014 (5). In an analysis of 1302 nulliparous women who wished to undergo a Caesarean section, fear of childbirth (FOC)is the only statistically signi cant predictor for women's wish on multivariable analysis (6). Therefore, FOC could be the root cause for the increased Caesarean delivery rate (3).
Childbirth is a common and normal physiological phenomenon, but can imaginablyevoke a widespectrum of positive and negative emotions (7).Because of the likelihood of pain and possible problems that may arise during labour and delivery, FOC is common among expectant mothers.Up to 20% of women experience some degree of FOC (8), though the rate is known to vary geographically.
FOC deserves attention as it can be disabling, by affecting the women's personal and social relationships, occupation (9)and overall quality of life (10).FOC can intensify labour pain (11) and result in a prolongedlabour duration witha lengthier active labour (12,13). Even after the delivery, FOC can lead to postpartum depression or anxiety (14),impair themother-infantattachment (13)and hinder the sexual interaction or desire with their partners (15,16).Women with FOC are also found to have a longer interval to their subsequent pregnancy, and a higher likelihood of undergoing a subsequent Caesarean section (17).
Few studies have been conducted among the Chinese population, but preliminaryevidence shows that even women regarded as having a "low risk" pregnancy commonly exhibitFOC manifestations. However, different instruments were used in the assessment of FOC with no or arbitrary cut-off values taken, renderingstandardised comparison with other cohorts di cult or impossible. (18, 19)Nonetheless, Chinese women who have FOC should also have similar distress and impact on their quality of life.
Of the variety of questionnaires available to evaluate FOC, The Wijma Delivery Expectancy/Experience questionnaire (W-DEQ) (20)is considered gold standard and is most often adopted. (21)(22)(23). It is a comprehensive self-report instrument for assessment of the severity of FOC in terms of the women's cognitive appraisal of delivery. W-DEQ is a reliable, valid and condition-speci c instrument for women with FOC. W-DEQ has been proven to be internally consistent and reproducible. (24)Versions A and B of the W-DEQ (W-DEQ-A and W-DEQ-B) are designed to measure their antenatal expectations and their experience of fear during childbirth respectively. It has 33 items in total, with ascoring system ranging from 0 to 165. A higher score indicates a greater level of fear. A score ≥ 85 indicates FOC, whereas a score of≥100 indicates severe FOC (25,26). The continuous scale is also helpful in measuring an individual's level of fear over time.
Among Chinese, the lack of such scales has led to insu cient knowledge on the psychological aspects of childbirth and the clinical impact from FOC. A Chinese version of W-DEQ-A has yet been available, and if developed, it can act as an invaluable instrument for Chinese speaking individuals worldwide.Therefore, the aim of this study is to translate and validate the W-DEQ-A in Hong Kong Chinese women. This wouldprovide a standard and reproducible tool, whilst minimizing the obstetrician's factor in varying the assessment. Furthermore, a validated questionnaire for FOC would also later serve as an objective instrumentwhen different antenatal interventions for FOC requires evaluation.

Methods
Translation process Written approval to use and translate the W-DEQ-A was obtained from the original author.
The W-DEQ-A was independently evaluated by two bilingual obstetrics researchers, with all items deemed appropriate. Forward translation of the W-DEQ-A to Chinese was then performed separately. The two translated questionnaires were reviewed in a meeting, and a single version was reached after going through items of inconsistency. Back-translation was performed by another bilingual professional who had no access to the original questionnaire. The original and back-translated versions were compared for any issues regarding accuracy and understanding in the Chinese cultural context by another researcher.A panel consisting of the researchers was held to review and settle on the nalised Chinese version.
After ensuring that there were no major discrepancies, the questionnaire was then distributed to a pilot group of 20women at the obstetric ward for feedback. The group found the questionnaire items appropriate, and they were able to comprehend and ll in the translated W-DEQ-A without problems.

