Full title: Managing the fear of childbirth, developing a care program: a multi-method study

Full title: Managing the fear of childbirth, developing a care program: a multi-method 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 Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Full title: Managing the fear of childbirth, developing a care program: a multi-method study Azam Bakhteh, Nasrin Jaberghaderi, Mitra kolivand, Mansour Rezaei, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2220461/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: Despite the importance of fear of childbirth and the necessity of implementing appropriate care methods to increase women's willingness to childbearing and their more tendency to perform natural childbirth, there is no clear process in this field in the care programs of the country's health system. The present study was designed with the aim of developing a guideline for managing the fear of childbirth in the current context. Methods: This is a multi-method study which was conducted in five stages within the framework of the National Institute for Health and Care Excellence (NICE) guideline. A research committee consisting of five focal and 16 secondary members was formed. The stages included determining the scope of the study, developing guideline (a qualitative study and a systematic review, triangulation of the data, and producing a preliminary draft), consultation stage (validation of the protocol Using nominal group method), as well as revision and publication stages. Results: The clinical guideline of Managing the fear of childbirth with 190 evidence-based recommendations was developed in seven main areas, including the Pre-pregnancy period, pregnancy period, making childbirth more pleasant, training empowerment of employees, improving the service delivery system, social support and clinical guide evaluation methods. Conclusions: We are hoping by applying this clinical guideline in maternal health care settings to move towards an integrated care plan for fear of child birth in the context of our health system. Health care organizations should support to form multi-specialty teams to care for mothers with fear of childbirth. Through holistic care, they can constantly examine the psychological needs of pregnant mothers, including the fear of childbirth, along with their other needs, and manage them correctly. fear of childbirth. Clinical guideline. Tokophobia. management. multi-method. Figures Figure 1 Plain English Summary Managing the fear of childbirth during the perinatal period is an important strategy for improving pregnant women’s attitude of childbearing, childbirth and to improve the health of mothers and infants. The results of this study provide the necessary information to carry out interventions needed to promote women's health during pregnancy and postpartum period. This study has a multi-stage design that consists of several consecutive phases. At first, with a qualitative approach, the researchers explained the concept, obstacles, facilitators, and suitable strategies to deal with the fear of childbirth, then using a systematic review of clinical trial studies and guidelines, they collected evidence related to the research topic . In the second stage, the results of the qualitative study and the systematic review of related studies have been combined with each other. By combining the results of the previous two stages, the initial draft of the guideline was designed based on the prioritized guidelines by a group of experts and validated for implementation. In the quantitative phase of the study, the validation of the guideline and the evaluation of the designed recommendations have been done using the AGREE tool. Over 85% agreement was expressed in different aspects of clinical guide validation. Only in the applicability domain, it got a lower score due to the need for structural changes in the healthcare service delivery system and the necessary budget allocation. 100% of the evaluators have recommended the use of the developed clinical guide. It is expected that by conducting this multi-stage study and providing guidelines appropriate to the cultural situation and the conditions of the society, the mental health of pregnant women, including the fear of childbirth and the attitude towards childbearing, and as a result, the health of the mother and the infant will improve. Introduction Fear of childbirth (FOC) is an extreme state of anxiety from phobia about childbirth( 1 ). FOC in pregnant women revolves around concerns such as the well-being of the child, pain, loss of control, medical interventions and the medical environment, unfamiliar healthcare providers during childbirth, and lack of support( 2 , 3 ). Results have shown that these fears are a source of anxiety in women, affect their everyday activities, lead to C-section, or prevent further pregnancies( 4 , 5 ). Some studies have suggested that a strong fear of Normal Vaginal Delivery (NVD) is an important factor in a pregnant mother's desire to have a cesarean section. Also, fear of pain, fear for the health of the baby, and fear of the situation not being controlled by the caregiver are the factors influencing the choice of cesarean section on normal delivery( 6 , 7 ). Reported incidence of FOC in pregnant women ranges from 8% in Europe to 24% in Australia( 8 ), 25% in Asia, and 26.9% in the United States( 9 ), with a recent systematic review reporting a global incidence of severe FOC of 6–10%( 4 ). Previous studies have found several risk fac tors for FOC in pregnant women, including maternal age, low educational level, parity, gestational age, depression, lack of social support, low self-esteem and low childbirth self-efficacy( 10 – 12 ). Some studies about planned measures to reduce the fear or anxiety of pregnant women have shown that a variety of counseling, support, and personal care programs with the presence of one or more members of the health care team such as midwives, psychologists, psychiatrists, counselors, and other specialists is effective in reducing mothers' fears and anxieties and reducing mothers' requests for cesarean section( 13 ).The purpose of interventions designed to reduce the fear of childbirth is to help control the anxiety associated with pregnancy and childbirth so that pregnant mothers can accept the doubts associated with it and reduce the stressors following the treatments to make better adaptations in pregnancy and refuse to request a cesarean section( 14 ). An integrative meta-diagnostic approach to reduce stress, which includes mental and physical exercises and appropriate behavioral interventions in the prenatal period, helps pregnancy health and reduces birth complications and can lead to the promotion of healthy parenting( 15 ). The evidence shows that developing special guidelines for health sector employees to properly manage the fear of childbirth is one of the priorities of care and support. Because it has been seen in various researches that proper treatment of fear in mothers can show its effect in reducing anxiety and depression, increasing self-efficacy and creating good pregnancy outcomes( 16 ). Providing clinical guidelines as a key component can be effective by presenting evidence-based care and thereby optimizing the care consequences and improving effective use of the healthcare system resources( 17 , 18 ). A review of the evidence in this regard shows that various clinical guidelines have been designed for mental health during pregnancy( 19 – 22 ), but only one of them specifically addresses the fear of childbirth( 23 ). The authors have prepared this guideline based on their field of expertise by mentioning the general headings and have refrained from addressing the details and the path of the interventions. On the other hand, these guideline recommendations were not graded based on the level of evidence. However, this is a general guideline and does not take into account the mental health care team, settings and human resources to provide care in cases of fear of childbirth based on our health system. A review of the literature about developing a clinical guideline of mental care shows that development of a clinical guideline should capture the complexities of healthcare provider organizations as well as ethical, legal, cultural, and economic aspects in any organization and country. In other words, the clinical guideline of a country may not be completely applicable for another context. Therefore, healthcare systems and organizations need standardization of their care policies in order to manage their resources and promote the care. Therefore, having a clinical guideline based on evidence-based recommendations, taking into account the needs of pregnant women and clinical expertise, is necessary to provide coherent mental health care, especially to deal with fear of childbirth. Based on this, the present study was designed for midwives with the aim of developing a clinical practice guide in Iran for the managing of fear of childbirth. Methods This multi-method design study was conducted in five stages within the framework of the National Institute for Health and Care Excellence (NICE) guideline( 24 ). This research was conducted from January2020 to June 2022. First, a research committee consisting of five members (the first author and research team) was created for performing qualitative study and searching the available reference in databases. Furthermore, 16 secondary members were added. Then 9 specialists in the Related scientific fields investigated the content validity of the clinical practice guideline. The NICE guide consists of six stages, but in this study, the last stage (updating phase) was not applicable( 24 ). 