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Original Article

Association between fear of childbirth and maternal acceptance of pregnancy* D. Cosßkuner Potur1 RN, PhD, R. Mamuk2 N. Demirci4 RN, PhD & Y. Hamlaci5 Msc

Msc ,

N.H. S ß ahin3

RN, PhD,

1 Assistant Professor, 4 Professor, Division of Nursing, Department of Obstetrics and Gynecology Nursing, Faculty of Health Sciences, Marmara University, 2 Midwife, Bagcılar Training and Research Hospital, 3 Professor, Department of Obstetrics and Gynecology Nursing, Florence Nightingale Nursing Faculty, Istanbul University, Istanbul, 5 Research Assistant, Division of Midwifery, Faculty of Health Sciences, Sakarya University, Sakarya, Turkey

COSßKUNER POTUR D., MAMUK R., SßAHIN N.H., DEMIRCI N. & HAMLACI Y. (2017) Association between fear of childbirth and maternal acceptance of pregnancy*. International Nursing Review 00, 000–000 Aim: This descriptive study aimed to explore the associations between fear of childbirth, acceptance of pregnancy and identification with the motherhood role among primipara women. Background: Women who have difficulty accepting their pregnancy have a harder time adapting to pregnancy and motherhood and experience more fears related to childbirth. The number of studies conducted on this topic is limited. Methods: This study involved 310 pregnant women admitted to a public hospital in Istanbul between January and June of 2013. A participant identification form, the Prenatal Self-Evaluation Questionnaire and the Wijma Delivery Expectancy/Experience Questionnaire Version A were used for data collection. Results: Pregnant women participating in the study experienced moderate levels fear of childbirth. Pregnant women who requested caesarean section experienced more intense fear of childbirth. Fear of childbirth scores had significant but weak correlations with acceptance of pregnancy and identification with the motherhood role. Conclusion: The findings showed that acceptance of pregnancy and identification with the motherhood role are weakly associated with fear of childbirth. Implications for nursing and health policy: The results from this study can be used to help: increase awareness among health professionals (doctors, nurses, midwives) in antenatal care services about a mother’s adaptation to pregnancy and the negative effects of fear of childbirth; direct future research examining factors affecting adaptation to pregnancy and fear of childbirth; establish routine assessments for adaptation to pregnancy and fear of childbirth; provide professional support for women with difficulties adapting to pregnancy and with fear of childbirth; result in reduced complications from invasive methods such as caesarean section due to less requests for these procedures; and promote the health of mothers and babies.

Correspondence address: Dilek Cosßkuner Potur, Division of Nursing, Department of Obstetrics and Gynecology Nursing, Faculty of Health Sciences, Marmara University, Basßıb€ uy€ uk Mah. Maltepe Basßıb€ uy€ uk Yolu Sk. No: 9/4/1 Maltepe, Istanbul 34854, Turkey; Tel: +90-216-4594554 – 1226; Fax: +90 216 399 62 42; E-mail: [email protected].

*This study was presented at the 9th Congress on Women’s Health & Disease, 28–30th August 2014, Athens, Greece. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Conflicts of Interest The authors declare that there is no conflict of interest.

© 2017 International Council of Nurses

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D. Cosßkuner Potur et al.

Keywords: Acceptance of Pregnancy, Antenatal Period, Caesarean Section, Fear of Childbirth, Midwife, Motherhood Role, Nurse, Prenatal Care, Spontaneous Vaginal Delivery, Turkey

