Journal of Religion and Health

https://doi.org/10.1007/s10943-020-01087-4

ORIGINAL PAPER

Relationship Between Fear of Childbirth and Psychological

and Spiritual Well‑Being in Pregnant Women

Gamze Bilgiç1 · Nevin Çıtak Bilgin2

Accepted: 5 September 2020

© Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
The aim of the study was to investigate the relationship between fear of child-
birth (FOC) and psychological (PWB) and spiritual well-being (SWB) in pregnant
women. Descriptive and relational study was conducted with 338 pregnant women
in Turkey. Information form, Wijma Delivery Expectancy/Experience Question-
naire-A, Spiritual Well-Being Scale and Psychological Well-Being Scale were used
for data collection. There was a negative correlation between SWB and PWB and
FOC in pregnant women. SWB explained 18% of the variance related to FOC which
increased to 24% with PWB. SWB was a partial mediating variable in PWB and
FOC relationship. PWB and SWB of pregnant women should be evaluated in order
to reduce FOC. PWB and SWB of pregnant women should be evaluated in order to
reduce FOC.

Keywords Fear of childbirth · Psychological well-being · Spiritual well-being ·

Spirituality

This study was presented as an oral presentation between 19 and 21 December 2019 at the 6th
International 17th National Nursing Congress in Ankara, Turkey.

The study has been produced from master theses.

* Nevin Çıtak Bilgin

nevincitak@yahoo.com
Gamze Bilgiç
gamzetasdelenbilgic@gmail.com
1
Nursing Care Department, Erenköy Psychiatric Hospital, Kadıköy, Istanbul, Turkey
2
Department of Obstetrics and Gynecology Nursing, Faculty of Health Sciences, Bolu Abant
Izzet Baysal University, Golkoy Campus, 14030 Bolu, Turkey

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 Journal of Religion and Health

Introduction

Pregnancy and childbirth are an existential threshold that a woman must pass during
the reproductive age (Nilsson et al. 2018). Expectations and experiences of women
about pregnancy and childbirth include happiness, belief and hope as well as anxiety
and fear (Mazúchová et al. 2017). Childbirth is a process filled with uncertainties, it
cannot be fully controlled and its outcomes cannot be predicted in advance; hence,
fear of childbirth (FOC) is a common problem in pregnant women (Nilsson et al.
2018; Mazúchová et al. 2017; Wijma et al. 1998). Studies demonstrate that 26–45%
of pregnant women experience moderate FOC (Bülbül et al. 2016; Güleç et al.
2014), while 8–27% experience severe FOC (Nilsson et al. 2018; Mazúchová et al.
2017). Studies in Turkey show that 10–14% of pregnant women in Turkey experi-
ence FOC at clinical levels (Bülbül et al. 2016; Akın et al. 2018).
There are several causes of FOC, and it is affected by sociodemographic,
obstetric and psychosocial factors. Studies show that age, education level,
whether pregnancy is planned, miscarriage/curettage history and information
about childbirth affect FOC (Phunyammalee et al. 2019; Laursen et al. 2008;
Gao et al. 2015; Toohill et al. 2014). Parity which is an obstetric feature is also
associated with FOC. Studies show that while nulliparas experience FOC due to
lack of experience and related uncertainties (Toohill et al. 2014), multiparas also
experience FOC due to previous negative birth experiences (Lukasse et al. 2014;
Körükçü et al. 2017; Şahin et al. 2009).
In recent years, it has been emphasized that birth and pregnancy are spiritual
experiences and spiritual well-being is necessary to prepare women for childbirth
(Abdollahpour and Khosravi 2018). King (2008) defined spirituality as the capac-
ity to use spiritual aspects such as reflecting on one’s existence, comprehending
the meaning of the world, knowing oneself and reaching higher spiritual levels.
Although spirituality was first associated with religion because it was a concept
mostly emphasized by religious leaders, today it is a broader concept than adher-
ence to religion (Bash 2004; Como 2007). Religion is a system that involves
sacred values and the idea of god which offers believers a way of life. Unlike
spirituality, religion is a ritual teaching (Como 2007). Religion can be defined as
a dimension of spirituality, but spirituality cannot be limited to religious beliefs
and practices (Çetinkaya et al. 2007). People have a spiritual dimension whether
or not they follow the practices that religion formally requires (Como 2007).
Spirituality is an important guide in individuals’ problem-solving behaviors
(Chaar et al. 2018). It is reported in the literature that those with high spirituality
levels better adapt to conditions and difficulties of life (Abdollahpour and Khos-
ravi 2018; Rowold 2011). Spiritual well-being facilitates coping with stress and
increases psychological well-being by positively affecting mental health (Chaar
et al. 2018; Dehestani et al. 2019). Spiritual well-being is associated with psycho-
logical well-being, happiness and stress levels (Rowold 2011), and fear of birth
decreases as spiritual well-being increases (Abdollahpour and Khosravi 2018).
Psychological well-being is associated with positive emotions that affect men-
tal and physical health (Fagbenro et al. 2018) and is defined as spiritual, emotional

