Pregnancy and child birth are significant life events in which physical, emotional and psychological changes occur. While childbirth is considered a natural physiological event, there is a lot of anxiety and fear in relation to labor and delivery for many women. Fear of childbirth (FOC), or tokophobia has become an important public health concern due to its association with adverse maternal and neonatal outcomes, elective cesarean section,

lengthy labor, postpartum depression, and negative birth experiences [1]. The maternal fear can vary from a slight feeling of anxiety to high psychological distress that can affect daily life and antenatal well-being. Over the last few years there has been an increased focus on gaining an understanding of the factors associated with fear of childbirth and the identification of women who could be at risk during pregnancy. Fear of childbirth is a phenomenon that encompasses biological, psychological, social and obstetric factors. 

The

fear may stem from uncertainty and lack of experience in primigravidas, and traumatic or negative previous birth experiences in multiparous women [2]. Past experiences are an important factor in determining mothers’ perceptions and expectations for the next birth. Pregnant women who have had with severe pain in labor, obstetric complications, emergency interventions, poor communication with health service staff, lack of emotional support, and disrespectful maternity care are more likely to experience greater fear of childbirth in subsequent pregnancies [3]. On the other hand, positive birth experiences with supportive healthcare, effective pain management, and a successful vaginal delivery can help mitigate maternal anxiety and boost confidence in future births.

Fear of childbirth is common in some groups and health care environments. In international studies it has been found that about 20-25% of pregnancy women face moderate fear and nearly 6-15% are experiencing severe fear of child birth all over the world [4]. Variations in prevalence might be explained by sociocultural beliefs, education level, health care system, and obstetric practices. Lack of awareness of maternal mental health issues and lack of psychological support during pregnancy are some of the factors that affect the under-recognition of childbirth-related fears in low and middle-income countries including Pakistan. Although there have been improvements in obstetric care, maternal psychological well-being is often overlooked in favour of physical health outcomes.

Frequently, childbirth fear is reported to be a strong predictor of future childbirth fear in women who have previously had traumatic birth experiences. Women who have an emergency cesarean section, instrumental vaginal delivery, postpartum hemorrhage, prolonged labor, stillbirth or neonatal complications often experience lingering emotional distress and anxiety during future pregnancies [5]. These experiences can cause a sense of helplessness, a lack of control and mistrust of health care providers. Studies have shown that women who have previously had traumatic delivery are more likely to ask for cesarean delivery as elective surgery in future pregnancy, because of fear of same complication or pain during labor [6]. This is one of the factors leading to the increasing rate of cesarean delivery worldwide with its additional burden on health care and morbidity to mother.

Psychological theories also indicate that childbirth experiences are influenced by subjective maternal perceptions of and responses to medical events. Women's experience of pain during labor, their interactions with health care providers, their dignity and participation in decision-making are all significant factors in their satisfaction with the birth [7]. Negative perceptions can continue after childbirth and impact upon maternal self-esteem, mother–infant bonding, and reproductive decisions. Those women who feel that giving birth was traumatic have a higher risk of developing postpartum depression, post-traumatic stress disorder (PTSD), and a fear of future pregnancies [8]. Thus, delivering better birth

experience has become a crucial element to respectful maternity care and quality obstetric services.

There are also a number of demographic and obstetric factors that have been linked to fear of childbirth. Fear and anxiety during pregnancy have been associated with younger maternal age, low level of education, low socioeconomic status, unplanned pregnancy, inadequate counseling during the antenatal period and lack of social support [9]. Also, women who have had a history of infertility, miscarriage or poor pregnancy outcomes may have increased worries about the safety of mother and fetus. Mother's expectation and fear are also shaped by cultural expectations and the stories of society about child birth. Many societies tell women frightening stories about pain and problems in childbirth from family members, friends or the media that can increase women's 'pregnant' anxiety before birth.

Doctors, midwives, nurses, and other professionals involved in maternal healthcare are key in minimizing worries and ensuring positive childbirth experiences. Emotional support, appropriate antenatal education, effective communication, pain management technique and respectful maternity care during labor have been found to increase women satisfaction and decrease childbirth related anxiety [10]. This has been shown to be effective in women with high levels of fear of childbirth in the form of midwife-led counselling programmes and psychological interventions, for example, cognitive behavioural therapy [11]. Antenatal screening will help to identify women who are at high risk so that interventions and care plans can be made at the right time.

