The mediating role of fear of childbirth in the relationship between intolerance of uncertainty and cesarean section preference among pregnant women

Objective: This study aims to investigate the relationship between intolerance of uncertainty and preference for cesarean section, and to explore whether fear of childbirth mediates the relationship between intolerance of uncertainty and preference for cesarean section.

Methods: A total of 310 pregnant women in the third trimester who attended outpatient clinics at Wuxi Maternal and Child Health Hospital from July to September 2024 were included in this study. The survey instruments used included a Sociodemographic Information Questionnaire, Intolerance of Uncertainty Scale-12, and the Fear of Birth Scale. Mediation analysis was conducted using R 4.4.3 software.

Results: A total of 310 surveys were distributed to participants, and ultimately 290 eligible questionnaires were collected, resulting in a response rate of 93.55%. The prevalence of cesarean section preference among participants was 20.69%. The mean score for intolerance of uncertainty was 30.94 ± 7.13, and the mean score for fear of childbirth was 51.50 ± 23.32. This study shows that intolerance of uncertainty and fear of childbirth are both positively associated with a preference for cesarean section. Fear of childbirth mediates the relationship between intolerance of uncertainty and preference for cesarean section.

Conclusions: Intolerance of uncertainty is a positive predictor of preference for cesarean section, and fear of childbirth mediates this association. These findings provide a basis for developing targeted interventions to reduce rates of unnecessary cesarean sections.

1 Introduction

In recent decades, the global cesarean section (CS) rate has been rising steadily (1). According to predictive analyses (2), by 2030, 28.5% of women worldwide are projected to give birth via CS. For a long time, China’s CS rate has remained at a high level globally. A survey conducted across 31 provinces in China revealed an overall CS rate of 44.5% (3), far exceeding the WHO recommendation of 10–15% (4).CS plays a crucial role in reducing maternal and neonatal morbidity and mortality in high-risk pregnancies (5). However, as an unnatural and traumatic mode of delivery, it may also entail both short-term and long-term health risks (6). In the short term, mothers may experience complications such as postpartum hemorrhage, infection, and even shock. In the long term, a history of cesarean delivery significantly increases the risk of placenta previa, miscarriage, and stillbirth in subsequent pregnancies (7). Multiple cesarean deliveries further elevate the likelihood of hysterectomy and surgery-related injuries (8). For offspring, existing research indicates that cesarean delivery is a significant risk factor for respiratory infections, asthma, and obesity during childhood (9). Furthermore, non-essential CS not only have negative impacts on maternal and infant health but may also lead to the waste of medical resources and increased economic burden (10, 11). Reducing non-medically indicated CS remains an urgent public health issue in China. Previous studies have shown that women’s delivery preferences during pregnancy can predict their actual mode of delivery (12). Therefore, timely assessment of pregnant women’s delivery preferences is of great significance for China and other countries with high CS rates.

The process from pregnancy to childbirth is highly complex for women and may be accompanied by a range of emotions, including joy, anxiety, and fear (13). Fear of childbirth (FOC) has become a global public health issue, which can have short-term and long-term impacts on women’s health and well-being (14). The prevalence of FOC varies by country, with a study by Huang et al. (15) reporting a rate of 67.1% in China. A substantial body of evidence indicates that FOC exerts numerous adverse effects on women’s physical and mental health. In the short term, FOC can weaken prenatal maternal–fetal attachment (16) and impair sleep quality (17). During labor, it further compromises the childbirth experience (18), prolongs labor duration (19), and increases the risk of adverse neonatal outcomes (14). In the long term, these negative effects extend into the postpartum period, manifesting as reduced quality of life (20), lower rates of successful breastfeeding (21), and elevated risks of postpartum post-traumatic stress disorder (22) and postpartum depression (18). Notably, FOC is often one of the factors leading pregnant women to request CS. Growing evidence shows that fear of childbirth is a major influence on delivery preferences, and high levels of FOC increase pregnant women’s preference for CS (23, 24).

Intolerance of uncertainty (IU) is defined as a cognitive bias (25) that leads individuals to overestimate the likelihood of adverse events in uncertain situations, thereby triggering fear (26, 27). Pregnancy is often an exciting yet uncertain period (28). For expectant mothers with a lower tolerance for uncertainty, facing the unfamiliar situation of childbirth can easily lead to the perception of delivery as a catastrophic event, thereby triggering intense FOC (29). It is worth noting that some positive outcomes have been achieved in intervention studies targeting FOC and IU. For instance, cognitive-behavioral group therapy has been proven effective in reducing IU levels among pregnant women (30). Similarly, systematic reviews indicate that mindfulness-based childbirth education can significantly alleviate fear of childbirth (31). In addition, previous research has shown a positive correlation between IU and the willingness to seek treatment (32). Pregnant women’s preference for a specific mode of delivery is a health-related behavioral intention (33). However, the specific role of IU in childbirth preferences remains unclear.