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and mental well-being (Rowold 2011). It is reported that when individuals have
positive psychological well-being levels, they can cope with problems even at the
times when they do not experience the most optimal mental and emotional states
in their lives (Fagbenro et al. 2018). Compared to other women, pregnant women
more commonly experience psychological problems such as anxiety and depres-
sion (Gölbaşı et al. 2010) which are positively associated with FOC (Akın et al.
2018). Studies have determined that psychosocial characteristics such as anxiety,
low self-esteem and depression affect women’s attitudes toward childbirth (Zar
et al. 2001; Greathouse 2014). Stress, anxiety and depression have been found
to threaten psychological well-being as well (Sanagoo et al. 2014; Dencker et al.
2019). Decreased psychological well-being during pregnancy increases adrenalin
secretion in the fetus by increasing maternal cortisol and directly affects the well-
being of the fetus (Fagbenro et al. 2018).
It is known that FOC causes fetal distress, bleeding, intervened delivery, pro-
longed or rapid delivery and difficulties in mother–infant attachment (Mazúchová
et al. 2017; Abdollahpour and Khosravi 2018; Markowska et al. 2017). It is also seen
that FOC negatively affects the acceptance of the role of pregnancy and motherhood
(Coşkuner Potur et al. 2017), decreases birth satisfaction (Körükçü et al. 2017) and
increases the optional C-section preference in the absence of medical indications
(Coşkuner Potur et al. 2017; Markowska et al. 2017). The national data in Turkey
show that C-section delivery significantly increased in time from 48% in 2013 to
52% in 2018. It is observed that 38% of pregnant women made decisions to deliver
through C-section before labor started, which shows the relationship between FOC
and optional C-section (TDHS 2018). The studies on FOC have mostly focused on
relationships with prevalence (Korukcu et al. 2012), some psychosocial (Greathouse
2014), sociodemographic and obstetric factors (Zar et al. 2001), predictors of FOC
(Bilgin et al. 2020a; Toohill et al. 2014; Gao et al. 2015) and on evaluating the effect
of childbirth education and health professional support (Güleç et al. 2014; Karabulut
et al. 2016; Bilgin et al. 2020b) on FOC. Studies on the effect of spiritual and psy-
chological well-being on the pregnancy and childbirth process in the world are lim-
ited (Abdollahpour and Khosravi 2018; Fagbenro et al. 2018; Sanagoo et al. 2014),
and no studies have been conducted in Turkey on the subject at the time of this
research. It should not be overlooked that childbirth is not only a biological process,
but also a life cycle that is spiritually and psychologically significant. Increased psy-
chological and spiritual well-being can help support women in defining the meaning
of childbirth and using appropriate coping mechanisms in dealing with the process
and uncertainties of childbirth and the pain during childbirth. Thus, positive mater-
nal and fetal outcomes can be obtained and rates of optional cesarean sections can
be reduced. Answers to the following questions were sought in the study with these
considerations in mind:

• What are the levels of FOC, psychological and spiritual well-being in pregnant
women?
• What are the views of pregnant women on childbirth and the practices that make
them feel good during pregnancy?
• Is the FOC related to psychological and spiritual well-being in pregnant women?

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• Does psychological and spiritual well-being predict FOC in pregnant women?

Materials and Methods

Study Design

This study was conducted descriptively and relationally to investigate the relation-
ship between FOC and psychological and spiritual well-being in pregnant women.
The study was carried out in a province in northern Turkey with pregnant women
who were admitted to Family Health Centers (FHCs) during October 2018–March
2019.

