The effect of mindfulness self-compassion training on the fear of childbirth among first time pregnant women: a randomized controlled trial

The effect of mindfulness self-compassion training on the fear of childbirth among first time pregnant women: a randomized controlled trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The effect of mindfulness self-compassion training on the fear of childbirth among first time pregnant women: a randomized controlled trial Ebrahimi Sareh, Narjes Sadat Borghei, Rahman Berdi Ozouni-Davaj, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6320037/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background : Pregnancy is a significant life event for all women, often accompanied by considerable joy; however, fear of childbirth increases as delivery approaches and has adverse effects on maternal mental health. Self-compassion, through the activation of the parasympathetic system, leads to physiological and psychological well-being and may reduce fear of childbirth. Therefore, this study aimed to determine the effect of mindful self-compassion on fear of childbirth in primiparous women under the coverage of comprehensive health service centers in Gorgan in 2024. Method : This randomized controlled trial was conducted as an interventional two-group study with a pre-post design on 42 pregnant women. Sampling was performed in two stages. In the first stage, sampling was done by convenience, and primiparous women with a gestational age of 12 weeks were invited to participate in the study. Eligible individuals were randomly assigned to either the intervention or control groups. The intervention group received eight weekly 90-minute sessions of mindful self-compassion training, while mothers assigned to the control group received no training. Both groups completed the Persian version of the Wijma Delivery Expectancy Questionnaire at two stages: once at the beginning of the study and again eight weeks later. The collected data were entered into SPSS version 18 and analyzed. Results : The mean total score of fear of childbirth in the intervention group (77.43±14.70) and control group (77.95±8.12) at the beginning of the study showed no statistically significant difference (P = 0.88). After the intervention, the mean total score of fear of childbirth in the intervention group (46.81±10.83) and control group (81.86±6.87) showed a statistically significant difference (P < 0.001). Cohen's d indicated that the intervention had a strong effect on reducing the mean total score and subscales of fear of childbirth (Cohen's d = -3.86). Conclusions : In the present study, the mindful self-compassion intervention reduced fear of childbirth in primiparous women. Therefore, it is suggested that this intervention be implemented in health care centers to reduce fear of childbirth so that pregnant women have a pleasant pregnancy experience. Trial registration: http://www.irct.ir/, IRCT20231025059856N1 registered November 19, 2023. Mindful Self-Compassion Intervention Pregnant Woman Fear of Childbirth Figures Figure 1 Background Pregnancy is a significant life event for all women, accompanied by high levels of emotions and anxiety ( 1 ). Fear of childbirth (FOC) is an emotion experienced by every pregnant woman, increasing as delivery approaches ( 2 ). This emotion is very common among pregnant women ( 3 ). In Iran, the prevalence of FOC varies between 17.3% and 89.3% ( 4 ). A study in Gorgan showed that the prevalence of mild, moderate, and severe FOC was 77.2%, 18.5%, and 4.3%, respectively ( 5 ). FOC can arise due to biological, psychological, social, or secondary factors, including fear of pain, bodily harm, death of oneself or the baby, personality traits, observing or hearing others' experiences, a history of traumatic life events or previous difficult or traumatic childbirth experiences, feelings of helplessness or maternal anxiety ( 6 , 7 , 8 ). Dissatisfaction with the partner relationship, lack of social support, and low socioeconomic status can also lead to FOC ( 6 , 7 , 8 ). Ultimately, each woman expresses this fear based on her experiences, which can manifest as anxiety, overt fear, nightmares, physical problems, difficulty concentrating, and disturbances in work and family relationships ( 9 ). Severe FOC can cause anxiety and pain during pregnancy, potentially influencing the choice of cesarean delivery ( 10 ). There is no consensus on the best intervention to reduce FOC ( 11 ). For example, participating in prenatal classes has been shown in some studies to reduce FOC and increase satisfaction with childbirth, self-efficacy related to childbirth, feelings of control, and maternal knowledge ( 12 , 13 ). However, other studies suggest these educational interventions are ineffective ( 14 , 15 ). Supportive interventions, such as the presence of a companion midwife in delivery wards, can be a simple and non-invasive method to reduce anxiety and fear of vaginal childbirth in pregnant women ( 16 ). Counseling interventions, such as cognitive therapy, have been used to address the patient's concept of the problem to reduce FOC and overcome it ( 9 ). Cognitive restructuring and relaxation are important methods for reducing stress and tension ( 17 , 18 ). Alternative therapeutic measures to reduce childbirth pain, such as visualization, music therapy, and massage ( 19 ), cognitive-behavioral therapy ( 20 ), progressive muscle relaxation ( 21 ), and mindfulness interventions ( 22 ), have been studied, showing promising results for treating or preventing various psychological problems and alleviating pain and improving well-being ( 23 ). Recently, self-compassion has been explored as an intervention for FOC. Self-compassion stimulates caregiving hormones (such as oxytocin) and physiological responses like reduced heart rate, cortisol levels, feelings of safety, connection, and compassionate motivation, leading to physiological and psychological health benefits through the activation of the parasympathetic system ( 24 ). Self-compassion is a skill that can be learned and changed through interventions such as teaching compassionate mind and mindfulness-based stress reduction ( 11 ). One form of self-compassion is mindful self-compassion (MSC), which combines compassion training and mindfulness ( 25 ). Mindfulness is a key way to increase self-compassion and a prerequisite for it ( 26 ). Self-compassion is a psychological factor whose impact on FOC has been less studied. Psychological research over the past decade has increased because self-compassion is associated with less anxiety ( 27 ). Regarding studies on self-compassion during pregnancy, limited research has been conducted. One study showed that increased self-compassion is related to reduce FOC in pregnant women ( 28 ). Another study found that mindfulness-based self-compassion is a valuable intervention for increasing intimacy satisfaction and reducing depression during pregnancy ( 29 ). Therefore, given the negative consequences of fear, anxiety, and emotional states related to childbirth in pregnant women, conducting interventional research in this area and providing new strategies to reduce FOC seems necessary. Thus, the present study aimed to investigate the effect of mindful self-compassion training on FOC in primiparous women. Materials and methods Trial design : This randomized controlled trial employed a two-group (intervention and control) with a pre-test, post-test and parallel design. The first-time pregnant women were randomly assigned to the control group with no intervention, and the intervention group received eight weekly sessions of mindful self-compassion online training. The Trial setting included all comprehensive health service centers in Gorgan (8 urban health centers and 28 bases), where pregnant women receive free prenatal care in Gorgan city, the capital of Golestan Province in northern Iran. Participant : The study population consisted of all first-time pregnant women under the coverage of Gorgan's comprehensive health centers with a gestational age of 14 weeks. The list of first-time pregnant women was obtained from the Golestan electronic medical record system (n=250) and eligible primiparous women (n=53) formed the study sample and were randomly assigned to either the intervention (n=27) or control group (n=26). Eligibility criteria for participant: Inclusion criteria included being Iranian, able to read and write in Persian, having a gestational age of 14 weeks and singleton pregnancy, willingness to participate in the study, and having a smartphone with the ability to use it. Exclusion criteria included high risk pregnancy, threatened miscarriage, mental disorders, history of suicide attempts and psychiatric medication use, education in medical or psychological fields, and completion of mindfulness, self-compassion, or CBT courses. procedure: From April 4 to April 14 2024, the first-time pregnant of two groups were contacted by phone (n=53) and explanation were given how to complete the froms and questionnaire online. Participants received links to online forms for demographic characteristic, inform consent and Wijma Delivery Expectancy Questionnaire (WDEQ). After the participants answered the online questionnaire questions, the data was exported in Excel format and assign participant to intervention and control groups. Intervention: The intervention group received MSC online training adapted from Neff and Germer’s protocol (25) From April 18 to June 13 2024. A separate Adobe Connect link was sent to the intervention group and explanations were given to coordinate the time of the online class. Weekly 90-minute training sessions were conducted for eight weeks, starting on April 18 for Subgroup 1 (Thirteen participants) and April 26 for Subgroup 2 (Fourteen participants). Education was provided online to avoid unnecessary travel for pregnant women. Sessions were recorded for offline access. Homework assignments were provided to reinforce concepts, and compliance was reviewed at the start of each session. Training was supervised by a licensed psychologist, Dr. Davaji (Table 1). Outcomes and monitoring: After eight week follow up, immediately after completing the eight weekly sessions of intervention group, From June 13 to June 20 2024, the link to complete the online questionnaire on FOC was sent to the individuals in both groups to evaluate FOC in two groups as primary outcomes. Harms: The control group (26 participants) received no MSC online training but completed the same online questionnaires. Mothers in the control group were willing to receive the intervention, received the educational package after the trial was completed. As shown in figure 1, the randomization and attrition data were done based on the Consolidated Standard of Reporting Trials (CONSORT) guidelines. During the intervention, 6 participants from the intervention group and 5 from the control group withdrew, leaving 21 participants per group for final analysis. Table 1: Overview of the Curriculum for online MSC intervention, broken down by sessions Intervention content sessions Discovering Mindful Self-Compassion: A welcome session, introducing the participants to the course and to one another. Session 1 also provides a conceptual introduction to self-compassion with informal practices that can be practiced during the week. 1 - Practicing Mindfulness: Anchors the program in mindfulness. Formal and informal mindfulness practices are taught to participants as well as the rationale for mindfulness in MSC. Participants learn about “resistance” and “backdraft” and how to manage backdraft with mindfulness practices. Sessions 1 and 2 include more didactic material than subsequent sessions in order to establish a conceptual foundation for the entire course. 