Maternal mental health is an under-researched field in the reproductive health research in developing countries including Pakistan. The majority of obstetric services concentrate on preventing physical complications and death; psychological considerations of childbirth are not particularly considered. For Pakistani women, other obstacles can include restricted decision making in health care, lack of information about childbirth, crowded health care facilities, and lack of emotional support during childbirth [12]. All these can have a negative impact on women's birth experiences and can contribute to fear during their next pregnancy. Moreover, there is a lack of local multicenter study to assess the association of previous birth experiences with fear of childbirth in Pakistani women.

Hence, it is important to understand how the previous child birth experiences affect the fear of the mothers for developing targeted interventions to enhance the psychological well-being of mothers and obstetric outcomes. Women who experienced negative birth experiences might benefit from more receiving antenatal counselling, psychological support and individual birth planning to decrease fear and increase confidence in the labour experience. When it comes to birth, if fear can be addressed, this could also lead to a decrease in unindicated cesarean section requests and to positive maternal experiences. Furthermore, modifiable health care-related factors (e.g., provider communication and labor support) can help improve the quality of maternity care.

The study was designed to assess the effect of past birth history on fear of childbirth in pregnant women visiting antenatal clinics, a multicenter study was conducted at Creek General Hospital and SESSI Landhi Hospital, Karachi. The results of this study can assist health care providers in identifying women who are at risk psychologically and suggest supportive interventions for future pregnancies that will enhance mental health and childbirth experiences.

This is a multicenter cross sectional study undertaken in the Department of Obstetrics and Gynecology of Creek General Hospital and SESSI Landhi Hospital, Karachi for six months 1^st November 2025 to 30^th April 2026, after approval of the institutional ethical review committees of both the hospitals involved. The population of the study were pregnant women who sought antenatal care at the outpatient clinics during the study period. Women aged 18–40 years with a history of at least one previous childbirth and who were willing to participate were included in the study. The exclusion criteria were primigravida women, women with psychiatric disorders diagnosed prior to the study, critically ill patients, and women with communication difficulties. A non-probability consecutive sampling technique was used for participant recruitment.

Sample size was determined by using the WHO sample size formula with 95% CI, 5% margin of error and 50% prevalence of fear of child birth among women with past negative experiences as per literature. 200 subjects were equally recruited from both study centers. All participants signed written informed consent forms before data collection and confidentiality of personal information was preserved throughout the study.

Data were gathered using a structured and pretested questionnaire using face-to-face interviews conducted by trained health care workers. The questionnaire was divided into parts on sociodemographic characteristics such as age, educational status, occupation, socioeconomic status and area of residence. Obstetric information included parity, gestational age, mode of previous delivery, obstetric complications, length of labor, perception of pain and neonatal outcomes. Each participant was asked to place their previous childbirth experience into a positive or negative category according to their subjective impression of the level of pain, emotional support, communication with health care providers, privacy, respect and overall satisfaction during delivery.

A validated childbirth fear assessment scale was used to assess maternal fear of childbirth. The scores obtained were classified as mild, moderate and severe fear. Moderate to severe scores were regarded as significant fear of childbirth. Other variables that may be associated with maternal fear, such as history of emergency cesarean section, instrumental delivery, postpartum complications, inadequate pain relief, and poor interaction with health care providers were also examined.

The collected data was entered and analyzed using Statistical Package for Social Sciences (SPSS) version 26. Continuous variables like age and gestational age were represented as mean ± standard deviation while the categorical variables like educational status, parity, mode of delivery, previous birth experience, fear categories were presented as frequencies and percentages. Chi square test was used to analyze the relationship between previous birth experience and maternal fear of child birth. Independent variables that were associated with fear of childbirth were also investigated for their significance through logistic regression analysis as appropriate. The statistical significance was set at p-values of ≤ 0.05.

This multicenter study included 200 pregnant women having at least one history of childbirth at both Creek general hospital and SESSI Landhi hospital, Karachi. The mean age of the participants was 28.6 ± 4.9 year and the mean gestational age was

30.2 ± 5.4 week. The age group of 26-30 years had the highest proportion of most participants (46.0%). In terms of educational status, 38.5% possessed secondary education while 27.0% and 21.5% had primary and higher education respectively. Most of the women were housewives (79.0%) and multiparous (64.5%).

