Prevalence and risk factors of fear of childbirth among pregnant women: A mixed-method study in Hebei Province, China

Abstract

Fear of childbirth (FOC) significantly impacts women's health and fertility intentions, contributing to adverse outcomes such as increased caesarean section rates and postpartum anxiety or depression. In China, declining fertility rates and high caesarean section rates are partly attributed to childbirth fear. However, current studies on FOC in China are limited, as most examine only specific populations or areas. The purpose of this study was to determine the psychometric properties of the simplified Chinese version of the Wijma Delivery Expectancy/Experience Questionnaire Version A (W- DEQ-A) in the general pregnant women population and to further investigate the prevalence and risk factors of FOC in a mixed-methods approach. Performed at a tertiary Chinese hospital in 2024, the study had two phases. In Phase 1, a cross-sectional survey was conducted to analyse the psychometric properties of the Chinese version of the W-DEQ-A using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Internal consistency reliability was also assessed, and the instrument was revised based on the results of the study. The resulting 19-item, five-factor version of the W-DEQ-A was found to be a reliable and valid measure of FOC for Mandarin- speaking groups. Phase 2 adopted an explanatory sequential design, surveying 314 pregnant women and conducting in-depth phenomenological interviews with 16 participants exhibiting severe FOC. The findings indicated a prevalence of 14.9%, which was related to age, gestational ,and parity. Risk factors were categorised as physiological (pre-pregnancy BMI, poor health or pregnancy complications, and unexpected foetal conditions), psychological (stress, self-doubt and low confidence, and previous negative childbirth experiences), and social (unmet social support needs, low household income and increased postpartum financial stress, horror stories from family or friends, negative information from the media, and excessive risk reminders from medical staff). These findings have important implications for clinical practice and policy. Integrating the validated W-DEQ-A into routine antenatal screening could help to identify at-risk women early on. Healthcare providers should receive training in culturally sensitive and empathetic risk communication. Furthermore, supportive social policies that address economic assistance and family pressures are essential to reducing FOC and enhancing maternal well-being across China. Keywords Fear of childbirth; Mixed-method; Pregnancy; Prevalence; Risk factors