2 Practicing Loving-Kindness: Introduces loving-kindness and the intentional practice of warming up awareness. Loving-kindness is cultivated before compassion because it is less challenging. Participants get a chance to discover their own lovingkindness and compassion phrases for use in meditation. help develop safety and trust in the group. 3 Discovering Your Compassionate Voice: Broadens loving-kindness meditation into a compassionate conversation with ourselves, especially how to motivate ourselves with kindness rather than self-criticism. By session 4, many participants discover that self-compassion is more challenging than expected so we explore what “progress” means and encourage participants to practice compassion for themselves when they stumble or feel like they are failing to learn self-compassion. 4 Living Deeply : Focuses on core values and the skill of compassionate listening. These topics and practices are less emotionally challenging than others in the course, and are introduced in the middle of the program to give participants an emotional break while still deepening the practice of self-compassion. Retreat: A chance for students to immerse themselves in the practices already learned and apply them to whatever arises in the mind during 4 hours of silence. Some new practices are introduced, including ones that provide an opportunity for physical activity such as mindfully enjoying nature and compassionate walking, 5 Meeting Difficult Emotions: Gives students an opportunity to test and refine their skills by applying them to difficult emotions. Students learn 3 strategies for addressing difficult emotions: labeling and finding emotion in the body, two traditional mindfulness practices, plus a compassion practice called soften-soothe-allow in which we are kind and tender to ourselves because we are experiencing difficult emotions. The emotion of shame is described and demystified in this session because shame is so often associated with self-criticism and is entangled with sticky emotions such as guilt and anger 6 Exploring Challenging Relationships: Relationships are the source of much of our emotional pain. This is the most emotionally activating session in the course but most students are ready for it after practicing mindful self-compassion for 6-7 weeks. Themes of Session 7 are anger in relationships, caregiver fatigue, and forgiveness. Rather than trying to repair old relationships, students learn to meet and hold their emotional needs, and themselves, with more compassion 7 – Embracing Your Life: Brings the course to a close with positive psychology and the practices of savoring, gratitude, and self-appreciation—three ways to embrace the good in our lives. To sustain self-compassion practice, we need to recognize and enjoy positive experiences as well. At the end of the course, students are invited to review what they have learned, what they would like to remember, and what they would like to practice after the course has ended . 8 Sample Size : The sample size was calculated based on parameters from the study by Byrne et al. (2013) with a large effect size and Cohen's d of 1.03 (13). With a confidence level of 95% and power of 90%, the minimum sample size per group was calculated to be 21. Considering a 30% dropout rate during the study, the final sample size was increased to 27 per group. Since no similar study assessing the effect of MSC onlinr training on FOC was found, the sample size was calculated assuming that MSC would have a similar effect to mindfulness in Byrne study. Randomization : After the participants answered the online questionnaire questions, the data was exported in Excel format by Ms. Ebrahimi, and Dr. borghei enrolled participant and Dr. Rajabi assign participant to intervention and control groups. Randomization was achieved using sealed envelopes, with half containing code A (intervention group) and the other half code B (control group). Participants were divided into an intervention group (n=27) and a control group (n=26). Blindning : Due to the nature of the intervention, blinding was not applicable. Data collection After the participants answered the questionnaire questions online and the study was closed, the data was exported in Excel format by the instructor, Ms. Ebrahimi, and then entered into SPSS software and analyzed by Dr. Rajabi. The data collection tool included a demographic questionnaire and the Wijma Fear of Childbirth Questionnaire as follow: A) Demographic and Obstetric Checklist This form included maternal age, education level, ethnicity, occupation, monthly income, and gestational age (based on first-trimester ultrasound before 12 weeks). B) Wijma Delivery Expectancy-Experience Questionnaire Version A (WDEQ-A ) This questionnaire was designed by Wijma in 1998 and has three versions and examines FOC in three stages: before (version A), after childbirth (version B), and during labor (DFS) (30). In this study, the Persian version A was used. this questionnaire has 33 items, but the Persian version, which was examined by Andron (2020) for validity, reliability, and psychometrics, did not include 2 items 24 and 31 in any of the six domains (lack of self-efficacy, fear, negative evaluation, lack of positive expectations, concern about harm to the child, and loneliness) and was removed (31). The remaining 31 items are scored on a six-point Likert scale from not at all (0) to very much (5). The minimum and maximum scores of the questionnaire are (0 and 155), with the lowest score being zero (no fear) and the highest score being 155 (highest level of fear). To investigate the validity and reliability of the wijma instrument, Andaroun et al. conducted a study on 220 primiparous women with gestational age of 28-30 weeks referring to health centers in Mashhad. The reliability of this questionnaire was confirmed with a Cronbach's alpha coefficient of 0.84, and its validity was correlated with the scores of the Beck Anxiety Inventory (r=0.414) and Beck Depression Inventory (r=0.287) (31). Statistical methods The collected data was entered into the SPSS version 18 statistical software. Then, frequency distribution tables were used to describe the demographic variables in the two intervention and control groups. The state of FOC was described using the mean/median and standard deviation/interquartile range index. The normality of the data was examined using the Shapiro-Wilk test and visually with a Q-Q plot. The comparison of the means in the two groups with regard to normality was examined using the independent t-test and Mann-whitney and to compare the means before and after in each group, the wilcoxon test was used. Ethical approval In this study, all ethical considerations in accordance with the Declaration of Helsinki were observed. These include obtaining a sampling permit, ensuring the confidentiality of information, and procuring informed consent. The ethical code of this project (IR.GOUMS.REC.1402.317) was duly registered on the website of the National Committee for Ethics in Biomedical Research and registered in the Iranian Clinical Trials Registry with the reference code IRCT20231025059856N1. Results Participant Characteristics The participant of study (n=53) were randomly assigned to either the intervention (n=27) or control group (n=26) and after intervention, leaving 21 participants per group for final analysis. The mean age of mothers in the intervention group was 25.33 ± 6.41 years, and in the control group, it was 25 ± 6.14 years. No statistically significant difference was observed between the two groups in terms of age (P = 0.985). Additionally, there were no significant differences between the control and intervention groups regarding education, employment status, ethnicity, and economic status, indicating that the groups were homogeneous in demographic variables (Table 2). Table 2 Participants’ demographic and obstetric characteristics at baseline of first time pregnant women who participated in the study Variable Domain Groups P-value* Intervention N(%) Control N(%) Education Level Under Diploma 4 (19) 4 (19) 0.758 Diploma 8 (38.1) 10 (47.6) Upper Diploma 9 (42.9) 7 (33.3) Job status Housewife 18 (85.7) 20 (95.2) 0.606 Employed 3 (14.3) 1 (4.8) Ethnicity Fars 15 (71.41) 17 (81) 0.719 Sistani 6 (28.6) 4 (19) Economic situation Low 3 (14.3) 3 (14.3) 0.907 Medium 11 (52.4) 13 (13) Good 7 (33.3) 5 (23.7) * Chi-square test Main Outcome Table 3 shows that the mean FOC scores before the intervention did not have a significant difference between the two groups, indicating they were homogeneous (P = 0.887). However, comparing the mean FOC scores in the groups after the intervention revealed that the total fear score in the intervention group was significantly lower than in the control group (P < 0.001). Cohen's d indicated that the intervention had a strong effect in reducing both the total and subscale scores of FOC (Cohen's d = -3.86). In the intervention group, the fear decreased, resulting in a negative difference between pre- and post-intervention scores. In contrast, the control group experienced an increase in fear, leading to a positive difference. Furthermore, comparing the mean scores of all subdomains of FOC between the intervention and control groups showed that the intervention group had significantly lower scores in all subdomains (P < 0.001). Table 3 Mean, standard deviation, effect size of fear of childbirth and its domain of first time pregnant women who participated in the study Outcome Time Groups Comparison between group MD b ; P-Value Effect Size (Cohen's d) (95% CI c ) Intervention Mean (SD a ) Control Mean (SD) Lack of self-efficacy Baseline 27.38 (4.06) 25.67 (3.72) 1.714; 0.161* 0.44 Post intervention 16.90 (3.81) 26.76 (3.18) -9.8; <0.001** -2.81 Fear Baseline 18.48 (5.30) 20.24 (2.57) -1.76; 0.456** -0.42 Post intervention 13.29 (4.72) 19.71 (2.81) -6.42; <0.001* -1.65 Negative appraisal Baseline 5.43 (1.89) 5.47 (1.50) -0.47; 0.843** -0.027 Post intervention 3.29 (0.85) 6.62 (1.02) -3.33; <0.001* -3.55 Lack of positive expectations Baseline 11.90 (2.79) 12.38 (1.07) -0.47; 0.756** -0.22 Post intervention 5.71 (1.68) 12.48 (1.29) -6.76; <0.001* -4.51 Worry about harming the child Baseline 6.67 (1.93) 6.29 (1.62) 0.38; 0.492* 0.21 Post intervention 2.29 (1.01) 7.24 (1.18) -4.95; <0.001* -4.51 isolation Baseline 7.57 (1.78) 7.90 (1.45) -0.33; 0.540** -0.20 Post intervention 5.33 (1.28) 9.05 (1.36) -3.71; <0.001* -2.81 Fear of childbirth Baseline 77.43 (14.70) 77.95 (8.12) 3.66; 0.887* - 0.044 Post intervention 46.81 (10.83) 81.86 (6.87) -35; <0.001* - 3.86 *Mann–Whitney U test** t-test It was noteworthy that in the intervention group, the FOC score decreased after the intervention compared to before the intervention, which was statistically significant (P<0.001). While in the control group, the mean total FOC score and the four domains of negative appraisal, lack of positive expectations, concern about harm to the child, and loneliness increased significantly (P<0.001). In the domain of lack of