Participants and Procedures

Power analysis was used to determine the sample size. It was determined that 296
pregnant women should be included in the study by considering the level of 30%
as moderate FOC in pregnant women (Güleç et al. 2014) and under the assumption
that this rate could be 40% with a difference of 10% with 95% power and α = 0.05
significance level. Since there were 14 FHCs in the city center when the study was
conducted, five FHCs were selected by simple random sampling considering the
ease of accessibility by a single researcher. The study was completed with 338 preg-
nant women admitted to selected FHCs who accepted to take part in the study, were
18–45 years of age, were literate, were primiparous or multiparous, had no commu-
nication problems, no history of multiple and risky pregnancies and no psychiatric
diagnosis.

Ethical Principles

Authorization for the study was obtained from the Clinical Research Ethics Com-
mittee (2018/275), and permit for the institution where the study was conducted was
received from the Provincial Health Directorate (2018/49769843-604). Consent for
the use of the selected scales was obtained by e-mail from the authors. Written and
verbal informed consent was obtained from the pregnant women with informed con-
sent forms for participation in the study.

Data Collection Tools

Information form, “Wijma Delivery Expectancy/Experience Questionnaire-A,”

“Spiritual Well-Being Scale” and “Psychological Well-Being Scale” were used
to collect research data. The pregnant women were informed about the study, and
their written and verbal permissions were obtained. Data collection forms were
given to the volunteer participants and collected by the researcher after completion.
Face-to-face interview method was not preferred in the data collection process to

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protect the privacy of the participants and ensure that the questions are replied more
comfortably.

Information Form

The form was prepared by the researchers based on the literature (Bülbül et al. 2016;
Güleç et al. 2014; Abdollahpour and Khosravi 2018; Nilsson et al. 2018). The form
included four questions on participants’ sociodemographic characteristics (age, edu-
cation level, work status and socioeconomic status) of the participants and seven
questions related to participants’ obstetric characteristics (gestational week, inten-
tions status of pregnancy, parity, status of miscarriage, antenatal education status,
etc.). In addition, two open-ended questions were asked about the meaning of child-
birth and the practices that make them feel good during pregnancy. The form con-
sisted of a total of 13 questions.

Wijma Delivery Expectancy/Experience Questionnaire‑A (W‑DEQ version A)

W-DEQ version A was developed to measure the FOC experienced by women

(Wijma et al. 1998). The 6-point Likert-type scale consists of 33 items. The mini-
mum and maximum scores that can be obtained from the scale are 0 and 165, respec-
tively. A high score indicates that the FOC experienced by women is high. The scale
assesses the FOC in four levels: low (score ≤ 37), moderate (38–65 points), high
(66–84 points) and clinical level (≥ 85 points). The Turkish validity and reliability
studies of the scale were conducted by Körükçü et al. (2012), and while the Cron-
bach’s alpha value of the scale is 0.89, it was found to be 0.94 in the present study.

Psychological Well‑Being Scale (PWBS)

The scale was developed by Diener et al. (2009) to measure sociopsychological well-
being. The scale was adapted to Turkish by Telef (2013). The 7-point Likert-type
scale consists of eight items and one dimension (1 = strongly disagree, 7 = strongly
agree). A high score indicates high level of psychological well-being. Cronbach’s
alpha value of the scale is 0.80, and this value was identified to be 0.89 in this study.

Spiritual Well‑Being Scale (SWBS)

The scale was developed by Ekşi and Kardaş (2017) to assess adults’ spiritual well-
being. The 5-point Likert-type scale consists of 29 items (1 = not applicable to me at
all, 5 = completely applicable to me). The minimum and maximum scores that can
be obtained from the scale are 29 and 145, respectively. A high score indicates that a
person’s spiritual well-being is high. The Cronbach’ alpha value of the scale is 0.88,
and this value was identified to be 0.90 in the present study.

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Data Analysis

Descriptive characteristics such as number, percentage, mean and standard deviation

were used in the study to evaluate the data related to descriptive characteristics. The
suitability of data for normal distribution was evaluated with skewness and kurtosis
values. It was found that WIJMA (skewness: ,249, kurtosis: –,418), PWBS (skew-
ness: –1,231, kurtosis: 1,799) and SWBS (skewness: –,969, kurtosis: ,957) showed
normal distribution. Pearson correlation analysis was used to examine the relation-
ship between FOC and psychological and spiritual well-being, and stepwise regres-
sion analysis was used to determine whether psychological and spiritual well-being
predicted FOC. Mediator variable analysis was then performed according to Baron
and Kenny’s (1986) criteria. The Sobel test was used to see whether the mediator
variable was partial. In order to examine the role of mediator variable, mediator var-
iable analysis was performed and Sobel test was utilized to examine the significance
of the relationship between mediator variable and predictor and predicted variable.
In the study, statistical significance was accepted as p < 0.05.