1) The stage of determining the scope: In our study in the first stage, the scope of the study and its objectives were determined in the research committee with focal members. Then, a decision was made on the following issue: “Which clinical questions should be addressed through the clinical practice guideline of management fear of childbirth?” 2) The stage of development: this stage was performed through discussion and decision-making in the research committee for conducting a qualitative study phase involving interpreting the understanding of managing of fear of childbirth concept, the needs of pregnant women, expectations, and skills of beneficiaries in the culture context as well as a systematic review phase (scoping search). In the qualitative study phase, 40 unstructured interviews were made with the participants in the study, including pregnant women, healthcare team members, and Health policy makers through conventional content analysis method. Writing of the qualitative phase of the study was based on the COREQ (consolidated criteria for reporting qualitative research) checklist. In the next step, by a systematic review, the available evidence on the literature and existing guidelines was extracted during an extensive search in databases. The systematic review was done based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2009. In the process of systematic review, first the research question was designed based on the study objectives through PIPOH method (Population, Intervention(s) (or diagnostic test) of interest, Professionals, Expected Outcomes, Healthcare setting and context). Through this method, the clinical question was designed as “What evidence-based interventions do health care providers and other members of the health care team use to reduce expectant mothers' fear of childbirth and promote their mental health?”. After designing the clinical question, three members (the first author and one member of the reproductive health group and finally one person with librarian expertise) searched the literature related to the topic. The search was carried out in the electronic databases, PubMed, Scopus, Embase, Web of Science, Clinical Key, Cochrane Library, and in specialized databases for guidelines, Agency for Healthcare Research and Quality & National Guideline Clearinghouse (NGC), Guideline International Network (G-I-N), National Institute for Health and Care Excellence, New Zealand Guidelines Group, National Health and Medical Research Council (NHMRC), The Scottish for Clinical Guidelines Network (SIGN), Clinical Trials.gov. At first, the title and summary of the extracted articles were independently screened by two authors according to the inclusion and exclusion criteria. In the next step, the full text of the selected articles was thoroughly studied by two authors. Eventually, 62 studies remained in the study (Fig. 1). (Fig. 1 here) Then, the information required for the studies was extracted and recorded in a designed form by the research team. At stage of development, the preliminary draft of the guideline was also developed in the research team through combining evidence-based recommendations from the results of the qualitative study phase and the systematic review. 3) Consultation stage: A panel group consisting of the specialists, i.e., the researchers and practitioners of the reproductive and mental health field, evaluated the draft of guidelines in terms of content validity using the nominal group technique. The specialists of the expert panel consisted of 16 scholars in the area of reproductive health and midwifery, gynecology and obstetrics, clinical psychology and psychiatry, health policy and university faculty members who had adequate skills and knowledge to comment on the studied subject, and expressed their interest to participate in the study. Based on the available sources, first the guide table of clinical components was designed in seven areas, and based on the opinions of people in each area, detailed descriptions of the relevant measures were included. Specific areas in this table include: the target group for the development of the clinical guide, the implementers of the implementation of the clinical guide, the necessary services for the development of the clinical guide (including educational services and individual and group counseling, psychological interventions and interventions related to Improving childbirth experiences), empowering the health team, improving the system of providing health services to pregnant women, social support for women suffering from fear of childbirth, forming peer groups, and monitoring indicators and evaluating the results of service implementation. Each of the areas of this table included different options that were the result of integration the results of the qualitative stage and the systematic review of articles. Based on the scores given by the panel members for each item, options were prioritized in each section. The results of prioritization were used in the compilation of recommendations related to different parts of the clinical guideline. The clinical guide for the management of fear of childbirth was developed with the aim of designing evidence-based recommendations based on the expectations and needs of expectant mothers and health team members in the context of Iranian culture. The recommendations of the clinical guidelines for the management of fear of childbirth in pregnant women (190 recommendations) were formed in seven main areas. Subsequently, this version of the guideline was provided to 12 scholars to evaluate the guideline by the AGREE-II reporting checklist (Appraisal of Guidelines for REsearch & Evaluation-II)( 25 ). 4) Revision stage: After critical appraisal of the descriptive comments in the research team, the necessary modifications were made. Then, the final version of the clinical practice guideline of management the fear of childbirth was produced. 5) Publication stage: Guideline recommendations are published in the first author’s Doctoral Thesis, alongside all evidence reviews, tables’ results, and methods. 6) Updating stage: The formal process for updating will begin three years after publication. When important changes are made, there will be a stakeholder consultation. The updated guideline will then be published, along with a list of changes from the previous version of it. As we were in the development stage, this stage was not included in our study. Results In the qualitative part of this study 40 participants including 15 pregnant women and 25 health care providers were included. From the analysis of the data obtained from the interviews, three themes emerged concerning the needs of mothers to properly manage the fear of childbirth: "Need to provide awareness and empowerment of mother and family", and "The need to pay attention to the mental health of pregnant women" and "Supporting needs (seeking support)". Overall, 1000 codes, 40 subcategories, 11 categories, and 3 themes were extracted from the text of the interviews (Table 1 ). Table 1 Main and subcategories obtained from the analysis of participants' interviews Theme Categories Subcategories Need to provide awareness and empowerment of mother and family The lack of awareness of mothers about pregnancy and childbirth Mother's ignorance of the pregnancy and childbirth process Inadequate maternal information on the advantages and disadvantages of NVD and C/S Lack of knowledge of preparation methods for childbirth Need to learn about pain relief methods The need to achieve more knowledge in reducing the fear of childbirth Need to know the facts of childbirth in different ways Lack of sensitivity of the couple to the specific conditions of pregnancy Improve the situation and reduce fear seeking more cognition Conscious choice of delivery method following cognition increase Educating and informing mothers and families The effect of education on the mother's physical and mental preparation Need to train spouse and family Continuous improvement of the training process taking into account the training needs Need to pay attention to the mental health of pregnant women The effect of maternal attitude on the process of pregnancy and childbirth The role of positive perceptions and thoughts in reducing the fear of childbirth The role of beliefs, previous experiences and negative mentality of the mother towards childbirth The importance of the impact