The Cognition-Affect-Conation (CAC) theory originates from the field of cognitive psychology and is referred to by scholars as the mental trilogy (34). The CAC model primarily comprises three processes: cognitive appraisal, affective response, and conative intention. This theory posits that cognition serves as the foundation for changing conation, affect acts as its driving force, and conation represents the ultimate outcome (35). In the present study, IU is defined as a cognitive bias, FOC is identified as the key affective factor, and preference for mode of delivery constitutes the final health-related conative behavior. The CAC theoretical model has been widely applied to study the formation of individual attitudes and behavioral intentions, demonstrating strong explanatory power (36). Based on this, this study, grounded in the C-A-C framework, proposes the mediating role of fear of childbirth in the relationship between IU and preference for cesarean section. The study has two main objectives (1): to examine the relationship between IU and preference for CS, and (2) to explore the potential mediating role of FOC in the association between IU and CS preference.

2 Materials and methods

2.1 Study design and participant

This study used a convenience sampling method to enroll pregnant women in the third trimester who attended the outpatient clinic at Wuxi Maternal and Child Health Care Hospital from July to September 2024 as study subjects. Inclusion criteria: (1) age≥18 years; (2) voluntary participation with written informed consent obtained; (3) gestational age ≥ 28 weeks; (4) singleton pregnancy. Exclusion criteria: (1) severe psychiatric disorders; (2) severe pregnancy complications or comorbidities; (3) presence of indications for cesarean section. According to the statistical Kendall sample estimation method (37), considering a 20% rate of invalid questionnaires, a total of 310 pregnant women were ultimately included as study subjects.

2.2 Instrument

2.2.1 Sociodemographic information questionnaire

Self-developed by the researcher after reviewing relevant literature, this questionnaire includes items such as the pregnant women’s age, place of residence, educational level, per capita monthly income, parity, history of infertility, employment status, history of cesarean section, and preference for mode of delivery.

2.2.2 Intolerance of uncertainty

IU was measured using the 12-item Intolerance of Uncertainty Scale (IUS-12). The original Intolerance of Uncertainty Scale (IUS) was developed by Freeston et al. (38) in 1994 and later revised into the short form (IUS-12) by Carleton et al. (39) in 2007. This scale was translated and adapted into the Chinese version by Wu (40) in 2016. The Chinese IUS-12 consists of 12 items across three dimensions: Prospective Avoidance (PA), Inhibitory Avoidance (IA), and Prospective Emotion (PE). All items are rated on a 5-point Likert scale. The total score ranges from 12 to 60, with higher scores indicating higher levels of IU. In the current study, the Cronbach’s α for this scale was 0.86, indicating good internal consistency.

2.2.3 Fear of childbirth

Fear of childbirth was assessed using the Fear of Birth Scale (FOBS) (41), which consists of two VAS. Participants were asked about their feelings regarding the upcoming delivery to evaluate worry and fear levels, requiring them to mark their responses on two 100-mm lines (ranging from 0 to 100). The total FOBS score was calculated as the mean score of the two items. A total score of ≥54 is considered indicative of FOC (42). The Cronbach’s α coefficient in this study was 0.90.

2.3 Data collection

The survey was conducted face-to-face with voluntary participation. Prior to the study, participants were informed of its purpose and significance, assured of their right to withdraw at any time, and guaranteed strict privacy protection. Questionnaires were distributed on-site, completed independently by participants, and immediately checked for completeness upon collection. Of the 310 questionnaires distributed, 290 were valid, yielding a valid response rate of 93.55%.

2.4 Ethical recognition

This study was approved by the Medical Ethics Committee of Wuxi Maternity and Child Health Care Hospital. (Approval number: 2024-01-0515-07).

2.5 Statistical analysis

Continuous variables are presented as mean ± standard error (SE), with group comparisons analyzed by independent samples t-tests. Categorical variables are described as counts and percentages [n (%)], with between-group comparisons assessed using chi-square tests. Since the dependent variable (childbirth preference) is categorical, the mediation analysis was conducted in three steps: First, logistic regression was used to examine the effect of intolerance of uncertainty on preference for cesarean section. Second, linear regression was used to test the effect of intolerance of uncertainty on the mediating variable (fear of childbirth level). Finally, both intolerance of uncertainty and fear of childbirth level were included in a logistic regression model to analyze their effects on preference for cesarean section, thereby assessing the mediating role of fear of childbirth. Mediation analysis was conducted using the RMediation package in R software, which is based on the distribution of the product (43, 44). All analyses were performed with IBM SPSS Statistics 26.0 and R 4.4.3, adopting a two-tailed significance threshold of P < 0.05.

