We recruited English speaking, pregnant people who were over the age of 18 and who were residing in an English language country to participate, via online forums frequented by pregnant people (e.g., pregnancy-related web sites and blogs). We planned for a sample size of approximately 500 individuals, following the recommendations of MacCallum et al. (41) for the sample size needs of an exploratory factor analysis (EFA). Our final sample consisted of 643 pregnant people.
Prospective participants were directed to the online survey via the study advertisement. In order to proceed and complete the survey, participants were required to acknowledge that they had read the study cover sheet/consent form and agreed to participate. For each survey completed, $0.50 was donated to the Children’s Health Foundation of Vancouver Island, British Columbia. The study was approved by the Behavioural Research Ethics Board of the University of British Columbia.
Background Questions. Participants completed a set of demographic questions (e.g., age, marital status, education, income, country of residence, and race and ethnicity), questions about the current pregnancy (e.g., method of conception, and number of fetuses), and previous pregnancies (if applicable) (e.g., the number of prior pregnancies, births, miscarriages, and vaginal and cesarean deliveries).
Birth Preferences. Using a 7-point Likert-type scale (ranging from a very strong preference for a vaginal birth to a very strong preference for a cesarean birth), participants were asked about mode of delivery preference (i.e., vaginal versus cesarean).
Childbirth Fear Questionnaire (CFQ) - Initial Item Pool. The initial pool for the CFQ comprised 49 items. We initially developed 49 items covering the following domains of potential childbirth-related fear: social embarrassment (e.g., fear of losing control), pain (i.e., fear of pain), pain medication (e.g., fear of not receiving the pain medication one is hoping for), mode of delivery (e.g., fear of a cesarean delivery), baby’s and mother’s physical safety (e.g., fear that one’s infant may be harmed or die during labour/delivery), changes to one’s body (e.g., scarring), sexual functioning (e.g., enjoying sexual activity less following delivery), and medical interventions (e.g., fear of having an episiotomy). CFQ items are scored on a 0 (not at all) to 4 (extremely) point, Likert-type scale.
CFQ items and item domains were developed by a team of perinatal researchers from the fields of psychology, midwifery and nursing, and based on earlier work in this area, including our own (42) The CFQ includes dimensions of fear that are commonly reported by pregnant people, such as fear of pain and fear that harm might come to the baby (30,43). In earlier work (42), maternal complications, feelings of embarrassment, fear of medical interventions/surgery, scarring, sexual functioning, and body damage, were also identified as areas of childbirth related fear and concern, and were considered when developing the items for the CFQ.
Our group of investigators collaborated in generating items for inclusion in the CFQ, reviewing item wording, and ensuring that all domains of fear deemed relevant to childbirth had been included in the initial pool of items. In recognition of the likelihood that the CFQ would include both a total scale score and subscale scores, we developed multiple items for each fear domain (a minimum of three items per subscale are needed to ensure a reasonable degree of internal consistency reliability). In order to be able to reduce the overall number of items, and develop subscales with high internal consistency reliability, each content domain initially included five or more items.
Wijma Delivery Expectancy Questionnaire (W-DEQ-A). The W-DEQ-A is a 33-item questionnaire, with items scored on a 0-5 Likert type scale, and a range of possible scores from 0 to 165. The psychometric properties of this assessment tool have been well established (12,18). In the current sample, the internal consistency reliability for the W-DEQ-A was 0.92. In addition to the W-DEQ-A total score, there is also data to support the use of a 6-item fear scale (44).
In this study, in error, we administered the W-DEQ-A using a 0-4 Likert type scale (rather than the usual 0-5 scale). We then prorated the W-DEQ-A scores to the more standard 0-5 point scale as follows: original W-DEQ-A score divided by four, multiplied by 5. Our rescaled mean W-DEQ-A (M = 55.9) score is consistent with those found in the literature which range from 52.9 to 68.3 (9). Our mean scores for both nulliparous (60.7) and multiparous people (50.2) were consistent with those reported in the literature (i.e., 54.1 to 68.51 and 50.3 to 60.7, respectively), as was the percentage of participants scoring above 85 (i.e., 7.5% to 15.6% in the literature, and 9.8% in the current study) (9). We are confident that our prorated W-DEQ-A scores are a valid estimate of correctly scaled W-DEQ-A items, and are valid to use as the main measure of convergent validity.