of psychological factors and thoughts on pregnancy acceptance The influence of previous beliefs, experiences and indoctrination of others in choosing the method of delivery The psychological burden of experiencing fear in mother and family (healthy transition anxiety) Persistence of previous experiences of fear in life (rooted phobia from childhood to adulthood) Fear experience in the first sexual intercourse (wedding night experience) Unpleasant experience of previous delivery and experiences of others (family and friends) Experience of psychological trauma in pregnant women Experience coping with fear Consequences of fear of childbirth Threat to married life The need for maternal psychological support during pregnancy The need to pay attention to the mental and psychological condition of pregnant women Lack of support and lack of proper counseling services Use of effective methods on fear and anxiety Supporting needs (seeking support) Pay attention to the role of the husband in supporting the mother Psychological and emotional support and sympathy from the husband Husband's inattention to wife Husband's companionship and attention to the mother's needs The importance of family support Need for family support The need for family presence during childbirth The importance of empathy and family companionship The importance of supporting medical staff (health team) Need support from health care providers and midwives Need to support the midwifery team during delivery The importance of maternal support by obstetricians The need for social support Cultural and welfare activities to support pregnant women in society The importance of using communication media The impact of using cyberspace In the extensive search of electronic databases, 4831 articles were obtained. After removing duplicate and irrelevant studies in the screening and selection stages, eventually, 62 articles were included in the study. In the search phase in the dedicated databases of clinical guidelines, at first 1651 primary studies were extracted, after removing duplicate and unrelated cases, 12 clinical guidelines published between 2011 and 2021 were included in the final review. In the search for evidence and clinical guidelines, criteria such as relevance to the subject of the research, year of compilation, language and credibility of the compiler of the clinical guide were considered. The clinical guideline of management the fear of childbirth was developed with 190 evidence-based recommendations in seven main areas: the pre-gestational period (12 recommendations), the pregnancy period (80 recommendations), the improving childbirth experiences (49 recommendations), the educational empowerment of health providers (9 recommendations), the improving the system of providing health services to pregnant women (26 recommendations), the social support and formation of peer groups (9 recommendations), and evaluation methods of clinical guideline (5 recommendations) ) Table 2 ). Table 2 The main areas and recommendations of the clinical guideline the management of fear of childbirth. Areas Evidence-based recommendations pre-gestational period (12 recommendations) 3 recommendations for education and counseling, 4 recommendations for screening and diagnosis, and 5 recommendations for interventions. Pregnancy period (80 recommendations) 34 recommendations for the prevention of fear of childbirth (14 items for general actions, 4 items for educational content of pregnant women, 7 items for the method of providing education to pregnant women, 5 items for the educational content of women's families and spouses, and 4 items for the method of teaching to spouses) 14 recommendations for screening and diagnosis, 24 recommendations for interventions and care, and 8 recommendations for measures related to spiritual health. Improving childbirth experiences (49 recommendations) 20 recommendations for providing respectful care to mothers in the hospital, 15 recommendations for the first stage of labor, 6 recommendations for the second stage of labor, and 8 recommendations for the postpartum stage. Educational empowerment of health providers ) 9 recommendations) 9 recommendations for educational programs necessary to improve the performance of midwifery health providers and students. Improving the system of providing health services to pregnant women (26 recommendations) 7 recommendations for reforming the structure of health services, 5 recommendations for motivating employees and 14 recommendations for policy making in the field promote normal vaginal delivery. Social support and formation of peer groups (9 recommendations) 9 recommendations for social support of women suffering from fear of childbirth, forming and setting up peer groups for pregnant women Evaluation methods of clinical guideline (5 recommendations) 5 recommendations for Indicators for monitoring and evaluating the results of interventions. Based on the standard score of AGREE-II checklist, the minimum and maximum scores were related to the domains of Applicability (80/86%) and Scope and Purpose (93/21%), respectively. The scores given by specialists to the clinical practice guideline in other domains ranged between 86/57 and 92/06%. In the end, in the final evaluation of the clinical guide, the evaluators declared their judgment about the quality of the guide and 100% of them recommended the use of the clinical guide. 72.2% strongly recommended the use of the clinical guide and 27.8% conditionally recommended the use of the clinical guide. (Minor changes in parts of the clinical guide were recommended based on the suggestions provided by the evaluators). Overall, the quality of the clinical practice guideline of managing the fear of childbirth was estimated as desirable. Discussion Evidence-based recommendations and expectations of pregnant women and healthcare team members developed the clinical guideline for managing the fear of childbirth. One hundred and ninety recommendations within seven areas in the Iranian culture context were made. Recommendations in the first three areas, regarding education, counseling, diagnosis, and treatment, are specifically designed for clients. The next two areas contain recommendations for empowering health providers and the health service delivery system. 14 recommendations of the clinical guide in two other areas are related to social services and evaluation methods. This guideline is applicable based on the levels of health care in the health system. The health system of our country functions as a coherent network at three levels and the Ministry of Health and Medical Education stands at the top level. The first level includes sectors in which the first and largest level of contact between the society and healthcare system occur. These sectors include health houses and rural and urban health centers, in addition to health posts. The second level includes sectors which are able to provide healthcare services at a more specialized level. They include district health centers as well as district general hospitals under the supervision of medical sciences universities. Healthcare services at specialized levels occur at the third level of the health system of the country. This level includes the province health center and specialized hospitals under the supervision of medical sciences universities ( 26 ). Concerning the structure of the health system of the country and access to resources, this guideline can be applied at all three levels. That is, it can be implemented in primary care, intermediate care, and finally, hospitals (emergency departments, delivery, postpartum and palliative care), as well as hospital-integrated services to community-based home care. Considering the negative effects of the fear of childbirth on the attitude of women of reproductive age to the issue of having children, attention has been paid to the needs of women before pregnancy. So that the first field is dedicated to training, counseling, screening and necessary interventions in the pre-pregnancy period. Mycroft et al also emphasize in the guide to tokophobia and Traumatic Experience of Childbirth on identifying and providing educational and counseling services to non-pregnant women with a negative attitude towards childbirth( 23 ). Several clinical guidelines have mentioned the issue of providing mental health services to pregnant mothers during the perinatal period and have provided specific recommendations for the diagnosis and management of cases with mental health disorders( 20 – 22 ). This is despite the fact that the issue of fear of childbirth has only been addressed in the guide to fear of childbirth (tokophobia)( 23 ). In the third area, providing respectful services to mothers during admission, in the first and second stage of childbirth and postpartum are mentioned as recommendations related to making childbirth pleasant. Increasing the mother's participation, self-confidence, independence of action and satisfaction in the process of physiological childbirth can make childbirth pleasant for the mother and the family and