Fear of childbirth in Iran: A systematic review of psychological intervention research

Abstract Background Due to the fear of childbirth (FOC) and failure to provide painless delivery in Iran, the prevalence rate of elective cesarean section (C-section) performed on request by pregnant women is on the rise. However, no systematic review assessing the results of studies in this respect has been thus far developed. Objective To systematically review published psychological intervention research reflecting on FOC in Iran. Materials and Methods In this systematic review, the databases of PubMed, MEDLINE, PsycINFO, Wiley, ISI Web of Science, Scopus, Science Direct, Cochrane Library, Google Scholar, and Scientific Information Database were searched to retrieve the relevant studies. Manual searches were performed to find the relevant articles and finally 21 intervention studies were reviewed. Results Based on the modified Jadad Scale, a methodological quality (risk of bias) assessment tool, 14 and 7 studies had acceptable or good and low quality, respectively. The included articles covered fear, fear of childbirth, pregnancy, and psychological intervention in Iran. Cognitive behavioral therapy, relaxation techniques, psychological counseling, childbirth preparation classes (CPCs), mindfulness programs, and psychoeducation had been also practiced as the main types of psychological interventions for reducing FOC in pregnant women. Conclusion There was no clear evidence to establish the most effective method for minimizing levels of FOC in pregnant women. Based on the assessment tool and since most of the studies had moderate or low quality, conducting standard and high-quality randomized controlled trials focusing on FOC in pregnant women is of most importance in Iranian population.


Introduction
Fear of childbirth (FOC) is still a critical problem during pregnancy for some women, especially the primiparous women (1)(2)(3). Based on the related literature, the prevalence rates of FOC may be different across cultures and in different countries (4)(5)(6). According to the results of Swedish studies, the prevalence of FOC in pregnant women had been reported to be about 20% and nearly 6-10% of women had intense fear (7)(8)(9); however, in Australian studies, up to 26% of women had suffered FOC (10,11).
Investigating the causes of FOC have further indicated that factors such as young maternal age, low levels of education (3,7), nulliparity, fear of having childbirth defects, prior negative experiences in particular prenatal complications (3,4,12), pre-existing psychological problems like lack of self-confidence regarding their ability for childbirth, low social support (2,12), and a history of anxiety or depression could be associated with FOC in pregnant women (2,(13)(14)(15). FOC can correspondingly have negative effects on maternal health such as delayed obstetric-therapeutic interventions due to the unfavorable communication with medical staff resulting in prolonged labor (6,13), higher risks of emergency cesarean section (C-section) and increased probability of instrumental vaginal delivery (3,7,16). The FOC also negatively influences mother-child relationships as well as child health status (4,16).
Studies in this respect have established that women affected with FOC mostly receive treatments such as supportive counseling visits by midwives, psychologists, or psychiatrists during pregnancy (7,17,18); for example, the results of an investigation in Sweden, assessing the effect of counseling on FOC, had revealed that although pregnant women in counseling groups had been satisfied with treatments, this intervention had failed to statistically reduce the levels of FOC (19). Accordingly, different intervention studies have been conducted on pregnant women with FOC all over the world with the aim of minimizing the levels of this critical condition (9,(20)(21)(22).

Materials and Methods
This study was a systematic review performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (28,29).

Literature and search strategy
A comprehensive literature search was conducted in electronic databases including classes" OR "couple preparation classes" OR "midwifery counseling" OR "psychological counseling" OR "psychoeducation programs"] AND ["Iran" OR "Iranian"]. In order to identify more relevant articles, the reference lists of the included studies were also searched manually.

Data extraction and analysis
The full-texts of the selected studies were carefully read, and the required information was extracted and summarized in descriptive tables and then cross-checked by FE.

Quality (risk of bias) assessment tool
The research team decided to assess the methodological quality (risk of bias) of the trials through the modified Jadad Scale (30,31). This validation tool is widely used to evaluate the quality of RCTs. It is also comprised of two sections. Studies with scores of 4-8 can thus represent good to excellent (i.e., high-quality) and those with scores of 0-3 can have poor or low quality (32,33) (Table   II).

Search results
The systematic search resulted in 1,859 articles. were included in this systematic review ( Figure   1). Table I (25,(42)(43)(44)(45)(46)(47)(48)(49)(50)(51)(52). Moreover, the blinding had been mentioned only in two studies (25,52) but the type of blinding had not been specified in one study (52). The included studies had implemented different types of interventions, so relaxation techniques had been used as  (35,45). In two studies, a mix of muscle relaxation techniques and guided imaginary (36) and a combination of cognitive behavioral therapy (CBT) and relaxation techniques had been employed as two interventional programs (49). In three studies using the CBT (41,48,50), one study had also added psychoeducation as an interventional program in frightened pregnant women (41).  (47), and reality therapy (39). In three studies, childbirth preparation classes (CPCs) had been held to reduce FOC in pregnant women (25,38,43).