Introduction Although pregnancy is a natural process for women, it involves physiological and psychological changes which necessitate adaptation (Beydag 2007). ‘Acceptance of pregnancy (AP) refers to women’s adaptive responses to the physiological and psychological changes experienced during pregnancy’ (Lederman & Weis 2009 p. 39). Every woman experiences and adapts to the pregnancy process differently (Yılmaz & Beji 2010). Even during a planned pregnancy, a woman can have difficulty adapting to the changes. Therefore, pregnancy can be a period of crisis for a woman and her family (Beydag & Mete 2008). Becoming pregnant by itself is insufficient for making a successful transition into being a mother (Beydag 2007). AP and identification with the motherhood role (IMR) are processes that take place throughout the pregnancy (Mercer 2004). ‘IMR corresponds to the mother’s attachment orientation and reflective functioning, or, her capacity to understand the nature of her baby’s and her own thoughts or mental states’ (Lederman & Weis 2009 p. 57). The experience of a healthy transition to motherhood from early pregnancy through birth is an important factor in the mother’s ability to cope and the foetus’ healthy development (Beydag 2007). In order to have a healthy transition to motherhood, it is important to be able to overcome problems encountered during the process and to adapt to the new circumstances (Beydag 2007). Various factors may influence adaptation to pregnancy and the motherhood role in pregnant women (Lederman & Weis 2009; Sercßekusß & Mete 2010a). These factors include mother’s characteristics, such as age (Emmanuel et al. 2008), educational level (Lederman & Weis 2009), whether or not the pregnancy was planned (Visger 2013), employment status (Kiehl et al. 2007), level of income (Lederman & Weis 2009) and social characteristics such as social support (Choi 2012; Mercer 2004; Sercßekusß & Mete 2010a) and family or spouse support (Lederman & Weis 2009). A study conducted in Turkey found that women who were highly educated, were employed, had a planned pregnancy, had knowledge about the pregnancy process, had a high income level and had social security adapted to pregnancy and IMR better than those who did not (Demirbasß & Kadıoglu 2014). A failure to accept pregnancy and the motherhood role may result in the mother not doing what is recommended or


needed during a pregnancy, such as seeking adequate care before the birth. This, in turn, may result in insufficient nutrition during the pregnancy as well as problems regarding the attachment process between the mother and the foetus. During the post-partum period, this situation may also cause negative interactions between the mother and the baby, as well as poor self-confidence, reduced life satisfaction and even post-partum depression in the mother (Kiehl et al. 2007; Lederman & Weis 2009; Sercßekusß & Mete 2010a). Thus, as reported in literature, women with difficulty accepting pregnancy have a harder time adapting to pregnancy and motherhood in addition to experiencing more fears related to childbirth (Lederman & Weis 2009). Fear of childbirth (FOC) is defined as the negative cognitive evaluation of childbirth, when one approaches birth in a fearful and anxious way (C ß icßek & Mete 2015). In various studies, 20–25% of pregnant women had a fear of childbirth (FOC; Fenwick et al. 2009; Salomonsson et al. 2013) and 5– 10% experienced serious anxiety and fear about the act of childbirth (Kjaergaard et al. 2008; Rouhe et al. 2009). In many studies, FOC in pregnant women has been associated with an increase in birth interventions, emergency Caesarean Sections (CS) and a preference for elective CS (Erg€ ol & K€ urt€ unc€ u 2014; Rouhe et al. 2009; Toohill et al. 2014a). As the act of giving birth draws nearer, a pregnant woman’s fear of giving birth increases (Wijma 2003). This is especially true if the pregnant woman is primipara. For these women, the unknown level of pain in childbirth causes unpreventable anxiety. Women who have given birth before may also experience fear due to negative past experiences (Anderson & Gill 2014). However, studies have shown that primipara women experience greater FOC than multipara women (Erg€ ol & K€ urt€ unc€ u 2014; Rouhe et al. 2009). CS births are common in Turkey, accounting for 48% of all births from 2008 to 2013 (TDHS 2013). Until recently, midwives and obstetrics specialists decided the delivery mode in Turkey, and it was legally acceptable to perform CS without indications of medical necessity (Official Newspaper Date: 4-07-2012, Number: 6354), according to the results of studies performed in Turkey and other countries. The mother’s request was also an important indicator for whether or not a CS was performed. Previous studies indicate that the most prominent reasons for a mother to prefer a CS are thinking it is healthier for both mother and baby; being pregnant at an