Findings

Table 1 displays the demographic and obstetric characteristics of the pregnant

women who participated in the study. The mean age of the pregnant women was
29.06 ± 5.2, and 42.3% were university graduates; 54.4% of pregnant women were
housewives, and 58.9% had income equivalent to their expenses. The mean gesta-
tional week of the participants was 27.14 ± 4.69, the majority of them had planned
pregnancies (82.5%) and 21.9% had a history of miscarriage; 50.3% of the pregnant
women were multiparous, and 52.9% of the participants who had given birth pre-
viously had cesarean section. Fifty-five percent of the pregnant women who par-
ticipated in the study stated that they received antenatal education and they received
their training mostly from healthcare personnel (43.5%).
Table 2 displays the W-DEQ, PWBS and SWBS mean scores of pregnant women.
The mean W-DEQ score of the pregnant women was 54.22 ± 26.65; 19.8% had high
level of FOC, while 13.9% had clinical-level FOC. The mean PWBS score of the
pregnant women was 46.21 ± 7.22; the mean SWBS score of the pregnant women
was 125.59 ± 12.97, and in general, their psychological and spiritual well-being lev-
els were high.
Table 3 presents the opinions of the pregnant women about childbirth and the
practices that make them feel good during pregnancy. Most of the pregnant women
(67.3%) who participated in the study had a positive view on childbirth, and 27.6%
emphasized the spiritual aspect of childbirth; 24.1% of the pregnant women reported
that relaxing activities such as resting, getting a massage and reading made them
feel good.
Table 4 displays the relationship between pregnant women’s FOC scores and their
psychological and spiritual well-being scores. A negative and moderate correlation
was identified between FOC and spiritual (r = −0.418, p < 0.001) and psychological

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Table 1  Sociodemographic Characteristics n %

and obstetric characteristics of
pregnant women (N = 338) Age (years)
18–24 65 19.2
25–31 172 50.9
32–38 81 24.0
39–43 20 5.9
Mean age: 29.06 ± 5.26 (range 18–43)
Education level
Primary school 77 22.8
High school 118 34.9
University 143 42.3
Working status
Unemployed 184 54.4
Employed 99 45.6
Income
Income more than expenses 65 19.2
Equal income and expenses 199 58.9
Income less than expenses 74 21.9
Gestational week
20–24 week 122 36.1
25–29 week 89 26.3
30–34 week 127 37.6
Mean gestational week 27.14 ± 4.69 (range 20–34)
Planning pregnancy
Planned 279 82.5
Unplanned 25 7.4
Unplanned but happy now 34 10.1
Parity
Nullipara 168 49.7
Multipara 170 50.3
Previous experience of miscarriage
No 264 78.1
Yes 74 21.9
Previous birth type (n = 170)
Caesarean section 90 52.9
Vaginal birth 80 47.1
Antenatal education
Yes 186 55.0
No 152 45.0
Antenatal education sources (n = 186)
Health care professionals 80 43.5
Antenatal education books 15 4.3
Antenatal education classes 59 31.7
Internet 32 8.5

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Table 2  Scores of fear of childbirth, psychological well-being and spiritual well-being scales in pregnant
women (N = 338)
Scales n %

W-DEQ-A
Low (0–37) 101 29.9
Moderate (38–65) 123 36.4
High (66–84) 67 19.8
Clinical (85 and above) 47 13.9
Mean SD

W-DEQ A (range 0–140) 54.22 26.65

PWBS (range 21–56) 46.21 7.22
SWBS (range 80–145) 125.59 12.97

PWBS Psychological Well-Being Scale, SWBS Spiritual Well-Being Scale, W-DEQ A Wijma Delivery
Expectancy Questionnaire version A

Table 3  Opinions of the pregnant women about childbirth and the practices that make them feel good
during pregnancy
Characteristics n %

Opinion about childbirth (n: ­373a)