Edinburgh Postnatal Depression Scale (EPDS). The EPDS is a 10-item self-report screening tool for pre and postnatal depression. The sensitivity and specificity of the EPDS are in acceptable ranges (65% - 100%, and 49% - 100%, respectively) (45). The EPDS is the most widely used screening tool for perinatal depression (46). It was included in this study as a measure of discriminant validity for the CFQ; childbirth fear should be no more than moderately correlated with depression. In the current sample, the internal consistency reliability of the EPDS was 0.88.
Mutilation Questionnaire (MQ). The MQ is a 30-item measure of blood and injury fears. Internal consistency for the MQ ranges from 0.75 to 0.86 (47). In the current sample, the internal consistency reliability was 0.87. High MQ scores are associated with fainting at the sight of blood and injury (47,48). The MQ was included as a second measure of discriminant validity for the CFQ; blood-injury fears should be no more than moderately correlated with fear of childbirth.
Data Analysis Strategy.
Factor analyses were performed in R (v. 3.3.2) (49) using the psych() package (v. 1.6.9) (50) for fitting exploratory factor analysis models. Accompanying visualizations were created using the ggplot2() package (v. 2.2.1) (51). Differences between correlations were tested using a test provided by Lee and Preacher (52), and standardized mean-difference effect sizes for t-tests (ds) were estimated using the calculator provided by Lakens (53). All other analyses were carried out using IBM SPSS Statistics (v23).
Exploratory Factor Analysis. We followed the recommendations of Sakaluk and Short (54) and others (e.g., (55)) for conducting exploratory factor analysis on all CFQ items. Specifically, all solutions extracted common factors via maximum likelihood estimation, in order to facilitate the calculation of model fit indices. We determined the number of factors to retain through a combination of criteria, including: (1) parallel analysis (56); (2) the minimum average partial (MAP) criterion (57); (3) interpretations of absolute and relative indexes of model fit (the root mean square error of approximation [RMSEA], and Tucker-Lewis Index [TLI], respectively) (58); (4) interpretations of the Bayesian Information Criterion (BIC); (5) nested model comparisons using likelihood-ratio tests between competing models; and (6) factor solution interpretability. All solutions were rotated to achieve simple structure and estimate factor correlations, using the oblique Oblimin method.
We considered items that loaded onto a factor at ≥ .35 to be substantive indicators of the underlying latent construct. Items that did not load onto any factor beyond this threshold were determined to be poor indicators, and would be removed from the final version of the CFQ.
Reliability and Validity Analyses. The remaining analyses involved descriptive data (means, standard deviations, and percentages), Cronbach alpha reliability coefficients, correlations, and independent-samples t-tests. Differences between correlations were tested using a test of the difference between two dependent correlations with one variable in common (52).
Participant demographic and reproductive information is presented in Table 2. Note that complications in the current pregnancy were reported by participants (22.9%), and ranged broadly in severity (e.g., early spotting, anemia, pre-eclampsia). In this sample, 21.3% of participants scored a 12 or greater (common cut-score for depression) on the EPDS.
Exploratory Factor Analysis of the CFQ
Results of our parallel analysis (see Figure 1) suggested a maximum of 13 factors ought to be retained, whereas the MAP test suggested 9 factors was sufficient. We then proceeded to evaluate indexes of model fit, information criteria, and nested model comparisons for 1-13 factor solutions (see Table 3).
Each additionally extracted factor significantly improved the fit of our model. Adequate model fit based on the RMSEA was achieved from a 6-factor model onward, whereas adequate model fit based on the TLI was achieved near the 9- to 10-factor models. The BIC indicated that our models became unnecessarily complex after the 11-factor solution, and our 13-factor solution failed to converge. We therefore examined the pattern matrixes of loadings for the 9-, 10-, and 11-factor solutions.