Fear of childbirth and acceptance of pregnancy

older age, which is becoming more common; and FOC, which is due to a lack of knowledge about childbirth (Atan et al. 2013; Wilkund et al. 2008). Although a law against performing CS in the absence of medical necessity was passed in 2012, the percentage of CS among all births rose to 51.1% in 2014, according to statistics from the Department of Health (TRMHSY 2014). The increase – not decrease – in the CS rate shows that the frequency of this procedure cannot be reduced by legal regulations alone. In the light of these findings, it can be presumed that the preference for CS may be due to failures in coping with FOC, which seems to be a result of not being able to adapt to pregnancy and the motherhood role. The present study was planned according to this assumption and aimed to determine the associations between FOC and adaptation to pregnancy and the motherhood role. The findings of this study are expected to make important contributions to midwives and nurses who provide pre-conceptional antenatal care by providing them with an understanding of the association between pregnancy, AP, IMR and FOC. In this study, primipara women were recruited to obtain a sample that was homogenous in terms of birth experiences. This descriptive study was performed to determine the association of FOC with AP and IMR. We sought to answer the following research questions: 1 Is there a difference in the levels of FOC, AP and IMR during pregnancies when spontaneous vaginal delivery (SVD) is desired compared to when a CS is desired? 2 Is there a difference in the levels of FOC, AP and IMR during a planned pregnancy compared to an unplanned pregnancy? 3 Is there an association between FOC during pregnancy and AP? 4 Is there an association between FOC during pregnancy and IMR?

Methods Study setting and sample

The population of this descriptive, correlational study consisted of pregnant women admitted for antenatal care in the antenatal polyclinics of a large, public hospital in Istanbul between January and June of 2013. In all, 10 784 pregnant women presenting at the hospital’s obstetrics polyclinic between those dates formed the universe of the study. At a 20% prevalence of FOC (Salomonsson et al. 2013) and a a 5% error rate, the sample size within this universe was calculated to be 243 with a 95% confidence interval. Sample selection was non-randomized and adhered


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to the following inclusion criteria: women were between the ages of 18 and 35, spoke and understood Turkish, were married, were primipara, were in gestational week 28–36 and had a single foetus and no pregnancy-related complications. All women who met these criteria were included in the study. Our sample was formed by 310 women who volunteered to participate. Data collection

For data collection, the participant identification form, the AP and IMR subdimensions of the Prenatal Self-Evaluation Questionnaire (PSEQ) and Version A of the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ A) were used. Data were collected from the pregnant women through faceto-face interviews conducted by the researcher. Instruments Participant identification form

The questionnaire, which was developed by the researchers based on literature, consists of 14 questions focused on the participants’ sociodemographic characteristics and topics related to pregnancy and delivery. The sociodemographic questions addressed age, marriage duration, education level, employment and smoking status. Obstetric questions addressed the current week of pregnancy, the amount of planning for the pregnancy by the woman and her spouse, and the desired delivery mode (SVD or CS). Prenatal self-evaluation questionnaire

The PSEQ, developed by Lederman, evaluates a pregnant woman’s adaptation to pregnancy and the motherhood role (Lederman & Weis 2009). Beydag & Mete (2008) tested the validity and reliability of the Turkish version of the scale. The scale includes seven subdimensions and 79 items. The Turkish version of the scale has a high internal consistency coefficient (Cronbach’s a: 0.81). The internal consistency coefficients of the subgroups range from 0.72 to 0.85 (Beydag & Mete 2008). In this study, the AP (14 items) and IMR (15 items) subscales were administered to participants (29 items total). Each item on the scale has four response categories. Adaptation to pregnancy is measured by the number of points ranging from 1 to 4 (1 being ‘not at all’ and 4 ‘very much so’). The minimum and maximum scores were 14 and 56 for the AP subscale, respectively, and 15 and 60 for the IMR subscale. Lower scores correspond to better AP and IMR (Beydag & Mete 2008). In this study, the Cronbach’s alpha coefficient was 0.84 for the AP subscale and 0.85 for the IMR subscale.