reduce the desire of the mother to perform a cesarean section. By the World Health Organization, the intrapartum care clinical guideline for a positive childbirth experience was published in 2018 with 56 recommendations. WHO recommends respectful maternal care (RMC), effective communication, companionship during labor, and continuity of care for a positive birth experience( 27 ). The recommendations of this clinical guideline are classified into three-time stages for providing care (peripartum, intrapartum and postpartum). In other studies, interventions to increase self-confidence or improve women's childbirth conditions have had positive results regarding making childbirth more pleasant( 28 – 30 ). In order to improve the structure of providing services to pregnant women in health systems, recommendations have been designed in the next two areas of the guideline. Educational empowerment of health providers and improving the system of providing health services to pregnant women are issues that were raised due to the low quality of health service provider systems. It is necessary to reform the service delivery system in order to improve the quality of care in the field of women's health, and the current structure should be revised and the performance procedure should be modified. Some studies in Iran have shown that the low quality of health services for women and the lack of proper education for them leads to a lack of belief in health services. It not only causes a decrease in the motivation of service providers, but also creates unmet needs of clients and their dissatisfaction with health services( 31 ). Regarding the educational empowerment of the health team, some studies stated that the necessary capacities to enable them to play the role they are responsible for in the system with high efficiency and effectiveness should be created by using appropriate training( 32 ). For this reason, paying attention to the educational needs of employees in order to improve the quality of training courses was brought up. The lack of a specific screening protocol for the fear of childbirth and its administration in pregnancy is an important factor in the low performance of the health team in this field. The establishment of new regulations by health system policymakers with the aim of changing the approach of identifying high-risk cases and operational solutions to remove obstacles to NVD will lead to a change in the service path for pregnant women. Researchers have suggested that protocols based on theories of health education be designed, implemented and evaluated in healthcare systems( 33 ). In these protocols, women who receive psychoeducation along with usual care methods will experience more positive pregnancy and birth experiences. Psychologically based interventions can play an effective role in reducing FOC during pregnancy and even childbirth. Therefore, creative and counseling-based methods should be used to improve women's psychological conditions by health care teams( 34 , 35 ). Social support and the formation of peer groups is another area of clinical guidance for the management of fear of childbirth. Considering the special conditions of pregnancy, women need multifaceted support, including family and community support in the form of cultural and welfare services. These supports reduce the psychological burden caused by pregnancy and with companionship, empathy and attention to the woman's needs from other people, are effective in reducing fears during pregnancy. In studies, increasing social support leads to a decrease in the fear of childbirth in primiparous women and an increase in their satisfaction with childbirth( 36 , 37 ). In addition to positive effects during pregnancy and childbirth, social support also has beneficial effects after childbirth. Studies have shown that women who received supportive measures during pregnancy had less depression than others in the postpartum period( 38 , 39 ). In recent years, more emphasis has been placed on that a significant part of health behaviors is the result of learning from others, and in particular, the effects of peer groups. Thus, the use of a peer education approach, which is considered a behavior change strategy, can be applied in this regard( 40 ).In a peer education approach, the peers communicate with other peers and transfer the information effectively thus affecting their counterparts( 41 ).The results of studies have shown that peer education has an effect on reducing the FOC in pregnant women. The mean scores of mothers’ fear in the peer education group after the intervention decreased compared to their mean scores before the intervention( 42 ). Considering the positive effect of peer groups in reducing fear of childbirth, recommendations were designed on this basis in this clinical guide. Considering the importance of evaluation in determining the positive performance of a process and the degree of success in achieving the goals, recommendations for its evaluation methods were designed in the last area of the clinical guide. In summary, applying this clinical guideline can help caregivers of the health system to move towards an integrated mental health care plan for pregnant women in our healthcare system. midwives can be in the core of the Maternal mental health team. Maternal mental health team consists of qualified healthcare providers who are all working under supervision of the Reproductive health specialist. Through holistic view, they can constantly examine the psychological needs of mothers, including fear of childbirth alongside their other needs and provided standard care to pregnant women by focusing on the process of identification, psychoeducation, follow-up and referral. Benefiting from the NICE guideline, grading the evidence, and critical appraisal of the clinical practice guideline by the AGREE-II have been the strong points of this study. Conclusion The guideline obtained from this research with regards to fear of childbirth can be employed for management, policymaking, educational, and research purposes, and be effective in enhancing the quality of services provided to pregnant mothers. Considering the increasing rate of C-section caused by fear of childbirth in Iran it is expected that with implementing of guideline, women would have greater tendency to undergo natural delivery. Further, implementation of the guideline will help gain awareness about the benefits and obstacles of executing this guideline across the Iranian population. Indeed, we could also provide this guideline to policymakers and planners, so that they would use it as a standard for Promotion of natural childbirth. Nevertheless, in this regard the grounds for implementing national protocols of management fear of childbirth such as human and financial resources as well as hospitalization environment should be provided. Since there is no comprehensive guideline in WHO or presented by other countries for management fear of childbirth, this study was designed to compose guideline in Iran based on a multiphase study. Tis guideline can be also considered in other parts of the world as well. Abbreviations NICE National Institute for Health and Care Excellence FOC Fear of childbirth NVD Normal Vaginal Delivery COREQ Consolidated criteria for Reporting Qualitative research PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analyses NGC National Guideline Clearinghouse G-I-N Guideline International Network NHMRC National Health and Medical Research Council SIGN The Scottish for Clinical Guidelines Network AGREE Appraisal of Guidelines for REsearch & Evaluation WHO World Health Organization RMC Respectful Maternal Care. Declarations Ethics approval and consent to participate Ethical approval to conduct this study (IR.SHMU.REC.1399.135) was granted by the Ethics Committee of Shahroud University of Medical Sciences, Iran. Written informed consent will take from each participant. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests Availability of data and materials The dataset supporting the conclusions of this article is available from the corresponding author upon reasonable request. Funding None. Authors’ contributions All the authors contributed to the conception and design of the study. AB drafted the first version of the manuscript. ZM, NJ, and MK revised the manuscript. MR critically reviewed the manuscript for important intellectual content. All authors approved the final version. Acknowledgements This paper was extracted from a reproductive health PhD thesis, approved by the research session of Shahroud University of Medical Sciences with code 873. Therefore, I would like to thank the Vice Chancellor for Research of Shahroud University of Medical Sciences. References Salomonsson B, Gullberg MT, Alehagen S, Wijma K. Self-efficacy beliefs and fear of childbirth in nulliparous women. J Psychosom Obstet Gynecol. 2013;34(3):116–21. Fenwick J, Toohill J, Creedy DK, Smith J, Gamble J. Sources, responses and moderators of childbirth fear in Australian women: a qualitative investigation. Midwifery. 