Positive (excitement, happiness, reproduction) 257 67.3
Negative (pain, fear, worry) 19 5.1
Spiritual (God’s grace, asylum in Allah by praying, opening the gates of heaven, eternity 97 27.6
of the mother, law of nature, the beginning of a new life, miracle, empowerment, peace)
Practices that make feel good during pregnancy (n = 386a)
Think about baby and make plans for the baby (hearing the heartbeat, feeling the move- 91 23.5
ment, talking to the baby, preparing the room and the other things)
Sports activities (hiking, pilates) 76 19.6
Relaxing activity (massage, sleep, rest, reading) 93 24.1
Social support (spouse, family, peer) 60 15.6
Health personnel support and training (attendance antenatal education classes, antenatal 14 3.7
visits, health personnel recommendations)
Spiritual activities (praying, chanting, meditation, Quran reading, praying, yoga) 52 13.5
a
Multiple answers were given

well-being (r = −0.400, p < 0.001). It was found that pregnant women with positive
spiritual and psychological well-being levels experienced lower levels of FOC.
The mediator role of spiritual well-being in the relationship between psychologi-
cal well-being and FOC is displayed in Fig. 1. According to the mediation crite-
ria, there should be significant relationships between independent variable, media-
tor variable and dependent variable, and when the mediator variable is added to the
design or equation, the relationship between the independent and dependent vari-
ables should decrease or become close to zero. Although the relationship between

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Table 4  Correlation between Scales W-DEQ A

fear of childbirth and
psychological well-being and r* p**
spiritual well-being in pregnant
women (N = 338) SWBS − 0.418 0.0001
PWBS − 0.400 0.0001

PWBS Psychological Well-Being Scale, SWBS Spiritual Well-Being

Scale, W-DEQ A Wijma Delivery Expectancy Questionnaire version
A
*Pearson correlation
**p < 0.001

Fig. 1  Mediator role of spiritual well-being for the between psychological well-being and fear of child-
birth

psychological well-being and FOC was −0.40 at the beginning of mediation analy-
sis, this relationship decreased to −0.27 when the spiritual well-being variable was
added to the design. Sobel test showed that this decrease was significant (Sobel
(Z) = −5.98, p < 0.001). This result indicates that spiritual well-being is a partial
mediator between psychological well-being and FOC (Fig. 1).
Table 5 presents the regression analysis of the relationship between FOC and
spiritual and psychological well-being in pregnant women. It was found that spirit-
ual well-being explained 18% of the variance related to FOC (F = 71.232, p < 0.001).
With the addition of psychological well-being, the variance related to FOC increased
to 24% and it was identified that psychological well-being was a significant variable
in explaining FOC (F = 51.867, p < 0.001).

Discussion

Birth is one of the most satisfying and powerful experiences in a woman’s life (Zar
et al. 2001). Nevertheless, the FOC significantly affects this experience (Bülbül
et al. 2016). W-DEQ score of pregnant women in the present study was found to
be similar (Bülbül et al. 2016; Phunyammalee et al. 2019) to the results obtained in
some studies, while it was higher than the results identified in some others (Güleç

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Table 5  Regression results between fear of childbirth and psychological and spiritual well-being in preg-
nant women (N = 338)
Step Predictors B SH β t R2 F

1 Constant 162.094 12.849 – 12.615* 0.175 71.232*

SWBS − 0.859 0.102 − 0.418 − 8.440*
2 Constant 79.252 12.812 – 13.991* 0.236 51.867*
SWBS − 0.625 0.108 − 0.304 − 5.796*
PWBS − 1.006 0.194 − 0.273 − 5.195*

PWBS Psychological Well-Being Scale, SWBS Spiritual Well-Being Scale, W-DEQ A Wijma Delivery
Expectancy Questionnaire version A
*p < 0.001

