Effect of Antenatal of brief-CBT on fear of childbirth, prenatal attachment, and quality of life (QoL): A Quasi-Experimental Study               

Effect of Antenatal of brief-CBT on fear of childbirth, prenatal attachment, and quality of life (QoL): A Quasi-Experimental Study | 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 Effect of Antenatal of brief-CBT on fear of childbirth, prenatal attachment, and quality of life (QoL): A Quasi-Experimental Study Mohammedamin Hajure, Habtemu Jarso Hebo, Negeso Gebeyehu Gejo, and 13 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6534688/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Mental health problems are common during pregnancy and are associated with maternal, fetal, and neonatal morbidity and mortality. While various interventions have been explored to address these challenges, evidence on the effectiveness of brief cognitive-behavioral techniques (CBT) for enhancing prenatal attachment and reducing fear of childbirth remains limited. So Thisstudy aimed to evaluate the effects of brief cognitive behavioral techniques on enhancing prenatal attachment, reducing fear of childbirth, and their secondary effect on the health-related quality of life (HRQOL) among pregnant women attending selected hospitals in the West Arsi zone, Ethiopia in 2024. Methods A quasi-experimental study was conducted from March 1 to July 30, 2024, in selected public hospitals of the West Arsi zone, Ethiopia. A total of 117 pregnant women attending antenatal care were included (58 in the experimental and 59 in the control group). Participants in the intervention group received CBT-based counselling in a group format (8 groups with 6–8 members each), with weekly sessionsover 8 weeks.Each sessions lasted 15–30 minutes. Result The findings indicated negligible significant differences in fear of childbirth between the intervention and control groups at baseline (t = 2.802, P < 0.05). Post-intervention, significant differences were observed between the groups in fear of childbirth (t=-3.51, P < 0.01) and depression subscales (t=-4.43, P < 0.001). However, no significant difference in the mean score was found in maternal antenatal attachment (MAAS) score during post-intervention (t=-.531, P = 0.149). Significant improvements were observed in the physical and psychological subscales of HRQOL following the intervention. Fear of childbirth ( β = -0.046), depressive symptoms ( β = -0.561), and good social support ( β = 0.080) were significant predictors of HRQoL (P value > 0.05). Conclusion This study demonstrates that CBT-based prenatal interventions effectively reduce childbirth-related fear and improve maternal quality of life. However, the intervention showed no significant effect on maternal-fetal attachment. These findings underscore the need for a holistic approach that incorporates both cognitive techniques to address maternal mental health and targeted strategies to enhance maternal wellbeing during pregnancy. Quasi experimental Brief cognitive technique Pregnant women Antenatal Ethiopia Figures Figure 1 Figure 2 Introduction Fear of childbirth is a term used to describe feelings of unease and worry before, during, or after childbirth, often triggered by thoughts of upcoming labor and delivery (1) or by witnessing the fearful reactions of others to labor and childbirth (2). This fear can not only prolong labor, require anesthesia, and increase the the likelihood of ceasarean sections but also cause extremely painful labor and delivery (3-5). Fear of childbirth is associated with negative birth outcomes, impacting woman's health and wellbeing both during and after pregnancy, often resulting in posttraumatic stress disorder (1). Studies have shown that lack of prenatal counseling (1, 6), childbirth experience, worry related to pain during childbirth, and a history of previous birth complications such as wounds, episiotomy, or perineal tears, contribute to fear of childbirth (7) (8). Additionally, psycho-socio-cultural factors, as well as perceived societal (7) and family support (5, 9, 10) were identified as related to fear of childbirth among women. Therefore, addressing mental health issues of pregnant and laboring women carefully during antenatal consultations or care is crucial. Moreover, research identified different factors affecting maternal-fetal attachment, including demographic (9), psychosocial (11), and obstetric (12) factors.(11,13). Factors such as better psychological functioning, good familial support, and having medical follow-ups, such as ultrasound, enhance maternal-fetal attachment, while the presence of psychological disorders and the use of psychoactive substances have been associated with lower levels of maternal-fetal attachment (1, 13). Research has established a positive association between maternal stress and fear of childbirth, with some studies indicating that this relationship may be moderate or favorable in nature (14, 15). Fear of childbirth is often triggered by concerns about pain and suffering to the mother or the unborn child, loss of control and autonomy, laboring alone, ruptures risk, mistrust of medical professionals, and past traumatic delivery experiences (16, 17). Cognitive techniques are beneficial in reducing fear of childbirth since they concentrate on the issue, alter the course of action, and do so quickly, helping them to cope with childbirth anxieties. It supports pregnant mothers in overcoming their anxieties about giving birth and having a more positive delivery (1, 12). Addressing prenatal mental health involves care during prenatal, encouragement, and educations are crucial. Pregnant women who feel more self-efficacious and in charge of their labor and delivery are more satisfied with the delivery event and have less anxiety of giving birth (18). Cognitive techniques help pregnant women overcome their concerns of labor and have a more satisfied birth experience via acknowledging and changing their adverse emotions. These techniques are among the interventions that can be used to manage childbirth anxieties (1, 4, 12). Earlier studies have shown that education reduces anxiety suffered at birth (19). Additionally, qualified midwives' psycho-education and antenatal education were successful in lowering fear of childbirth (20, 21). This is in contrast to earlier research findings (16, 22) that showed CBT-based prenatal and postpartum training to have no effect and seem inadequate on the parental attachment. Others, however, particularly when given in the form of relaxation training (23) showed a positive or promising effect on the maternal attachment. Medication administration is not generally recommended during pregnancy and is only required in cases of moderate to severe level of psychological condition. The presence of minor psychological symptoms during the antepartum period can be adequately treated without the use of medication (24, 25). This is well evidenced via best practice guidelines used in different countries such as USA (American Psychiatric Association [APA] (26), Canada(27), United Kingdom (28), and Australia (29) states psychological interventions as the primarily treatments modality psychological disorders such as (30) during perinatal period, while medications are only considered for severe presentations. So, cognitive behavioral therapy, interpersonal psychotherapy, behavioral activation therapy, and problem-solving therapy are all included in the World Health Organization's mental health gap (31) intervention guide, which was created particularly for health care workers in countries with limited resources. Women’s perceived quality of life is essential to the particularly during perinatal health which includes domains such as physical, psychological, and social domains and is influenced by medical and social events that are important to women throughout pregnancy (32). Considering an earlier intervention on the fear of childbirth and prenatal attachment of pregnant women, two studies using antenatal education (19) and CBT techniques (33) in Turkey and only a single study from LMIC country (1, 34) used group psychotherapy and found promising outcome. No study was done in other LMIC countries like sub-Saharan Africa. Since the efficacy of this strategy has not yet been examined and a study took an opportunity to use antenatal care window since to recognize pregnant women for FOC and PA as the majority of them visit health care institutions in Ethiopia at this moment. Barriers to low access of mental health in the perinatal care in LMIC setting are includes cultural belief or societal norms, the severity of the condition, language barrier, personal behavior, and ineffective mental health care infrastructures. There is still a high rate of maternal and newborn mortality in Ethiopia despite the government's emphasis on maternal and child health. The mental health aspects have received less attention because the health care system for women usually places more emphasis on physical health (35) which have resulted in about 96% huge gaps in treatment for common antenatal condition like depression(30). Furthermore, the researches that are now accessible on antenatal mental healthcare were carried out in high-income nations, and less is known about the issue in low-income nations. So in order to control disparity, it is planned to conduct culturally specific, locally appropriate psychological interventions on the fear of childbirth and prenatal attachment to be delivered by non-specialist medical personnel in the routine maternal and childcare. Specifically, systematic review conducted by Wang X et al., 2023 (36) suggested that psychological education such as psycho-education, prenatal education, and counselling was found efficacious to effectively enhance prenatal attachment, reduce anxiety and depression whereas cognitive‐behavioural therapy and other beneficial approaches require further research (37). As far as we are aware, this is the first interventional study to assess to examine the effect of brief CBT on the fear of childbirth and prenatal attachment in Ethiopia. Accordingly, a quasi-experimental study was conducted, comparing women who receive brief CBT session (experimental group), with those who receive routine antenatal care (control group). Operational definitions Fear of childbirth : Measured using W-DEQ Version A, with scores ranging from 0 to 5, where 0 denotes "extremely" and 5 denotes "not at all,". The total score ranges from 0 to 165. A higher score indicates an increase, while a lower score reflects a reduced fear (9). Maternal antenatal attachment scale: Women's prenatal attachment increases as the score on the scale increases and decreases as the score decreases (38). HRQOL : Measured and classified using the mean WHOQOL-BREF score. Participants with a score less than or equal to the mean were categorized as having a poor QOL, whereas those with a score greater than the mean were classified as having a good QOL (39). Depression : Measured using the PHQ-9 scale. Participants with a score of five or higher were considered to have depression. Depression severity was categorized based on the PHQ-9 score: minimal (5-9), mild (10-14), moderate-severe (15-20), and severe (>20). Minimal (5-9), mild (10-14), and score of 5 or > indicate depression (40). Perceived social support: Assessed using the OSLO-3 scale, where a score of 3–8 indicates poor social support, 9–11 indicates moderate social support, and 12–14 indicates strong social support (41). Current use of substance: Defined as the use of alcohol, khat, or cigarettes for non-medical purposes within the past 3 months, as assessed by the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) (42). Methods Study setting: This study was conducted in selected hospitals within the west Arsi zone, Oromia Regional State, Ethiopia. Loke Primary Hospital and Negele Arsi Primary Hospital were assigned as the control and intervention groups, respectively. Negele Arsi Hospital is located approximately 21 kilometers from Shashemene, the capital of the West Arsi Zone, and 250 kilometers from Addis Ababa, the capital of Ethiopia. Loke Primary Hospital is situated in Siraro, one of the woredas in the Great Rift Valley within the West Arsi Zone (unpublished data). Study design : A quasi-experimental study with a single group pre-post-test design was used. One hospital was randomly assigned as an intervention group, and the other usual antenatal care as the control group. Data were collected for both groups. The intervention group received brief CBT sessions, while the control group did not. Post-intervention data collection allowed for a comparison of outcomes between the two groups. Population: The source population included all pregnant women attending antenatal care at public primary hospitals in the West Arsi zone. The study population comprised sampled mothers attending antenatal care at selected hospitals and present during the baseline data collection, intervention, follow-up, and post-intervention periods. Regarding the eligibility criteria, pregnant women were eligible for inclusion if they were aged 18 years or older, had a gestational age between 20–32 weeks, were able to read and write, and had no history of previous cesarean section delivery or complicated pregnancy. Additionally, participants could not have engaged in psychotherapy within 6 weeks prior to or during the study and needed to score above the mean on the W-DEQ and MAAS instruments. Participants were excluded if they had acute mental health conditions or were receiving treatment for such conditions. Woment with a current or past history of structured brief CBT for fear of childbirth or prenatal attachment were also excluded. Furthermore, participants unable to comprehend the intervention process or those who missed counselling sessions were ineligible. As to hospital selection, following WHO recommendations for integrating mental health into primary care settings, the four primary hospitals in the west Arsi zone (Loke, Negele Arsi, Nansabo, and Kokosa) were considered. Using a lottery method, Loke and Negele Arsi hospitals were selected as the control and intervention groups, respectively. Average monthly antenatal care attendance was obtained to estimate a two-month sample size. Consecutive sampling was used to recruit participants Fig 1. Sample size determination techniques The sample was calculated using G*power software version 3.1.9.2. Based on similar studies, an effect size of 0.5, a power of 80%, and alpha of 0.05 were considered in sample size determination for this study (43). Accordingly, sample size was calculated for both outcomes with the largest sample