Of the respondents, 84 (42.0%) women had a negative experience during their previous birth and 116 (58.0%) had a positive experience during their previous birth. 93 (46.5%) participants had moderate to severe fear of childbirth. Women who had a negative childbirth experience had significantly more fear than women with positive childbirth experiences (68.1% versus 30.2%, p < p<0.001).

Maternal fear of childbirth was significantly associated with previous cesarean section, long labor time, poor communication with healthcare providers, and inadequate pain management. Women with emergency cesarean section (ECS) in their last pregnancy had a higher proportion with moderate to severe fear (71.4%) than women with previous vaginal delivery (38.0%). Likewise, women who felt the lack of emotional support in labor had a higher risk for fear in future pregnancies.

Table 1: Sociodemographic and Obstetric Characteristics of Participants (n=200)

Table 2: Association Between Previous Birth Experience and Fear of Childbirth

The association between previous childbirth experience and fear of childbirth was statistically significant. Women with negative previous birth experiences had significantly higher levels of moderate to severe fear compared to women reporting positive birth experiences (p<0.001).

Table 3: Factors Associated with Moderate to Severe Fear of Childbirth

Overall, the findings of this study indicate that previous negative childbirth experiences significantly increase maternal fear of childbirth in subsequent pregnancies. Obstetric complications and inadequate intrapartum support were major contributors to maternal fear among the studied population.

The aim of the present multicenter study was to assess the effect of past childbirth experiences on pregnant women attending the antenatal clinics at Creek General Hospital and SESSI Landhi Hospital, Karachi, in regard to fear of childbirth. The results showed that there was a significant difference between women who reported a negative childbirth experience and those who reported a positive experience in the past in terms of fear of childbirth, with women with negative previous experiences having significantly higher levels of moderate to severe fear of childbirth. Additionally, the study found that emergency cesarean section, prolonged labor, poor management of labor pain, lack of communication with health care providers, and emotional failure during labor were significant factors that influenced maternal fear in future pregnancies. Anxiety about giving birth has become a well known issue for psychiatric health in mothers around the globe. In this study, most of the respondents (44.8%) had moderate to severe fear of childbirth. This has been seen in other countries around the world. A longitudinal cohort study conducted by Nilsson et al. showed that negative

previous experiences with childbirth negatively affected maternal anxiety and fear in subsequent pregnancies, especially for women who felt childbirth was traumatic or poorly managed [16]. Similarly, severe childbirth fear was identified as a major psychological disorder impacting maternal health and the family relationship as well as reproductive choices by Wijma and colleagues [17]. The present study confirms the link between traumatic birth events and childbirth fear that have been reported in the past in different international studies. Mothers who had previous emergency cesarean section had significantly higher fear levels in subsequent pregnancies. The results are similar to those of Pang et al. [18] who found that women who had undergone EOI in pregnancy were more likely than controls to experience grief, anxiety and emotional stress after pregnancy. Emergency cesarean delivery is frequently characterized by loss of control, fear of the baby's safety and psychological trauma, which can all play a role in a prolonged childbirth fear. Among the current study, long labour was found to be significantly linked to moderate to severe FEMA. Waldenström et al. also noted that women with long and painful births were more likely to report that childbirth was a traumatic

experience and that they subsequently became frightened and unhappy with maternity care [19]. Long labour time can cause physical fatigue, helplessness and emotional strain, especially if there is not enough support or communication from the health care professionals. Another key factor that emerged in this study leading to maternal fear was the perception of pain and a lack of pain management. Women who reported the lack of pain relief during previous deliveries had significantly higher fear of childbirth scores. This finding corroborates with the work of Alehagen et al., showing that severe labour pain and poor pain management during labour had a negative impact on the maternal birth experience and fear during subsequent pregnancies [20]. Labor pain is more than just physical, it is also very emotional and psychological. Labour experiences may also be negatively affected by fear and anxiety, which may increase sensitivity to pain. One of the other key findings of this study was the strong relationship between poor communication with the health care workers and fear of childbirth. Women who experienced negative treatment from healthcare professionals, such as feeling unsupported, disrespectful or inattentive, were at higher risk of developing childbirth fear.Women who had negative experiences from healthcare professionals, including feeling unsupported, disrespectful or inattentive, were at higher risk of developing childbirth fear. This finding is consistent with Bell and Andersson's research which identified disrespectful maternity care, inability to make informed decisions, and poor provider-patient communication as significant factors in a traumatic birth experience [21]. The use of effective communication and respectful maternity care is vital in establishing maternal trust, calming maternal anxiety and enhancing overall maternal childbirth satisfaction. In the current study, lack of emotional support during labor was also a significant factor that was associated with maternal fear. Emotional support of healthcare professionals, spouse and family members have been demonstrated to positively impact labour experiences and maternal confidence. Taheri et al. found in their systematic review that provision of emotional and psychological support throughout labor decreases the fear, stress during birth, and risk of traumatic birth experience [22]. Emotional support creates a positive perception of childbirth and greater control during labour for women. The present study results are especially significant in the developing countries including Pakistan where the mental health services to mothers are limited. The stigma attached to mental illness in Pakistan, a lack of antenatal counseling, overcrowding in maternity units, and limited resources could be some factors that affect the negative experience of childbirth for Pakistani women. Husain et al. noted that the respondents in their study of pregnant women in South Asian healthcare centers had high anxiety and depressive symptomology, and that the pregnant women were poorly supported in their psychosocial needs [23]. Therefore, it is crucial to care for the mental health of the mother during pregnancy to support the well-being of the mother and the likelihood of a successful pregnancy. The findings of this