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Wijma delivery expectancy/experience questionnaire version A

The W-DEQ A, developed by Wijma, Wijma and Zar, evalu€ et al. 2012). ates a pregnant woman’s FOC (K€ or€ ukcßu € et al. (2012) tested the validity and reliability of the K€ or€ ukcßu Turkish version of the questionnaire. The split-half reliability and internal consistency of the scale exceeds 0.87, which indi€ et al. 2012). In the cates the scale is a reliable tool (K€ or€ ukcßu current study, the Cronbach’s alpha value for the W-DEQ A was found to be 0.89. The response categories ranged between 0 and 5, using a 6-point Likert-type format, with 0 corresponding to ‘extremely’ and 5 corresponding to ‘not at all’. The scores could range from 0 to 165. Higher scores correspond to higher FOC levels (K€ or€ ukcßu € et al. 2012).

Table 1 Socio-Demographic characteristics of participants (n = 310) Characteristics Education Primary education High school University Employment Employed Unemployed Cigarette smoking Yes No Total

n

%

240 47 23

77.4 15.2 7.4

74 236

23.9 76.1

42 268 310

13.5 86.5 100.0

Data analysis

The Statistical Package for the Social Sciences (SPSS) 15.0 (SPSS Inc., Chicago, IL, USA) was used in data analysis. P values of less than 0.05 were considered statistically significant. Descriptive statistics, including frequency, means and standard deviations, were calculated. Reliability was tested through Cronbach’s alpha coefficients. The Kolmogorov– Smirnov test was performed to test whether the data were normally distributed. The Mann–Whitney U-test was conducted in order to compare AP and IMR scores according to obstetric features, as the scale scores did not show normal distribution. An independent sample t-test was also performed as the FOC scores showed normal distribution. The scores for AP and IMR were not distributed normally, so their relationships to FOC were analysed through the Spearman correlation analysis. Ethical considerations

During every stage of the study, we strictly adhered to ethical principles and the principles set forth in the Declaration of Helsinki. Ethical approval was obtained prior to the study from the Institutional Review Board of the hospital where the study was conducted (date: 14-01-2013, number: GOKAEK/ 2013-98). Pregnant women in the sample read and signed informed consent forms indicating that they voluntarily participated in the study.

mean gestational week was 33.86 4.57 (minimum: 28, maximum: 36). Of the participants, 81.9% were aged between 18 and 27 years, 58.4% were in the 33th–36th gestational week 88.4% had a planned pregnancy, and 60.3% planned to have SVD. The mean W-DEQ A score was 65.16 22.63, while the mean AP and IMR subdimension scores from the PSEQ were 22.33 6.37 and 21.65 4.56, respectively. There were no significant differences between mean FOC, AP and IMR scores according to age group (P > 0.05). Mean FOC scores of women in the 33rd–36th gestational weeks ranged from 28 to 32. Although there seemed to be an increase in FOC according to gestational week, this difference was not statistically significant (P > 0.05). However, there were significant differences in mean AP and IMR scores according to gestational week (P < 0.05). It was determined that women had better AP and IMR during the 33rd–36th gestational weeks than those in the 28th–32nd gestational weeks. Women who had planned pregnancies had a lower mean AP score than those who did not, and the association between these factors was highly significant (P < 0.001). Women who wanted a CS had higher FOC scores than those who wanted SVD; this association was highly significant (P < 0.001). When we examined the association of FOC with AP and IMR, we found a significant, positive, but weak correlation (r: 0.251, P < 0.001; r: 0.199, P < 0.001; Table 3).