3 Results

3.1 Demographic and obstetric characteristics of the study population

The study included 290 pregnant women aged 18 to 43 years, with a mean age of 29.90 ± 3.99 years. Among the participants, 87.59% of the pregnant women resided in urban areas, 84.14% had an education level of college or above, and 75.52% had a per capita monthly income of ≥5000 CNY. In terms of employment status, 76.21% were employed and 23.79% were unemployed. Furthermore, regarding previous experiences, 68.97% were primiparous, 10.34% had a history of infertility, and 7.24% had a previous cesarean section (Table 1).

Table 1

Table 1. Sociodemographic and Obstetrics Characteristics of the Participants (n=290).

3.2 Mean scores for intolerance of uncertainty and fear of childbirth among pregnant women

The mean scores for fear of childbirth and intolerance of uncertainty among pregnant women were 51.50 ± 23.32 and 30.94 ± 7.13, respectively, as shown in Table 2.

Table 2

Table 2. Fear of childbirth and intolerance of uncertainty scores of pregnant women (n = 290).

3.3 Characteristics of pregnant women by mode of delivery preference

Among the participants, 230 women (79.31%) preferred vaginal birth (VB) while 60 (20.69%) preferred cesarean section (CS). As presented in Table 3, the two groups showed no statistically significant differences in age, educational level, per capita monthly income, employment, parity, or residential area.

Table 3

Table 3. Characteristics of pregnant women stratified by preference for mode of delivery.

3.4 Mediation analyses

Conducting a logistic regression analysis with CS preference (Y) as the dependent variable and IU (X) as the independent variable yielded c = 0.217, SE(c) = 0.037. Performing a linear regression analysis with FOC (M) as the dependent variable and IU (X) as the independent variable resulted in a coefficient a = 1.396, SE(a) = 0.176. Finally, conducting a logistic regression analysis with CS preference (Y) as the dependent variable and IU (X) and FOC (M) as the independent variables produced coefficients b = 0.112, c’ = 0.125, SE(b) = 0.020, and SE(c’) = 0.044 (Table 4).

Table 4

Table 4. Using the product distribution method to test the mediating effect.

The total effect of IU on CS preference (p < 0.001) and the direct effect (p = 0.005) were both statistically significant. Based on the product distribution method of the RMediation package, the 95% confidence interval for the mediating effect is [27.68337, 66.24118], which does not include zero. Therefore, the mediating role of FOC between IU and CS preference was significant. The analysis of the mediating effect pathway is shown in Figure 1.

Figure 1

Figure 1. Mediation model diagram of fear of childbirth between pregnant women's intolerance of uncertainty and preference for cesarean section.

4 Discussion

In this study, we explored the relationships among IU, FOC, and CS preference, and examined the mediating role of FOC in the association between IU and CS preference, thereby revealing the potential pathways through which IU influences CS preference.

The present study showed a CS preference rate of 20.69%, which is close to the findings of Sun et al. (33), but lower than those reported by Welay et al. (45) in a study conducted in eastern Ethiopia. This discrepancy may be attributed to regional differences in the sociocultural characteristics of the study populations. Latifnejad et al. (46) argue that social, religious, and cultural beliefs significantly influence pregnant women’s delivery preferences. In this study, the mean IU score was 30.94 ± 7.13, which is higher than the result reported by Flink et al. (47). This may be related to regional differences in the sociocultural context, clinical characteristics, and healthcare environment of the participants. The mean fear of childbirth score among pregnant women in this study was 51.50 ± 23.32, higher than that reported by Zeng et al. (48). This difference may be attributed to variations in the characteristics of the study populations. Pregnant women’s preferences for childbirth can influence the actual mode of delivery. A deeper understanding of these preferences not only helps clinicians better understand pregnant women’s psychological needs and decision-making motivations, but also provides scientific evidence for policymakers, enabling the development of more targeted interventions and health guidance strategies.

In this study, we found that women with higher levels of IU are more likely to prefer CS as their mode of delivery. A previous qualitative study exploring the perceptions of women and healthcare professionals regarding CS delivery (49) indicated that IU can influence pregnant women’s cognitive appraisal of childbirth, thereby increasing their preference for CS. Furthermore, existing evidence suggests that pregnant women with lower tolerance for uncertainty tend to overestimate the likelihood of negative outcomes when facing the unpredictable nature of childbirth. This cognitive bias not only intensifies psychological distress but also undermines their confidence in effectively coping with labor (26), and childbirth self-efficacy has been shown to be negatively associated with CS preference (33). Therefore, enhancing pregnant women’s tolerance for uncertainty may help reduce their preference for CS.