Recruitment and study phase
Recruitment of participants occurred between Marchand June 2020. All Chinese women attending antenatal booking visit atTsan Yuk hospital in Hong Kong were invited to join the study to validate the W-DEQ-A.
Exclusion criteria included those under 18 years old, those withintellectual or mental impairment making completion of questionnaire challenging, refusal by women, incompletequestionnaires, and women who had a test-retest interval beyond 20 days. Women were recruited by the research team and dedicated research assistants. Written consents were obtained, and all women were given verbal and written explanations.
The state-trait anxiety inventory state (STAI) and Edinburghpostpartum depression scale (EPDS) were used as assessments of the validity of the Chinese version of the W-DEQ-A. Hong Kong Chinese versions arealready available for both tools and validated for use (27,28).
The STAI consists of 2 subscales with 20 items each on a 4-point Likert scale, which examines 2 dimensions of anxiety, namely state and trait anxiety. It is one of the most frequently utilised self-report measuresto assess anxiety during pregnancy (29). It has demonstrated high validity and reliability among Asian countries including Hong Kong (30,31). The score can range from 20-80 for each subscale, with higher scores corresponding to a higher level of anxiety.
The EPDS is the most widely adopted screening tool for both antenatal and postnatal depression worldwide (29,32). It consists of 10 self-reported questions, where each item is rated from 0 (normal) to 3 (severe), totalling to a maximum score of 30. It demonstrates satisfactory psychometric properties(28). The Chinese version of EPDS is currently utilised among public hospitals in Hong Kong.
The Chinese versions of the W-DEQ-A, STAI and EPDS were distributed for completion by participating women. Basic demographics and the preferred mode of delivery in their current pregnancy were collected. They were required to ll in the same questionnaires via an online platform about 2 weeks after initial completion to establish test-retest reliability.
Basic demographics including age, educational and marital status, past psychiatric history and social history, were obtained from their medical records. Women who had stable antenatal course before the repeat test were used in the analysis of the test-retest reliability. Those who had received psychiatric interventions in between were excluded from the test-retest reliability analysis.

Statistical analysis and sample size calculation
The subject-to-item ratio of any measurement scale wassuggested to be 5:1 (33,34). As there were 33 items in W-DEQ-A, a sample size of 165 (33 x 5) was required to ful l the criteria. A sample size of 165pregnant women would be su cient to ful l the aforementioned criteria and to assess the correlation of the other questionnaires with the W-DEQ-A.
Statistical analysis was performed by using SPSS Statistics (Version 26.0. Armonk, NY: IBM Corp). W-DEQ-A score ≥ 85 at their rst visit was de ned as women having FOC, while score of ≥ 100 indicated severe FOC. Data were presented as mean and standard deviation (SD) for continuous data or n and percentage for categorical data. Differences according to demographic or obstetric characteristics were analysed by student's t test or Mann-Whitney test for continuous data and chi-square test for categorical data. Exploratory factor analysis was conducted to analyse the factor validity. Principal component analysis with varimax rotation was performed on 33 items, and the number of factors were de ned by the use of scree plots.
Internal consistency of W-DEQ-A and its subscales was assessed using Cronbach's alpha test, and the scores from their rst visit was used. A Cronbach's alpha coe cient of >0.7 was considered as adequate internal consistency (35). The test-retest reliability was assessed by Intraclass Correlation Coe cient (ICC). An ICC value of 0.4 or less was considered as poor to fair agreement, 0.41 to 0.6 as moderate agreement, 0.61 to 0.8 as good agreement and 0.81-1.0 as excellent agreement (36).The convergent validity of W-DEQ-A was estimated by Pearson's correlation with STAI and EPDS. A p value <0.05 was considered statistically signi cant.

Results
Demographics and patient characteristics A total of 301 pregnant women were invited into this study. One woman declined to join,while 121 had not completed the second set of questionnaires. The remaining 179 women lled in the re-test questionnaire online. The interval between the rst and second test ranged from 14-42days. Eight women were excluded from the study as the time gap between the test and retest was beyond 20 days. Twentyone women were further excluded from the study due to incompletequestionnaires. Upon review of all medical records, none were noted to have circumstantial changes or have received psychiatric interventions. 150 women were nally included in the study and had their results analysed ( Figure   1).There were no signi cantdifferencesin terms of demographic or obstetric characteristics (Supplementary table 1) and the W-DEQ-A scores between those who were excluded and included in this study; the mean W-DEQ-Ascores were 66.4 (SD 17.43) and 65.0 (SD 18.6) respectively (p=0.537). Table 1 showed the demographic data of women with and without FOC, using W-DEQ-A score of 85 as cut off. All participants were of Chinese ethnicity with a mean age of 32.8 (SD 3.8, range 24-45). The mean gestational age at recruitmentwas 13.6 weeks. 88(58.7%) women were nulliparous.

W-DEQ-A scores
The participants had an average W-DEQ-A score of 65.0 (SD 18.6).17 (11.3%) were found to have FOC using the cut-off of≥85. Women with FOC were found to be signi cantly associated with a history of psychiatric disorder. Other demographics and their intended mode of delivery were not associated with FOC (Table 1). Table 2showed the mean W-DEQ-A scores according to various demographic and obstetric characteristics.Nulliparity, primigravida, and insu cient partner support were signi cantly associated with a higher W-DEQ-A score(p<0.05) ( Table 2).
Concerning the relationship between FOC and the preferred mode of delivery, women who preferred vaginal delivery tended to have lower W-DEQ-A score, although it was not statistically signi cant. However, among nulliparous women speci cally, those who preferred a vaginal delivery had a signi cantly lower score than those who preferred Caesarean section, with mean (SD) W-DEQ-A scores of 67.1 (14.8) compared to 75.9 (15.9) (p = 0.036).
Exploratory factor analysis 32 of the translated W-DEQ-A items was further divided into 4 factors based on the exploratory factor analysis results ( Table 3). The factors were extracted after visual assessment of the scree plot. Together these 4 factors would explain a cumulative variance of 51.2%. The 4 factors were de ned assense of isolation, moment of birth, negative emotion, and lack of positive self-evaluation, which was similar to previous studies.Question 26 ("allow my body to take total control") was removed from the factor analysis, as its factor loading was less than 0.3.