Results Participants’ sociodemographic characteristics are presented in Table 1. Their mean age was 23.54 4.31, and their ages ranged from 18 to 35. The mean length of marriage was 2.02 1.89 years. Of the women, 77.4% had graduated from primary school, 76.1% were unemployed and 13.5% smoked. As shown in Table 2, the mean scores for FOC, AP and IMR were compared by age and obstetric characteristics. The


Discussion The aim of this study was to examine the association of FOC during pregnancy with AP and IMR. In our study, it was determined that FOC had significant but weak correlations with AP and IMR. It was found that women in the 33rd–36th gestational weeks had better AP and IMR compared to those in the 28th–32nd gestational weeks; however, they had similar


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Table 2 The mean fear of childbirth, acceptance of pregnancy and identification with motherhood role scores according to age and obstetric characteristics (n = 310) Questionnaires

Characteristics Maternal age (year) 18–27 year 28–35 year Gestational week 28–32 week 33–36 week Status of the planned of pregnancy Planned Unplanned Desired delivery mode Spontaneous vaginal delivery (SVD) Caesarean section (CS)

WDEQ-A

Acceptance of pregnancy

Identification with motherhood role

n

Mean SD

Mean SD

Mean SD

310

65.15 22.63

22.33 6.37

21.65 4.56

n

%

Mean SD

P*

Median (quartiles)†

P‡

Median (quartiles)

P‡

254 56

81.9 18.1

64.56 22.02 67.91 25.23

0.316

21 (18–25) 20.50 (18–25)

0.552

21 (18–23) 21 (19–24.75)

0.174

129 181

41.6 58.4

63.98 21.45 66.00 23.45

0.440

22 (19–27) 20 (18–24)

0.007

22 (20–25) 20 (18–23)

0.001

274 36

88.4 11.6

66.77 22.55 66.11 23.30

0.660

20 (18–24) 27 (24–35.25)

0.001

21 (19–23) 23 (18–28)

0.152

187 123

60.3 39.7

59.44 19.06 73.86 24.83

0.002

21 (18–21) 21 (18.25–26.50)

0.779

18 (21–23) 19 (21.20–25.75)

0.203

PSEQ, Prenatal Self-Evaluation Questionnaire; SD, standard deviation; W-DEQ A, Wijma Delivery Expectancy/Experience Questionnaire version A. *Independent Sample t-test. † The 25th and 75th percentile. ‡ Mann–Whitney U-test.

Table 3 The relationship between fear of childbirth and the acceptance of pregnancy and identification with a motherhood role PSQE

Acceptance of pregnancy Identification with motherhood role

WDEQ-A R

P*

0.251 0.199

0.001 0.001

PSEQ, Prenatal Self-Evaluation Questionnaire; W-DEQ A, Wijma Delivery Expectancy/Experience Questionnaire version A. *Spearman correlation.

levels of FOC. Participants who planned their pregnancies were found to better accept pregnancy. Pregnant women who requested CS were found to be experiencing more intense FOC. AP and IMR are expected to increase with gestational age. In a study conducted in Turkey, it was found that there was no association between the gestational week and AP and IMR


(S€ onmezer et al. 2015). Similarly, in a study carried out in Korea, it was determined that there was no association between gestational week and psychosocial adaptation to pregnancy (Choi 2012). However, in the present study, it was found that women in the 33rd–36th gestational weeks showed better adaptation than those in the 28th–32nd gestational weeks. This finding can be explained by the fact that only primipara women were included in this study, that pregnant women in the last trimester were included in the sample and that the majority of these participants had a planned pregnancy. Of the participants in the present study, 11.6% stated that they did not plan their pregnancies. According to the Turkey Population and Health Survey 2013 (Turkey Demographic and Health Survey (TDHS) 2013), approximately a quarter of all pregnancies in the country are unplanned. Of those who had unplanned pregnancies, 11% reported that they would have preferred pregnancy later in life (Turkey Demographic and Health Survey (TDHS) 2013). This result supports our study. Having a planned pregnancy increases adaptation to pregnancy. Demirbasß & Kadıoglu (2014) found an important