efficacy, this increase was not significant (P=0.132), and only in the domain of fear, we witnessed a slight decrease that was not significant (P=0.396). (Table 3). Discussion The present study was conducted with the aim of examining the effect of MSC online training on FOC in primiparous women. As observed, the results of a study on 42 primiparous women showed that MSC online intervention reduces FOC. In line with the results of our study, Simon et al., in examining the effect of self-compassion on FOC, showed that self-compassion leads to a reduction in FOC, and the subscales of self-compassion that led to less FOC were self-kindness and mindfulness (32). A study by Samios et al. in 2021 also supported the effect of self-compassion on reducing FOC (11). Erbil found in their study that self-compassion abilities have a protective role in psychological distress in the perinatal period (7). Gutavdeer et al. (2019) showed that self-efficacy, self-esteem and optimism have a negative and significant relationship with FOC (8). Research also shows that self-compassion is associated with less anxiety and greater optimism, suggesting that self-compassion is more strongly associated with natural birth beliefs, as optimism is associated with greater beliefs about birth as a natural process (33). Findings from two clinical trials from Sweden and the Netherlands on the effects of mindfulness-based birth and parenting programs in pregnant women on perceived stress and depressive symptoms and high levels of FOC were positive. The mindfulness intervention was even shown to be more effective in reducing perceived stress and risk of perinatal depression compared with the Lamaze birthing course (34, 35). In line with our study aim, a study focusing on Dutch pregnant women with high FOC showed that a mindfulness intervention had a positive effect on reducing FOC and catastrophic beliefs about labor pain compared with usual care, and also had a significant effect on reducing the desire to perform obstetric interventions in the absence of labor symptoms (36). Felder et al. (2016) also found similar protective effects of self-compassion in reducing the severity of depressive and anxiety symptoms (37). Costa et al. showed in their study that self-compassion was also associated with greater pain acceptance and less distress in patients with chronic pain (38). Martin et al. conducted a mindfulness-based and compassion-based program for pregnant women and their partners to reduce depressive symptoms during pregnancy and postpartum, and the results of the study showed that the mindfulness-based compassion intervention had a significant positive effect on reducing postpartum depression (32). Research has shown that mindfulness-based programs (MBPs) are effective for a variety of psychological and physical conditions, including depression, anxiety, stress, and chronic pain in clinical and nonclinical populations (39). MBPs have also shown potential in reducing anxiety, depression, and stress in pregnant women (40). Mindfulness is commonly described as “a form of nonjudgmental, nonreactive attention to experiences occurring in the present moment, including cognitions, feelings, and bodily sensations as well as sights, sounds, and smells” (41). Research on mindfulness and behavioral regulation in populations with emotional dysregulation has shown that approaching and observing their intense emotions may improve their ability to tolerate negative emotional states and cope effectively with them. It is possible that pregnant women who participate in a mindfulness training course may be able to approach and pay attention to their FOC and fearful beliefs and thus be able to tolerate them during labor (42). Mindfulness practice encourages awareness of all cognitive, emotional, and physical states related to labor while being nonjudgmental and nonreactive, allowing for the challenges of labor to be present. In other words, maintaining conscious awareness of fearful feelings and beliefs about labor, without judgment or reaction, may help regulate behavior in labor and lead to changes toward adaptation to labor (43). In a study by Veringa Skiba et al., a mindfulness intervention was significantly superior to routine comprehensive care in reducing FOC, perception of labor pain catastrophizing, preference for nonurgent obstetric interventions, and increased labor pain acceptance (35). In line with our study, Duncan et al. also showed that mindful childbirth education improved women’s evaluations of labor and psychological functioning compared with standard childbirth education. Participants in the above study showed higher labor self-efficacy, fewer postpartum depression symptoms, and a tendency to use less painkillers and opioids during labor (44). In mindfulness, the individual is taught to focus on internal stimuli and teaches participants to accept and not judge or react, even if the stimulus is distressing to them. Therefore, self-compassion is an essential component of mindfulness-related interventions and is significantly associated with reduced anxiety, depression, and overall mental health (45). As observed in the present study, combining the two interventions of self-compassion and mindfulness and performing the intervention of "mindful self-compassion training" had much more significant effects on the mental health of pregnant women. The preparation of the intervention content by the researchers in collaboration with a psychologist and their direct supervision in all counseling sessions resulted in appropriate validity of this intervention, but given that it was a thesis project, long-term follow-up was not conducted due to the student's accelerated graduation. It is recommended that further follow-ups be planned and implemented after the intervention until before delivery. Additionally, this study was conducted on low-risk primiparous women and cannot be generalized to all pregnant women. Finally, it should be noted that due to the type of study, it was not possible to blind the participants in both the control and intervention groups and the researchers. Conclusion Online MSC intervention resulted in a reduction in the overall mean score of FOC in primiparous women in the intervention group. Therefore, with the effectiveness of this intervention, it can be suggested to health policymakers that MSC online training be implemented in reproductive health counseling clinics for people with high FOC who are referred from health and medical centers to reduce FOC, so that pregnant mothers enjoy better mental health during pregnancy, and on the other hand, FOC is also reduced, and unnecessary interventions and cesarean sections are reduced. Abbreviations CONSORT. Consolidated Standards for Reporting Trials. GOUMS: Golestan University of Medical Sciences Version A W-DEQ A: Wijma Delivery Expectancy/Experience Questionnaire FOC: fear of childbirth MSC: mindful self-compassion Declarations Acknowledgements This article is part of the master's thesis in midwifery counseling. The authors thank GOUMS for supporting this project. We would like to thank the esteemed professors, especially the esteemed supervisor and the esteemed professors of the advisor and the vice president of research, technology and ethics at Golestan University of Medical Sciences, the midwives working in comprehensive health centers, and all the mothers who participated in the research and those who cooperated in the implementation of this research. Ethics approval and consent to participate: In this study, all ethical considerations in accordance with the Declaration of Helsinki were observed. The ethical code of this project (IR.GOUMS.REC.1402.317) was duly registered on the website of the National Committee for Ethics in Biomedical Research and eligible mothers signed an informed consent online before participating in the study and were assured the confidentiality. Consent for publication: All authors have consent for publication. Availability of data and materials: The datasets used and analyzed during the current study available from the corresponding author on reasonable request. Competing interests: The authors declare any conflict of interest. Funding: Research and technology deputy of Golestan University of medical sciences funding this research . Authors' contributions: "SA conducted data sampling and prepared the draft of the work. NSB supervised the overall project and participated in the design, interpretation of data with the first author. RBOD supervised the intervention and AR performed the statistical analysis. 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Staying well during pregnancy and the postpartum: A pilot randomized trial of mindfulness-based cognitive therapy for the prevention of depressive relapse/recurrence. J Consult Clin Psychol. 2016;84(2):134. Zou L, Yeung A, Quan X, Boyden SD, Wang H. A systematic review and meta-analysis of mindfulness-based (Baduanjin) exercise for alleviating musculoskeletal pain and improving sleep quality in people with chronic diseases. Int J Environ Res Public Health. 2018;15(2):206. Gilbert P. The origins and nature of compassion focused therapy. Br J Clin Psychol. 2014;53(1):6–41. Germer C, Neff K. Mindful self-compassion (MSC). Handbook of mindfulness-based programmes: Routledge. 2019:357 – 67. Neff KD, Germer CK. A pilot study and randomized controlled trial of the mindful self-compassion program. J Clin Psychol. 2013;69(1):28–44. Neff KD. The Development and Validation of a Scale to Measure Self-Compassion. Self Identity. 2003;2(3):223–50. Erbil N. Relationship of Self-Compassion and Fear of Childbirth among Pregnant Women. Int J Caring Sci. 2022;15(1):255. Kumar SA, Franz MR, DiLillo D, Brock Rebecca L. Promoting resilience to depression among couples during pregnancy: The protective functions of intimate relationship satisfaction and self-compassion. Fam Process. 2023;62(1):387–405. Wijma K, Wijma B, Zar M. Psychometric aspects of the W-DEQ; a new questionnaire for the measurement of fear of childbirth. J Psychosom Obstet Gynecol. 1998;19(2):84–97. Andaroon N, Kordi M, Ghasemi M, Mazlom R. The validity and reliability of the Wijma delivery expectancy/experience questionnaire (Version a) in primiparous women in Mashhad, Iran. Iran J Med Sci. 2020;45(2):110. Sacristan-Martin O, Santed MA, Garcia-Campayo J, Duncan LG, Bardacke N, Fernandez-Alonso C, et al. A mindfulness and compassion-based program applied to pregnant women and their partners to decrease depression symptoms during pregnancy and postpartum: Study protocol for a randomized controlled trial. Trials. 2019;20:1–15. Terry ML, Leary MR. Self-compassion, self-regulation, and health. Self identity. 2011;10(3):352–62. Lönnberg G, Jonas W, Unternaehrer E, Bränström R, Nissen E, Niemi M. Effects of a mindfulness based childbirth and parenting program on pregnant women's perceived stress and risk of perinatal depression–Results from a randomized controlled trial. J Affect Disord. 2020;262:133–42. Veringa-Skiba IK, de Bruin EI, van Steensel FJ, Bögels SM. Fear of childbirth, nonurgent obstetric interventions, and newborn outcomes: A randomized controlled trial comparing mindfulness‐based childbirth and parenting with enhanced care as usual. Birth. 2022;49(1):40–51. Moscucci O. Holistic obstetrics: the origins of natural childbirth in Britain. Postgrad Med J. 2003;79(929):168–73. Felder JN, Lemon E, Shea K, Kripke K, Dimidjian S. Role of self-compassion in psychological well-being among perinatal women. Arch Women Ment Health. 