size were 102. Accounting for a 15% attrition rate, the total sample size was 117 (59 in the intervention group and 58 in the control group). Study subjects were recruited through consecutive sampling techniques ensuring equal allocation. Study variables Dependent variable : Fear of childbirth and prenatal attachment Independent variable s: Socio-demographic factors: age, gestational age, educational status of the mother and father, marital status, and monthly income. Obstetric and clinical factors : parity, pregnancy status (wanted or unwanted), preferred mode of birth, chronic medical conditions (e.g., hypertension, diabetes), history of birth complications (e.g., cesarean section, instrumental delivery, labor dystocia, tear). Psychosocial factors: use of substances (alcohol, cigarette, khat) , s ocial support , trauma, prior pregnancy experience , family size, quality of life, depression, and post-traumatic stress disorder. Data collection instrument Primarily outcome Fear of childbirth: Measured using the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ), a 33-item with a five-point Likert scale (0 = no to 5 = very high) Likert scale and total scale ranging from 0-165. (44). The instrument includes 33 items with It has shown good validity and reliability (Cronbach’s alpha was 0.89 and 0.93, respectively) (44). The instrument was validated among pregnant women with satisfactory internal consistency (α = 0.84) (8) The Cronbach's alpha for the current study is 0.86. Maternal Antenatal Attachment Scale (MAAS): The instrument was developed by Condon in 1993(45) and Golbasi et al. conducted a validity and reliability analysis of the instrument in Turkey in 2015. The measure, which consists of 19 items, assesses a potential mother's attitudes, behaviors, and sentiments regarding the fetus. The Likert-type scale has five items, each of which is rated between 1 and 5. The scale contains two sub-dimensions: "time devoted to attachment" (items 1, 2, 4, 5, 8, 14, 17, 18) and "quality of attachment" (items 3, 6, 9, 10, 11, 12, 13, 15, 16, 19). Since item 7 have no bearing on any sub-dimension, the total score is the only factor taken into account. Inverted codes are found in items 1, 3, 5, 6, 7, 9, 10, 12, 15, 16, and 18. There is no threshold value on the scale. Greater scores correspond to greater attachment levels (38). The Cronbach's alpha for the current study is 0.731. Secondary outcome I- Health-Related Quality of life assessment tools: The WHOQOL-BREF, a shorter version of the WHO quality of life questionnaires, was used to measure quality of life as an intermediary variable. There are 26 items in all, 24 of which are divided into the four categories namely physical (7 item), psychological (item 6), social relationships (item 3), and environmental (item 8). To evaluate a person's impression of their overall health and quality of life, the final two questions was scored separately. The raw scores for each item was converted to a range between 4 and 20, then to corresponding ranges between 0 and 100. Every item of the WHOQOL-BREF is rated on a Likert scale from (very dissatisfied) to 5 (very satisfied), and the score spans from 26 (lowest score) to 130 (highest score). Additionally, the mean of each domain and the mean total score were determined. In several contexts, the instrument was applied to pregnant women (31) and received strong internal consistency validation in the Ethiopian setting (Cronbach's alpha = 0.93)(46, 47). The Cronbach's alpha of the item for the current study is 0.892 Independents variables) I - Socio-demographic, clinical and psychosocial factors: We extensively reviewed earlier literature and identified the following variable in the socio-demographic profile: age, age, gestational age, educational status of mother and father, marital status, parity, status of pregnancy (wanted or unwanted), preferred mode of birth for current pregnancy, another chronic medical illness (hypertension, diabetes mellitus, etc), history of birth complication ( ceaseran section, instrumental delivery, labor dystocia, tear), and current use of drugs (alcohol, cigarette, khat), social support, prior pregnancy experience and family size. III – Patient Health Questionnaires (PHQ-9) - The PHQ-9 is a nine-item, self-administered questionnaire used to assess for depression symptoms. The nine PHQ-9 items depend entirely on the 9- DSM-IV (Diagnostic and Statistical Manual, Fourth Edition) major depression disorder diagnostic criteria. Total PHQ-9 scores, used to assess severity, vary from 0 (lack of depressed symptoms) to 27 (most severe depressive symptoms). Scores for each of the 9 items range from 0 (not at all) to 3 (almost daily). When 5 or more of the 9 symptoms have been present for "more than half the days" (a score of 2) during the course of the previous two weeks and one of the symptoms is a depressed mood or loss of interest (anhedonia), major depression is considered to be present. The isntrument was now validated in Afaan Oromom language for use (Woldetensay, 2018 (40). Intervention protocol CBT protocol The protocol for CBT was designed by reviewing different manual, guidelines and consultation with the experts in the field of psychiatry and adapted into Ethiopian context. The treatment was offered to participants free of charge. CBT sessions were delivered in a group therapy format and the sessions were offered in successive weeks by trained mental health counsellor. The control group was not given any intervention. The protocol was then administered to the intervention group in a group format (8 groups, each group consists of 6-8 members), and the sessions were offered once per week for 8 weeks succeesively, each session lasting from 15-30 minutes in length. Participants in the control condition will visit the antenatal unit based on their scheduled appointments. The research assistant was employed from community health care workers and communicates for any concern they have on the research. She/he will register their phone numbers and gives his own to ease communication and effort was made to provide a safe, engaging, and welcoming environment for the participants during each session. Participants were asked to complete written assessments twice: during the baseline assessment and at the completion of the CBT group program. After the session ends post-test was given to the intervention group, and the control group received only routine care. Details of the protocol are summarized in Supplementary 1 . A detailed description of session-by-session content of the CBGT protocol adopted (48). An interviewer administered questionnaires was used to collect data. A questionnaire is prepared in English language was back to back translated into local language (Afaan Oromo and Amharic) with the experts in the field. A total of 5% of the recruited sample participated in the pilot study at Nansabo primarily hospital 2week before the actual data collection. Training was given to the four data collectors, two supervisors, research assistant and counsellor. Any error, ambiguity, incompleteness, or other encountered problems was addressed immediately after supervisor receives filled questionnaire from each data collectors. Data was collected in two different phases. First, baseline data on the fear of childbirth and prenatal attachment of the pregnant women was collected. Initially, mothers attending antenatal follow-up were enrolled in the study from the two hospitals for 2 weeks. Baseline information regarding demographic and clinical information was obtained for all participants using an interview-administered questionnaire and chart review for clinical variables. An initial evaluation was undertaken to determine study eligibility based on the eligibility criteria, followed by a monitoring period to collect pre-intervention fear of childbirth (FOC) and Maternal Antenatal Attachment Scale (MAAS) data among study participants. Second, after the intervention phase is completed, end-line data on the fear of childbirth and prenatal attachment of pregnant women was collected. Considering data processing and analysis, Epi-data version 4.4.1, then exported to the SPSS version 27 software was used for data entry and analysis respectively. We have assessed the intervention effects at baseline and post intervention using the bivariable analyses comparing the intervention conditions to the control condition. We have examined the treatment effects using a GLM to account for correlations between repeated measurements for quality of life. An Independent sample t-test and one-way ANOVA was used to compare the intervention and control groups. The effect size was interpreted based on 0.01 = small effect; 0.06 = moderate effect; and 0.15 = large effect(49). Ethical considerations Ethical clearance was obtained from research ethical review of Shashemene campus, Madda Walabu University (RCSTT 15/2024). Then official letter was sent to selected stakeholder (Zonal health office, Hospitals). Selected participants were told about nature, purposes, benefits and adverse effects of the study and invited to participate. Confidentiality was ensured. Participation was completely voluntary, with no economic or other motivation, and each participant signed written informed consent for their participation. RESULT Fidelity of the intervention A total of 117 pregnant women participated in the study, with 58 and 59 women enrolled in the intervention and control groups, respectively. In the intervention group, seven (7) mothers did not complete the baseline assessment (four requested referral to other healthcare institutions, and three did not return to the institution or could not be traced during the study period). In the control group, five mothers did not complete the baseline assessment (three due to referral to another center and two did not return to the center). Additionally, three respondents from the intervention group did not complete the intervention, resulting in 51 mothers completingthe final interview or assessment Fig 2. Baseline characteristics of the study population There were no significant differences between groups in mean age or gestational week. Educational attainment varied modestly: 59.3% of controls versus 49.1% of the intervention group had only a primary education. Unemployment rates were similarly high in both arms (72.5% of controls; 70.7% of the intervention group). Most pregnancies were planned (85.2% control; 74.5% intervention), and a preference for vaginal delivery was common across both groups. However, baseline measures revealed that the intervention group had significantly lower social support compared with controls ( Table 1). Prenatal attachment and fear of childbirth There was no significant difference in the pre-intervention mean scores for the W-DEQ and MAAS between the two groups (Table 2). However, a negligible significant difference was observed in fear of childbirth scores at baseline (t=2.802, p = 0.005), with the intervention group showing higher fear levels. Further, a significant mean difference between the two groups during pre-intervention scores MAAS, Rosenberg scores and depression score were not found (P > 0.05) (Table 2). Mean post-intervention scores for the two groups for MAAS, Rosenberg, and W-DEQ are given in Table 2. A significant mean difference was found between the groups (P<0.01) in terms of Rosenberg, and W-DEQ. The mean score of fear of childbirth (W-DEQ) among women during preintervention in the experimental group was higher than that of the women in the control group, which indicates that their fear of child birth was higher than that of the women in the control group (P <0.01). Moreover, the mean difference for W-DEQ in the post intervention was lower as compared to pre-intervention score (t=2.679, P<0.01). This point for reduced fear of childbirth among pregnant women who received psychological intervention as compared to control group. There is no significant difference in the mean score of maternal antenatal attachment (MAAS) score during post intervention (t=-1.352, P=0.181). The mean score of maternal self - esteem in the experimental group was higher than that of the women in the control group, which indicates that their self-esteem was higher than that of the women in the control group (P< 0.001). The differences between the groups for fear of childbirth and self-esteem sub scales were significant in the post intervention ((t=2.679, P<0.01), and t=4.642 P<0.001, respectively). This finding indicates that the intervention had beneficial effects of lowering the mean score of the fear of childbirth and enhancing maternal self-esteem (Table 2). Quality of life among study participants The intervention group had significantly higher post-intervention mean scores in the physical (t = 8.09, p = <0.001) and psychological (t=-1.62, p = <0.001) domains of quality of life compared to the control group, while no significant differences were observed in the other domain of quality of life. Moreover, larger mean difference was observed in the physical domain as compared to other quality of life in the post intervention period. (Table 3) A generalized linear model was used to assess the influence of maternal antenatal attachment, fear of childbirth, and other explanatory variables on maternal quality of life. The analysis included factors such as fear of childbirth, depressive symptoms, self-esteem, maternal antenatal attachment, preferred mode of delivery, parity, and social support. In the final model, three variables emerged as significant predictors of maternal quality of life: fear of childbirth (β = -0.046), depressive symptoms (β = -0.561), and social support (β = 0.080). In the final analysis, the mean scores of maternal antenatal attachment, self-esteem, depressive symptoms, fear of childbirth, and social support showed a highly significant association with maternal quality of life (R = .518, R² = .483, F = 14.9, P < 0.001), collectively accounting for 52% of the total variance in the quality of life score. ( Table 4). Discussion Cognitive-behavioral training is a flexible, problem-focused, and low-risk intervention that has proven particularly effective in addressing birth-related anxiety and associated psychosocial factors. To the best of our knowledge, this is the first study conducted in Ethiopia to evaluate the effectiveness of a brief cognitive-behavioral intervention among pregnant women receiving care in primary healthcare settings. Pregnancy-related education and counseling were found to enhance women’s self-determination, support their adaptation to new life circumstances, and reduce psychological distress (50). Research suggests that enhanced and