2015;31(1):239–46. Fisher C, Hauck Y, Fenwick J. How social context impacts on women's fears of childbirth: a Western Australian example. Soc Sci Med. 2006;63(1):64–75. O'Connell MA, Leahy-Warren P, Khashan AS, Kenny LC, O'Neill SM. Worldwide prevalence of tocophobia in pregnant women: systematic review and meta‐analysis. Acta Obstet Gynecol Scand. 2017;96(8):907–20. Khwepeya M, Lee GT, Chen S-R, Kuo S-Y. Childbirth fear and related factors among pregnant and postpartum women in Malawi. BMC Pregnancy Childbirth. 2018;18(1):1–10. Swift EM, Gottfredsdottir H, Zoega H, Gross MM, Stoll K. Opting for natural birth: A survey of birth intentions among young Icelandic women. Sex Reproductive Healthc. 2017;11:41–6. Demšar K, Svetina M, Verdenik I, Tul N, Blickstein I, Velikonja VG. Tokophobia (fear of childbirth): prevalence and risk factors. J Perinat Med. 2018;46(2):151–4. Toohill J, Creedy DK, Gamble J, Fenwick J. A cross-sectional study to determine utility of childbirth fear screening in maternity practice–An Australian perspective. Women Birth. 2015;28(4):310–6. Stoll K, Edmonds JK, Hall WA. Fear of childbirth and preference for cesarean delivery among young American women before childbirth: a survey study. Birth. 2015;42(3):270–6. Räisänen S, Lehto S, Nielsen H, Gissler M, Kramer M, Heinonen S. Fear of childbirth in nulliparous and multiparous women: a population-based analysis of all singleton births in F inland in 1997–2010. BJOG: An International Journal of Obstetrics & Gynaecology. 2014;121(8):965–70. Hamama-Raz Y, Sommerfeld E, Ken-Dror D, Lacher R, Ben-Ezra M. The role of intra-personal and inter-personal factors in fear of childbirth: a preliminary study. Psychiatr Q. 2017;88(2):385–96. Symonides A, Mogilnicka I, Krulak K, Kacperczyk J, Dobrowolska-Redo A, Romejko-Wolniewicz E. Understanding tokophobia phenomenon as a key to proper management. Microcephaly associated with Zika virus infection–prevention, diagnosis and treatment. 2016:12. Weaver J, Browne J, Aras-Payne A, Magill-Cuerden J. A comprehensive systematic review of the impact of planned interventions offered to pregnant women who have requested a caesarean section as a result of tokophobia (fear of childbirth). JBI Evid Synthesis. 2013;11(1):70–122. Scollato A, Lampasona R. Tokophobia. When fear of childbirth prevails. Mediterranean Journal of Clinical Psychology. 2013;1(1). Hosseini VM, 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. Larsson B, Hildingsson I, Ternström E, Rubertsson C, Karlström A. Women’s experience of midwife-led counselling and its influence on childbirth fear: A qualitative study. Women Birth. 2019;32(1):e88–94. Bahramnezhad F, Cheraghi MA. Realization of Clinical Guidelines in Providing Health Services. Hayat J. 2015;21(3):1–4. Ansari S, Rashidian A. Guidelines for guidelines: are they up to the task? A comparative assessment of clinical practice guideline development handbooks. PLoS ONE. 2012;7(11):e49864. Dennis C, Vigod S. PCMCH Guidance Document: Perinatal Mental Health, Guidance for the identification and management of mental health in pregnant or postpartum individuals Ontario’s Provincial Council for Maternal and Child Health. 2021. Austin M-P, Highet N. Mental health care in the perinatal period: Australian clinical practice guideline. 2017. NICE. Antenatal and postnatal mental health: Clinical management and service guidance. Leicester: British Psychological Society; 2016. Mental Health Care in the Perinatal Period. the royal australian and new zealand college of obstetricians and gynaecologists Women’s Health Committee and approved by the RANZCOG Board and Council. March 2018. Mycroft R, Taha S. Fear of Childbirth (Tokophobia) and Traumatic Experience of Childbirth: Best Practice Toolkit. NHS Pan-London Perinatal Mental Health Networks; 2018. p. 16. National Institute For Clinical. Excellence, Developing NICE guidelines: the manual.. Manchester. 2014. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. Development of the AGREE II, part 1: performance, usefulness and areas for improvement. CMAJ. 2010;182(10):1045–52. Asefzadeh S, Rezaee A. Health managment. 2012. Organization WH. WHO recommendations on intrapartum care for a positive childbirth experience. World Health Organization; 2018. Forster DA, McLachlan HL, Davey M-A, Biro MA, Farrell T, Gold L, et al. Continuity of care by a primary midwife (caseload midwifery) increases women’s satisfaction with antenatal, intrapartum and postpartum care: results from the COSMOS randomised controlled trial. BMC Pregnancy Childbirth. 2016;16(1):1–13. Meedya S, Fahy K, Parratt JA. The Milky Way educational and support programme: Structure, content and strategies. Women Birth. 2016;29(4):388–93. Ghanbari-Homaie S, Meedya S, Mohammad-Alizadeh-Charandabi S, Jafarabadi MA, Mohammadi E, Mirghafourvand M. Recommendations for improving primiparous women’s childbirth experience: results from a multiphase study in Iran. Reproductive health. 2021;18(1):1–13. Allahqoli L, Rahmani A, GHANEI GR, Fallahi A, Hashemian M, Fallahi H, et al. Job Burnout from the Perspective of Health Educators: Challenges and Needs. 2019. Masoumi SZ, Kazemi F, Oshvandi K, Jalali M, Esmaeili-Vardanjani A, Rafiei H. Effect of training preparation for childbirth on fear of normal vaginal delivery and choosing the type of delivery among pregnant women in Hamadan, Iran: a randomized controlled trial. J family reproductive health. 2016;10(3):115. Striebich 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. Akgün M, Boz I, Özer Z. The effect of psychoeducation on fear of childbirth and birth type: systematic review and meta-analysis. J Psychosom Obstet Gynecol. 2020;41(4):253–65. Gargari MA, Esmailpour K, Mirghafourvand M, Nourizadeh R, Mehrabi E. Effects of Psycho-education Interventions on Perceived Childbirth Fear and Anxiety by Pregnant Women: A Systematic Review and Meta-analysis. 2021. Jaghargh MV, Alizadeh KH. Determining the Predictive Factors of Fear of Childbirth Based on Personality Traits, Social Support and Emotional Regulation among Nulliparous Pregnant Mothers in Bandar Abbas. 2017. Sadeghi Aval Shahr H, Moosavi Sahebalzamani S, Jahdi F, Neisani Samani L, Haghani H. Relationship between Perceived Social Support in First Pregnancy with Birth Satisfaction in Primigravid Women Referred to Shahid Akbar Abadi Hospital. Prev Care Nurs Midwifery J. 2014;4(1):54–64. Spoozak L, Gotman N, Smith MV, Belanger K, Yonkers KA. Evaluation of a social support measure that may indicate risk of depression during pregnancy. J Affect Disord. 2009;114(1–3):216–23. AZH N, YOUNESIAN M, Fili A, ABBASI MA. The study of supportive activities during pregnancy on postpartum depression. 2006. United Nations Population Fund and Youth Peer Education Network. Training of Trainers Manual: From theory to practice in peer education. Arlington: United Nations Population Fund; 2014. Speizer IS, Magnani RJ, Colvin CE. The effectiveness of adolescent reproductive health interventions in developing countries: a review of the evidence. J Adolesc Health. 2003;33(5):324–48. Rahmani R, Moghadam FY, Hadizadeh-Talasaz F, Reza M. The effect of peer education on fear of childbirth in pregnant women: A randomized clinical trial. International Journal of Women’s Health and Reproduction Sciences. 2019. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2220461","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":148821863,"identity":"14536a6b-6b23-4e38-9305-3c4d4712695c","order_by":0,"name":"Azam Bakhteh","email":"","orcid":"","institution":"Shahroud University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Azam","middleName":"","lastName":"Bakhteh","suffix":""},{"id":148821864,"identity":"d5934286-5238-4247-9aa0-980bf98fcf3c","order_by":1,"name":"Nasrin Jaberghaderi","email":"","orcid":"","institution":"Kermanshah University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Nasrin","middleName":"","lastName":"Jaberghaderi","suffix":""},{"id":148821865,"identity":"82918310-dbe6-403b-bbe1-d220d777e4cf","order_by":2,"name":"Mitra kolivand","email":"","orcid":"","institution":"Kermanshah University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mitra","middleName":"","lastName":"kolivand","suffix":""},{"id":148821866,"identity":"db13593a-8b42-4b69-8188-686416dffb51","order_by":3,"name":"Mansour Rezaei","email":"","orcid":"","institution":"Kermanshah University of Medical Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mansour","middleName":"","lastName":"Rezaei","suffix":""},{"id":148821867,"identity":"47f52824-6ada-426c-9d50-4be2e9c3fe8e","order_by":4,"name":"Zahra Motaghi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+klEQVRIie3RsWrDMBCAYYkDZ7k0q0Na/AoJnQItfhWLQKbkHRQMyuJkLAke+haZZW7okgcoqEOnTh1supjgQuUupYRYHTvon06gDyGOMZ/v/6ZxAKB1aceg577OZUuGayWKXUvgj4SNj8dbwvbsItEDPb3Wp5dr9pyM6e50iK6A8bJadDyRz8Vqs31DvksSWm7NRAGD4f5wmcBoMZH9jBDCRNMyM9ySAPodJLBk9WlJEApJ08zEToKWpFgTIhIjVhvhJOFoLvIbSRj2FCs20swU8LTzL1E+09V7Q3FMg4+ybsz94zotyqqDfMfVr6FdlLPmbPD5fD7fT1+yDFhJo0jfUgAAAABJRU5ErkJggg==","orcid":"","institution":"Shahroud University of Medical