2016;19:687–90. Costa J, Pinto-Gouveia J. Acceptance of pain, self‐compassion and psychopathology: Using the Chronic Pain Acceptance Questionnaire to identify patients' subgroups. Clin Psychol Psychother. 2011;18(4):292–302. Alsubaie M, Abbott R, Dunn B, Dickens C, Keil TF, Henley W, et al. Mechanisms of action in mindfulness-based cognitive therapy (MBCT) and mindfulness-based stress reduction (MBSR) in people with physical and/or psychological conditions: A systematic review. Clin Psychol Rev. 2017;55:74–91. Dhillon A, Sparkes E, Duarte RV. Mindfulness-based interventions during pregnancy: A systematic review and meta-analysis. Mindfulness. 2017;8:1421–37. Baer RA. Self-focused attention and mechanisms of change in mindfulness-based treatment. Cogn Behav Ther. 2009;38(S1):15–20. Hayes SC, Luoma JB, Bond FW, Masuda A, Lillis J. Acceptance and commitment therapy: Model, processes and outcomes. Behav Res Ther. 2006;44(1):1–25. Veringa-Skiba IK, Ziemer K, de Bruin EI, de Bruin EJ, Bögels SM. Mindful awareness as a mechanism of change for natural childbirth in pregnant women with high fear of childbirth: a randomised controlled trial. BMC Pregnancy Childbirth. 2022;22(1):47. Duncan LG, Cohn MA, Chao MT, Cook JG, Riccobono J, Bardacke N. Benefits of preparing for childbirth with mindfulness training: a randomized controlled trial with active comparison. BMC Pregnancy Childbirth. 2017;17:1–11. Pereira A, Xavier S, Bento E, Azevedo J, Marques M, Soares M, et al. Mindfulness, self-compassion and depressive symptoms in pregnant women. Eur Psychiatry. 2016;33(S1):S420–S. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6320037","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":472714475,"identity":"8783ba99-7ff6-4f98-866b-4f551d078e42","order_by":0,"name":"Ebrahimi Sareh","email":"","orcid":"","institution":"Counseling and Reproductive Health Research Center, School of Nursing and Midwifery, Golestan University of Medical Sciences, Gorgan","correspondingAuthor":false,"prefix":"","firstName":"Ebrahimi","middleName":"","lastName":"Sareh","suffix":""},{"id":472714476,"identity":"4d29a111-3160-40f0-b02f-fd86b00f008a","order_by":1,"name":"Narjes Sadat Borghei","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7UlEQVRIiWNgGAWjYBACAyBmZmCQkGNjZj74gIHhAPFajPnZ25INSNHCkDiz54yaBFFazNl7H78uqLBg3HAjh62ap+aOHD8D88NHN/Bosew5bmY944wEs8GN3GO3eY49M5ZsYDM2zsHnsBtpbMa8bRJsBjfy0m7zsB1O3HCAh02asJZ/EjwGN3LMinn+EaeF+TFvg4SEZM8ZM2beNiK0WPYcY2PmOSZhAApkybl9h40lmwn4xZy9jfkzT01dfRswKj+8+XZYjp+9+eFjfFqAgE0CxmLiAZHM+JWDlXyAsRh/EFY9CkbBKBgFIxAAAJ7xS4QZPFx7AAAAAElFTkSuQmCC","orcid":"","institution":"Counseling and Reproductive Health Research Center, School of Nursing and Midwifery, Golestan University of Medical Sciences, Gorgan","correspondingAuthor":true,"prefix":"","firstName":"Narjes","middleName":"Sadat","lastName":"Borghei","suffix":""},{"id":472714477,"identity":"b4679d72-5e9b-4228-aeb1-2e16a690865d","order_by":2,"name":"Rahman Berdi Ozouni-Davaj","email":"","orcid":"","institution":"Health Management and Social Development Research Center, Golestan university of medical sciences, Gorgan","correspondingAuthor":false,"prefix":"","firstName":"Rahman","middleName":"Berdi","lastName":"Ozouni-Davaj","suffix":""},{"id":472714478,"identity":"9a28096a-370d-4c84-bb40-0d2d16176063","order_by":3,"name":"Abdolhalim Rajabi","email":"","orcid":"","institution":"Environmental Health Research Center, Department of Biostatistics and Epidemiology, Faculty of Health, Golestan University of Medical Sciences, Gorgan","correspondingAuthor":false,"prefix":"","firstName":"Abdolhalim","middleName":"","lastName":"Rajabi","suffix":""}],"badges":[],"createdAt":"2025-03-27 11:23:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6320037/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6320037/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85075164,"identity":"b1a9a396-30ae-4a6e-955b-3daf85177a0a","added_by":"auto","created_at":"2025-06-20 16:24:30","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":104498,"visible":true,"origin":"","legend":"\u003cp\u003eResearch implementation process\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6320037/v1/a70b3bd31fa96a5622cbb737.jpg"},{"id":85077439,"identity":"a2aa78b9-404e-4750-bd4b-a84bff52d8b7","added_by":"auto","created_at":"2025-06-20 16:56:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1083272,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6320037/v1/e102ff3f-0950-4014-b0c8-63a4882262ca.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The effect of mindfulness self-compassion training on the fear of childbirth among first time pregnant women: a randomized controlled trial","fulltext":[{"header":"Background","content":" \u003cp\u003ePregnancy is a significant life event for all women, accompanied by high levels of emotions and anxiety (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Fear of childbirth (FOC) is an emotion experienced by every pregnant woman, increasing as delivery approaches (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). This emotion is very common among pregnant women (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). In Iran, the prevalence of FOC varies between 17.3% and 89.3% (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). A study in Gorgan showed that the prevalence of mild, moderate, and severe FOC was 77.2%, 18.5%, and 4.3%, respectively (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFOC can arise due to biological, psychological, social, or secondary factors, including fear of pain, bodily harm, death of oneself or the baby, personality traits, observing or hearing others' experiences, a history of traumatic life events or previous difficult or traumatic childbirth experiences, feelings of helplessness or maternal anxiety (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Dissatisfaction with the partner relationship, lack of social support, and low socioeconomic status can also lead to FOC (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Ultimately, each woman expresses this fear based on her experiences, which can manifest as anxiety, overt fear, nightmares, physical problems, difficulty concentrating, and disturbances in work and family relationships (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Severe FOC can cause anxiety and pain during pregnancy, potentially influencing the choice of cesarean delivery (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere is no consensus on the best intervention to reduce FOC (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). For example, participating in prenatal classes has been shown in some studies to reduce FOC and increase satisfaction with childbirth, self-efficacy related to childbirth, feelings of control, and maternal knowledge (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). However, other studies suggest these educational interventions are ineffective (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Supportive interventions, such as the presence of a companion midwife in delivery wards, can be a simple and non-invasive method to reduce anxiety and fear of vaginal childbirth in pregnant women (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Counseling interventions, such as cognitive therapy, have been used to address the patient's concept of the problem to reduce FOC and overcome it (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Cognitive restructuring and relaxation are important methods for reducing stress and tension (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Alternative therapeutic measures to reduce childbirth pain, such as visualization, music therapy, and massage (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), cognitive-behavioral therapy (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), progressive muscle relaxation (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), and mindfulness interventions (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), have been studied, showing promising results for treating or preventing various psychological problems and alleviating pain and improving well-being (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRecently, self-compassion has been explored as an intervention for FOC. Self-compassion stimulates caregiving hormones (such as oxytocin) and physiological responses like reduced heart rate, cortisol levels, feelings of safety, connection, and compassionate motivation, leading to physiological and psychological health benefits through the activation of the parasympathetic system (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Self-compassion is a skill that can be learned and changed through interventions such as teaching compassionate mind and mindfulness-based stress reduction (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). One form of self-compassion is mindful self-compassion (MSC), which combines compassion training and mindfulness (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Mindfulness is a key way to increase self-compassion and a prerequisite for it (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Self-compassion is a psychological factor whose impact on FOC has been less studied. Psychological research over the past decade has increased because self-compassion is associated with less anxiety (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRegarding studies on self-compassion during pregnancy, limited research has been conducted. One study showed that increased self-compassion is related to reduce FOC in pregnant women (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Another study found that mindfulness-based self-compassion is a valuable intervention for increasing intimacy satisfaction and reducing depression during pregnancy (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Therefore, given the negative consequences of fear, anxiety, and emotional states related to childbirth in pregnant women, conducting interventional research in this area and providing new strategies to reduce FOC seems necessary. Thus, the present study aimed to investigate the effect of mindful self-compassion training on FOC in primiparous women.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003e\u003cstrong\u003eTrial design\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eThis randomized controlled trial employed a two-group (intervention and control) with a pre-test, post-test and parallel design. The first-time pregnant women were randomly assigned to the control group with no intervention, and the intervention group received eight weekly sessions of mindful self-compassion online training.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Trial setting\u003c/strong\u003e included all comprehensive health service centers in Gorgan (8 urban health centers and 28 bases), where pregnant women receive free prenatal care in Gorgan city, the capital of Golestan Province in northern Iran.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipant\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eThe study population consisted of all first-time pregnant women under the coverage of Gorgan\u0026apos;s comprehensive health centers with a gestational age of 14 weeks. The list of first-time pregnant women was obtained from the Golestan electronic medical record system (n=250) and eligible primiparous women (n=53) formed the study sample and were randomly assigned to either the intervention (n=27) \u0026nbsp;or control group (n=26).