Reliability
The internal consistency and test-retest reliability were computed ( Table 4).The Cronbach's alpha for the total score of W-DEQ-A was 0.907,with the subscales of W-DEQ-A ranging from 0.777-0.828,demonstrating excellent internal consistency.The test-retest reliability of each item and the subscales as re ected by the intraclass correlation coe cient ranged from 0.633 to 0.821.The test-retest reliability of the total score of W-DEQ-A was 0.867, which was an acceptable level.

Convergent validity
The convergent validity was measured by the Pearson's correlation of W-DEQ-A score with STAI-S, STAI-T and EPDS scores, which showed a positive correlation with the total W-DEQ-A score( Table 5). The Pearson's r values for STAI-S, STAI-T and EPDS were 0.583, 0.608 and 0.459 respectively, indicating that the higher the score of W-DEQ-A, the more severe the symptoms of anxiety and depression. Signi cant association was found between the total score and scores of each W-DEQ-A subscale with STAI-S, STAI-T and EPDS (p<0.01 Discussion FOC has been gaining increasing attention in the recent decade, particularly among Western countries. Due to the potential detrimental impact on the women's life, it is necessary to identify pregnant women with FOC in order to design interventions to improve their childbirth experience. Speci c instruments should be used, which would be crucial to better understand and measure FOC, and to fully assess its impact on women. Fear-avoidance beliefs and behaviour can then potentially be modi ed; recent studies have shown that antenatal education and counselling may be helpful in reducing FOC and is associated with a higher rate of vaginal delivery (37). W-DEQ-A enables a more detailed assessment of the severity and speci c concerns related to antenatal FOC. The differences in language, culture and religious practices may affect the use of such instruments, thus necessitating adjustments and validation. Our current study demonstrates that the Chinese version of W-DEQ-A is reliable for use in pregnant women.
An exploratory factor analysis was performed to test the construct validity, which displayed satisfactory factor loadings for all except one item (question 26). Question 26 was excluded due to low factor loading, in order to achieve a satisfactory solution. This is one of the frequently removed items from the W-DEQ-A during factor analysis(38, 39). Similar to prior studies, our translated version also demonstrates four dimensions (39,40).
Our studydemonstrates comparable psychometric properties to other translated versions of W-DEQ-A. A high internal consistency is seen, comparable to the Cronbach's alpha of 0.93 in the original W-DEQ-A. Given the similar internal reliability estimate toothertranslated versions of W-DEQ-A, our study gives further support for a consistent reliability of this instrument across various languages and cultures (41,42).
A 2-week interval was adopted between the two tests, allowing up to a delay of 6 days. This is an appropriate time interval to assess test-retest reliability, which is short enough to prevent circumstantial changes over the course of the pregnancy, but long enough to prevent recall of answers from memory. ICC values are interpreted as excellent when exceeding 0.81(36), thus con rming a good test-retest reliability of our translated W-DEQ-A.
The validity of this translated questionnaire is supported by a positive correlation with STAI-S, STAI-T and EPDS. There is a knownsigni cantassociation between FOC and anxiety (43)or depression(8). Despite being classi ed under anxiety disorders in pregnancy (44), FOC is known to be distinct from anxiety in terms of its neurological mechanism, thus should be considered separately (45). The moderate correlations between W-DEQ-A and these assessments echo this nding, and suggestthat women with FOC may not necessarily be anxious or depressed.
Our results also paint a preliminary picture on the condition of FOC in expectant mothers in Hong Kong. In this study population, 11.3% women were found to have FOC, which is similar in incidence to other countries(8). W-DEQ-A scores were found to be lower in women with increasing parity in this study, which is in line with other developed countries(46).Prior delivery experience is known to have a signi cant impact on subsequent amount of fear. It is reasonable that among nulliparous women, the element of uncertainty would increase the fear and anxiety related to childbirth. In our study, up to 20.5%nulliparous women had hoped to have a Caesarean section for delivery. This is found to be much higher than other Western countries such as the United states of America and Norway, where only 3.5% and 3.1% nulliparous women voiced a preference for Caesarean delivery antenatally. (47,48). In contrast, up to 17% primigravida women in China wished to undergo Caesarean section for childbirth, which is more comparable to the results of our study (49). The apparent differences may be related to the difference in cultural beliefs, clinical practices and government policies (50). Previous studies have shown that Hong Kong Chinese women have a lower perceived level of control during natural labour than women in Western countries (51), which in turn relates to a higher level of maternal anxiety. They also tend to be less con dent in their ability to cope with labour pain (52).Our validated Chinese version of W-DEQ-A would de nitely serve as a tool to prospectively correlate FOC and the mode of delivery. This in turn helps to assess interventions aiming to alter their anxiety and fear during pregnancy, especially in the climate of a rising Caesarean section rate in China and Hong Kong. In like manner, our study shows that nulliparous women who had preferred Caesarean delivery share a signi cantly higher W-DEQ-A score.
Psychosocial factors such as women's perception of partner availabilityduringthe course of pregnancy was found to be signi cantly related to the level ofFOC. Culturally, Chinese women has a high expectation on their spouses' emotional support throughout pregnancy and during childbirth (52).Our current study also a rms the negative correlation between partner support and FOC. While studieshave shown that partner adjustment and the partner's life satisfaction may in uence FOC (53), further researchis required to delineate the exact relationship and whether partner involvement in antenatal counselling would be useful to reduce FOC.