This study shows that FOC is positively associated with preference for CS, indicating that pregnant women with higher levels of FOC tend to have a stronger preference for CS. This finding is consistent with the report by Chen et al. (50). The formation of FOC is a complex psychological process, often involving fear of pain, loss of control, etc. (51). Wigert et al. (13) reported that pregnant women with FOC are more likely to view CS as a controllable, predictable option that avoids the anticipated pain of labor. Furthermore, high levels of FOC are also associated with prenatal anxiety and depression (52, 53), and these psychological conditions themselves may influence childbirth preferences, leading pregnant women to prefer CS as a way to end pregnancy more quickly during the course of their pregnancy (54). Larsson et al. (55) demonstrated that interventions targeting FOC in pregnant women can effectively reduce their preference for CS. Therefore, healthcare professionals should place significant emphasis on prenatal FOC, and through measures such as antenatal health education and psychological counseling, promptly identify women at risk and provide necessary interventions and support. These efforts may help reduce CS preference, minimize unnecessary cesarean deliveries, and ultimately improve maternal and neonatal health outcomes.

According to the CAC Theory, emotions play a crucial role as a bridge connecting cognition and behavioral intention (56). The mediation analysis based on cross-sectional data in this study indicates that fear of childbirth may potentially serve as a mediator between intolerance of uncertainty and the preference for cesarean section. Specifically, the data reveal that IU is not only directly associated with a stronger preference for CS but is also indirectly linked to it through the exacerbation of FOC. This pattern suggests that for pregnant women with high levels of IU, the inherent uncertainties of the childbirth process may be more likely to be appraised as threatening, thereby intensifying their FOC (29), which in turn is associated with an increased inclination to choose cesarean section. This finding provides a plausible explanatory framework for understanding the psychological mechanisms underlying the preference for CS without medical indications, while also pointing to potential directions for clinical intervention. Therefore, in prenatal care, it is recommended to particularly focus on pregnant women with high IU traits, providing them with targeted psychological support and systematically implementing screening and management for FOC. Interventions based on the findings of this study could be explored as a potential pathway to reduce the rate of CS without medical indications.

Our study has some limitations. First, this study employed a convenience sampling method, with all participants recruited from the same tertiary hospital. Although this approach enhances data collection efficiency, it may introduce selection bias, thereby limiting the generalizability of the findings. Consequently, the conclusions of this study should be interpreted with caution when extended to broader populations. Future research should further validate the generalizability of the results through multi-center, random sampling designs and by including pregnant women with diverse characteristics. Second, as a cross-sectional study, this research can only reveal statistical associations and theoretical mediating pathways between variables, without establishing causal relationships. Subsequent studies should adopt longitudinal tracking or experimental designs to further validate the underlying mechanisms among the variables. Additionally, this study did not control for other potential confounding factors that may simultaneously influence IU and FOC, such as clinical anxiety, depressive symptoms, or personality traits. Future research should incorporate more comprehensive psychological assessment tools and control for such variables in statistical models to more accurately evaluate the independent effects of IU on FOC and CS preferences.

5 Conclusions

This study indicates that pregnant women’s IU and FOC are positively associated with preference for CS.FOC mediates the relationship between IU and CS preference. These findings provide a basis for developing targeted interventions to reduce rates of unnecessary cesarean sections.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

This study was approved by the Medical Ethics Committee of Wuxi Maternity and Child Health Care Hospital (Approval number: 2024-01-0515-07). The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

FZ: Data curation, Formal analysis, Writing – original draft. YZ: Formal analysis, Writing – original draft. ML: Funding acquisition, Resources, Supervision, Writing – review & editing. SH: Conceptualization, Methodology, Software, Supervision, Writing – review & editing. NZ: Data curation, Investigation, Writing – review & editing. WZ: Investigation, Writing – review & editing. NW: Investigation, Writing – review & editing.

Funding

The author(s) declared that financial support was received for this work and/or its publication. This study was supported by the Wuxi Maternal and Child Health Research Project (FYKY202201) from the Wuxi Municipal Health Commission and the Scientific Research Project (Z202502) from the Wuxi Nursing Association.

Acknowledgments

We would like to thank the Wuxi Maternal and Child Health Care Hospital for its support of this study. We would also like to thank all the mothers who participated in this study.

Conflict of interest

The authors declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Generative AI statement

The author(s) declare that Generative AI was not used in the creation of this manuscript.