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEligibility criteria for participant:\u0026nbsp;\u003c/strong\u003eInclusion criteria included being Iranian, able to read and write in Persian, having a gestational age of 14 weeks and singleton pregnancy, willingness to participate in the study, and having a smartphone with the ability to use it. Exclusion criteria included high risk pregnancy, threatened miscarriage, mental disorders, history of suicide attempts and psychiatric medication use, education in medical or psychological fields, and completion of mindfulness, self-compassion, or CBT courses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eprocedure:\u0026nbsp;\u003c/strong\u003eFrom April 4 to April 14 2024, the first-time pregnant \u0026nbsp;of two groups were contacted by phone (n=53) and explanation were given how to complete the froms and questionnaire online. Participants received links to online forms for demographic characteristic, inform consent and Wijma Delivery Expectancy Questionnaire (WDEQ). After the participants answered the online questionnaire questions, the data was exported in Excel format and assign participant to intervention and control groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntervention:\u0026nbsp;\u003c/strong\u003eThe intervention group received MSC online training adapted from Neff and Germer\u0026rsquo;s protocol (25) From April 18 to June 13 2024. A separate Adobe Connect link was sent to the intervention group and explanations were given to coordinate the time of the online class. Weekly 90-minute training sessions were conducted for eight weeks, starting on April 18 \u0026nbsp;for Subgroup 1 (Thirteen participants) and April 26 for Subgroup 2 (Fourteen participants). Education was provided online to avoid unnecessary travel for pregnant women. Sessions were recorded for offline access. Homework assignments were provided to reinforce concepts, and compliance was reviewed at the start of each session. Training was supervised by a licensed psychologist, Dr. Davaji (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcomes and monitoring:\u003c/strong\u003e After eight week follow up, immediately after completing the eight weekly sessions of intervention group, From June 13 to June 20 2024, the link to complete the online questionnaire on FOC was sent to the individuals in both groups to evaluate FOC in two groups as primary outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHarms:\u0026nbsp;\u003c/strong\u003eThe control group (26 participants) received no MSC online training but completed the same online questionnaires. Mothers in the control group were willing to receive the intervention, received the educational package after the trial was completed.\u003c/p\u003e\n\u003cp\u003eAs shown in figure 1, the randomization and attrition data were done based on the Consolidated Standard of Reporting Trials (CONSORT) guidelines. During the intervention, 6 participants from the intervention group and 5 from the control group withdrew, leaving 21 participants per group for final analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1: \u0026nbsp;Overview of the Curriculum \u0026nbsp;for online MSC intervention, broken down by sessions\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"642\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 595px;\"\u003e\n \u003cp\u003eIntervention content\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003esessions\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 595px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiscovering Mindful Self-Compassion:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eA welcome session, introducing the participants to the course and to one another.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSession 1 also provides a conceptual introduction to self-compassion with informal practices that can be practiced during the week.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 595px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e- Practicing Mindfulness:\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eAnchors the program in mindfulness. Formal and informal mindfulness practices are taught to participants as well as the rationale for mindfulness in MSC. Participants learn about \u0026ldquo;resistance\u0026rdquo; and \u0026ldquo;backdraft\u0026rdquo; and how to manage backdraft with mindfulness practices. Sessions 1 and 2 include more didactic material than subsequent sessions in order to establish a conceptual foundation for the entire course.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 595px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePracticing Loving-Kindness:\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eIntroduces loving-kindness and the intentional practice of warming up awareness. Loving-kindness is cultivated before compassion because it is less challenging. Participants get a chance to discover their own lovingkindness and compassion phrases for use in meditation. help develop safety and trust in the group.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 595px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiscovering Your Compassionate Voice:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eBroadens loving-kindness meditation into a compassionate conversation with ourselves, especially how to motivate ourselves with kindness rather than self-criticism. By session 4, many participants discover that self-compassion is more challenging than expected so we explore what \u0026ldquo;progress\u0026rdquo; means and encourage participants to practice compassion for themselves when they stumble or feel like they are failing to learn self-compassion.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 595px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLiving Deeply\u003c/strong\u003e: Focuses on core values and the skill of compassionate listening. These topics and practices are less emotionally challenging than others in the course, and are introduced in the middle of the program to give participants an emotional break while still deepening the practice of self-compassion.\u003c/p\u003e\n \u003cp\u003eRetreat: A chance for students to immerse themselves in the practices already learned and apply them to whatever arises in the mind during 4 hours of silence. Some new practices are introduced, including ones that provide an opportunity for physical activity such as mindfully enjoying nature and compassionate walking,\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 595px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMeeting Difficult Emotions:\u0026nbsp;\u003c/strong\u003eGives students an opportunity to test and refine their skills by applying them to difficult emotions. Students learn 3 strategies for addressing difficult emotions: labeling and finding emotion in the body, two traditional mindfulness practices, plus a compassion practice called soften-soothe-allow in which we are kind and tender to ourselves because we are experiencing difficult emotions. The emotion of shame is described and demystified in this session because shame is so often\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eassociated with self-criticism and is entangled with sticky emotions such as guilt and anger\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 595px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExploring Challenging Relationships:\u003c/strong\u003e Relationships are the source of much of our emotional pain. This is the most emotionally activating session in the course but most students are ready for it after practicing mindful self-compassion for 6-7 weeks. Themes of Session 7 are anger in relationships, caregiver fatigue, and forgiveness. Rather than trying to repair old relationships, students learn to meet and hold their emotional needs, and themselves, with more compassion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 595px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026ndash; Embracing Your Life:\u0026nbsp;\u003c/strong\u003eBrings the course to a close with positive psychology and the practices of savoring, gratitude, and self-appreciation\u0026mdash;three ways to embrace the good in our lives. To sustain self-compassion practice, we need to recognize and enjoy positive experiences as well. At the end of the course, students are invited to review what they have learned, what they would like to remember, and what they would like to practice after the course has ended\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eSample Size\u003c/strong\u003e: The sample size was calculated based on parameters from the study by\u0026nbsp;Byrne\u0026nbsp;et al. (2013) with a large effect size and Cohen\u0026apos;s d of 1.03 (13). With a confidence level of 95% and power of 90%, the minimum sample size per group was calculated to be 21. Considering a 30% dropout rate during the study, the final sample size was increased to 27 per group. Since no similar study assessing the effect of MSC onlinr training on FOC was found, the sample size was calculated assuming that MSC would have a similar effect to mindfulness in Byrne study.\u003c/p\u003e\n\u003cp\u003e\u003cimg width=\"255\" height=\"63\" src=\"https://myfiles.space/user_files/69519_bce2c0439cd956a6/69519_custom_files/img1750436389.jpg\" alt=\"image\"\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003cimg width=\"261\" height=\"38\" src=\"https://myfiles.space/user_files/69519_bce2c0439cd956a6/69519_custom_files/img1750436389.png\" alt=\"image\"\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRandomization\u003c/strong\u003e: After the participants answered the online questionnaire questions, the data was exported in Excel format by Ms. Ebrahimi, and Dr. borghei enrolled participant and Dr. Rajabi assign participant to intervention and control groups. Randomization was achieved using sealed envelopes, with half containing code A (intervention group) and the other half code B (control group). Participants were divided into an intervention group (n=27) and a control group (n=26).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBlindning\u003c/strong\u003e: Due to the nature of the intervention, blinding was not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter the participants answered the questionnaire questions online and the study was closed, the data was exported in Excel format by the instructor, Ms. Ebrahimi, and then entered into SPSS software and analyzed by Dr. Rajabi.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe data collection tool included a demographic questionnaire and the Wijma Fear of Childbirth Questionnaire as follow:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA) Demographic and Obstetric Checklist\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This form included maternal age, education level, ethnicity, occupation, monthly income, and gestational age (based on first-trimester ultrasound before 12 weeks).