Description of studies characteristics
The gestational age of pregnant women at the time of intervention had also not been reported in the inclusion criteria of three studies (37,42,49). In one study, each gestational age had been acceptable for being included in the study (34). The range of gestational age in pregnant women for participating in the studies based on 16 studies had been from 4 to 37 wk of gestational age.
Except for one study whose primary outcome was pregnant women's attitudes toward FOC (38)

CBT
A total of four studies had used CBT as an intervention program to lower the levels of fear in their participants (41,(48)(49)(50). For example, in a study, a nine-session CBT program had been accordingly considered for the intervention and control groups without any therapeutic plans. In

Relaxation techniques
In three studies, the effect of relaxation on FOC among pregnant women had been evaluated (35,36,45). In the investigation by Khorsandi and colleagues, six sessions of relaxation classes were held as an effective strategy to cope with FOC. In these educational sessions, exercises such as deep breathing, tension-release relaxation, as well as conditional, differential, and rapid relaxation along with positive mental imagery or visualization related to delivery had been taught to the experimental group and a significant difference had been established in the mean ± SD of FOC between the two groups (p < 0.001). Also, natural delivery rate had increased considerably in the experimental group compared with the controls (p < 0.001) (45). In another study, an eight-session relaxation program had been considered for pregnant women at gestational age of 20-37 wk in the intervention group.
However, the details of the educational sessions had not been specified. The mean ± SD of FOC score in the intervention group had also decreased significantly compared with those at the pre-intervention stage (p < 0.001) and also the mean score of FOC in this group had significantly declined compared with the control group (p < 0.001). Moreover, 49% and 32% of the individuals in the relaxation and control groups had respectively undergone natural delivery (p = 0.033) (35). Furthermore, one study had compared the effect of methods such as muscle relaxation and guided imagery on the FOC in primiparous women  Based on the quality (risk of bias) assessment tool, this study had received the highest score in terms of quality (25). In the study by Rastegari and coworkers, the effect of CPCs on attitudes toward  In this study, women with major psychiatric disorders had not been included. During the intervention, two individuals had also been excluded from the control group due to preterm labor (40).

Mindfulness program
In two studies, mindfulness had been applied as an intervention program to lower FOC among pregnant women (34,42). In this line, a study was

Other interventional programs
In this respect, one study had reflected on In this study, the samples had been divided into two intervention and control groups using a non-randomized purposeful sampling method.
All participants had completed the study and were included in data analysis (39).        (54). Another study had further reported that ICBT had led to more realistic attitudes toward natural childbirth, increased self-confidence, and ability to cope with labor process (55). In contrast with the aforementioned results, one study had revealed contradictory results in which ICBT had no significant effect on the levels of FOC in the intervention group (53). Other studies had similarly demonstrated that CBT had significantly reduced the mean score of FOC, decreased labor pain, shortened the second stage of labor, and ultimately reduced the levels of fear of blood and injection phobia (56,57).

Discussion
All Iranian studies included in this systematic review had confirmed the effectiveness of counseling in reducing FOC among pregnant women.
In this regard, a longitudinal study in Sweden comparing two groups of women with and without prenatal counseling had established that women in the counseling group had reported higher FOC one year after childbirth and the elective C-section was more prevalent among the counseling group (19).
Also, in another study, pregnant women receiving midwifery counseling had been satisfied with their treatment but they had reported more frightening The literature review had found that relaxation used as a method associated with psychoeducation was an effective strategy in preparing women for motherhood and decreasing their severe FOC (59,60). In this regard, midwife-led (20) (20,61). This systematic literature review showed that CPCs had been used for coping with labor and improving mother-child health status (62,63). Based on a Swedish study comparing the effectiveness of CPCs and routine prenatal care, the results had revealed that the given method had decreased parental stress in the early stage of parenthood but it had achieved no effectiveness in terms of the need to use analgesia during labor (62). The results of an Iranian study using CPCs and measuring its effects on mother-child health status had further revealed the effectiveness of this method in mother-child health status and lowered rates of C-section requests by pregnant women (63).

Clinical implication
This study can be a good resource for psychiatrists to review the current interventional studies on FOC and select the best interventions choices for the management of their patients. Also, the findings of this systematic review presented the importance of conducting high-quality interventional studies to improve the psychological status of pregnant women in Iranian population.

Strength and limitations
The major strength of this study was a systematic review of the published Iranian intervention research on FOC using the PRISMA guidelines.
Due to differences and heterogeneities in the