comprehensive prenatal education programs significantly improve maternal adaptability during the postpartum period compared to standard programs. Evidence indicates that these programs can enhance pregnant women’s knowledge, attitudes, and preferences regarding mode of delivery. Furthermore, they have been shown to positively influence birth preparedness, mental well-being, and overall birth outcomes—contributing to reductions in anxiety and depressive symptoms, and potentially increasing the likelihood of vaginal birth. (51). This study aimed to assess the impact of cognitive-behavioral therapy (CBT)-based education on pregnant women’s fear of childbirth and prenatal attachment. The findings revealed that women who received CBT interventions reported significantly reduced childbirth-related fear compared to the control group receiving standard prenatal education. However, the intervention had no measurable effect on prenatal attachment. Notably, this research contributes to the limited literature on evidence-based prenatal care in Ethiopia, challenging traditional educational approaches. These findings align with previous studies conducted elsewhere that antenatal education is associated with significant reduction of fear of childbirth (52) (53, 54). Furthermore, earlier research on the effect of cognitive-behavioral based training programmes on pregnant women's fear of childbirth (38),(55) found that the programmes improved women’s coping skill with and lessen their fear of childbirth. The similarities could account for comparable study designs and population types in both settings, despite differences in session length, patient characteristics, and study setting. Unexpectedly, this study found no significant effect of CBT on maternal-fetal attachment, which is consistent with previous research but contradicts data that suggest psychological therapies improve attachment. Cultural and socioeconomic differences in understanding of maternal-fetal bonding may account for the disparities. Previous research showed that health facilities and related authorities should consider providing psychological therapies, such as mindfulness mother training programs on maternal-fetal attachment, in addition to routine prenatal care (56). Notably, the current study's findings demonstrated that a brief cognitive intervention had no influence on the mean score of maternal-fetal attachment following intervention, which was consistent with previous research findings (19). However, this contradicted the findings of a prior study, which found that the psychological intervention improved mother fetal attachment (56, 57). In a summary, several research (22, 58, 59) have shown that relaxation training is useful throughout the prenatal period. However, they discovered that parental attachment was unaffected by education delivered prior to prenatal sessions. The discrepancy between the findings could be explained by the respondents' understanding and significance of the maternal fetal attachment notion for women (60) based on their social and cultural backgrounds. Maternal stress can also have an impact on child outcomes by disrupting the functioning of both the mother and the fetus (61), and it is significantly linked to psychological health, the maternal-fetal relationship, and baby outcomes (62, 63). According to a prospective descriptive study (64), a woman's confidence in her ability to use coping mechanisms and relaxation techniques during labour and delivery decreased with her anxiety level. In this way, a decrease in prenatal education-induced fear of childbirth could give rise to improved maternal attachment and quality of life after the intervention. Consistent with the aforementioned results, the current study revealed that pregnant women who received counselling using brief cognitive behavioral techniques (W-DEQ) had a lower mean score in their fear of childbirth (P<0.01) than they had before the intervention. This was at odds with the findings of study from Victoria (65) and Sweden (66) who found that prenatal education had no impact on a woman's experience of giving birth and that this was likely due to insufficient preparation (65). The observed variations in outcomes may stem from differences in study design, intervention duration, and contextual settings. Multivariable regression analysis revealed a significant inverse association between fear of childbirth and quality of life, with each unit increase in childbirth fear corresponding to a 22.5% reduction in quality of life. This relationship may be mediated by fear-induced impairments in problem-solving abilities, social functioning, and physical health maintenance. Cognitive-behavioral interventions specifically target catastrophic thought patterns (e.g., “Childbirth will destroy my body”), thereby reducing the cognitive distortions that both intensify fear of childbirth and disrupt daily functioning. As these irrational fears subside, women are able to participate more fully in occupational and social activities, which in turn enhance multiple domains of their quality of life. Depression emerged as another significant predictor of quality of life in the final regression model (t =-4.727, p = 0.001), with a moderate-to-large effect size (partial η² = 0.168). While existing literature suggests prenatal stress may enhance maternal-fetal attachment, it simultaneously elevates risk for prenatal depression. This paradoxical relationship may ultimately contribute to quality-of-life deterioration. Consistent with previous findings, depression demonstrated significant negative associations across all QOL domains (67-69). The analysis revealed that each unit increase in perceived social support was associated with a 4.3% improvement in quality of life scores (t = 2.194, p≤ 0.05). This positive association between social support and QOL aligns with established findings in the literature (70-72). This observed association may be explained by the stress-buffering effect of social support during pregnancy. Psychosocial encouragement and practical assistance can mitigate depressive symptoms, thereby indirectly enhancing overall quality of life. In the final regression model, clinical variables including parity and preferred delivery mode showed no statistically significant association with quality of life (all p > 0.05). The absence of a significant relationship between these clinical variables and maternal quality of life may reflect the effectiveness of counseling provided in our sample or the greater influence of other psychological determinants. Moreover, it suggests that clinical factors may exert less impact on quality of life than key psychosocial elements such as fear of childbirth, depressive symptoms, and social support. Limitation of the study: This study employed a quasi-experimental design, which lacks randomization in the sampling technique. This limitation may affect the generalizability of the findings and conclusions. Furthermore, the study did not include midline assessments to evaluate the impacts of the educational intervention over the short term. The groups were not randomized, as it was assumed that women would be hesitant to participate training sessions they did not wish to attend, potentially leading higher dropout rates. Another weakness of this study could be the use of a self-reportedmeasures, which may introduce response bias. Furthermore, the varying trimesters of the pregnant participants might have introduced confounding factors that could influence the outcome. Lastly, the study could not determine whether women with higher levels of childbirth fear and lower prenatal attachment readinesswere more likely to receive parity interventions, which may have affected the results. Conclusion The study’s findings suggest that, cognitive-behavioral therapy during pregnancy could help reduce women's fear of childbirth and improve their quality of life. However, the intervention did not demonstrate a significant effect on improving maternal-fetal bonding. To improve maternal mental health and well-being, adopting a comprehensive strategy that incorporates cognitive approaches is essential. These findings underscore the need for a holistic approach that incorporates both cognitive techniques to address maternal mental health and targeted strategies to enhance maternal wellbeing during pregnancy. Reccommendation : Efforts to prevent maternal mental health challenges in Ethiopia should focus on culturally specific, locally appropriate psychological interventions that integrate cognitive approaches. These interventions could be delivered by non-specialist medical personnel as part of routine maternal and childcare, ensuring alignment with the maternal continuum of care. Future research should prioritize well-designed randomized controlled trials with larger sample sizes to generate robust evidence and enable firm conclusions. Abbreviations APA - American Psychiatric Association CBT –Cognitive Behavioral Techniques FOC – Fear of Complication HRQOL – Health Related Quality of Life Mh-GAP – mental health Global Action Programme LMIC – Low and Middle Income Countries MDD – Major Depression Disorder PAI - Prenatal Attachment Inventory PHC – Primarily Health Care USA – United States of America W-DEQ- Wijma Delivery Expectancy/Experience Questionnaire Declarations Author Contribution MAH, MM, JE, AM, and WG wrote and designed the protocol, led the data collection process, analysed the data, and reviewed and edited the manuscript. AW, BM, GW, GN, SS revises and approves the protocol, takes part in data analysis, reviews and edits the manuscript. LW, SW, FB, BG, HJ, NG, DY contributed to data analysis, drafting the manuscript, critically reviewing and approving the manuscript for publication. All authors read and approved the final manuscript. 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Baseline characteristics of the study participants, 2024 Characteristics Intervention group [n=51], (n %) Control group [n=54], n (%) P-value Age ¶ 26.12±4.16 26.20±4.05 0.915 Gestational week ¶ 22.94±2.99 22.91±2.79 0.952 Current living status* Live with her husband 46(46.0) 54(54.0) Χ 2 = .018 Live without her husband 5(100) - Mothers level of education* Primarily education 25(43.9%) 32(56.1%) Χ 2 = .150 Secondary education 7(38.9%) 11(61.1%) College and above 19(63.3%) 11(36.7%) Spouse level of education* Unable to read and write 24(60.0%) 16(40.0%) Χ 2 =.181 Primarily education 20(40.8%) 29(59.2%) Secondary education 7(43.8%) 9(56.3%) Occupational status * Unemployed 37(64.9%) 20(35.1%) Χ 2 <0.001 employed 14(29.2%) 34(70.8%) Residence Urban 28(45.9%) 33(54.1%) Χ2=.519 Rural 23(52.3%) 21(47.7%) Parity * Nulliparous 25(42.4%) 34(57.6%) Χ 2 = .150 Multiparous 26(56.5%) 20(43.5%) Preferred mode of birth* Vaginal 42(46.7%) 48(53.3%) Χ 2 =.339 Caesarean section 9(60.0%) 6(40.0%) Social support * Poor 16(80) 4(20) Χ 2 =.003 Moderate 30(44.8) 37(55.2) Strong 5(27.8) 13(72.2) Status of the current pregnancy * Wanted 38(45.2) 46(54.8) Χ 2 =.172 Unwanted 13(61.9) 8(38.1) Value in parenthesis are percentage, ¶ frequency, * Mean±standard deviation Table 2. Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ), Maternal self-esteem and antenatal attachment score (MAAS) and depression score before and after intervention Scales Pre test Post test Intervention group(n=51) , Mean (SD) Control group (n=54), Mean (SD) P – value T Mean difference Intervention group(n=51), Mean (SD) Control group (n=54) , Mean (SD) P- value T Mean difference W-DEQ 51.18±11.13 46.37±5.264 0.005 2.802 4.806 45.90±5.947 43.22±4.073 0.008 2.679 2.680 MAAS 21.14 ± 0.775 21.17±0.720 0.841 -.202 -.029 21.96±1.113 22.24±1.008 0.181 -1.352 -.280 Rosenberg Self-esteem 23.94±0.881 24.08±0.917 0.448 -.761 -.134 24.27±0.874 23.52±0.795 <0.001 4.642 0.756 PHQ-9 2.98±1.30 3.13±1.82 0.632 -.485 -.149 2.706±1.100 2.75±1.59 <0.001 -.201 0.053 Note: Abbreviation: SD, Standard Deviation; MAAS, Maternal antenatal attachment scale, W-DEQ= Wijma Delivery Expectancy/Experience Questionnaire, PHQ -9 - Patient Health Questionnaires 9 item. Table 3. Association between domains of HRQOL for CG and/or IG (Mean ±SD) after the intervention, 2024. NB: IG –intervention group, CG: control group Domain of HRQOL IG (n=51) CG (n=54) t p-value 95% CI Mean difference Physical health 23.69±1.463 22.06 ± 0.231 8.09 0.000 (1.23, 2.03) 1.631 Psychological 18.59±1.344 18.96 ± 1.009 -1.62 0.000 (-.833, .084) -.375 Social domain 10.08± 0.595 9.26± 0.442 7.92 0.841 (0.617,1.02) .819 Environmental 21.61±0.850 20.81± 0.992 4.39 0.000 (0.434,1.15) .793 Table 4. The effect of W-DEQ, MAAS and other independent variables on quality of life scale of pregnant women: results of multiple regression analysis (n=105) Independent variable 95% Confidence Interval Β SE t Lower bound Upper bound Partial Eta Squared P-value Coefficient 65.53 5.38 12.18 54.85 76.21 .605 <0.001 Self esteem .366 .197 1.860 -.025 .757 .034 .066 MAAS .113 .126 1.898 -.137 .362 .008 .372 W-DEQ -.046 .012 -3.77 -.070 -.022 .128 <.0001 PHQ-9 -.561 .127 -4.727 -.812 -.309 .168 <.0001 Social support 0.080 .038 2.095 .004 .155 .043 .039 Vaginal delivery preference -.323 .520 -.621 -1.36 .710 0.004 0.094 Nulliparous parity .418 .353 1.183 -2.83 1.12 0.014 .240 Note: model adjusted for: Maternal age, gestational week, parity, pregnancy status, educational status of mothers and fathers R 2 = .518, Adjusted R 2 = .483, F: 14.90, P<0.001, The bold P values indicate statistically significant differences, Abbreviation: SE, Standard error; MAAS, Maternal antenatal attachment scale, W-DEQ= Wijma Delivery Expectancy/Experience Questionnaire, PHQ -9 - Patient Health Questionnaires 9 item Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile.docx Supplementary file 1. Four week CBT sessions for the fear of childbirth and prenatal among pregnant women Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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11:23:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6534688/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6534688/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88003058,"identity":"d3200093-a74a-4438-b9c5-ea76a4232123","added_by":"auto","created_at":"2025-07-31 10:30:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":72411,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic presentation of sampling technique\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-6534688/v1/89f7afdf24c86e43d730dd10.png"},{"id":88003059,"identity":"944eacd9-1346-4768-8fc4-200e6858b638","added_by":"auto","created_at":"2025-07-31 10:30:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":59309,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram of the research procedures\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-6534688/v1/e45c2611e8ba947a8b43c1f1.png"},{"id":96605260,"identity":"33b03331-5507-495f-8928-23ed69ac46c3","added_by":"auto","created_at":"2025-11-24 09:21:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1274970,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6534688/v1/e1536a5b-1149-4727-b957-e27c770b7a99.pdf"},{"id":88003062,"identity":"c4db4e88-ef06-4541-9565-681102ff7683","added_by":"auto","created_at":"2025-07-31 10:30:05","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":27950,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplementary file 1. Four week CBT sessions for the fear of childbirth and prenatal among pregnant women\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Supplementaryfile.docx","url":"https://assets-eu.researchsquare.com/files/rs-6534688/v1/076fc1af88fc9698d0a8fa64.