Sciences","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Zahra","middleName":"","lastName":"Motaghi","suffix":""}],"badges":[],"createdAt":"2022-10-31 06:44:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2220461/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2220461/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":28684845,"identity":"8239e184-f2d8-4e30-bf9d-ff4f6a0828b8","added_by":"auto","created_at":"2022-11-04 21:12:32","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":30637,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"fig.1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-2220461/v1/82fc9ebe8d9474ddbd44b1a4.jpg"},{"id":28798604,"identity":"bed7b526-1d3a-4827-a981-4b1330407bfc","added_by":"auto","created_at":"2022-11-08 11:29:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":351952,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2220461/v1/5275f2e1-817d-4a1d-9083-1336e92abab9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Full title: Managing the fear of childbirth, developing a care program: a multi-method study","fulltext":[{"header":"Plain English Summary","content":"\u003cp\u003eManaging the fear of childbirth during the perinatal period is an important strategy for improving pregnant women\u0026rsquo;s attitude of childbearing, childbirth and to improve the health of mothers and infants. The results of this study provide the necessary information to carry out interventions needed to promote women\u0026apos;s health during pregnancy and postpartum period. This study has a multi-stage design that consists of several consecutive phases.\u0026nbsp;At first, with a qualitative approach, the researchers explained the concept, obstacles, facilitators, and suitable strategies to deal with the fear of childbirth, then using a systematic review of clinical trial studies and guidelines, they collected evidence related to the research topic\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e In the second stage, the results of the qualitative study and the systematic review of related studies have been combined with each other. By combining the results of the previous two stages, the initial draft of the guideline was designed based on the prioritized guidelines by a group of experts and validated for implementation. In the quantitative phase of the study, the validation of the guideline and the evaluation of the designed recommendations have been done using the AGREE tool. Over 85% agreement was expressed in different aspects of clinical guide validation. Only in the applicability domain, it got a lower score due to the need for structural changes in the healthcare service delivery system and the necessary budget allocation. 100% of the evaluators have recommended the use of the developed clinical guide. It is expected that by conducting this multi-stage study and providing guidelines appropriate to the cultural situation and the conditions of the society, the mental health of pregnant women, including the fear of childbirth and the attitude towards childbearing, and as a result, the health of the mother and the infant will improve.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eFear of childbirth (FOC) is an extreme state of anxiety from phobia about childbirth(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). FOC in pregnant women revolves around concerns such as the well-being of the child, pain, loss of control, medical interventions and the medical environment, unfamiliar healthcare providers during childbirth, and lack of support(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Results have shown that these fears are a source of anxiety in women, affect their everyday activities, lead to C-section, or prevent further pregnancies(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Some studies have suggested that a strong fear of Normal Vaginal Delivery (NVD) is an important factor in a pregnant mother's desire to have a cesarean section. Also, fear of pain, fear for the health of the baby, and fear of the situation not being controlled by the caregiver are the factors influencing the choice of cesarean section on normal delivery(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Reported incidence of FOC in pregnant women ranges from 8% in Europe to 24% in Australia(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), 25% in Asia, and 26.9% in the United States(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), with a recent systematic review reporting a global incidence of severe FOC of 6\u0026ndash;10%(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Previous studies have found several risk fac tors for FOC in pregnant women, including maternal age, low educational level, parity, gestational age, depression, lack of social support, low self-esteem and low childbirth self-efficacy(\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Some studies about planned measures to reduce the fear or anxiety of pregnant women have shown that a variety of counseling, support, and personal care programs with the presence of one or more members of the health care team such as midwives, psychologists, psychiatrists, counselors, and other specialists is effective in reducing mothers' fears and anxieties and reducing mothers' requests for cesarean section(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).The purpose of interventions designed to reduce the fear of childbirth is to help control the anxiety associated with pregnancy and childbirth so that pregnant mothers can accept the doubts associated with it and reduce the stressors following the treatments to make better adaptations in pregnancy and refuse to request a cesarean section(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). An integrative meta-diagnostic approach to reduce stress, which includes mental and physical exercises and appropriate behavioral interventions in the prenatal period, helps pregnancy health and reduces birth complications and can lead to the promotion of healthy parenting(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The evidence shows that developing special guidelines for health sector employees to properly manage the fear of childbirth is one of the priorities of care and support. Because it has been seen in various researches that proper treatment of fear in mothers can show its effect in reducing anxiety and depression, increasing self-efficacy and creating good pregnancy outcomes(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Providing clinical guidelines as a key component can be effective by presenting evidence-based care and thereby optimizing the care consequences and improving effective use of the healthcare system resources(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). A review of the evidence in this regard shows that various clinical guidelines have been designed for mental health during pregnancy(\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), but only one of them specifically addresses the fear of childbirth(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The authors have prepared this guideline based on their field of expertise by mentioning the general headings and have refrained from addressing the details and the path of the interventions. On the other hand, these guideline recommendations were not graded based on the level of evidence. However, this is a general guideline and does not take into account the mental health care team, settings and human resources to provide care in cases of fear of childbirth based on our health system. A review of the literature about developing a clinical guideline of mental care shows that development of a clinical guideline should capture the complexities of healthcare provider organizations as well as ethical, legal, cultural, and economic aspects in any organization and country.\u003c/p\u003e \u003cp\u003eIn other words, the clinical guideline of a country may not be completely applicable for another context. Therefore, healthcare systems and organizations need standardization of their care policies in order to manage their resources and promote the care. Therefore, having a clinical guideline based on evidence-based recommendations, taking into account the needs of pregnant women and clinical expertise, is necessary to provide coherent mental health care, especially to deal with fear of childbirth. Based on this, the present study was designed for midwives with the aim of developing a clinical practice guide in Iran for the managing of fear of childbirth.