Strengths
This is the rst Chinese version of W-DEQ-A, which was produced after a rigorous translation process in accordance to recommendations by international organisations (54). Our participants were recruited at the general antenatal booking visit to avoid selection bias. Both nulliparous and multiparous women were included in the study. Going forward, it would be worthwhile to use this questionnaire to assess the FOCin selected populations such as teenage pregnancies, those with more complex medical histories or hospitalised pregnant women.

Limitations
There are limitations to this study. Only two questionnaires were used for analysis of the convergent validity, as there have been limited validated questionnaires available in the Chinese version; nonetheless, both validated questionnaires are widely used in the literature to assess anxiety during pregnancy and our data exhibited good correlation. Secondly, we havenot looked into the responsiveness of the study, as there is currently no standardised treatment available to women with FOC in Hong Kong. Further studies may be conducted to test the psychometric properties of this questionnaire pre-and postinterventions.Thirdly, all patients had been recruited at a public hospital in Hong Kong, where Caesarean sections based on maternal request or social reasons are not available. Thus, it is possible that patients with FOC who have decided to have a Caesarean delivery might have opted for private obstetric care instead and would not have been invited to participate in this study. Fourthly, the data available for nal analysis did not reach the calculated sample size. We tried to overcome this by recruiting more subjects, but a signi cant portion of women had notcompletedthe second questionnaire. As our analysis showed good validity and reliability, the nal interpretation should not be affected. Finally, whileW-DEQ-A is useful for the antenatal assessment of FOC, another assessment tool would be required for FOC post-delivery. A validation study of the Chinese version of W-DEQ-B is currently underway for postpartum individuals.

Conclusion
The Chinese version of W-DEQ-A is a valid and a reliable condition-speci c questionnaire for women with fear of childbirth. The mean W-DEQ-A score among the Hong Kong Chinese population is 65 out of 165. 11.3% women were found to have FOC. 72% and 22.7% women preferred vaginal delivery and Caesarean section respectively. Obstetricians should be mindful that expectant mothers, especially nulliparous women, may be troubled or have speci c worries relating to the delivery. These concerns should be appropriately dealt with to allow a smooth delivery and transition to motherhood. Particular attention should also be given to their partners in view of the potential impact of partner support on women's FOC. With the availability of this validated Chinese version of W-DEQ-A, clinicians can use this measure to assess the severity of one's FOC over the course of her pregnancy, and to monitor the success of any medical or psychological interventions. It remains hopeful that further research in this area would help to reduce FOC among women worldwide.

Consent for publication -not applicable
Availability of data and materials -The authors declare that the data supporting the ndings of this study are available within the article. We do not have consent from participants or the Institutional Review Board to share the data collected for the study. Any inquiries can be made to the corresponding author.
Competing interests -The authors declare that there are no competing interests.

Funding -not applicable
Author's contributions -T.H.T.L. developed the study proposal, managed the research implementation, assisted in data analysis and wrote the manuscript. S.T.K. participated in the development of the study protocol, participated in research team meetings, and reviewed the manuscript. W.W. participated in the development of the study protocol, analysed the data and reviewed the results of the study. M.T.Y.S.participated in research team meetings, supervised the development of the study, and reviewed the nal manuscript. K.W.C.supervised the development of the study protocol, monitored the study progress, reviewed the results and reviewed the nal manuscript. All authors have read and approved the manuscript.