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association between AP, being ready for IMR and finding the strength to cope with possible problems. Demirbasß and Kadıoglu’s study supports our findings. In the literature, FOC has been measured using different methods. W-DEQ A is the most commonly used scale for determining FOC during the prenatal period (Fenwick et al. 2009; Kjaergaard et al. 2008; K€ or€ ukcßu € et al. 2012; Rouhe et al. 2009; Ryding et al. 2015). The W-DEQ A scale score average for participants in this study was 65.16 22.63, indicating that they experienced moderate levels of FOC. In a large-scale study conducted in six European countries by Ryding et al. (2015), and in many other national and international studies, pregnant women were found to experience moderate levels of FOC as measured by WDEQ-A (Karabulut et al. 2016; Toohill et al. 2014b). Identification and evaluation of FOC by midwives and nurses are important to determining the factors that cause FOC and to developing appropriate interventions (C ß icßek & Mete 2015). National and international studies have proven that antenatal education reduces FOC (Fenwick et al. 2015; Karabulut et al. 2016; Kızılırmak & Basßer 2016). Antenatal education is provided through standard programs in developed countries, but such education generally is lacking in developing countries (Gagnon & Sandall 2007). This is the case in Turkey, where, unlike in many Western countries, a standard approach to birth preparation classes does not exist (Sercßekusß & Yenal 2015). Few institutions in Turkey provide such services, and those that do are generally in major cities. Most classes are private, and the number of pregnant women who benefit from them is very small (Sercßekusß & Mete 2010b). Particularly during antenatal monitoring, nurses and midwives can help women experiencing FOC cope by providing education and counselling during routine care services. Nurses and midwives should evaluate FOC experienced by pregnant women again after providing education and counselling. If the fear has not decreased, women should be referred to psychological counselling or, if available, childbirth preparation classes (C ß icßek & Mete 2015). During the study period, there was no pregnancy education unit in the clinic nor were childbirth education classes provided. Therefore, the pregnant women in our sample did not receive education in this regard. FOC contributes to avoidance of SVD (Sercßekusß 2011). In our study, pregnant women who desired a CS were determined to be experiencing more intense FOC. In studies in Turkey and other countries, elective CS deliveries were found to be performed mostly due to FOC (Atan et al. 2013; Cosßar & Demirci 2012; Rouhe et al. 2009; Ryding et al. 2015; Wilkund et al. 2008). These results support the present study.


The role of motherhood is defined as the process of a woman learning motherhood behaviours. Acceptance of this role begins before conception and is completed within a year after birth. A previous study reported that 32–46% of pregnant women thought that motherhood would affect their lives negatively, and that this feeling was connected to primipara status and the experience of fear regarding motherhood (Stevens-Simon et al. 2005). Melender & Lauri (1999) indicated that experiencing excessive FOC during pregnancy is associated with various negative physical outcomes as well as difficulties in psychosocial adaptation to pregnancy and the parental role. In literature, it has been reported that women who have difficulty accepting pregnancy have a harder time adapting to pregnancy and motherhood and experience more fears related to childbirth (Demirbasß & Kadıoglu 2014; Lederman & Weis 2009). However, this assumption was not supported by studies and no international nor national studies have examined the associations between AP, IMR, and FOC. In the current study, FOC was weakly associated with AP and IMR. In an investigation of the reasons for FOC with 496 primipara women in gestational weeks 37–39, Wilkund et al. (2008) identified negative expectations of motherhood, fear of losing control or acting out during delivery and thoughts about the infant being hurt as factors for FOC. Kaya & Sßahin (2017) found that pregnant women who attended parenthood preparation classes adapted better to the role of motherhood. In a study performed in Turkey, pregnant women who attended birth preparation classes were found to have lower FOC and higher AP, while IMR was unaffected (Karabulut et al. 2016). In the current study, it was found that women in the 33rd36th gestational weeks had higher FOC compared to women in the 28th-32th gestational weeks, although this difference was not statistically significant. This finding suggests that FOC increases as birth approaches. The present study and Wilkund et al. (2008) was conducted with women in the last trimester of pregnancy. If we take into consideration the fact that FOC strongly intensifies in the last trimester, it is clear that these fears should be addressed by midwives and nurses, as counselling may reduce FOC (C ß icßek & Mete 2015). To decrease FOC, women should be evaluated from the moment they plan conception through pregnancy and delivery. Although the associations found between FOC, AP and IMR were weak, they were significant enough to be noticed statistically. Therefore, providing midwives and nurses with knowledge on how to reduce FOC so that they can apply these interventions to their patients may also help improve AP and IMR in these pregnant women.