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect of Antenatal of brief-CBT on fear of childbirth, prenatal attachment, and quality of life (QoL): A Quasi-Experimental Study ","fulltext":[{"header":"Introduction","content":"\u003cp\u003eFear of childbirth is a term used to describe feelings of unease and worry before, during, or after childbirth, often triggered by thoughts of upcoming labor and delivery (1) or by witnessing the fearful reactions of others to labor and childbirth (2). This fear can not only prolong labor, require anesthesia, and increase the the likelihood of ceasarean sections but also cause extremely painful labor and delivery (3-5). Fear of childbirth is associated with \u0026nbsp;negative birth outcomes, impacting woman\u0026apos;s health and wellbeing both during and after pregnancy, often resulting in posttraumatic stress disorder (1). Studies have shown that lack of prenatal counseling (1, 6), childbirth experience, worry related to pain during childbirth, and a history of previous birth complications such as wounds, episiotomy, or perineal tears, contribute to fear of childbirth (7) (8). Additionally, psycho-socio-cultural factors, as well as perceived societal (7) and family support (5, 9, 10) were identified as related to fear of childbirth among women. Therefore, addressing mental health issues of pregnant and laboring women carefully during antenatal consultations or care is crucial. Moreover, research identified different factors affecting maternal-fetal attachment, including demographic (9), psychosocial (11), and obstetric (12) factors.(11,13). Factors such as better psychological functioning, good familial support, and having medical follow-ups, such as ultrasound, enhance maternal-fetal attachment, while the presence of psychological disorders and the use of psychoactive substances have been associated with lower levels of maternal-fetal attachment (1, 13).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResearch has established a positive association between maternal stress and fear of childbirth, with some studies indicating that this relationship may be moderate or favorable in nature (14, 15).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFear of childbirth is often triggered by concerns about pain and suffering to the mother or the unborn child, loss of control and autonomy, laboring alone, ruptures risk, mistrust of medical professionals, and past traumatic delivery experiences (16, 17). Cognitive techniques are beneficial in reducing fear of childbirth since they concentrate on the issue, alter the course of action, and do so quickly, helping them to cope with childbirth anxieties. It supports pregnant mothers in overcoming their anxieties about giving birth and having a more positive delivery (1, 12). Addressing prenatal mental health involves care during prenatal, encouragement, and educations are crucial. Pregnant women who feel more self-efficacious and in charge of their labor and delivery are more satisfied with the delivery event and have less anxiety of giving birth (18).\u003c/p\u003e\n\u003cp\u003eCognitive techniques help pregnant women overcome their concerns of labor and have a more satisfied birth experience via acknowledging and changing their adverse emotions. These techniques are among the interventions that can be used to manage childbirth anxieties (1, 4, 12). Earlier studies have shown that education reduces anxiety suffered at birth (19). Additionally, qualified midwives\u0026apos; psycho-education and antenatal education were successful in lowering fear of childbirth (20, 21). This is in contrast to earlier research findings (16, 22) that showed CBT-based prenatal and postpartum training to have no effect and seem inadequate on the parental attachment. Others, however, particularly when given in the form of relaxation training (23) showed a positive or promising effect on the maternal attachment.\u003c/p\u003e\n\u003cp\u003eMedication administration is not generally recommended during pregnancy and is only required in cases of moderate to severe level of psychological condition. The presence of minor psychological symptoms during the antepartum period can be adequately treated without the use of medication (24, 25).\u003c/p\u003e\n\u003cp\u003eThis is well evidenced via best practice guidelines used in different countries such as USA (American Psychiatric Association [APA] (26), Canada(27), United Kingdom (28), and Australia (29) states psychological interventions as the primarily treatments modality psychological disorders such as (30) during perinatal period, while medications are only considered for severe presentations. So, cognitive behavioral therapy, interpersonal psychotherapy, behavioral activation therapy, and problem-solving therapy are all included in the World Health Organization\u0026apos;s mental health gap (31) intervention guide, which was created particularly for health care workers in countries with limited resources. Women\u0026rsquo;s perceived quality of life is essential to the particularly during \u0026nbsp; perinatal health which includes domains such as physical, psychological, and social domains and is influenced by medical and social \u0026nbsp;events that are important to women throughout pregnancy (32).\u003c/p\u003e\n\u003cp\u003eConsidering an earlier intervention on the fear of childbirth and prenatal attachment of pregnant women, two studies using antenatal education (19) and CBT techniques (33) in Turkey and only a single study from LMIC country (1, 34) used group psychotherapy and found promising outcome. No study was done in other LMIC countries like sub-Saharan Africa. Since the efficacy of this strategy has not yet been examined and a study took an opportunity to use antenatal care window since to recognize pregnant women for FOC and PA as the majority of them visit health care institutions in Ethiopia at this moment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBarriers to low access of mental health in the perinatal care in LMIC setting are includes cultural belief or societal norms, the severity of the condition, language barrier, personal behavior, and ineffective mental health care infrastructures. There is still a high rate of maternal and newborn mortality in Ethiopia despite the government\u0026apos;s emphasis on maternal and child health. The mental health aspects have received less attention because the health care system for women usually places more emphasis on physical health (35) which have resulted in about 96% huge gaps in treatment for common antenatal condition like depression(30). Furthermore, the researches that are now accessible on antenatal mental healthcare were carried out in high-income nations, and less is known about the issue in low-income nations. So in order to control disparity, it is planned to conduct culturally specific, locally appropriate psychological interventions on the fear of childbirth and prenatal attachment to be delivered by non-specialist medical personnel in the routine maternal and childcare. Specifically, systematic review conducted by Wang X et al., 2023 (36) suggested that psychological education such as psycho-education, prenatal education, and counselling was found efficacious to effectively enhance prenatal attachment, reduce anxiety and depression whereas cognitive‐behavioural therapy and other beneficial \u0026nbsp;approaches require further research (37). As far as we are aware, this is the first interventional study to assess to examine the effect of brief CBT on the fear of childbirth and prenatal attachment in Ethiopia. Accordingly, a quasi-experimental study was conducted, comparing women who receive brief CBT session (experimental group), with those who receive routine antenatal care (control group).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOperational definitions\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFear of childbirth\u003c/strong\u003e: Measured using W-DEQ Version A, with scores ranging from 0 to 5, where 0 denotes \u0026quot;extremely\u0026quot; and 5 denotes \u0026quot;not at all,\u0026quot;. The total score ranges from 0 to 165. A higher score indicates an increase, while a lower score reflects a reduced fear (9).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaternal antenatal attachment scale:\u0026nbsp;\u003c/strong\u003eWomen\u0026apos;s prenatal attachment increases as the score on the scale increases and decreases as the score decreases (38).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHRQOL\u003c/strong\u003e: Measured and classified using the mean WHOQOL-BREF score. Participants with a score less than or equal to the mean were categorized as having a poor QOL, whereas those with a score greater than the mean were classified as having a good QOL (39).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDepression\u003c/strong\u003e: Measured using the PHQ-9 scale. Participants with a score of five or higher were considered to have depression. Depression severity was categorized based on the PHQ-9 score: minimal (5-9), mild (10-14), moderate-severe (15-20), and severe (\u0026gt;20). Minimal (5-9), mild (10-14), and score of 5 or \u0026gt; indicate depression (40).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerceived social support:\u003c/strong\u003e Assessed using the OSLO-3 scale, where a score of 3\u0026ndash;8 indicates poor social support, 9\u0026ndash;11 indicates moderate social support, and 12\u0026ndash;14 indicates strong social support (41).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCurrent use of substance:\u003c/strong\u003e Defined as the use of alcohol, khat, or cigarettes for non-medical purposes within the past 3 months, as assessed by the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) (42).\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy setting:\u0026nbsp;\u003c/strong\u003eThis study was conducted in selected hospitals within the west Arsi zone, Oromia Regional State, Ethiopia. Loke Primary Hospital and Negele Arsi Primary Hospital were assigned as the control and intervention groups, respectively. Negele Arsi Hospital is located approximately 21 kilometers from Shashemene, the capital of the West Arsi Zone, and 250 kilometers from Addis Ababa, the capital of Ethiopia. Loke Primary Hospital is situated in Siraro, one of the woredas in the Great Rift Valley within the West Arsi Zone (unpublished data).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e A quasi-experimental study with a single group pre-post-test design was used. One hospital was randomly assigned as an intervention group, and the other usual antenatal care as the control group. \u0026nbsp;Data were collected for both groups. The intervention group received brief CBT sessions, while the control group did not. Post-intervention data collection allowed for a comparison of outcomes between the two groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePopulation:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe source population included all pregnant women attending antenatal care at public primary hospitals in the West Arsi zone. The study population comprised sampled mothers attending antenatal care at selected hospitals and present during the baseline data collection, intervention, follow-up, and post-intervention periods.\u003c/p\u003e\n\u003cp\u003eRegarding the eligibility criteria, pregnant women were eligible for inclusion if they were aged 18 years or older, had a gestational age between 20\u0026ndash;32 weeks, were able to read and write, and had no history of previous cesarean section delivery or complicated pregnancy. Additionally, participants could not have engaged in psychotherapy within 6 weeks prior to or during the study and needed to score above the mean on the W-DEQ and MAAS instruments.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants were excluded if they had acute mental health conditions or were receiving treatment for such conditions. Woment with a current or past history of structured brief CBT for fear of childbirth or prenatal attachment were also excluded. Furthermore, participants unable to comprehend the intervention process or those who missed counselling sessions were ineligible. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs to hospital selection, following WHO recommendations for integrating mental health into primary care settings, the four primary hospitals in the west Arsi zone (Loke, Negele Arsi, Nansabo, and Kokosa) were considered. Using a lottery method, Loke and Negele Arsi hospitals were selected as the control and intervention groups, respectively. Average monthly antenatal care attendance was obtained to estimate a two-month sample size. Consecutive sampling was used to recruit participants \u003cstrong\u003eFig 1.\u003c/strong\u003e\u003c/p\u003e\n\u003cp id=\"_Toc171038360\"\u003e\u003cstrong\u003eSample size determination techniques\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sample was calculated using G*power software version 3.1.9.2.\u003cem\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/em\u003eBased on similar studies, an effect size of 0.5, a power of 80%, and alpha of 0.05 were considered in sample size determination for this study (43). Accordingly, sample size was calculated for both outcomes with the largest sample size were 102. Accounting for a 15% attrition rate, the total sample size was 117 (59 in the intervention group and 58 in the control group). Study subjects were recruited through consecutive sampling techniques ensuring equal allocation.