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB) Wijma Delivery Expectancy-Experience Questionnaire Version A (WDEQ-A\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis questionnaire was designed by Wijma in 1998 and has three versions and examines FOC in three stages: before (version A), after childbirth (version B), and during labor (DFS) (30). In this study, the Persian version A was used. this questionnaire has 33 items, but the Persian version, which was examined by Andron (2020) for validity, reliability, and psychometrics, did not include 2 items 24 and 31 in any of the six domains (lack of self-efficacy, fear, negative evaluation, lack of positive expectations, concern about harm to the child, and loneliness) and was removed (31). The remaining 31 items are scored on a six-point Likert scale from not at all (0) to very much (5). The minimum and maximum scores of the questionnaire are (0 and 155), with the lowest score being zero (no fear) and the highest score being 155 (highest level of fear). To investigate the validity and reliability of the wijma instrument, Andaroun et al. conducted a study on 220 primiparous women with gestational age of 28-30 weeks referring to health centers in Mashhad. The reliability of this questionnaire was confirmed with a Cronbach\u0026apos;s alpha coefficient of 0.84, and its validity was correlated with the scores of the Beck Anxiety Inventory (r=0.414) and Beck Depression Inventory (r=0.287) (31).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe collected data was entered into the SPSS version 18 statistical software. Then, frequency distribution tables were used to describe the demographic variables in the two intervention and control groups. The state of FOC was described using the mean/median and standard deviation/interquartile range index. The normality of the data was examined using the Shapiro-Wilk test and visually with a Q-Q plot. The comparison of the means in the two groups with regard to normality was examined using the independent t-test and Mann-whitney and to compare the means before and after in each group, the wilcoxon test was used.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, all ethical considerations in accordance with the Declaration of Helsinki were observed. These include obtaining a sampling permit, ensuring the confidentiality of information, and procuring informed consent. The ethical code of this project (IR.GOUMS.REC.1402.317) was duly registered on the website of the National Committee for Ethics in Biomedical Research and registered in the Iranian Clinical Trials Registry with the reference code IRCT20231025059856N1.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipant Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe participant of study (n=53) were randomly assigned to either the intervention (n=27) \u0026nbsp;or control group (n=26) and after intervention, leaving 21 participants per group for final analysis. The mean age of mothers in the intervention group was 25.33 \u0026plusmn; 6.41 years, and in the control group, it was 25 \u0026plusmn; 6.14 years. No statistically significant difference was observed between the two groups in terms of age (P =\u0026nbsp;0.985).\u0026nbsp;Additionally, there were no significant differences between the control and intervention groups regarding education, employment status, ethnicity, and economic status, indicating that the groups were homogeneous in demographic variables (Table 2).\u003c/p\u003e\n\u003cp\u003eTable 2 Participants\u0026rsquo; demographic and obstetric characteristics at baseline\u0026nbsp;of first time pregnant women who participated in the study\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"706\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDomain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 299px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroups\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003eIntervention\u003c/p\u003e\n \u003cp\u003eN(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003eControl\u003c/p\u003e\n \u003cp\u003eN(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation Level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 152px;\"\u003e\n \u003cp\u003eUnder Diploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e4 (19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e4 (19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 138px;\"\u003e\n \u003cp\u003e0.758\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 152px;\"\u003e\n \u003cp\u003eDiploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e8 (38.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e10 (47.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 152px;\"\u003e\n \u003cp\u003eUpper Diploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e9 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e7 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eJob status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 152px;\"\u003e\n \u003cp\u003eHousewife\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e18 (85.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e20 (95.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 138px;\"\u003e\n \u003cp\u003e0.606\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 152px;\"\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e3 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e1 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 152px;\"\u003e\n \u003cp\u003eFars\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e15 (71.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e17 (81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 138px;\"\u003e\n \u003cp\u003e0.719\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 152px;\"\u003e\n \u003cp\u003eSistani\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e6 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e4 (19)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEconomic situation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 152px;\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e3 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e3 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 138px;\"\u003e\n \u003cp\u003e0.907\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 152px;\"\u003e\n \u003cp\u003eMedium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e11 (52.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e13 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 152px;\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e7 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 142px;\"\u003e\n \u003cp\u003e5 (23.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e* Chi-square test\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMain Outcome\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 3 shows that the mean FOC scores before the intervention did not have a significant difference between the two groups, indicating they were homogeneous (P = 0.887). However, comparing the mean FOC scores in the groups after the intervention revealed that the total fear score in the intervention group was significantly lower than in the control group (P \u0026lt; 0.001). Cohen\u0026apos;s d indicated that the intervention had a strong effect in reducing both the total and subscale scores of FOC (Cohen\u0026apos;s d = -3.86). In the intervention group, the fear decreased, resulting in a negative difference between pre- and post-intervention scores. In contrast, the control group experienced an increase in fear, leading to a positive difference. Furthermore, comparing the mean scores of all subdomains of FOC between the intervention and control groups showed that the intervention group had significantly lower scores in all subdomains (P \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eTable 3 Mean, standard deviation, effect size of fear of childbirth and its domain of first time pregnant women who participated in the study\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"724\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTime\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 232px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroups\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComparison between group MD\u003csup\u003eb\u003c/sup\u003e; P-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEffect Size\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Cohen\u0026apos;s d)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(95% CI\u003csup\u003ec\u003c/sup\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntervention\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD\u003csup\u003ea\u003c/sup\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLack of self-efficacy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e27.38 (4.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e25.67 (3.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e1.714; 0.161*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003ePost intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e16.90 (3.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e26.76 (3.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e-9.8; \u0026lt;0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e-2.81\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFear\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e18.48 (5.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e20.24 (2.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e-1.76; 0.456**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e-0.42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003ePost intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e13.29 (4.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e19.71 (2.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e-6.42; \u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e-1.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNegative appraisal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e5.43 (1.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e5.47 (1.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e-0.47; 0.843**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e-0.027\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003ePost intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e3.29 (0.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e6.62 (1.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e-3.33; \u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e-3.55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLack of positive expectations\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e11.90 (2.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e12.38 (1.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e-0.47; 0.756**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e-0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003ePost intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e5.71 (1.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e12.48 (1.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e-6.76; \u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e-4.51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWorry about harming the child\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e6.67 (1.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e6.29 (1.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e0.38; 0.492*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003ePost intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e2.29 (1.