research also contribute to the increasing evidence of the association between fear of childbirth and greater desire for cesarean section deliveries. Women who have a history of traumatic birth may request elective cesarean sections to prevent or alleviate the expected pain of labor and the possibility of complications. Fenwick et al. found that high levels of childbirth fear can affect women's choices of birth mode and can be a key factor in increasing cesarean section rates throughout the world [24]. The implications are significant for healthcare systems since unnecessary cesarean deliveries add to healthcare costs and carry a risk of surgery for mothers. The psychological effects of traumatic childbirth experiences can be beyond the period of pregnancy and birth. A few studies have indicated that women who experience severe childbirth fear are at risk for postpartum depression and post-traumatic stress disorder. Söderquist et al. [25] conducted a study on the psychological effects of traumatic birth experiences which found psychological effects that persisted for months or years after birth. These impacts on mental health can have negative effects on the maternal-infant bond, breastfeeding and future plans for reproduction. This study results reinforce the need of the individualized antenatal counseling and psychological screening of women who had previous negative childbirth experiences. Identifying female patients early who are at increased risk can help to ensure prompt interventions like counselling, birth preparedness education, and emotional support programs. Counselling and CBT by midwives have been shown to help reduce fears surrounding childbirth and increase maternal confidence [26]. Therefore, it is recommended that patient-centred maternity care practices are established, with a particular focus on emotional health as well as physical health. The study has some advantages such as multicenter design and the study area is relatively under-explored in Pakistan. Some restrictions must be noted though. As the study is cross-sectional, it does not enable causal relationship. Further, self-reported measures were used to evaluate fear and birth experiences that could be susceptible to recall bias and subjectivity. However, the results of this study are informative for the local context as a contribution to the psychological consequences of past birth experiences on birth fear in mothers. In general, the present study demonstrates the strong impact of negative previous childbirth experiences on maternal fear during subsequent childbirths. In the Pakistani healthcare context, better quality of intrapartum care, respectful maternity care, effective communication between care providers and mothers, and supportive psychological support before the delivery could help alleviate fear of childbirth and enhance maternal health outcomes.

This multicenter study shows that there is a significant effect of previous birth on maternal fears of childbirth. Those women who had had negative childbirth experiences were found to have significantly higher scores for moderate to severe fear than those who had had positive childbirth experiences. Key contributors to increased fear

during later-pregnancies were emergency cesarean section, prolonged labour, poor pain relief at birth, poor communication with health care providers and poor emotional support during birth. The results indicate that childbirth is an intense psychological experience as well as a physical one, and that it affects the perception that the mother has of the birth and of herself when she is pregnant again. Negative experiences during labour may have long term emotional outcomes, such as mothers confidence, pregnancy planning and mode of delivery preference. In general, better quality care during birth, respectful maternity care, good communication, appropriate pain management and emotional support are critical to decrease fear of birth if this is to be avoided. The early diagnosis of women who have had previous traumatic birth and targeted psychological and antenatal counseling can have a significant effect on the well being of the mother and the outcome of her pregnancy in future pregnancies.