\u0026nbsp;\u003c/p\u003e\n\u003cp id=\"_Toc171038361\"\u003e\u003cstrong\u003eStudy variables\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDependent variable\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eFear of childbirth\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eand prenatal attachment\u0026nbsp;\u003c/p\u003e\n\u003cp id=\"_Toc171038363\"\u003e\u003cstrong\u003eIndependent variable\u003c/strong\u003e\u003cstrong\u003es:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eSocio-demographic factors: age, gestational age, educational status of the mother and father, marital status, and monthly income.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eObstetric and clinical factors\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eparity, pregnancy status (wanted or unwanted), preferred mode of birth, chronic medical conditions (e.g., hypertension, diabetes), history of birth complications (e.g., cesarean section, instrumental delivery, labor dystocia, tear).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePsychosocial factors:\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003euse of substances (alcohol, cigarette, khat)\u003cstrong\u003e, s\u003c/strong\u003eocial support\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003etrauma,\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eprior pregnancy experience\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003efamily size, quality of life, depression, and post-traumatic stress disorder.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp id=\"_Toc171038364\"\u003e\u003cstrong\u003eData collection instrument\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrimarily outcome\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFear of childbirth:\u003c/strong\u003e Measured using the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ), a 33-item with a five-point Likert scale (0 = no to 5 = very high) Likert scale and total scale ranging from 0-165. (44). The instrument includes 33 items with \u0026nbsp;It has shown good validity and reliability (Cronbach\u0026rsquo;s alpha was 0.89 and 0.93, respectively) (44). The instrument was validated among pregnant women with satisfactory internal consistency (\u0026alpha;\u0026thinsp;=\u0026thinsp;0.84) (8) The Cronbach\u0026apos;s alpha for the current study is 0.86.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaternal Antenatal Attachment Scale (MAAS):\u0026nbsp;\u003c/strong\u003eThe instrument was developed by Condon in 1993(45) and Golbasi et al. conducted a validity and reliability analysis of the instrument in Turkey in 2015. The measure, which consists of 19 items, assesses a potential mother\u0026apos;s attitudes, behaviors, and sentiments regarding the fetus. The Likert-type scale has five items, each of which is rated between 1 and 5. The scale contains two sub-dimensions: \u0026quot;time devoted to attachment\u0026quot; (items 1, 2, 4, 5, 8, 14, 17, 18) and \u0026quot;quality of attachment\u0026quot; (items 3, 6, 9, 10, 11, 12, 13, 15, 16, 19). Since item 7 have no bearing on any sub-dimension, the total score is the only factor taken into account. Inverted codes are found in items 1, 3, 5, 6, 7, 9, 10, 12, 15, 16, and 18. There is no threshold value on the scale. Greater scores correspond to greater attachment levels (38). The Cronbach\u0026apos;s alpha for the current study is 0.731.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSecondary outcome\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eI- Health-Related Quality of life assessment tools:\u0026nbsp;\u003c/strong\u003eThe WHOQOL-BREF, a shorter version of the WHO quality of life questionnaires, was used to measure quality of life as an intermediary variable. There are 26 items in all, 24 of which are divided into the four categories namely physical (7 item), psychological (item 6), social relationships (item 3), and environmental (item 8). To evaluate a person\u0026apos;s impression of their overall health and quality of life, the final two questions was scored separately. The raw scores for each item was converted to a range between 4 and 20, then to corresponding ranges between 0 and 100. Every item of the WHOQOL-BREF is rated on a Likert scale from (very dissatisfied) to 5 (very satisfied), and the score spans from 26 (lowest score) to 130 (highest score). Additionally, the mean of each domain and the mean total score were determined. In several contexts, the instrument was applied to pregnant women (31) and received strong internal consistency validation in the Ethiopian setting (Cronbach\u0026apos;s alpha = 0.93)(46, 47). The Cronbach\u0026apos;s alpha of the item for the current study is 0.892\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIndependents variables)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;I - Socio-demographic, clinical and psychosocial factors:\u0026nbsp;\u003c/strong\u003eWe extensively reviewed earlier literature and identified the following variable in the socio-demographic profile: age, age, gestational age, educational status of mother and father, marital status, parity, status of pregnancy (wanted or unwanted), preferred mode of birth for current pregnancy, another chronic medical illness (hypertension, diabetes mellitus, etc), history of birth complication ( ceaseran section, instrumental delivery, labor dystocia, tear), and current use of drugs (alcohol, cigarette, khat), social support, prior pregnancy experience and family size.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIII \u0026ndash; Patient Health Questionnaires (PHQ-9) -\u0026nbsp;\u003c/strong\u003eThe PHQ-9 is a nine-item, self-administered questionnaire used to assess for depression symptoms. The nine PHQ-9 items depend entirely on the 9- DSM-IV (Diagnostic and Statistical Manual, Fourth Edition) major depression disorder diagnostic criteria. Total PHQ-9 scores, used to assess severity, vary from 0 (lack of depressed symptoms) to 27 (most severe depressive symptoms). Scores for each of the 9 items range from 0 (not at all) to 3 (almost daily). When 5 or more of the 9 symptoms have been present for \u0026quot;more than half the days\u0026quot; (a score of 2) during the course of the previous two weeks and one of the symptoms is a depressed mood or loss of interest (anhedonia), major depression is considered to be present. The isntrument was now validated in Afaan Oromom language for use (Woldetensay, 2018 (40).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntervention protocol\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCBT protocol\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe protocol for CBT was designed by reviewing different manual, guidelines and consultation with the experts in the field of psychiatry and adapted into Ethiopian context. The treatment was offered to participants free of charge. CBT sessions were delivered in a group therapy format and the sessions were offered in successive weeks by trained mental health counsellor. The control group was not given any intervention. \u0026nbsp;The protocol was then administered to the intervention group in a group format (8 groups, each group consists of 6-8 members), and the sessions were offered once per week for 8 weeks succeesively, each session lasting from 15-30 minutes in length. Participants in the control condition will visit the antenatal unit based on their scheduled appointments. The research assistant was employed from community health care workers and communicates for any concern they have on the research. She/he will register their phone numbers and gives his own to ease communication and effort was made to provide a safe, engaging, and welcoming environment for the participants during each session. Participants were asked to complete written assessments twice: during the baseline assessment and at the completion of the CBT group program. After the session ends post-test was given to the intervention group, and the control group received only routine care. Details of the protocol are summarized in \u003cstrong\u003eSupplementary 1\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA detailed description of session-by-session content of the CBGT protocol adopted (48). An interviewer administered questionnaires was used to collect data. A questionnaire is prepared in English language was back to back translated into local language (Afaan Oromo and Amharic) with the experts in the field. A total of 5% of the recruited sample participated in the pilot study at Nansabo primarily hospital 2week before the actual data collection. Training was given to the four data collectors, two supervisors, research assistant and counsellor. Any error, ambiguity, incompleteness, or other encountered problems was\u0026nbsp;addressed immediately after supervisor receives filled questionnaire from each data collectors.\u003c/p\u003e\n\u003cp id=\"_Toc171038367\"\u003eData was collected in two different phases. First, baseline data on the fear of childbirth and prenatal attachment of the pregnant women was collected. Initially, mothers attending antenatal follow-up were enrolled in the study from the two hospitals for 2 weeks. Baseline information regarding demographic and clinical information was obtained for all participants using an interview-administered questionnaire and chart review for clinical variables. An initial evaluation was undertaken to determine study eligibility based on the eligibility criteria, followed by a monitoring period to collect pre-intervention fear of childbirth (FOC) and Maternal Antenatal Attachment Scale (MAAS) data among study participants. Second, after the intervention phase is completed, end-line data on the fear of childbirth and prenatal attachment of pregnant women was collected.\u003c/p\u003e\n\u003cp\u003eConsidering data processing and analysis,\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eEpi-data version 4.4.1, then exported to the SPSS version 27 software was used for data entry and analysis respectively. We have assessed the intervention effects at baseline and post intervention using the bivariable analyses comparing the intervention conditions to the control condition. We have examined the treatment effects using a GLM to account for correlations between repeated measurements for quality of life. An Independent sample t-test and one-way ANOVA was used to compare the intervention and control groups. The effect size was interpreted based on 0.01 = small effect; 0.06 = moderate effect; and 0.15 = large effect(49).\u0026nbsp;\u003c/p\u003e\n\u003cp id=\"_Toc171038370\"\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance was obtained from research ethical review of Shashemene campus, Madda Walabu University (RCSTT 15/2024). Then official letter was sent to selected stakeholder (Zonal health office, Hospitals). Selected participants were told about nature, purposes, benefits and adverse effects of the study and invited to participate. Confidentiality was ensured. Participation was completely voluntary, with no economic or other motivation, and each participant signed written informed consent for their participation.\u0026nbsp;\u003c/p\u003e"},{"header":"RESULT ","content":"\u003cp\u003e\u003cstrong\u003eFidelity of the intervention\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;A total of 117 pregnant women participated in the study, with 58 and 59 women enrolled in the intervention and control groups, respectively. In the intervention group, seven (7) mothers did not complete the baseline assessment (four requested referral to other healthcare institutions, and three did not return to the institution or could not be traced during the study period). In the control group, five mothers did not complete the baseline assessment (three due to referral to another center and two did not return to the center). Additionally, three respondents from the intervention group did not complete the intervention, resulting in 51 mothers completingthe final interview or assessment\u0026nbsp;\u003cstrong\u003eFig 2.\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBaseline characteristics of the study population\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were no significant differences between groups in mean age or gestational week. Educational attainment varied modestly: 59.3% of controls versus 49.1% of the intervention group had only a primary education. Unemployment rates were similarly high in both arms (72.5% of controls; 70.7% of the intervention group). Most pregnancies were planned (85.2% control; 74.5% intervention), and a preference for vaginal delivery was common across both groups. However, baseline measures revealed that the intervention group had significantly lower social support compared with controls (\u003cstrong\u003eTable 1).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrenatal attachment and fear of childbirth\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was no significant difference in the pre-intervention mean scores for the W-DEQ and MAAS between the two groups \u003cstrong\u003e(Table 2).\u0026nbsp;\u003c/strong\u003eHowever, a negligible significant difference was observed in fear of childbirth scores at baseline (t=2.802, p = 0.005), with the intervention group showing higher fear levels. Further, a significant mean difference between the two groups during pre-intervention scores MAAS, Rosenberg scores and depression score were not found (P \u0026gt; 0.05) \u003cstrong\u003e(Table 2).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMean post-intervention scores for the two groups for MAAS, Rosenberg, and W-DEQ are given in \u003cstrong\u003eTable 2.\u003c/strong\u003e A significant mean difference was found between the groups (P\u0026lt;0.01) in terms of Rosenberg, and W-DEQ. The mean score of fear of childbirth (W-DEQ) among women during preintervention in the experimental group was higher than that of the women in the control group, which indicates that their fear of child birth was higher than that of the women in the control group (P \u0026lt;0.01). Moreover, the mean difference for W-DEQ in the post intervention was lower as compared to pre-intervention score (t=2.679, P\u0026lt;0.01). This point for reduced fear of childbirth among pregnant women who received psychological intervention as compared to control group.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;There is no significant difference in the mean score of maternal antenatal attachment (MAAS) score during post intervention (t=-1.352, P=0.181). The mean score of maternal self - esteem in the experimental group was higher than that of the women in the control group, which indicates that their self-esteem was higher than that of the women in the control group (P\u0026lt; 0.001). \u0026nbsp;The differences between the groups for fear of childbirth and self-esteem sub scales were significant in the post intervention ((t=2.679, P\u0026lt;0.01), and t=4.642 P\u0026lt;0.001, respectively). This finding indicates that the intervention had beneficial effects of lowering the mean score of the fear of childbirth and enhancing maternal self-esteem\u003cstrong\u003e\u0026nbsp;(Table 2).