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e7.24 (1.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e-4.95; \u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; -4.51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eisolation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e7.57 (1.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e7.90 (1.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e-0.33; 0.540**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;-0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003ePost intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e5.33 (1.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e9.05 (1.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e-3.71; \u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; -2.81\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFear of childbirth\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e77.43 (14.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e77.95 (8.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e3.66; 0.887*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e- 0.044\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003ePost intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e46.81 (10.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e81.86 (6.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e-35; \u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e- 3.86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e*Mann\u0026ndash;Whitney U test** \u0026nbsp; \u0026nbsp; \u0026nbsp; t-test\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIt was noteworthy that in the intervention group, the FOC score decreased after the intervention compared to before the intervention, which was statistically significant (P\u0026lt;0.001). While in the control group, the mean total FOC score and the four domains of negative appraisal, lack of positive expectations, concern about harm to the child, and loneliness increased significantly (P\u0026lt;0.001). In the domain of lack of efficacy, this increase was not significant (P=0.132), and only in the domain of fear, we witnessed a slight decrease that was not significant (P=0.396). (Table 3).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study was conducted with the aim of examining the effect of MSC online training on FOC in primiparous women. As observed, the results of a study on 42 primiparous women showed that MSC online intervention reduces FOC.\u003c/p\u003e\n\u003cp\u003eIn line with the results of our study, Simon et al., in examining the effect of self-compassion on FOC, showed that self-compassion leads to a reduction in FOC, and the subscales of self-compassion that led to less FOC were self-kindness and mindfulness (32). A study by Samios et al. in 2021 also supported the effect of self-compassion on reducing FOC (11). Erbil found in their study that self-compassion abilities have a protective role in psychological distress in the perinatal period (7). Gutavdeer et al. (2019) showed that self-efficacy, self-esteem and optimism have a negative and significant relationship with FOC (8). Research also shows that self-compassion is associated with less anxiety and greater optimism, suggesting that self-compassion is more strongly associated with natural birth beliefs, as optimism is associated with greater beliefs about birth as a natural process (33). Findings from two clinical trials from Sweden and the Netherlands on the effects of mindfulness-based birth and parenting programs in pregnant women on perceived stress and depressive symptoms and high levels of FOC were positive. The mindfulness intervention was even shown to be more effective in reducing perceived stress and risk of perinatal depression compared with the Lamaze birthing course (34, 35). In line with our study aim, a study focusing on Dutch pregnant women with high FOC showed that a mindfulness intervention had a positive effect on reducing FOC and catastrophic beliefs about labor pain compared with usual care, and also had a significant effect on reducing the desire to perform obstetric interventions in the absence of labor symptoms (36).\u003c/p\u003e\n\u003cp\u003eFelder et al. (2016) also found similar protective effects of self-compassion in reducing the severity of depressive and anxiety symptoms (37). Costa et al. showed in their study that self-compassion was also associated with greater pain acceptance and less distress in patients with chronic pain (38). Martin et al. conducted a mindfulness-based and compassion-based program for pregnant women and their partners to reduce depressive symptoms during pregnancy and postpartum, and the results of the study showed that the mindfulness-based compassion intervention had a significant positive effect on reducing postpartum depression (32).\u003c/p\u003e\n\u003cp\u003eResearch has shown that mindfulness-based programs (MBPs) are effective for a variety of psychological and physical conditions, including depression, anxiety, stress, and chronic pain in clinical and nonclinical populations (39). MBPs have also shown potential in reducing anxiety, depression, and stress in pregnant women (40). Mindfulness is commonly described as “a form of nonjudgmental, nonreactive attention to experiences occurring in the present moment, including cognitions, feelings, and bodily sensations as well as sights, sounds, and smells” (41). Research on mindfulness and behavioral regulation in populations with emotional dysregulation has shown that approaching and observing their intense emotions may improve their ability to tolerate negative emotional states and cope effectively with them. It is possible that pregnant women who participate in a mindfulness training course may be able to approach and pay attention to their FOC and fearful beliefs and thus be able to tolerate them during labor (42). Mindfulness practice encourages awareness of all cognitive, emotional, and physical states related to labor while being nonjudgmental and nonreactive, allowing for the challenges of labor to be present. In other words, maintaining conscious awareness of fearful feelings and beliefs about labor, without judgment or reaction, may help regulate behavior in labor and lead to changes toward adaptation to labor (43). In a study by Veringa Skiba et al., a mindfulness intervention was significantly superior to routine comprehensive care in reducing FOC, perception of labor pain catastrophizing, preference for nonurgent obstetric interventions, and increased labor pain acceptance (35). In line with our study, Duncan et al. also showed that mindful childbirth education improved women’s evaluations of labor and psychological functioning compared with standard childbirth education. Participants in the above study showed higher labor self-efficacy, fewer postpartum depression symptoms, and a tendency to use less painkillers and opioids during labor (44). In mindfulness, the individual is taught to focus on internal stimuli and teaches participants to accept and not judge or react, even if the stimulus is distressing to them. Therefore, self-compassion is an essential component of mindfulness-related interventions and is significantly associated with reduced anxiety, depression, and overall mental health (45). As observed in the present study, combining the two interventions of self-compassion and mindfulness and performing the intervention of \"mindful self-compassion training\" had much more significant effects on the mental health of pregnant women.\u003c/p\u003e\n\u003cp\u003eThe preparation of the intervention content by the researchers in collaboration with a psychologist and their direct supervision in all counseling sessions resulted in appropriate validity of this intervention, but given that it was a thesis project, long-term follow-up was not conducted due to the student's accelerated graduation. It is recommended that further follow-ups be planned and implemented after the intervention until before delivery. Additionally, this study was conducted on low-risk primiparous women and cannot be generalized to all pregnant women. Finally, it should be noted that due to the type of study, it was not possible to blind the participants in both the control and intervention groups and the researchers.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOnline MSC intervention resulted in a reduction in the overall mean score of FOC in primiparous women in the intervention group. Therefore, with the effectiveness of this intervention, it can be suggested to health policymakers that MSC online training be implemented in reproductive health counseling clinics for people with high FOC who are referred from health and medical centers to reduce FOC, so that pregnant mothers enjoy better mental health during pregnancy, and on the other hand, FOC is also reduced, and unnecessary interventions and cesarean sections are reduced.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCONSORT. Consolidated Standards for Reporting Trials. GOUMS: Golestan University of Medical Sciences\u003c/p\u003e\n\u003cp\u003eVersion A\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eW-DEQ A: Wijma Delivery Expectancy/Experience Questionnaire\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eFOC: fear of childbirth\u003c/p\u003e\n\u003cp\u003eMSC: mindful self-compassion\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis article is part of the master\u0026apos;s thesis in midwifery counseling. The authors thank GOUMS for supporting this project. We would like to thank the esteemed professors, especially the esteemed supervisor and the esteemed professors of the advisor and the vice president of research, technology and ethics at Golestan University of Medical Sciences, the midwives working in comprehensive health centers, and all the mothers who participated in the research and those who cooperated in the implementation of this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eIn this study, all ethical considerations in accordance with the Declaration of Helsinki were observed. The ethical code of this project (IR.GOUMS.REC.1402.317) was duly registered on the website of the National Committee for Ethics in Biomedical Research and eligible mothers signed an informed consent online before participating in the study and were assured the confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003e All authors have consent for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The datasets used and analyzed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare any conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e Research and technology deputy of Golestan University of medical sciences funding this research\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e \u0026quot;SA conducted data sampling and prepared the draft of the work. NSB supervised the overall project and participated in the design, interpretation of data with the first author. RBOD\u003c/p\u003e\n\u003cp\u003esupervised the intervention and AR performed the statistical analysis. All authors approved the final version and are accountable for their contributions.\u0026quot;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNilsson C, Hessman E, Sj\u0026ouml;blom H, Dencker A, Jangsten E, Mollberg M, et al. Definitions, measurements and prevalence of fear of childbirth: a systematic review. BMC Pregnancy Childbirth. 