Recommendations

The results of this study indicate that early screening of fear of childbirth should be routinely conducted as part of the antenatal care of women, especially multiparous women with previous delivery experiences which were negative or traumatic. To support, inform and involve women in decision making during labour, healthcare providers need to be trained in respectful maternity care, in effective communication skills and in empathetic patient interaction. Ensuring good management of pain and access to suitable options for pain relief during labour and birth, both pharmacological and non-pharmacological, should be given special consideration to ensure the mother feels comfortable, and the pain is minimised, relieving psychological distress. Furthermore, there is a need for structured antenatal counseling sessions and child birth education in maternity units to mentally prepare women for the process of delivery and deal with misconceptions and fears of delivery. Those who have a high fear of childbirth or have had an unpleasant birth experience should be referred to psychological support/counselling services. Emphasis should be placed on the need for continuous emotional support during childbirth via trained birth companions, midwives, or family members, which is known to enhance birth satisfaction and decrease fear, in hospital policies. These can be helpful in enhancing the psychological well-being of mothers and their positive childbirth experiences in future pregnancies in tertiary care centers like Creek General Hospital and SESSI Landhi Hospital.

Authors’ Contributions

Dr. Fauzia Shakeel was involved in the conceptualization, design, data collection at Creek General Hospital, and drafting and critical revision of the manuscript. Dr. Gulnaz Ayaz participated in the design, interpretation and substantive intellectual review of the manuscript. Dr. Nighat Sultana helped in collecting data at the SESSI Landhi hospital, providing coordination in data analysis,

and editing and reviewing the manuscript. Dr Hassena participated in the clinical supervision and validation of obstetric data and the general analysis of the results of the study. All authors read and approved the final manuscript, and agree to be held accountable for all aspects of the work.