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References

1. Angolile CM, Max BL, Mushemba J, and Mashauri HL. Global increased cesarean section rates and public health implications: A call to action. Health Sci Rep. (2023) 6:e1274. doi: 10.1002/hsr2.1274

PubMed Abstract | Crossref Full Text | Google Scholar

2. Betran AP, Ye J, Moller AB, Souza JP, and Zhang J. Trends and projections of caesarean section rates: global and regional estimates. BMJ Global Health. (2021) 6. doi: 10.1136/bmjgh-2021-005671

PubMed Abstract | Crossref Full Text | Google Scholar

3. Yin S, Chen L, Zhou Y, Yuan P, Guo X, Lu J, et al. Evaluation of cesarean rates for term, singleton, live vertex deliveries in China in 2020 among women with no prior cesarean delivery. JAMA network Open. (2023) 6:e234521. doi: 10.1001/jamanetworkopen.2023.4521

PubMed Abstract | Crossref Full Text | Google Scholar

4. Betran AP, Torloni MR, Zhang JJ, and Gülmezoglu AM. WHO statement on caesarean section rates. BJOG: an Int J obstetrics gynaecology. (2016) 123:667–70. doi: 10.1111/1471-0528.13526

PubMed Abstract | Crossref Full Text | Google Scholar

5. Chinese Society of Perinatal Medicine, Chinese Medical Association; Chinese Society of Obstetricians and Gynecologists; Obstetrics Subgroup, Chinese Society of Obstetrics and Gynecology, Chinese Medical Association. Expert consensus on complex cesarean section (2024). Zhonghua fu chan ke za zhi. (2025) 60(1):3–10. doi: 10.3760/cma.j.cn112141-20241014-00552

PubMed Abstract | Crossref Full Text | Google Scholar

6. Sandall J, Tribe RM, Avery L, Mola G, Visser GH, Homer CS, et al. Short-term and long-term effects of caesarean section on the health of women and children. Lancet (London England). (2018) 392:1349–57. doi: 10.1016/s0140-6736(18)31930-5

PubMed Abstract | Crossref Full Text | Google Scholar

7. Keag OE, Norman JE, and Stock SJ. Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis. PloS Med. (2018) 15:e1002494. doi: 10.1371/journal.pmed.1002494

PubMed Abstract | Crossref Full Text | Google Scholar

8. Marshall NE, Fu R, and Guise JM. Impact of multiple cesarean deliveries on maternal morbidity: a systematic review. Am J obstetrics gynecology. (2011) 205:262.e1–8. doi: 10.1016/j.ajog.2011.06.035

PubMed Abstract | Crossref Full Text | Google Scholar

9. Słabuszewska-Jóźwiak A, Szymański JK, Ciebiera M, Sarecka-Hujar B, and Jakiel G. Pediatrics consequences of caesarean section-A systematic review and meta-analysis. Int J Environ Res Public Health. (2020) 17. doi: 10.3390/ijerph17218031

PubMed Abstract | Crossref Full Text | Google Scholar

10. Albarqouni L, Abukmail E, MohammedAli M, Elejla S, Abuelazm M, Shaikhkhalil H, et al. Low-value surgical procedures in low- and middle-income countries: A systematic scoping review. JAMA network Open. (2023) 6:e2342215. doi: 10.1001/jamanetworkopen.2023.42215

PubMed Abstract | Crossref Full Text | Google Scholar

11. Metwali NY, Ahmed RA, Hussain Timraz J, Irfan H, Makarfi SM, Metwali MY, et al. Evidence-based strategies to minimize unnecessary primary cesarean sections: A comprehensive review. Cureus. (2024) 11):e74729. doi: 10.7759/cureus.74729

PubMed Abstract | Crossref Full Text | Google Scholar

12. Brinson AK, Jahnke HR, Rubin-Miller L, Henrich N, Peahl A, Shah N, et al. Digital health’s influence on the association between birth preference and vaginal birth. Birth (Berkeley Calif). (2024) 51:752–61. doi: 10.1111/birt.12831

PubMed Abstract | Crossref Full Text | Google Scholar

13. Wigert H, Nilsson C, Dencker A, Begley C, Jangsten E, Sparud-Lundin C, et al. Women’s experiences of fear of childbirth: a metasynthesis of qualitative studies. Int J Qual Stud Health well-being. (2020) 15:1704484. doi: 10.1080/17482631.2019.1704484

PubMed Abstract | Crossref Full Text | Google Scholar

14. Dencker A, Nilsson C, Begley C, Jangsten E, Mollberg M, Patel H, et al. Causes and outcomes in studies of fear of childbirth: A systematic review. Women birth: J Aust Coll Midwives. (2019) 32:99–111. doi: 10.1016/j.wombi.2018.07.004

PubMed Abstract | Crossref Full Text | Google Scholar

15. Huang J, Huang J, Li Y, and Liao B. The prevalence and predictors of fear of childbirth among pregnant Chinese women: a hierarchical regression analysis. BMC pregnancy childbirth. (2021) 21:643. doi: 10.1186/s12884-021-04123-7