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuality of life among study participants\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe intervention group had significantly higher post-intervention mean scores in the physical (t = 8.09, p = \u0026lt;0.001) and psychological (t=-1.62, p = \u0026lt;0.001) domains of quality of life compared to the control group, while no significant differences were observed in the other domain of quality of life. Moreover, larger mean difference was observed in the physical domain as compared to other quality of life in the post intervention period. (Table 3)\u003c/p\u003e\n\u003cp\u003eA generalized linear model was used to assess the influence of maternal antenatal attachment, fear of childbirth, and other explanatory variables on maternal quality of life. The analysis included factors such as fear of childbirth, depressive symptoms, self-esteem, maternal antenatal attachment, preferred mode of delivery, parity, and social support. In the final model, three variables emerged as significant predictors of maternal quality of life: fear of childbirth (\u0026beta; = -0.046), depressive symptoms (\u0026beta; = -0.561), and social support (\u0026beta; = 0.080).\u003c/p\u003e\n\u003cp\u003eIn the final analysis, the mean scores of maternal antenatal attachment, self-esteem, depressive symptoms, fear of childbirth, and social support showed a highly significant association with maternal quality of life (R = .518, R\u0026sup2; = .483, F = 14.9, P \u0026lt; 0.001), collectively accounting for 52% of the total variance in the quality of life score. ( Table 4).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCognitive-behavioral training is a flexible, problem-focused, and low-risk intervention that has proven particularly effective in addressing birth-related anxiety and associated psychosocial factors. To the best of our knowledge, this is the first study conducted in Ethiopia to evaluate the effectiveness of a brief cognitive-behavioral intervention among pregnant women receiving care in primary healthcare settings. Pregnancy-related education and counseling were found to enhance women\u0026rsquo;s self-determination, support their adaptation to new life circumstances, and reduce psychological distress (50). Research suggests that enhanced and comprehensive prenatal education programs significantly improve maternal adaptability during the postpartum period compared to standard programs. Evidence indicates that these programs can enhance pregnant women\u0026rsquo;s knowledge, attitudes, and preferences regarding mode of delivery. Furthermore, they have been shown to positively influence birth preparedness, mental well-being, and overall birth outcomes\u0026mdash;contributing to reductions in anxiety and depressive symptoms, and potentially increasing the likelihood of vaginal birth. (51).\u003c/p\u003e\n\u003cp\u003eThis study aimed to assess the impact of cognitive-behavioral therapy (CBT)-based education on pregnant women\u0026rsquo;s fear of childbirth and prenatal attachment. The findings revealed that women who received CBT interventions reported significantly reduced childbirth-related fear compared to the control group receiving standard prenatal education. However, the intervention had no measurable effect on prenatal attachment. Notably, this research contributes to the limited literature on evidence-based prenatal care in Ethiopia, challenging traditional educational approaches.\u003c/p\u003e\n\u003cp\u003eThese findings align with previous studies conducted elsewhere that antenatal education is associated with significant reduction of fear of childbirth (52)\u0026nbsp; (53, 54). Furthermore, earlier research on the effect of cognitive-behavioral based training programmes on pregnant women\u0026apos;s fear of childbirth (38),(55) found that the programmes improved women\u0026rsquo;s coping skill with and lessen their fear of childbirth. The similarities could account for comparable study designs and population types in both settings, despite differences in session length, patient characteristics, and study setting.\u003c/p\u003e\n\u003cp\u003eUnexpectedly, this study found no significant effect of CBT on maternal-fetal attachment, which is consistent with previous research but contradicts data that suggest psychological therapies improve attachment. Cultural and socioeconomic differences in understanding of maternal-fetal bonding may account for the disparities. Previous research showed that health facilities and related authorities should consider providing psychological therapies, such as mindfulness mother training programs on maternal-fetal attachment, in addition to routine prenatal care (56). Notably, the current study\u0026apos;s findings demonstrated that a brief cognitive intervention had no influence on the mean score of maternal-fetal attachment following intervention, which was consistent with previous research findings (19).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, this contradicted the findings of a prior study, which found that the psychological intervention improved mother fetal attachment (56, 57). In a summary, several research (22, 58, 59) have shown that relaxation training is useful throughout the prenatal period. However, they discovered that parental attachment was unaffected by education delivered prior to prenatal sessions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe discrepancy between the findings could be explained by the respondents\u0026apos; understanding and significance of the maternal fetal attachment notion for women (60) based on their social and cultural backgrounds.\u0026nbsp;Maternal stress can also have an impact on child outcomes by disrupting the functioning of both the mother and the fetus\u0026nbsp;(61), and it is significantly linked to psychological health, the maternal-fetal relationship, and baby outcomes\u0026nbsp;(62, 63).\u003c/p\u003e\n\u003cp\u003eAccording to a prospective descriptive study (64), a woman\u0026apos;s confidence in her ability to use coping mechanisms and relaxation techniques during labour and delivery decreased with her anxiety level. In this way, a decrease in prenatal education-induced fear of childbirth could give rise to improved maternal attachment and quality of life after the intervention. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsistent with the aforementioned results, the current study revealed that pregnant women who received counselling using brief cognitive behavioral techniques (W-DEQ) had a lower mean score in their fear of childbirth (P\u0026lt;0.01) than they had before the intervention. This was at odds with the findings of study from Victoria (65) and Sweden (66) who found that prenatal education had no impact on a woman\u0026apos;s experience of giving birth and that this was likely due to insufficient preparation (65). The observed variations in outcomes may stem from differences in study design, intervention duration, and contextual settings. Multivariable regression analysis revealed a significant inverse association between fear of childbirth and quality of life, with each unit increase in childbirth fear corresponding to a 22.5% reduction in quality of life. This relationship may be mediated by fear-induced impairments in problem-solving abilities, social functioning, and physical health maintenance.\u0026nbsp;Cognitive-behavioral interventions specifically target catastrophic thought patterns (e.g., \u0026ldquo;Childbirth will destroy my body\u0026rdquo;), thereby reducing the cognitive distortions that both intensify fear of childbirth and disrupt daily functioning. As these irrational fears subside, women are able to participate more fully in occupational and social activities, which in turn enhance multiple domains of their quality of life.\u003c/p\u003e\n\u003cp id=\"_Toc171038374\"\u003eDepression emerged as another significant predictor of quality of life in the final regression model (t =-4.727, p = 0.001), with a moderate-to-large effect size (partial \u0026eta;\u0026sup2; = 0.168). While existing literature suggests prenatal stress may enhance maternal-fetal attachment, it simultaneously elevates risk for prenatal depression. This paradoxical relationship may ultimately contribute to quality-of-life deterioration. Consistent with previous findings, depression demonstrated significant negative associations across all QOL domains\u0026nbsp;(67-69). The analysis revealed that each unit increase in perceived social support was associated with a 4.3% improvement in quality of life scores (t = 2.194, p\u0026le; 0.05). This positive association between social support and QOL aligns with established findings in the literature (70-72). This observed association may be explained by the stress-buffering effect of social support during pregnancy. Psychosocial encouragement and practical assistance can mitigate depressive symptoms, thereby indirectly enhancing overall quality of life. In the final regression model, clinical variables including parity and preferred delivery mode showed no statistically significant association with quality of life (all p \u0026gt; 0.05). The absence of a significant relationship between these clinical variables and maternal quality of life may reflect the effectiveness of counseling provided in our sample or the greater influence of other psychological determinants. Moreover, it suggests that clinical factors may exert less impact on quality of life than key psychosocial elements such as fear of childbirth, depressive symptoms, and social support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitation\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;of the study:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study employed a quasi-experimental design, which lacks randomization in the sampling technique. This limitation may affect the generalizability of the findings and conclusions. Furthermore, the study did not include midline assessments to evaluate the impacts of the educational intervention over the short term.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe groups were not randomized, as it was assumed that women would be hesitant to participate training sessions they did not wish to attend, potentially leading higher dropout rates. Another weakness of this study could be the use of a self-reportedmeasures, which may introduce response bias.\u003c/p\u003e\n\u003cp\u003eFurthermore, the varying trimesters of the pregnant participants might have introduced confounding factors that could influence the outcome. Lastly, the study could not determine whether women with higher levels of childbirth fear and lower prenatal attachment readinesswere more likely to receive parity interventions, which may have affected the results.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003estudy\u0026rsquo;s findings suggest that, cognitive-behavioral therapy during pregnancy could help reduce women\u0026apos;s fear of childbirth and improve their quality of life. However, the intervention did not demonstrate a significant effect on improving maternal-fetal bonding. To improve maternal mental health and well-being, adopting a comprehensive strategy that incorporates cognitive approaches is essential. These findings underscore the need for a holistic approach that incorporates both cognitive techniques to address maternal mental health and targeted strategies to enhance maternal wellbeing during pregnancy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReccommendation\u003c/strong\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEfforts to prevent maternal mental health challenges in Ethiopia should focus on culturally specific, locally appropriate psychological interventions that integrate cognitive approaches. These interventions could be delivered by non-specialist medical personnel as part of routine maternal and childcare, ensuring alignment with the maternal continuum of care. Future research should prioritize well-designed randomized controlled trials with larger sample sizes to generate robust evidence and enable firm conclusions.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAPA - American Psychiatric Association\u003c/p\u003e\n\u003cp\u003eCBT \u0026ndash;Cognitive Behavioral Techniques\u003c/p\u003e\n\u003cp\u003eFOC \u0026ndash; Fear of Complication\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHRQOL \u0026ndash; Health Related Quality of Life\u003c/p\u003e\n\u003cp\u003eMh-GAP \u0026ndash; mental health Global Action Programme\u003c/p\u003e\n\u003cp\u003eLMIC \u0026ndash; Low and Middle Income Countries\u003c/p\u003e\n\u003cp\u003eMDD \u0026ndash; Major Depression Disorder\u003c/p\u003e\n\u003cp\u003ePAI - Prenatal Attachment Inventory\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePHC \u0026ndash; Primarily Health Care\u003c/p\u003e\n\u003cp\u003eUSA \u0026ndash; United States of America\u003c/p\u003e\n\u003cp\u003eW-DEQ- Wijma Delivery Expectancy/Experience Questionnaire\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMAH, MM, JE, AM, and WG wrote and designed the protocol, led the data collection process, analysed the data, and reviewed and edited the manuscript. AW, BM, GW, GN, SS revises and approves the protocol, takes part in data analysis, reviews and edits the manuscript. LW, SW, FB, BG, HJ, NG, DY contributed to data analysis, drafting the manuscript, critically reviewing and approving the manuscript for publication. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eAuthors would like to thank Maddawalabu University for providing funding and ethical approval to undertake this paper. Our deepest thanks go to all stakeholders take part for the success of this research work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSaisto T, Halmesmaki E. Fear of childbirth: a neglected dilemma. Acta Obstet Gynecol Scand. 2003;82(3):201-8.\u003c/li\u003e\n\u003cli\u003eDencker A, Nilsson C, Begley C, Jangsten E, Mollberg M, Patel H, et al. Causes and outcomes in studies of fear of childbirth: A systematic review. 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The importance of social support in the associations between psychological distress and somatic health problems and socio-economic factors among older adults living at home: a cross sectional study. BMC Geriatr. 2012;12:27.\u003c/li\u003e\n\u003cli\u003eGroup WAW. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): development, reliability and feasibility. Addiction. 2002;97(9):1183-94.\u003c/li\u003e\n\u003cli\u003eGolbasi TUZ. Effect of an educational program based on cognitive behavioral techniques on fear of childbirth and the birth process. Journal of Psychosomatic Obstetrics \u0026amp; Gynecology. 2018.\u003c/li\u003e\n\u003cli\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 Gynaecol. 1998;19(2):84-97.\u003c/li\u003e\n\u003cli\u003eCondon JT. The assessment of antenatal emotional attachment: development of a questionnaire instrument. Br J Med Psychol. 1993;66 ( Pt 2):167-83.\u003c/li\u003e\n\u003cli\u003eTesfaye M, Olsen MF, Medhin G, Friis H, Hanlon C, Holm L. Adaptation and validation of the short version WHOQOL-HIV in Ethiopia Int J Ment Health Syst. 2016; 9(10):29.\u003c/li\u003e\n\u003cli\u003eGelaye H, Andualem A. Quality of life and associated factors among family caregivers of individuals with psychiatric illness at DRH, South Wollo, Ethiopia, 2020. Sci Rep. 2022;12(1):18550.\u003c/li\u003e\n\u003cli\u003eWolff J, Esposito-Smythers C, Frazier E, Stout R, Gomez J, Massing-Schaffer M, et al. A randomized trial of an integrated cognitive behavioral treatment protocol for adolescents receiving home-based services for co-occurring disorders. J Subst Abuse Treat. 2020;116:108055.\u003c/li\u003e\n\u003cli\u003eCohen J. Statistical Power Analysis for the Behavioral Sciences. LAWRENCE ERLBAUM ASSOCIATES P, editor1988.\u003c/li\u003e\n\u003cli\u003eFenwick J, Toohill J, Gamble J, Creedy DK, Buist A, Turkstra E, et al. Effects of a midwife psycho-education intervention to reduce childbirth fear on women\u0026apos;s birth outcomes and postpartum psychological wellbeing. BMC Pregnancy Childbirth. 2015;15:284.\u003c/li\u003e\n\u003cli\u003eGagnon AJ, Sandall J. Individual or group antenatal education for childbirth or parenthood, or both. Cochrane Database Syst Rev. 2007;2007(3):CD002869.\u003c/li\u003e\n\u003cli\u003eMoghaddam Hosseini V, Nazarzadeh M, Jahanfar S. Interventions for reducing fear of childbirth: A systematic review and meta-analysis of clinical trials. Women Birth. 2018;31(4):254-62.\u003c/li\u003e\n\u003cli\u003eStoll K, Swift EM, Fairbrother N, Nethery E, Janssen P. A systematic review of nonpharmacological prenatal interventions for pregnancy-specific anxiety and fear of childbirth. Birth. 2018;45(1):7-18.\u003c/li\u003e\n\u003cli\u003eStriebich S, Mattern E, Ayerle GM. Support for pregnant women identified with fear of childbirth (FOC)/tokophobia - A systematic review of approaches and interventions. Midwifery. 2018;61:97-115.\u003c/li\u003e\n\u003cli\u003eGhasemi F, Bolbol-Haghighi N, Mottaghi Z, Hosseini SR, Khosravi A. The Effect of Group Counseling with Cognitive-Behavioral Approach on Self-Efficacy of Pregnant Women\u0026rsquo;s Choice of Vaginal Delivery. Iranian Journal of Psychiatry and Behavioral Sciences. 2018;In Press(In Press).\u003c/li\u003e\n\u003cli\u003eGheibi Z, Abbaspour Z, Haghighyzadeh MH, Javadifar N. Effects of a mindfulness-based childbirth and parenting program on maternal-fetal attachment: A randomized controlled trial among Iranian pregnant women. Complement Ther Clin Pract. 2020;41:101226.\u003c/li\u003e\n\u003cli\u003eAnjarwati PAMH. The Effect of Maternal-Fetal Attachment Education on Pregnant Women\u0026rsquo;s Mental Health. Journal of Health Technology Assessment in Midwifery 2019;Vol. 2(No. 1):pp. 50-8.\u003c/li\u003e\n\u003cli\u003eChuang LL, Lin LC, Cheng PJ, Chen CH, Wu SC, Chang CL. The effectiveness of a relaxation training program for women with preterm labour on pregnancy outcomes: a controlled clinical trial. Int J Nurs Stud. 2012;49(3):257-64.\u003c/li\u003e\n\u003cli\u003eNichols M. Adjustment to New Parenthood: Attenders versus Nonattenders at Prenatal Education Classes. BIRTH March 1995 22(1).\u003c/li\u003e\n\u003cli\u003eWalsh J. Definitions matter: if maternal-fetal relationships are not attachment, what are they? Arch Womens Ment Health. 2010;13(5):449-51.\u003c/li\u003e\n\u003cli\u003eStaneva AA, Bogossian F, Wittkowski A. The experience of psychological distress, depression, and anxiety during pregnancy: A meta-synthesis of qualitative research. Midwifery. 2015;31(6):563-73.\u003c/li\u003e\n\u003cli\u003eBecker M, Weinberger T, Chandy A, Schmukler S. Depression During Pregnancy and Postpartum. Curr Psychiatry Rep. 2016;18(3):32.\u003c/li\u003e\n\u003cli\u003eWakeel F, Wisk LE, Gee R, Chao SM, Witt WP. The balance between stress and personal capital during pregnancy and the relationship with adverse obstetric outcomes: findings from the 2007 Los Angeles Mommy and Baby (LAMB) study. Arch Womens Ment Health. 2013;16(6):435-51.\u003c/li\u003e\n\u003cli\u003eBeebe B, Messinger D, Bahrick LE, Margolis A, Buck KA, Chen H. A systems view of mother-infant face-to-face communication. Dev Psychol. 2016;52(4):556-71.\u003c/li\u003e\n\u003cli\u003eFabian HM, Radestad IJ, Waldenstrom U. Childbirth and parenthood education classes in Sweden. Women\u0026apos;s opinion and possible outcomes. Acta Obstet Gynecol Scand. 2005;84(5):436-43.\u003c/li\u003e\n\u003cli\u003eSchneider Z. Antenatal Education classes in Victoria: What the women said. AUSTRALIAN COLLEGE OF MIDWIVES. 2001;VOL 14 (NO 3).\u003c/li\u003e\n\u003cli\u003eAurpibul L, Tongprasert F, Wichasilp U, Tangmunkongvorakul A. Depressive Symptoms Associated with Low Quality of Life Among Pregnant and Postpartum Women Living with HIV in Chiang Mai, Thailand. Int J MCH AIDS. 2020;9(3):421-9.\u003c/li\u003e\n\u003cli\u003eBo HX, Yang Y, Zhang DY, Zhang M, Wang PH, Liu XH, et al. The Prevalence of Depression and Its Association With Quality of Life Among Pregnant and Postnatal Women in China: A Multicenter Study. Front Psychiatry. 2021;12:656560.\u003c/li\u003e\n\u003cli\u003eNazarpour S, Simbar M, Kiani Z, Khalaji N, Khorrami Khargh M, Naeiji Z. The relationship between quality of life and some mental problems in women with gestational diabetes mellitus (GDM): a cross-sectional study. BMC Psychiatry. 2024;24(1):511.\u003c/li\u003e\n\u003cli\u003eElsenbruch S, Benson S, Rucke M, Rose M, Dudenhausen J, Pincus-Knackstedt MK, et al. Social support during pregnancy: effects on maternal depressive symptoms, smoking and pregnancy outcome. Hum Reprod. 2007;22(3):869-77.\u003c/li\u003e\n\u003cli\u003eLi F, Luo S, Mu W, Li Y, Ye L, Zheng X, et al. Effects of sources of social support and resilience on the mental health of different age groups during the COVID-19 pandemic. BMC Psychiatry. 2021;21(1):16.\u003c/li\u003e\n\u003cli\u003eShishehgar S, Dolatian M, Majd HA, Bakhtiary M. Perceived pregnancy stress and quality of life amongst Iranian women. Glob J Health Sci. 2014;6(4):270-7.\u003c/li\u003e\n\u003cli\u003eHUSSEIN JW. A CULTURAL REPRESENTATION OF WOMEN IN THE OROMO SOCIETY. African Study Monographs. 2004;25(3).\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable \u0026nbsp;1. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eBaseline characteristics of the study participants, 2024\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"111%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntervention group [n=51], \u0026nbsp;(n %)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl group [n=54], n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003eAge \u003csup\u003e\u0026para;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e26.12\u0026plusmn;4.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e26.20\u0026plusmn;4.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.915\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003eGestational week \u003csup\u003e\u0026para;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e22.94\u0026plusmn;2.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e22.91\u0026plusmn;2.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.952\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eCurrent living status*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003eLive with her husband\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e46(46.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e54(54.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026Chi;\u003c/em\u003e\u003cem\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e= .018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003eLive without her husband\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e5(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e\u0026nbsp;-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eMothers level of education*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003ePrimarily education\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e25(43.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e32(56.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026Chi;\u003c/em\u003e\u003cem\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e= .150\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003eSecondary education\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e7(38.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e11(61.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003eCollege and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e19(63.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e11(36.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eSpouse level of education*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003eUnable to read and write\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e24(60.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e16(40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026Chi;\u003c/em\u003e\u003cem\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e=.181\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003ePrimarily education\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e20(40.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e29(59.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003eSecondary education\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e7(43.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e9(56.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eOccupational status *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003eUnemployed\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e37(64.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e20(35.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026Chi;\u003c/em\u003e\u003cem\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003eemployed\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e14(29.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e34(70.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eResidence\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003eUrban\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e28(45.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e33(54.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026Chi;2=.519\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003eRural\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e23(52.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e21(47.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eParity *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003eNulliparous\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e25(42.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e34(57.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026Chi;\u003c/em\u003e\u003cem\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e= .150\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003eMultiparous\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e26(56.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e20(43.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003ePreferred mode of birth*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003eVaginal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e42(46.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e48(53.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026Chi;\u003c/em\u003e\u003cem\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e=.339\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003eCaesarean section\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e9(60.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e6(40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eSocial support *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003ePoor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e16(80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e4(20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026Chi;\u003c/em\u003e\u003cem\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e=.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003eModerate\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e30(44.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e37(55.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003eStrong\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e5(27.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e13(72.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eStatus of the current pregnancy *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003eWanted\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e38(45.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e46(54.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026Chi;\u003c/em\u003e\u003cem\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e=.172\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003eUnwanted\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e13(61.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e8(38.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eValue in parenthesis are percentage, \u003csup\u003e\u0026para;\u003c/sup\u003efrequency, \u003cstrong\u003e*\u003c/strong\u003eMean\u0026plusmn;standard deviation\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2. \u0026nbsp; Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ), Maternal self-esteem and antenatal attachment score (MAAS) and depression score before and after intervention\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"113%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eScales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Pre test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Post test\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003eIntervention group(n=51) , Mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eControl group (n=54), \u0026nbsp;Mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003eP \u0026ndash; value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003eT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eMean difference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003eIntervention group(n=51), \u0026nbsp;Mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eControl group\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n=54) , Mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003eP- value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003eT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003eMean difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003eW-DEQ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e51.18\u0026plusmn;11.