The 9-factor solution was supported by the MAP test and had acceptable fit according to the RMSEA, and near-acceptable fit according to the TLI1; it was also the most conceptually interpretable of the three solutions we investigated in detail. The 10-factor solution, though acceptably fitting according to both the RMSEA and TLI, yielded a tenth factor that was not conceptually coherent. The 11-factor solution, finally, was also acceptably fitting, but the extracted eleventh factor had no substantially loading items. We therefore selected the 9-factor solution as the best fitting and conceptually interpretable model of the CFQ items.
Factor loadings for the final nine factors are presented in Table 4, and represent: (1) Fear of loss of sexual pleasure / attractiveness (SEX), (2) Fear of pain from a vaginal birth (PAIN), (3) Fear of medical interventions (INT), (4) Fear of embarrassment (SHY), (5) Fear of harm to baby (HARM), (6) Fear of cesarean birth (CS), (7) Fear of mom or baby dying (DEATH), (8) Fear of insufficient pain medication (MEDS), and (9) Fear of body damage from a vaginal birth (DAMAGE). The nine CFQ factors were generally weakly-to-moderately correlated (see Table 4), with most correlations below r = .60. The exceptions were the Fear of loss of sexual pleasure / attractiveness and Fear of body damage from a vaginal birth (r = .62), Fear of harm to baby and Fear of mom or baby dying (r = .78), and the Fear of cesarean birth and Fear of medical interventions (r = .60) factors, which were strongly associated.
Descriptive, Reliability, and Validity Analyses
Descriptive Analyses. Means and standard deviations for the 9 subscales, and the CFQ Total scale scores are presented in Table 6.
Reliability Analyses. The Cronbach alpha for the overall 40-item scale was 0.94. Cronbach alphas for the individual subscales ranged from .76 to .94. Specifically, Cronbach’s alphas were .93 for Fear of loss of sexual pleasure/attractiveness, .94 for Fear or pain from a vaginal birth, .82 for Fear of medical interventions, .84 for Fear of embarrassment, .93 for Fear of harm to baby, .85 for CS, .86 for Fear of mom of baby dying, .76 for Fear of insufficient pain medication, and .85 for Fear of body damage from a vaginal birth.
Convergent/Discriminant Validity. The convergent/discriminant validity of the CFQ was assessed by comparing the relationship between the CFQ and the W-DEQ-A, and the relationships between the CFQ and measures of depressed mood (the EPDS) and blood and injury fears (the MQ). We predicted that the CFQ would correlate more strongly with both the W-DEQ-A (another measure of fear of childbirth) full scale and the W-DEQ-A fear scale than with either the MQ or EPDS(44). The correlations between the CFQ and the W-DEQ-A (full and fear scales) were 0.41 (p < 0.001) and 0.57 (p < 0.001) respectively. The correlation between the CFQ and the EPDS was 0.35 (p < .001), and the correlation between the CFQ and the MQ was 0.28 (p < 0.001). The CFQ-W-DEQ-A (full scale) correlation was significantly greater than the CFQ-MQ correlation, z = 2.73, p = 0.006, but not the CFQ-EPDS correlation, z = 1.60, p = 0.109. The CFQ-W-DEQ-A (fear scale) correlation was significantly greater than both the CFQ-MQ correlation, z = 7.17, p < 0.001, and the CFQ-EPDS correlation, z = 6.61, p < 0.001.
Birth Preferences. A second approach to assessing the validity of the CFQ was to compare participants who reported a preference for a vaginal delivery to those who reported a preference for a cesarean delivery. We predicted that participants who reported a preference for a cesarean delivery would also report higher levels of fear of pain from a vaginal birth, fear of harm to baby, fear of mom or baby dying, fear of insufficient pain medication, and fear of damage to one’s body from a vaginal birth, but lower levels of fear of cesarean delivery and fear of medical interventions, compared with those who reported a preference for a vaginal birth.