PubMed Abstract | Crossref Full Text | Google Scholar

16. Gürsoy B and Palas Karaca P. The relationship between fear of birth and prenatal attachment and childbirth self-efficacy perception in Primigravida women. BMC pregnancy childbirth. (2025) 25:462. doi: 10.1186/s12884-025-07555-7

PubMed Abstract | Crossref Full Text | Google Scholar

17. Banaei M, Alizadeh S, Roozbeh N, Ghare-Naz MS, Taghvaei E, Parviz L, et al. Sleep quality during pregnancy: the role of anxiety, fear of childbirth, and obstetric factors - a multicenter cross-sectional study. BMC Public Health. (2025) 25:3797. doi: 10.1186/s12889-025-25142-5

PubMed Abstract | Crossref Full Text | Google Scholar

18. Gosselin P, Chabot K, Béland M, Goulet-Gervais L, and Morin AJ. Fear of childbirth among nulliparous women: Relations with pain during delivery, post-traumatic stress symptoms, and postpartum depressive symptoms. L’Encephale. (2016) 42:191–6. doi: 10.1016/j.encep.2016.01.007

PubMed Abstract | Crossref Full Text | Google Scholar

19. Sanni KR, Eeva E, Noora SM, Laura KS, Linnea K, and Hasse K. The influence of maternal psychological distress on the mode of birth and duration of labor: findings from the FinnBrain Birth Cohort Study. Arch women’s Ment Health. (2022) 25:463–72. doi: 10.1007/s00737-022-01212-0

PubMed Abstract | Crossref Full Text | Google Scholar

20. Artieta-Pinedo I, Paz-Pascual C, Bully P, and Espinosa M. Pregnancy variables that impact postpartum quality of life: a multicenter prospective study. Sci Rep. (2025) 15:31294. doi: 10.1038/s41598-025-10699-3

PubMed Abstract | Crossref Full Text | Google Scholar

21. Vasanen M, Kukkonen A, Backman K, Hantunen S, and Keski-Nisula L. Fear of childbirth impairs breastfeeding success independent of mode of birth. Breastfeeding medicine: Off J Acad Breastfeeding Med. (2024) 19:932–40. doi: 10.1089/bfm.2024.0024

PubMed Abstract | Crossref Full Text | Google Scholar

22. Horsch A, Garthus-Niegel S, Ayers S, Chandra P, Hartmann K, Vaisbuch E, et al. Childbirth-related posttraumatic stress disorder: definition, risk factors, pathophysiology, diagnosis, prevention, and treatment. . Am J obstetrics gynecology. (2024) 230:S1116–s1127. doi: 10.1016/j.ajog.2023.09.089

PubMed Abstract | Crossref Full Text | Google Scholar

23. Elgzar WT, Alshahrani MS, and Ibrahim HA. Mode of delivery preferences: the role of childbirth fear among nulliparous women. Front Psychol. (2023) 14:1221133. doi: 10.3389/fpsyg.2023.1221133

PubMed Abstract | Crossref Full Text | Google Scholar

24. Miller YD and Danoy-Monet M. Reproducing fear: the effect of birth stories on nulligravid women’s birth preferences. BMC pregnancy childbirth. (2021) 21:451. doi: 10.1186/s12884-021-03944-w

PubMed Abstract | Crossref Full Text | Google Scholar

25. Qiang J, He X, Xia Z, Huang J, and Xu C. The association between intolerance of uncertainty and academic burnout among university students: the role of self-regulatory fatigue and self-compassion. Front Public Health. (2024) 12:1441465. doi: 10.3389/fpubh.2024.1441465

PubMed Abstract | Crossref Full Text | Google Scholar

26. Ji K, Li Z, Zhao Y, Sun L, and Min H. Effect of intolerance of uncertainty on fear of childbirth in primiparas: A moderated mediating model. Sichuan da xue xue bao Yi xue ban = J Sichuan Univ Med Sci edition. (2023) 54:837–42. doi: 10.12182/20230760506

PubMed Abstract | Crossref Full Text | Google Scholar

27. Han L, Bai H, Lun B, Li Y, Wang Y, and Ni Q. The prevalence of fear of childbirth and its association with intolerance of uncertainty and coping styles among pregnant chinese women during the COVID-19 pandemic. Front Psychiatry. (2022) 13:935760. doi: 10.3389/fpsyt.2022.935760

PubMed Abstract | Crossref Full Text | Google Scholar

28. Larkin P, Begley CM, and Devane D. Women’s experiences of labour and birth: an evolutionary concept analysis. Midwifery. (2009) 25:e49–59. doi: 10.1016/j.midw.2007.07.010