Implications for nursing and health policy In Turkey, there is a need for studies that enable the standardization of care services and the establishment of routine psychosocial health assessments. In particular, care services and assessments for adaptation to pregnancy and FOC should be adopted by relevant health professionals (doctors, nurses, midwives), ideally with a holistic approach. Awareness of these issues needs to increase among health professionals. Nurses and midwives working at antenatal clinics should be encouraged to conduct studies on factors that influence AP and FOC. It should be ensured that women having difficulties adapting to their pregnancies will attend health education programmes and childbirth education classes. Mothers who participate in childbirth education classes will gain an increased level of knowledge on pregnancy and childbirth and will acquire various skills related to the process. This may result in helping them adapt to and accept their pregnancy and motherhood role, as well as help them cope with their fears. For these reasons, childbirth education classes should become widespread throughout our country by adopting international health policies. Studies should be initiated in order to ensure all pregnant women will be able to attend these classes. Increasing adaptation to pregnancy will help reduce FOC and the rate of invasive labour procedures such as CS, which are often preferred due to FOC, as well as help promote the health of the mothers and babies.

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weak correlations with AP and IMR. For this reason, research on factors that may influence FOC, AP and IMR, such as spousal or psychosocial support, should be carried out. In addition, it is recommended to investigate AP and IMR in both women who experience FOC and those who do not.

Acknowledgements The authors thank the pregnant women who participated in the study.

Author contributions Study design: DCP, RM, NHSß, ND, YH Data collection/analysis: DCP, RM, NHSß, ND, YH Drafting of manuscript: DCP, RM, NHSß, ND, Critical revision for intellectual content: DCP, RM, NHSß, ND Study supervision: DCP, NHSß, ND

References Anderson, C.A. & Gill, M. (2014) Childbirth related fears and psychological birth trauma in younger and older age adolescents. Applied Nursing Research, 27, 242–248. doi:10.1016/j.apnr.2014.02.008. € Duran, E.T., Kavlak, O. & Sevil, U. (2013) Spontaneous Atan, S.U., vaginal delivery or caesarean section? What do Turkish women think? International Journal of Nursing Practice, 19, 1–7. doi:10.1111/ijn. 12029.

Limitation of study The present study has a number of limitations. Most importantly, the association between FOC and IMR was evaluated during the pregnancy, and thus, the study was not performed prospectively relative to the post-natal development of the motherhood role. Another important limitation is that the study was conducted in a single city in western Turkey. FOC among women who live in different regions of Turkey could have distinctive cultural characteristics, which might affect AP and IMR. In this regard, however, conducting the study in Istanbul provided at least some advantage opposed to conducting it another major city, as Istanbul residents include migrants from all regions of Turkey. Achieving a sufficient sample size and including women from different socioeconomic levels are strengths of this study. Further research with a multicentre study design is recommended. An additional limitation of this study was that it did not consider or address psychosocial and spousal support in relation to the pregnancies and FOC.

Conclusion The current study provided information on the associations of FOC with AP and IMR. FOC scores had significant but


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