The majority of the people in our sample indicated a strong or a very strong preference for a vaginal childbirth (83.8%, n = 539), whereas only a small proportion indicated a strong or a very strong preference for a cesarean delivery (5.1%, n = 33). Consistent with the above hypotheses, compared with those who strongly preferred a vaginal birth, people who strongly preferred a cesarean delivery reported higher scores on the Fear of pain from a vaginal birth , t (34.08) = -2.83, p = .008, ds = 0.68, Fear of harm to baby , t (570) = -2.84, p = .005, ds = 0.51, Fear of mom or baby dying , t (570) = -2.81, p = .005, ds = 0 .50, and Fear of insufficient pain medication , t (33.50) = -5.54, p < .001, ds = 1.53, subscales of the CFQ, but lower scores on the Fear of cesarean birth, t (37.22) = 6.64, p < .001, ds = -1.07, and the Fear of medical interventions, t (570) = 2.15, p = .032, ds = -0.39, subscales of the CFQ. However, mean subscale scores did not differ significantly between participants who indicated a preference for a vaginal birth compared with those who indicated a preference for a cesarean birth for the Fear of loss of sexual pleasure/attractiveness, ds = 0.23, Fear of embarrassment, ds = 0.05, or the Fear of body damage from a vaginal birth, ds = 0.04, subscales of the CFQ. The means and standard deviations for these subscale differences are presented in Table 7.
Parity. Nulliparous and multiparous participants differed significantly on six of the nine CFQ subscales, and the CFQ Total scales. In each case, nulliparous participants scored higher than multiparous participants. Specifically, nulliparous participants scored higher than multiparous participants on the CFQ factors: Fear of loss of sexual pleasure/attractiveness, t (639.43) = 6.34, p < .001, ds = 0.50, Fear of pain from a vaginal birth, t (641) = 8.70, p < .001, ds = 0.69, Fear of embarrassment, t (640.80) = 6.29, p < .001, ds = 0.50, Fear of harm to baby t (641) = 2.88, p = .004, ds = 0.23, Fear of insufficient pain medication t (639.22) = 3.98, p < .001, ds = 0.31, and Fear of body damage from a vaginal birth t (641) = 6.49, p < .001, ds = 0.51, and CFQ Total scores t (641) = 5.83, p < .001, ds = 0.45. Nulliparous and multiparous participants did not differ significantly on the Fear of medical interventions, ds = 0.01, Fear of cesarean birth, ds = 0.13, or the Fear of mom or baby dying subscales, ds = 0.03. Means and standard deviations by parity, are presented in Table 7.
Country. Canadian and American participants differed on only two of nine CFQ subscales, Fear of medical interventions, t (605) = -2.40, p = .017, ds = 0.21, and Fear of cesarean birth, t (605) = -3.00, p = .003, ds = 0.26. In both instances, American participants reported higher levels of fear, though the magnitude of these nationality differences were generally smaller than those between birth preference and parity groups. Means and standard deviations by country for Canada and the US are presented in Table 7.
In our development/validation study of the initial 49 CFQ items, involving 643 pregnant people, exploratory factor analysis resulted in a 9-factor scale, supported by MAP test with acceptable fit based on RMSEA. The resulting 9 factors represent: (1) Fear of loss of sexual pleasure / attractiveness (SEX), (2) Fear of pain from a vaginal birth (PAIN), (3) Fear of medical interventions (INT), (4) Fear of embarrassment (SHY), (5) Fear of harm to baby (HARM), (6) Fear of cesarean birth (CS), (7) Fear of mom or baby dying (DEATH), (8) Fear of insufficient pain medication (MEDS), and (9) Fear of body damage from a vaginal birth (DAMAGE). Subscales were weakly to moderately correlated with a small number of strong correlations (Fear of loss of sexual pleasure/attractiveness with Fear of body damage from a vaginal birth, Fear of harm to baby with Fear of mom or baby dying, and Fear of cesarean birth with Fear of medical interventions). Cronbach alpha coefficients for the total scale and individual subscales were all above .76. Strong evidence of convergent/discriminant validity was found when comparing the 9-factor CFQ with another measure of fear of childbirth and measures of blood, injury injection fears and depressed mood. The CFQ subscale means were also compared across subgroups (e.g., preferred mode of delivery) with hypothesized differences supported by the data.