PubMed Abstract | Crossref Full Text | Google Scholar

29. Rondung E, Ekdahl J, and Sundin Ö. Potential mechanisms in fear of birth: The role of pain catastrophizing and intolerance of uncertainty. Birth (Berkeley Calif). (2019) 46:61–8. doi: 10.1111/birt.12368

PubMed Abstract | Crossref Full Text | Google Scholar

30. Donegan E, Frey BN, McCabe RE, Streiner DL, and Green SM. Intolerance of uncertainty and perfectionistic beliefs about parenting as cognitive mechanisms of symptom change during cognitive behavior therapy for perinatal anxiety. Behav Ther. (2022) 53:738–50. doi: 10.1016/j.beth.2022.02.005

PubMed Abstract | Crossref Full Text | Google Scholar

31. Dinç S, Erdoğan E, and Doğan RA. The effect of mindfulness-based childbirth education intervention on fear of childbirth: systematic review and meta-analysis. Rev da Associacao Med Bras (1992). (2024) 70:e20240167. doi: 10.1590/1806-9282.20240167

PubMed Abstract | Crossref Full Text | Google Scholar

32. Dean KE, Long ACJ, Matthews RA, and Buckner JD. Willingness to seek treatment among black students with anxiety or depression: the synergistic effect of sociocultural factors with symptom severity and intolerance of uncertainty. Behav Ther. (2018) 49:691–701. doi: 10.1016/j.beth.2017.12.008

PubMed Abstract | Crossref Full Text | Google Scholar

33. Sun N, Yin X, Qiu L, Yang Q, Shi X, Chang J, et al. Factors associated with Chinese pregnant women’s preference for a cesarean section based on the theory of planned behaviour. Trop Med Int health: TM IH. (2020) 25:209–15. doi: 10.1111/tmi.13323

PubMed Abstract | Crossref Full Text | Google Scholar

34. Hilgard ER. The trilogy of mind: cognition, affection, and conation. J history Behav Sci. (1980) 16:107–17. doi: 10.1002/1520-6696(198004)16:2<107::AID-JHBS2300160202>3.0.CO;2-Y

Crossref Full Text | Google Scholar

35. Zeng S, Lin X, and Zhou L. Factors affecting consumer attitudes towards using digital media platforms on health knowledge communication: Findings of cognition-affect-conation pattern. Front Psychol. (2023) 14:1008427. doi: 10.3389/fpsyg.2023.1008427

PubMed Abstract | Crossref Full Text | Google Scholar

36. Liang Z, Hui T, and Sea P. Is price most important? Healthcare tourism in Southeast Asia. J Tourism Geographies. (2017) 19:823–47. doi: 10.1080/14616688.2017.1376224

Crossref Full Text | Google Scholar

37. Di J, Jia M, Zhou Y, Zhu Q, Wu L, and Liu J. Motivational factors for dietary intake behavior in gestational diabetes mellitus: A cross-sectional study. Heliyon. (2024) 10:e35317. doi: 10.1016/j.heliyon.2024.e35317

PubMed Abstract | Crossref Full Text | Google Scholar

38. Freeston MHUL, Rhéaume J, Letarte H, Dugas MJ, and Ladouceur R. Why do people worry? J Pers Individ Dif. (1994) 17:791–802. doi: 10.1016/0191-8869(94)90048-5

Crossref Full Text | Google Scholar

39. Carleton RN, Norton MA, and Asmundson GJ. Fearing the unknown: a short version of the Intolerance of Uncertainty Scale. J Anxiety Disord. (2007) 21:105–17. doi: 10.1016/j.janxdis.2006.03.014

PubMed Abstract | Crossref Full Text | Google Scholar

40. Wu LJ, Wang JN, and Qi XD. Validity and reliability of the intolerance of uncertainty scale-12 in middle school students. Chin Ment Health J. (2016) 30:700–5. doi: 10.3969/j.issn.1000-6729.2016.09.012

Crossref Full Text | Google Scholar

41. Haines H, Pallant JF, Karlström A, and Hildingsson I. Cross-cultural comparison of levels of childbirth-related fear in an Australian and Swedish sample. Midwifery. (2011) 27:560–7. doi: 10.1016/j.midw.2010.05.004

PubMed Abstract | Crossref Full Text | Google Scholar

42. Haines HM, Pallant JF, Fenwick J, Gamble J, Creedy DK, Toohill J, et al. Identifying women who are afraid of giving birth: A comparison of the fear of birth scale with the WDEQ-A in a large Australian cohort. Sexual Reprod healthcare: Off J Swedish Assoc Midwives. (2015) 6:204–10. doi: 10.1016/j.srhc.2015.05.002

PubMed Abstract | Crossref Full Text | Google Scholar

43. Tofighi D and MacKinnon DP. RMediation: an R package for mediation analysis confidence intervals. Behav Res Methods. (2011) 43:692–700. doi: 10.3758/s13428-011-0076-x