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis multi-method design study was conducted in five stages within the framework of the National Institute for Health and Care Excellence (NICE) guideline(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). This research was conducted from January2020 to June 2022. First, a research committee consisting of five members (the first author and research team) was created for performing qualitative study and searching the available reference in databases. Furthermore, 16 secondary members were added. Then 9 specialists in the Related scientific fields investigated the content validity of the clinical practice guideline. The NICE guide consists of six stages, but in this study, the last stage (updating phase) was not applicable(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e1) The stage of determining the scope: In our study in the first stage, the scope of the study and its objectives were determined in the research committee with focal members. Then, a decision was made on the following issue: \u0026ldquo;Which clinical questions should be addressed through the clinical practice guideline of management fear of childbirth?\u0026rdquo;\u003c/p\u003e \u003cp\u003e2) The stage of development: this stage was performed through discussion and decision-making in the research committee for conducting a qualitative study phase involving interpreting the understanding of managing of fear of childbirth concept, the needs of pregnant women, expectations, and skills of beneficiaries in the culture context as well as a systematic review phase (scoping search). In the qualitative study phase, 40 unstructured interviews were made with the participants in the study, including pregnant women, healthcare team members, and Health policy makers through conventional content analysis method. Writing of the qualitative phase of the study was based on the COREQ (consolidated criteria for reporting qualitative research) checklist. In the next step, by a systematic review, the available evidence on the literature and existing guidelines was extracted during an extensive search in databases. The systematic review was done based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2009. In the process of systematic review, first the research question was designed based on the study objectives through PIPOH method (Population, Intervention(s) (or diagnostic test) of interest, Professionals, Expected Outcomes, Healthcare setting and context). Through this method, the clinical question was designed as \u0026ldquo;What evidence-based interventions do health care providers and other members of the health care team use to reduce expectant mothers' fear of childbirth and promote their mental health?\u0026rdquo;. After designing the clinical question, three members (the first author and one member of the reproductive health group and finally one person with librarian expertise) searched the literature related to the topic. The search was carried out in the electronic databases, PubMed, Scopus, Embase, Web of Science, Clinical Key, Cochrane Library, and in specialized databases for guidelines, Agency for Healthcare Research and Quality \u0026amp; National Guideline Clearinghouse (NGC), Guideline International Network (G-I-N), National Institute for Health and Care Excellence, New Zealand Guidelines Group, National Health and Medical Research Council (NHMRC), The Scottish for Clinical Guidelines Network (SIGN), Clinical Trials.gov. At first, the title and summary of the extracted articles were independently screened by two authors according to the inclusion and exclusion criteria. In the next step, the full text of the selected articles was thoroughly studied by two authors. Eventually, 62 studies remained in the study (Fig.\u0026nbsp;1).\u003c/p\u003e \u003cp\u003e(Fig.\u0026nbsp;1 here)\u003c/p\u003e \u003cp\u003eThen, the information required for the studies was extracted and recorded in a designed form by the research team. At stage of development, the preliminary draft of the guideline was also developed in the research team through combining evidence-based recommendations from the results of the qualitative study phase and the systematic review.\u003c/p\u003e \u003cp\u003e3) Consultation stage: A panel group consisting of the specialists, i.e., the researchers and practitioners of the reproductive and mental health field, evaluated the draft of guidelines in terms of content validity using the nominal group technique. The specialists of the expert panel consisted of 16 scholars in the area of reproductive health and midwifery, gynecology and obstetrics, clinical psychology and psychiatry, health policy and university faculty members who had adequate skills and knowledge to comment on the studied subject, and expressed their interest to participate in the study. Based on the available sources, first the guide table of clinical components was designed in seven areas, and based on the opinions of people in each area, detailed descriptions of the relevant measures were included. Specific areas in this table include: the target group for the development of the clinical guide, the implementers of the implementation of the clinical guide, the necessary services for the development of the clinical guide (including educational services and individual and group counseling, psychological interventions and interventions related to Improving childbirth experiences), empowering the health team, improving the system of providing health services to pregnant women, social support for women suffering from fear of childbirth, forming peer groups, and monitoring indicators and evaluating the results of service implementation. Each of the areas of this table included different options that were the result of integration the results of the qualitative stage and the systematic review of articles. Based on the scores given by the panel members for each item, options were prioritized in each section. The results of prioritization were used in the compilation of recommendations related to different parts of the clinical guideline.\u003c/p\u003e \u003cp\u003eThe clinical guide for the management of fear of childbirth was developed with the aim of designing evidence-based recommendations based on the expectations and needs of expectant mothers and health team members in the context of Iranian culture. The recommendations of the clinical guidelines for the management of fear of childbirth in pregnant women (190 recommendations) were formed in seven main areas. Subsequently, this version of the guideline was provided to 12 scholars to evaluate the guideline by the AGREE-II reporting checklist (Appraisal of Guidelines for REsearch \u0026amp; Evaluation-II)(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e4) Revision stage: After critical appraisal of the descriptive comments in the research team, the necessary modifications were made. Then, the final version of the clinical practice guideline of management the fear of childbirth was produced.\u003c/p\u003e \u003cp\u003e5) Publication stage: Guideline recommendations are published in the first author\u0026rsquo;s Doctoral Thesis, alongside all evidence reviews, tables\u0026rsquo; results, and methods.\u003c/p\u003e \u003cp\u003e6) Updating stage: The formal process for updating will begin three years after publication. When important changes are made, there will be a stakeholder consultation. The updated guideline will then be published, along with a list of changes from the previous version of it. As we were in the development stage, this stage was not included in our study.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn the qualitative part of this study 40 participants including 15 pregnant women and 25 health care providers were included. From the analysis of the data obtained from the interviews, three themes emerged concerning the needs of mothers to properly manage the fear of childbirth: \"Need to provide awareness and empowerment of mother and family\", and \"The need to pay attention to the mental health of pregnant women\" and \"Supporting needs (seeking support)\". Overall, 1000 codes, 40 subcategories, 11 categories, and 3 themes were extracted from the text of the interviews (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eMain and subcategories obtained from the analysis of participants' interviews\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTheme\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCategories\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSubcategories\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"11\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eNeed to provide awareness and empowerment of mother and family\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eThe lack of awareness of mothers about pregnancy and childbirth\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMother's ignorance of the pregnancy and childbirth process\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInadequate maternal information on the advantages and disadvantages of NVD and C/S\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLack of knowledge of preparation methods for childbirth\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNeed to learn about pain relief methods\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eThe need to achieve more knowledge in reducing the fear of childbirth\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNeed to know the facts of childbirth in different ways\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLack of sensitivity of the couple to the specific conditions of