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e46.37\u0026plusmn;5.264\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e2.802\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e4.806\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e45.90\u0026plusmn;5.947\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e43.22\u0026plusmn;4.073\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e2.679\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e2.680\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003eMAAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e21.14 \u0026plusmn; 0.775\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e21.17\u0026plusmn;0.720\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e0.841\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e-.202\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e-.029\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e21.96\u0026plusmn;1.113\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e22.24\u0026plusmn;1.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e0.181\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e-1.352\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e-.280\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003eRosenberg\u003c/p\u003e\n \u003cp\u003eSelf-esteem\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e23.94\u0026plusmn;0.881\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e24.08\u0026plusmn;0.917\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e0.448\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e-.761\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e-.134\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e24.27\u0026plusmn;0.874\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e23.52\u0026plusmn;0.795\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e4.642\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e0.756\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003ePHQ-9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e2.98\u0026plusmn;1.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e3.13\u0026plusmn;1.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e0.632\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e-.485\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e-.149\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e2.706\u0026plusmn;1.100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e2.75\u0026plusmn;1.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e-.201\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003e0.053\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote:\u0026nbsp;Abbreviation: SD, Standard Deviation; MAAS, Maternal antenatal attachment scale, W-DEQ= Wijma Delivery Expectancy/Experience Questionnaire, PHQ\u003cstrong\u003e-9 -\u0026nbsp;\u003c/strong\u003ePatient Health Questionnaires 9 item. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable \u0026nbsp;3. Association between domains of HRQOL for CG and/or IG (Mean \u0026plusmn;SD) after the intervention, 2024.\u003c/p\u003e\n\u003cp\u003eNB: IG \u0026ndash;intervention group, CG: control group\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"616\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDomain of HRQOL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eIG (n=51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003eCG (n=54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003eMean difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003ePhysical health\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e23.69\u0026plusmn;1.463\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e22.06 \u0026plusmn; 0.231\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e8.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e(1.23, 2.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e1.631\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003ePsychological\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e18.59\u0026plusmn;1.344\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e18.96 \u0026plusmn; 1.009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e-1.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e(-.833, .084)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e-.375\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003eSocial domain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e10.08\u0026plusmn; 0.595\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e9.26\u0026plusmn; 0.442\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e7.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e0.841\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e(0.617,1.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e.819\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 117px;\"\u003e\n \u003cp\u003eEnvironmental\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e21.61\u0026plusmn;0.850\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 98px;\"\u003e\n \u003cp\u003e20.81\u0026plusmn; 0.992\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e4.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e(0.434,1.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e.793\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable \u0026nbsp;4.\u0026nbsp;The effect of W-DEQ, MAAS and other independent variables on quality of life scale of pregnant women: results of multiple regression analysis (n=105)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"688\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003eIndependent variable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 203px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% Confidence Interval\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026Beta;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eSE \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003et\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003eLower bound\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003eUpper bound\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003ePartial Eta Squared\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003eP-value\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCoefficient\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e65.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e5.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e12.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e54.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e76.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e.605\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelf esteem\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e.366\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e.197\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e1.860\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e-.025\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e.757\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e.034\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e.066\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMAAS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e.113\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e.126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e1.898\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e-.137\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e.362\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e.372\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eW-DEQ\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e-.046\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e.012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e-3.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e-.070\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e-.022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e.128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePHQ-9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e-.561\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e.127\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e-4.727\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e-.812\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e-.309\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e.168\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt;.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocial support\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e0.080\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e.038\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e2.095\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e.155\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e.043\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; .039\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVaginal delivery preference\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e-.323\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e.520\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e-.621\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e-1.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e.710\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.094\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 140px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNulliparous parity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 49px;\"\u003e\n \u003cp\u003e.418\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e.353\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e1.183\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e-2.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e1.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e.240\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cem\u003eNote:\u003c/em\u003e model adjusted for: Maternal age, gestational week, parity, pregnancy status, educational status of mothers and fathers R\u003csup\u003e2\u003c/sup\u003e= .518, Adjusted R\u003csup\u003e2\u003c/sup\u003e = .483, F: 14.90, P\u0026lt;0.001, The bold \u003cem\u003eP\u0026nbsp;\u003c/em\u003evalues indicate statistically significant differences, Abbreviation: SE, Standard error; MAAS, Maternal antenatal attachment scale, W-DEQ= Wijma Delivery Expectancy/Experience Questionnaire, PHQ\u003cstrong\u003e-9 -\u0026nbsp;\u003c/strong\u003ePatient Health Questionnaires 9 item\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Quasi experimental, Brief cognitive technique, Pregnant women, Antenatal, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-6534688/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6534688/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eMental health problems are common during pregnancy and are associated with maternal, fetal, and neonatal morbidity and mortality. While various interventions have been explored to address these challenges, evidence on the effectiveness of brief cognitive-behavioral techniques (CBT) for enhancing prenatal attachment and reducing fear of childbirth remains limited. So Thisstudy aimed to evaluate the effects of brief cognitive behavioral techniques on enhancing prenatal attachment, reducing fear of childbirth, and their secondary effect on the health-related quality of life (HRQOL) among pregnant women attending selected hospitals in the West Arsi zone, Ethiopia in 2024.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA quasi-experimental study was conducted from March 1 to July 30, 2024, in selected public hospitals of the West Arsi zone, Ethiopia. A total of 117 pregnant women attending antenatal care were included (58 in the experimental and 59 in the control group). Participants in the intervention group received CBT-based counselling in a group format (8 groups with 6\u0026ndash;8 members each), with weekly sessionsover 8 weeks.Each sessions lasted 15\u0026ndash;30 minutes.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e\u003cp\u003eThe findings indicated negligible significant differences in fear of childbirth between the intervention and control groups at baseline (t\u0026thinsp;=\u0026thinsp;2.802, P\u0026thinsp;\u003cb\u003e\u0026lt;\u003c/b\u003e\u0026thinsp;0.05). Post-intervention, significant differences were observed between the groups in fear of childbirth (t=-3.51, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and depression subscales (t=-4.43, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). However, no significant difference in the mean score was found in maternal antenatal attachment (MAAS) score during post-intervention (t=-.531, P\u0026thinsp;=\u0026thinsp;0.149). Significant improvements were observed in the physical and psychological subscales of HRQOL following the intervention. Fear of childbirth (\u003cem\u003eβ\u003c/em\u003e = -0.046), depressive symptoms (\u003cem\u003eβ\u003c/em\u003e = -0.561), and good social support (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.080) were significant predictors of HRQoL (P value\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThis study demonstrates that CBT-based prenatal interventions effectively reduce childbirth-related fear and improve maternal quality of life. However, the intervention showed no significant effect on maternal-fetal attachment. These findings underscore the need for a holistic approach that incorporates both cognitive techniques to address maternal mental health and targeted strategies to enhance maternal wellbeing during pregnancy.\u003c/p\u003e","manuscriptTitle":"Effect of Antenatal of brief-CBT on fear of childbirth, prenatal attachment, and quality of life (QoL): A Quasi-Experimental Study ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-31 10:30:00","doi":"10.21203/rs.3.rs-6534688/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5751151b-466c-4a39-b9f7-59831cf6a114","owner":[],"postedDate":"July 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-21T17:40:33+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-31 10:30:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6534688","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6534688","identity":"rs-6534688","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}