PubMed Abstract | Crossref Full Text | Google Scholar

44. Pan Y, Li L, Xia X, Li Z, Dai J, Wu J, et al. Mediation by elevated prolactin in the relationship between childhood trauma and first-episode drug-naïve schizophrenia. BMC Psychiatry. (2025) 25:223. doi: 10.1186/s12888-025-06629-2

PubMed Abstract | Crossref Full Text | Google Scholar

45. Welay FT, Gebresilassie B, Asefa GG, and Mengesha MB. Delivery mode preference and associated factors among pregnant mothers in harar regional state, eastern Ethiopia: A cross-sectional study. BioMed Res Int. (2021) 2021:1751578. doi: 10.1155/2021/1751578

PubMed Abstract | Crossref Full Text | Google Scholar

46. Latifnejad Roudsari R, Zakerihamidi M, and Merghati Khoei E. Socio-cultural beliefs, values and traditions regarding women’s preferred mode of birth in the north of Iran. Int J Community based Nurs midwifery. (2015) 3:165–76.

PubMed Abstract | Google Scholar

47. Flink IK, Engström J, Vastamäki S, Vixner L, and Engman L. Expecting the uncertain: The applicability of the intolerance of uncertainty model on fear of childbirth. J psychosomatic obstetrics gynaecology. (2023) 44:2243648. doi: 10.1080/0167482x.2023.2243648

PubMed Abstract | Crossref Full Text | Google Scholar

48. Zeng TY, Ju DD, Zhang K, and Wu MLY. Childbirth readiness mediates the relationship between medical social support and fear of childbirth among primiparas. J Nurs Sci. (2023) 38:80–3. doi: 10.3870/j.issn.1001-4152.2023.11.080

Crossref Full Text | Google Scholar

49. Nuampa S, Ratinthorn A, Lumbiganon P, Rungreangkulkij S, Rujiraprasert N, Buaboon N, et al. Because it eases my Childbirth Plan”: a qualitative study on factors contributing to preferences for caesarean section in Thailand. BMC pregnancy childbirth. (2023) 23:280. doi: 10.1186/s12884-023-05576-8

PubMed Abstract | Crossref Full Text | Google Scholar

50. Chen X, Jing L, Liu H, Huang S, Yan L, Jiang Q, et al. Fear of childbirth and its influence on women’s delivery choices: a prospective-longitudinal study. Psychology Health Med. (2025) 11:1–18. doi: 10.1080/13548506.2025.2465650

PubMed Abstract | Crossref Full Text | Google Scholar

51. Takegata M, Haruna M, Morikawa M, Yonezawa K, Komada M, and Severinsson E. Qualitative exploration of fear of childbirth and preferences for mode of birth among Japanese primiparas. Nurs Health Sci. (2018) 20:338–45. doi: 10.1111/nhs.12571

PubMed Abstract | Crossref Full Text | Google Scholar

52. Jing Q, Jie J, Ke X, Liu Y, Xiumin D, Xiuchuan L, et al. The relationship between fear of childbirth and prenatal depression in pregnant women during pregnancy: a cross-lagged analysis. BMC pregnancy childbirth. (2025) 25:192. doi: 10.1186/s12884-025-07321-9

PubMed Abstract | Crossref Full Text | Google Scholar

53. Chen Y, Zhao J, Zheng J, Zou Z, and Chen X. Relationship between fear of childbirth and oral health-related quality of life in pregnant women: the mediating effect of pregnancy anxiety. J Oral rehabilitation. (2025) 52:474–82. doi: 10.1111/joor.13897

PubMed Abstract | Crossref Full Text | Google Scholar

54. Begum J and Mitra S. Preference and associated factors for cesarean delivery among pregnant women: A cross-sectional study. J Family Reprod Health. (2024) 18:20–9. doi: 10.18502/jfrh.v18i1.15435

PubMed Abstract | Crossref Full Text | Google Scholar

55. Larsson B, Karlström A, Rubertsson C, Ternström E, Ekdahl J, Segebladh B, et al. Birth preference in women undergoing treatment for childbirth fear: A randomised controlled trial. Women birth: J Aust Coll Midwives. (2017) 30:460–7. doi: 10.1016/j.wombi.2017.04.004

PubMed Abstract | Crossref Full Text | Google Scholar

56. Tian K, Hao L, Xuan W, Phongsatha T, Hao R, and Wei W. The impact of perceived value and affection on Chinese residents’ continuous use intention of mobile health science information: An empirical study. Front Public Health. (2023) 11:1034231. doi: 10.3389/fpubh.2023.1034231

PubMed Abstract | Crossref Full Text | Google Scholar