1. O’Connell MA, Leahy-Warren P, Kenny LC, Khashan AS. The prevalence and risk factors of fear of childbirth among pregnant women: A systematic review and meta-analysis. Acta Obstet Gynecol Scand. 2017;96(8):907-920. doi:10.1111/aogs.13138
2. Nilsson C, Lundgren I, Karlström A, Hildingsson I. Self reported fear of childbirth and its association with women’s birth experience and mode of delivery. Women 2012;25(3):114-121. doi:10.1016/j.wombi.2011.06.001
3. Størksen HT, Garthus-Niegel S, Adams SS, Vangen S, Eberhard-Gran M. Fear of childbirth and elective caesarean section: A population-based study. BMC Pregnancy              2015;15:221. doi:10.1186/s12884-015-0655-4
4. Raisanen S, Lehto SM, Nielsen HS, Gissler M, Kramer MR, Heinonen S. Fear of childbirth predicts postpartum depression: A population-based analysis. J Affect Disord. 2013;146(2):201-205. doi:10.1016/j.jad.2012.08.036
5. Elvander C, Cnattingius S, Kjerulff KH. Birth experience in women with low, intermediate or high levels of fear: Findings from the First Baby Study. Birth. 2013;40(4):289-296. doi:10.1111/birt.12065
6. Fenwick J, Gamble J, Nathan E, Bayes S, Hauck Y. Pre- and postpartum levels of childbirth fear and the relationship to birth outcomes in a cohort of Australian women. J Clin Nurs. 2009;18(5):667-677. doi:10.1111/j.1365-2702.2008.02568.x
7. Hodnett ED. Pain and women’s satisfaction with the experience of childbirth: A systematic review. Am J Obstet Gynecol. 2002;186(5 Suppl Nature):S160-S172. doi:10.1067/mob.2002.121141
8. Andersen LB, Melvaer LB, Videbech P, Lamont RF, Joergensen JS. Risk factors for developing post-traumatic stress disorder following childbirth: A systematic review. Acta Obstet Gynecol Scand. 2012;91(11):1261-1272. doi:10.1111/j.16000412.2012.01476.x
9. Sydsjö G, Bladh M, Lilliecreutz C, Persson A, Vyssoki B, Josefsson A. Obstetric outcomes for nulliparous women who received routine individualized treatment for severe fear of childbirth. BMC Pregnancy Childbirth. 2012;12:125. doi:10.1186/1471-2393-12-125
10. Bohren MA, Hofmeyr GJ, Sakala C, Fukuzawa RK, Cuthbert Continuous support for women during childbirth. Cochrane      Database      Syst       Rev. 2017;7(7):CD003766. doi:10.1002/14651858.CD003766.pub6
11. Rouhe H, Salmela-Aro K, Halmesmäki E, Saisto Fear of childbirth according to parity, gestational age, and obstetric history. BJOG. 2009;116(1):67-73. doi:10.1111/j.1471-0528.2008.02002.x
12. Ali TS, Azam SI, Ali BS, Tabbusum G, Moin SS. Frequency and associated factors for anxiety and depression in pregnant women: A hospital-based cross-sectional study. ScientificWorldJournal. 2012;2012:653098. doi:10.1100/2012/653098
13. Saisto T, Halmesmäki E. Fear of childbirth: A neglected dilemma. Acta Obstet Gynecol Scand. 2003;82(3):201-208. doi:10.1034/j.1600-0412.2003.00114.x
14. Fisher C, Hauck YL, Fenwick J. How social context impacts on women’s fears of childbirth: A Western Australian example. Soc Sci Med. 2006;63(1):64-75. doi:10.1016/j.socscimed.2005.11.065
15. Garthus-Niegel S, Knoph C, von Soest T, Nielsen CS, Eberhard-Gran M. The role of labor pain and overall birth experience in the development of posttraumatic stress symptoms: A longitudinal cohort study. Birth. 2014;41(1):108-115. doi:10.1111/birt.12093
16. Nilsson C, Bondas T, Lundgren I. Previous birth experience in women with intense fear of J Obstet Gynecol Neonatal Nurs. 2010;39(3):298-309. doi:10.1111/j.1552-6909.2010.01139.x
17. Wijma K, Wijma B, Zar Psychometric aspects of the W-DEQ; a new questionnaire for the measurement of fear of childbirth. J Psychosom Obstet Gynaecol. 1998;19(2):84-97. doi:10.3109/01674829809048501
18. Pang MW, Leung TN, Lau TK, Chung Impact of first childbirth on changes in women's preference for mode of delivery: Follow-up of a longitudinal observational study. Birth. 2008;35(2):121-128. doi:10.1111/j.1523-536X.2008.00225.x
19. Waldenström U, Hildingsson I, Rubertsson C, Rådestad I. A negative birth experience: Prevalence and risk factors in a national sample. Birth. 2004;31(1):17-27. doi:10.1111/j.0730-7659.2004.0270.x
20. Alehagen S, Wijma K, Wijma B. Fear during labor. Acta Obstet Gynecol Scand. 2001;80(4):315-320. doi:10.1034/j.1600-0412.2001.080004315.x
21. Bell AF, Andersson E. The birth experience and women’s postnatal depression: A systematic review. 2016;39:112-123. doi:10.1016/j.midw.2016.04.014
22. Taheri M, Takian A, Taghizadeh Z, Jafari N, Sarafraz
23. Creating a positive perception of childbirth experience: Systematic review and meta-analysis of prenatal and intrapartum interventions. Reprod Health. 2018;15(1):73. doi:10.1186/s12978-018-0511-x
24. Husain N, Cruickshank K, Husain M, Khan S, Tomenson B, Rahman Social stress and depression during pregnancy and in the postnatal period in British Pakistani mothers: A cohort study. J Affect Disord. 2012;140(3):268-276. doi:10.1016/j.jad.2012.02.009
25. Fenwick J, Staff L, Gamble J, Creedy DK, Bayes S. Why do women request caesarean section in a normal, healthy first pregnancy? Midwifery. 2010;26(4):394-
26. doi:10.1016/j.midw.2008.10.011
27. Söderquist J, Wijma B, Wijma K. The longitudinal course of post-traumatic stress after childbirth. J Psychosom Obstet Gynaecol. 2006;27(2):113-119. doi:10.1080/01674820600712172
28. Saisto T, Toivanen R, Salmela-Aro K, Halmesmäki E. Therapeutic group psychoeducation and relaxation in treating fear of Acta Obstet Gynecol Scand. 2006;85(11):1315-1319. doi:10.1080/00016340600714520
29. Laursen M, Hedegaard M, Johansen C. Fear of childbirth: Predictors and temporal changes among nulliparous women in the Danish National Birth BJOG.  2008;115(3):354-360. doi:10.1111/j.1471-0528.2007.01583.x
30. Rouhe H, Salmela-Aro K, Gissler M, Halmesmäki E, Saisto T. Mental health problems common in women with fear of childbirth. BJOG. 2011;118(9):1104-1111. doi:10.1111/j.1471-0528.2011.02967.x