2018;18:1\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoroglu CO, Surucu SG, Vurgec BA, Usluoglu F. The fear of labor and the roles of midwives. LIFE: Int J Health Life-Sciences. 2017;3:51\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaisto T, Halmesm\u0026auml;ki E. 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The relaxation and stress reduction workbook. New Harbinger; 2008.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAkbarzadeh M, Toosi M, Zare N, Sharif F. Effect Of Relaxation And Attachment Behaviors Training On Anxiety In First-Time Mothers In Shiraz City, 2010: A Randomized Clinical Trial (Clinical Trial Article). 2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlijani H, Sadat Borghei N, Behnampour N. The Effect of Group Educations based on Cognitive-Behavioral Techniques on Fear of Child Birth in Primiparous mothers, Gorgan 2017. J Res Dev Nurs Midwifery. 2020;17(0):0.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaisto T, Toivanen R, Salmela-Aro K, Halmesm\u0026auml;ki E. Therapeutic group psychoeducation and relaxation in treating fear of childbirth. Acta Obstet Gynecol Scand. 2006;85(11):1315\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDimidjian S, Goodman SH, Felder JN, Gallop R, Brown AP, Beck A. Staying well during pregnancy and the postpartum: A pilot randomized trial of mindfulness-based cognitive therapy for the prevention of depressive relapse/recurrence. J Consult Clin Psychol. 2016;84(2):134.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZou L, Yeung A, Quan X, Boyden SD, Wang H. A systematic review and meta-analysis of mindfulness-based (Baduanjin) exercise for alleviating musculoskeletal pain and improving sleep quality in people with chronic diseases. Int J Environ Res Public Health. 2018;15(2):206.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGilbert P. The origins and nature of compassion focused therapy. Br J Clin Psychol. 2014;53(1):6\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGermer C, Neff K. Mindful self-compassion (MSC). Handbook of mindfulness-based programmes: Routledge. 2019:357\u0026thinsp;\u0026ndash;\u0026thinsp;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeff KD, Germer CK. A pilot study and randomized controlled trial of the mindful self-compassion program. J Clin Psychol. 2013;69(1):28\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeff KD. The Development and Validation of a Scale to Measure Self-Compassion. Self Identity. 2003;2(3):223\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErbil N. Relationship of Self-Compassion and Fear of Childbirth among Pregnant Women. Int J Caring Sci. 2022;15(1):255.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumar SA, Franz MR, DiLillo D, Brock Rebecca L. Promoting resilience to depression among couples during pregnancy: The protective functions of intimate relationship satisfaction and self-compassion. Fam Process. 2023;62(1):387\u0026ndash;405.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWijma K, Wijma B, Zar M. Psychometric aspects of the W-DEQ; a new questionnaire for the measurement of fear of childbirth. J Psychosom Obstet Gynecol. 1998;19(2):84\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAndaroon N, Kordi M, Ghasemi M, Mazlom R. The validity and reliability of the Wijma delivery expectancy/experience questionnaire (Version a) in primiparous women in Mashhad, Iran. Iran J Med Sci. 2020;45(2):110.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSacristan-Martin O, Santed MA, Garcia-Campayo J, Duncan LG, Bardacke N, Fernandez-Alonso C, et al. A mindfulness and compassion-based program applied to pregnant women and their partners to decrease depression symptoms during pregnancy and postpartum: Study protocol for a randomized controlled trial. Trials. 2019;20:1\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTerry ML, Leary MR. Self-compassion, self-regulation, and health. Self identity. 2011;10(3):352\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eL\u0026ouml;nnberg G, Jonas W, Unternaehrer E, Br\u0026auml;nstr\u0026ouml;m R, Nissen E, Niemi M. Effects of a mindfulness based childbirth and parenting program on pregnant women's perceived stress and risk of perinatal depression\u0026ndash;Results from a randomized controlled trial. J Affect Disord. 2020;262:133\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVeringa-Skiba IK, de Bruin EI, van Steensel FJ, B\u0026ouml;gels SM. Fear of childbirth, nonurgent obstetric interventions, and newborn outcomes: A randomized controlled trial comparing mindfulness‐based childbirth and parenting with enhanced care as usual. Birth. 2022;49(1):40\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoscucci O. Holistic obstetrics: the origins of natural childbirth in Britain. Postgrad Med J. 2003;79(929):168\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFelder JN, Lemon E, Shea K, Kripke K, Dimidjian S. Role of self-compassion in psychological well-being among perinatal women. Arch Women Ment Health. 2016;19:687\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCosta J, Pinto-Gouveia J. Acceptance of pain, self‐compassion and psychopathology: Using the Chronic Pain Acceptance Questionnaire to identify patients' subgroups. Clin Psychol Psychother. 2011;18(4):292\u0026ndash;302.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlsubaie M, Abbott R, Dunn B, Dickens C, Keil TF, Henley W, et al. Mechanisms of action in mindfulness-based cognitive therapy (MBCT) and mindfulness-based stress reduction (MBSR) in people with physical and/or psychological conditions: A systematic review. Clin Psychol Rev. 2017;55:74\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDhillon A, Sparkes E, Duarte RV. Mindfulness-based interventions during pregnancy: A systematic review and meta-analysis. Mindfulness. 2017;8:1421\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaer RA. Self-focused attention and mechanisms of change in mindfulness-based treatment. Cogn Behav Ther. 2009;38(S1):15\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHayes SC, Luoma JB, Bond FW, Masuda A, Lillis J. Acceptance and commitment therapy: Model, processes and outcomes. Behav Res Ther. 2006;44(1):1\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVeringa-Skiba IK, Ziemer K, de Bruin EI, de Bruin EJ, B\u0026ouml;gels SM. Mindful awareness as a mechanism of change for natural childbirth in pregnant women with high fear of childbirth: a randomised controlled trial. BMC Pregnancy Childbirth. 2022;22(1):47.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDuncan LG, Cohn MA, Chao MT, Cook JG, Riccobono J, Bardacke N. Benefits of preparing for childbirth with mindfulness training: a randomized controlled trial with active comparison. BMC Pregnancy Childbirth. 2017;17:1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePereira A, Xavier S, Bento E, Azevedo J, Marques M, Soares M, et al. Mindfulness, self-compassion and depressive symptoms in pregnant women. Eur Psychiatry. 2016;33(S1):S420\u0026ndash;S.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Mindful Self-Compassion, Intervention, Pregnant Woman, Fear of Childbirth","lastPublishedDoi":"10.21203/rs.3.rs-6320037/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6320037/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Pregnancy is a significant life event for all women, often accompanied by considerable joy; however, fear of childbirth increases as delivery approaches and has adverse effects on maternal mental health. Self-compassion, through the activation of the parasympathetic system, leads to physiological and psychological well-being and may reduce fear of childbirth. Therefore, this study aimed to determine the effect of mindful self-compassion on fear of childbirth in primiparous women under the coverage of comprehensive health service centers in Gorgan in 2024.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e: This randomized controlled trial was conducted as an interventional two-group study with a pre-post design on 42 pregnant women. Sampling was performed in two stages. In the first stage, sampling was done by convenience, and primiparous women with a gestational age of 12 weeks were invited to participate in the study. Eligible individuals were randomly assigned to either the intervention or control groups. The intervention group received eight weekly 90-minute sessions of mindful self-compassion training, while mothers assigned to the control group received no training. Both groups completed the Persian version of the Wijma Delivery Expectancy Questionnaire at two stages: once at the beginning of the study and again eight weeks later. The collected data were entered into SPSS version 18 and analyzed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The mean total score of fear of childbirth in the intervention group (77.43±14.70) and control group (77.95±8.12) at the beginning of the study showed no statistically significant difference (P = 0.88). After the intervention, the mean total score of fear of childbirth in the intervention group (46.81±10.83) and control group (81.86±6.87) showed a statistically significant difference (P \u0026lt; 0.001). Cohen's d indicated that the intervention had a strong effect on reducing the mean total score and subscales of fear of childbirth (Cohen's d = -3.86).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: In the present study, the mindful self-compassion intervention reduced fear of childbirth in primiparous women. Therefore, it is suggested that this intervention be implemented in health care centers to reduce fear of childbirth so that pregnant women have a pleasant pregnancy experience.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration: \u003c/strong\u003ehttp://www.irct.ir/, IRCT20231025059856N1 registered November 19, 2023.\u003c/p\u003e","manuscriptTitle":"The effect of mindfulness self-compassion training on the fear of childbirth among first time pregnant women: a randomized controlled trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-20 16:24:25","doi":"10.21203/rs.3.rs-6320037/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-01T12:01:09+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-17T23:23:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-16T21:07:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"208297738945335677781644830585059627515","date":"2025-10-14T18:01:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"149007783638434596879487304095326424654","date":"2025-10-07T08:50:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"120584306964487927171282066016014532338","date":"2025-06-26T06:21:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-17T18:00:30+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-12T06:44:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-20T18:25:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-19T06:17:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-04-19T06:16:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"13b3f6c8-bbbe-455d-88dd-1c734131f49b","owner":[],"postedDate":"June 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-31T03:23:20+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-20 16:24:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6320037","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6320037","identity":"rs-6320037","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}