et al. 2014; Khorsandi et al. 2008) and yet lower than the results obtained in some
(Körükcü et al. 2017; Mortazavi and Agah 2018; Rouhe et al. 2014). Differences in
study findings may be related to how FOC is defined, the measurement tools used
and demographic, obstetric and psychosocial characteristics of the population and
the quality of health care provided. However, it was found in the study that one-
third of pregnant women experienced high or clinical level FOC, and this result was
higher than the study results identifying that 5–11% of pregnant women experienced
severe FOC (Nilsson et al. 2018; Bülbül et al. 2016; Zar et al. 2001). This find-
ing suggests that FOC is an important problem in pregnant women that needs to be
addressed. Previous studies have identified that FOC and negative attitudes toward
labor decreased in pregnant women who received antenatal training (Akın et al.
2018; Körükçü et al. 2017; Fink et al. 2012). The fact that half of pregnant women
who participated in this study did not receive antenatal training may be related to
FOC. In Turkey, routine antenatal training is provided in family health centers and in
the antenatal clinics of hospitals. Pregnant women are expected to attend at least four
monitoring visits (TDHS 2018). These follow-ups frequently focus on the physical
examinations of pregnant women, laboratory tests, immunization, pregnancy-related
complaints, trainings and treatments related to danger signs during pregnancy and
what to do (Republic of Turkey Ministry of Health 2014). Apart from these routine
antenatal follow-ups, pregnant women can also attend antenatal education classes
that focus on the psychosocial aspect of pregnancy and childbirth to increase their
self-efficacy about childbirth. In addition to the rate of pregnant women who did
not receive antenatal education, low participation rate in antenatal education classes
may also be associated with FOC in the study.
The state of well-being during pregnancy may change (Gölbaşı et al. 2010;
Rosario et al. 2017). In the present study, the mean PWBS score of the pregnant
women was 46.21 ± 7.22 and it can be argued that their psychological well-being
was generally high. In their study, Abdollahpour and Khosravi (2018) determined
that that pregnant women had moderate psychological well-being. Psychological
well-being of pregnant women is significant since it is associated with pregnancy
complications, negative childbirth experiences and postpartum mood disorders
(Körükçü et al. 2017; Mortazavi and Agah 2018; Fink et al. 2012). High levels of

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psychological well-being of pregnant women can be considered as positive. The

fact that most of the pregnant women had intended pregnancies and 78.1% did not
have a history of miscarriage/curettage in the present population may have posi-
tively affected well-being levels.
Throughout history, it is believed in different cultures that pregnancy and
childbirth enrich women’s spirituality (Abdollahpour and Khosravi 2018; Callis-
ter and Khalaf 2010). Studies show that women view pregnancy and childbirth as
a spiritual experience that brings them closer to God (Callister and Khalaf 2010;
Callister et al. 1999). In this study, the spiritual well-being of pregnant women
was determined to be high. The study findings are similar to those in Iran and
America that also assessed pregnant women’s well-being to be high (Abdollah-
pour and Khosravi 2018; Dunn et al. 2007). While religious and cultural beliefs
help women define the meaning of pregnancy and childbirth, the fact should not
be overlooked that planned pregnancies and receiving antenatal education can
also contribute to spiritual well-being of pregnant women.
Spiritual and psychosocial factors appear to be associated with FOC (Rouhe
et al. 2014; Taghizdeh et al. 2017). In this study, it was determined that as the
state of spiritual well-being increased, the FOC decreased and that spiritual well-
being had a partial mediator role between psychological well-being and FOC.
The findings of the present study are similar to the results of the study that found
a negative relationship between spiritual well-being and FOC (Abdollahpour and
Khosravi 2018). Previous studies have shown that spiral well-being increases
women’s self-confidence in managing the birth process appropriately, enhances
their strength in coping with negative situations (Abdollahpour and Khosravi
2018; Rosario et al. 2017; Taghizdeh et al. 2017) and decreases their anxiety
levels during childbirth (Dehestani et al. 2019). Khodabakhshi Koolaee (2013)
determined that spiritual well-being is significantly related to the ability to cope
with stress in pregnant women in Iran. These results support the partial mediator
role of spiritual well-being between psychological well-being and FOC.
Praying to God is an approach that reduces anxiety and provides peace and
tranquility when one is scared (Rosario et al. 2017). Studies conducted with
pregnant women have found that spiritual interventions such as prayer therapy,
listening to Qur’an and religious conversations reduce anxiety and depression
levels of pregnant women and have a positive effect on coping behaviors dur-
ing labor (Sanagoo et al. 2014; Jabbari et al. 2017). The systematic review of
12 studies conducted by Fink et al. (2012) that investigated the techniques to
comfort women during pregnancy and their maternal and fetal effects shows that
relaxation attempts such as imagination, yoga and massage decreased maternal
heart rate, blood pressure, blood cortisol level, anxiety, stress and depression and
increased dopamine and serotonin levels in pregnant women, thereby increasing
their psychological well-being. It can be argued that spiritual approaches should
be supported in reducing FOC since the present study found that 27.6% of the
pregnant women regarded childbirth as a spiritual experience (as seen in expres-
sions such as “the grace of Allah, taking sanctuary in Allah through prayers,
opening the gates of heaven, mother’s immortality, empowerment, finding
peace”) and that 13.5% of them reported that activities such as praying, listening

