The purpose of this study was to design and evaluate the psychometric properties of FFCS. The final FFCS, which had the desired validity and reliability, included 17 items and two factors consisting of fear of childbirth process (12 items), fear of hospital (five items) which explained 50.82% of the total variance. In the reliability test, the FFCS showed an acceptable internal consistency. The reliability of the entire FFCS had an alpha of 0.84, and also the omega was excellent and acceptable.
In this study, the most common indicators of model fitness were evaluated, and all factor loads above 0.5 were indicative of a minimum acceptable factor load. Therefore, based on the confirmatory factor analysis, all fitness indicators had a suitable standard level and the model fitness was appropriate.
The first CFA showed that a latent layer was existent, so the secondary order CFA was used and confirmed the FFCS with two subscales and 17 items; The two subscales represent a more general concept called tocophobia. Tocophobia is comprised of the words “tocos” (a Greek word meaning childbirth) and “phobia” (26). Tocophobia is considered by its proponents to be a “non-logical fear of childbirth” (27). The word “tocophobia” as a medical condition was first used by Hofberg and Brockington in 2000 (28). Tocophobia is divided into two types. Primary tocophobia is the destructive fear of childbirth in the first pregnancy that has no previous experience. Another type of tocophobia is secondary tocophobia, which, unlike primary tocophobia, is related to the experience of traumatic childbirth in the past (29). There is comparatively little research on men’s experience of tocophobia. Published evidence from India showed that larger proportion (78.40%) of first time expectant fathers suffered from tocophobia primarily related to the health and life of their partner and child, labor and delivery process, professional competency, behavior, insufficient medical treatment, fear of not being treated with respect and dignity, fear of partners’ and own capabilities, fear of exclusion from decision making, financial matter and fear of responsibilities as fathers in varying intensity from low to severe level (30).
The first subscale identified in the exploratory factor analysis was fear of childbirth process. This subscale explained a higher amount of variance than the other subscale. Some fathers have stated that process of labor and childbirth lead to phobia in them (30). From labor-associated fears reported by fathers have been seeing their spouse in pain and agony (31), harm to fetus during child-birth, being in an unfamiliar, awkward (32), episiotomy, the risk of maternal complications and death associated with cesarean section (6, 33), irreversible rupture (5), prolonged labor (34, 35), and fear regarding the child welfare (36). Fathers have also been concerned regarding their ability to provide appropriate support to their spouse during labor and childbirth and how to react to labor-related events (7). In line with this finding, other research that has examined the fear of childbirth in fathers shows that the uppermost fear were related to the health and life of the baby, the health and life of the woman, and the labor and delivery process (5).
Fear of hospital was the second subscale of the FFCS. The hospital may be a very upsetting and fearful environment for many individuals and this may promote phobia in fathers (6). These findings suggest that some of the risk factors for fear of childbirth within the health care system (5). In fact, health care providers have been identified as both a cause of fear and a key factor in reducing the fear of childbirth.
A handful of instruments have been used to investigate the fear of childbirth in fathers. Among them, FFCS seems to be a good instrument for measuring fear of childbirth in fathers. Although the validity and reliability of Ringler's questionnaire were confirmed but, this questionnaire includes 52 items, which arguably too long for fathers to respond to, especially given the busyness of fathers (13).
The W-DEQ is another instrument that used in fathers and included two versions for assessing childbirth fear during pregnancy (version A) and after childbirth (version B) (14, 37). The scales were designed to measure different dimensions of childbirth fear, though it was ideated as a one-dimensional instrument. Wijma et al, estimated the reliability of the questionnaire by split half and using Cronbach's alpha by 0.89 and 0.93, respectively (14). The W-DEQ, is suitable instrument for pregnant women but was not specifically designed for fathers, whereas the FFCS is purposely designed for fathers who their spouses are pregnant.
Among the latest available questionnaire on fear of childbirth is the FOBS, which comes in two forms - a single item and a new version with two items (16, 17). In new version, the two items measuring fear and worry were strongly correlated (= 0.83). The inclusion of two items allows an estimate of the scale’s reliability (using Cronbach’s alpha), something that is not possible for single-item ratings (16, 38). In new version, the Cronbach alpha value was 0.91, indicating that the scale has very high levels of internal consistency. Mann–Whitney U-tests revealed no statistically significant difference in FOBS scores for the single item (median = 38, mean = 41.00, SD = 21) and the two items (median = 37, mean = 38.20, SD = 24.10) (16). But despite the use of instruments in fathers, there is no accurate data to show that the cut-off rate set for the statistical population of women in men is also indicative of fear (9).
FFCS was designed by reproductive health specialist, psychiatrist and midwifery consultant. The socio-cultural context of Iranian society, which is an important, was only addressed in the FFCS. The other father's fear of childbirth questionnaires have all been designed in other countries, and have only been translated to Persian, whereas the FFCS is made by the indigenous people, although literature view has been used for comprehensiveness.