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to hymns, meditation, reading Qur’an, praying, and so on, made them feel good
about childbirth.
In addition to spiritual well-being, psychological well-being is also associated
with FOC (Fagbenro et al. 2018). This study determined that as psychological
well-being of pregnant women increased, their FOC decreased. The study find-
ings are consistent with the results of studies in Iran, Finland and Nigeria which
identified that psychological well-being is negatively related to FOC (Mortazavi
and Agah 2018; Adejuwon et al. 2018). Contrary to demographic and obstetric
characteristics, it is possible to control psychosocial factors. This study found
that spiritual well-being explained 18% of the variance in the FOC, and when
psychological well-being was added to the model in the second step, the vari-
ance increased to 24%. Spiritual well-being and psychological well-being directly
affect mental and physical health (Safara et al. 2019). Nowadays, childbirth has
become increasingly medical (Adejuwon et al. 2018) and the psychosocial aspect
of childbirth is generally ignored (Fink et al. 2012). However, women also need
traditional and spiritual care in addition to biomedical care in coping with anxiety
during pregnancy and childbirth (Fagbenro et al. 2018; Adejuwon et al. 2018).

Limitations of the Study

This study was conducted in the north of Turkey in only one province. The results
of the study are limited to the responses of pregnant women and cannot be gen-
eralized. FOC, psychological and spiritual well-being may vary among women
living in rural areas in different regions of Turkey due to the different sociocul-
tural characteristics. For this reason, similar studies can be carried out which will
include different parts of the country and the rural areas. Also qualitative research
on the subject and experimental studies involving psychological and spiritual
well-being interventions can be conducted. Nevertheless, reaching the sufficient
sample size is the strength of the study. Being the first national research in which
these scales related to FOC were used together and emphasizing this issue for the
first time in Turkey are the other strengths of this research.

Conclusion

FOC is higher in pregnant women; however, pregnant women with positive spir-
itual well-being and psychological well-being experience lower FOC. While spir-
itual well-being explained 18% of the variance related to FOC on its own, the
variance explained with psychological well-being increased to 24%. Spiritual
well-being is a partial mediator in the relationship between psychological well-
being and FOC. In this context, it seems important to ensure that healthcare ser-
vices planned to reduce the FOC include spiritual and psychological well-being.

13
Journal of Religion and Health

Implications for Practice

Considering the multifaceted nature of the FOC, it is important to establish ante-

natal services based on this multidimensionality and on individualized care (Ron-
dung et al. 2016). Evidence shows that psychosocial and spiritual approaches
offered by healthcare personnel reduce the FOC (Phunyammalee et al. 2019; Jab-
bari et al. 2017; Adejuwon et al. 2018; Desmawati and Chatchawet 2019). In Tur-
key, antenatal care services are mostly for routine follow-up; therefore, there is
a need to conduct routine psychosocial health assessments as well. Participation
of the pregnant women in antenatal education classes should be supported, and it
should be ensured that the midwives/nurses organize these trainings in a way to
increase the spiritual and psychological well-being of pregnant women. Qualita-
tive studies should be used to assess the psychosocial and spiritual well-being and
expectations of pregnant women in more detail. An increase in coping with FOC,
a decrease in the desire for optional cesarean and a more positive birth experi-
ence for women can be ensured by providing individualized training programs
and antenatal trainings by taking into consideration the concepts of psychological
well-being and spiritual well-being that are associated with the FOC.

Acknowledgements We thank all the pregnant women participated in this study.

Authors’ Contributions G.B was involved in literature review, the design of the study, data collection,
statistical analysis and writing of manuscript. N.Ç.B. was involved in the design of the study, statistical
analysis and writing of manuscript. All authors approved the final version of the study for submission.

Funding This research received no specific grant from any funding agency in the public, commercial or
not-for-profit sectors.

Compliance with Ethical Standards

Conflict of interest The authors declare that they have no financial or nonfinancial conflict of interest with
any organization related to the contents of this paper.

Ethical Approval This article does not contain any studies with human participants or animals performed
by any of the authors. All procedures performed in this study including data collection from the partici-
pants were in accordance with the 1964 Declaration of Helsinki and its later amendments or comparable
ethical standards.

Informed Consent All the research participants were informed about the objectives and procedures of the
study. Informed consent was obtained from all individual participants included in the study.

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