pregnancy\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eImprove the situation and reduce fear seeking more cognition\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eConscious choice of delivery method following cognition increase\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eEducating and informing mothers and families\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe effect of education on the mother's physical and mental preparation\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNeed to train spouse and family\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eContinuous improvement of the training process taking into account the training needs\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"13\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eNeed to pay attention to the mental health of pregnant women\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eThe effect of maternal attitude on the process of pregnancy and childbirth\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe role of positive perceptions and thoughts in reducing the fear of childbirth\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe role of beliefs, previous experiences and negative mentality of the mother towards childbirth\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe importance of the impact of psychological factors and thoughts on pregnancy acceptance\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe influence of previous beliefs, experiences and indoctrination of others in choosing the method of delivery\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eThe psychological burden of experiencing fear in mother and family (healthy transition anxiety)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePersistence of previous experiences of fear in life (rooted phobia from childhood to adulthood)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFear experience in the first sexual intercourse (wedding night experience)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUnpleasant experience of previous delivery and experiences of others (family and friends)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eExperience of psychological trauma in pregnant women\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eExperience coping with fear\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eConsequences of fear of childbirth\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThreat to married life\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eThe need for maternal psychological support during pregnancy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe need to pay attention to the mental and psychological condition of pregnant women\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLack of support and lack of proper counseling services\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUse of effective methods on fear and anxiety\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"12\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSupporting needs (seeking support)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003ePay attention to the role of the husband in supporting the mother\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePsychological and emotional support and sympathy from the husband\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHusband's inattention to wife\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHusband's companionship and attention to the mother's needs\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eThe importance of family support\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNeed for family support\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe need for family presence during childbirth\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe importance of empathy and family companionship\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eThe importance of supporting medical staff (health team)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNeed support from health care providers and midwives\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNeed to support the midwifery team during delivery\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe importance of maternal support by obstetricians\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eThe need for social support\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCultural and welfare activities to support pregnant women in society\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe importance of using communication media\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe impact of using cyberspace\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eIn the extensive search of electronic databases, 4831 articles were obtained. After removing duplicate and irrelevant studies in the screening and selection stages, eventually, 62 articles were included in the study. In the search phase in the dedicated databases of clinical guidelines, at first 1651 primary studies were extracted, after removing duplicate and unrelated cases, 12 clinical guidelines published between 2011 and 2021 were included in the final review. In the search for evidence and clinical guidelines, criteria such as relevance to the subject of the research, year of compilation, language and credibility of the compiler of the clinical guide were considered.\u003c/p\u003e\n\u003cp\u003eThe clinical guideline of management the fear of childbirth was developed with 190 evidence-based recommendations in seven main areas: the pre-gestational period (12 recommendations), the pregnancy period (80 recommendations), the improving childbirth experiences (49 recommendations), the educational empowerment of health providers (9 recommendations), the improving the system of providing health services to pregnant women (26 recommendations), the social support and formation of peer groups (9 recommendations), and evaluation methods of clinical guideline (5 recommendations) ) Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eThe main areas and recommendations of the clinical guideline\u0026nbsp;the management of fear of childbirth.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003cth style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003eAreas\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003eEvidence-based recommendations\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr style=\"height: 83px;\"\u003e\n\u003ctd style=\"height: 83px;\" align=\"left\"\u003e\n\u003cp\u003epre-gestational period\u003c/p\u003e\n\u003cp\u003e(12 recommendations)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 83px;\" align=\"left\"\u003e\n\u003cp\u003e3 recommendations for education and counseling,\u003c/p\u003e\n\u003cp\u003e4 recommendations for screening and diagnosis, and\u003c/p\u003e\n\u003cp\u003e5 recommendations for interventions.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 157px;\"\u003e\n\u003ctd style=\"height: 157px;\" align=\"left\"\u003e\n\u003cp\u003ePregnancy period\u003c/p\u003e\n\u003cp\u003e(80 recommendations)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 157px;\" align=\"left\"\u003e\n\u003cp\u003e34 recommendations for the prevention of fear of childbirth\u003c/p\u003e\n\u003cp\u003e(14 items for general actions, 4 items for educational content of pregnant women, 7 items for the method of providing education to pregnant women, 5 items for the educational content of women's families and spouses, and 4 items for the method of teaching to spouses)\u003c/p\u003e\n\u003cp\u003e14 recommendations for screening and diagnosis,\u003c/p\u003e\n\u003cp\u003e24 recommendations for interventions and care, and\u003c/p\u003e\n\u003cp\u003e8 recommendations for measures related to spiritual health.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 107px;\"\u003e\n\u003ctd style=\"height: 107px;\" align=\"left\"\u003e\n\u003cp\u003eImproving childbirth experiences\u003c/p\u003e\n\u003cp\u003e(49 recommendations)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 107px;\" align=\"left\"\u003e\n\u003cp\u003e20 recommendations for providing respectful care to mothers in the hospital,\u003c/p\u003e\n\u003cp\u003e15 recommendations for the first stage of labor,\u003c/p\u003e\n\u003cp\u003e6 recommendations for the second stage of labor, and\u003c/p\u003e\n\u003cp\u003e8 recommendations for the postpartum stage.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 72px;\"\u003e\n\u003ctd style=\"height: 72px;\" align=\"left\"\u003e\n\u003cp\u003eEducational empowerment of health providers\u003c/p\u003e\n\u003cp\u003e) 9 recommendations)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 72px;\" align=\"left\"\u003e\n\u003cp\u003e9 recommendations for educational programs necessary to improve the performance of midwifery health providers and students.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 83px;\"\u003e\n\u003ctd style=\"height: 83px;\" align=\"left\"\u003e\n\u003cp\u003eImproving the system of providing health services to pregnant women\u003c/p\u003e\n\u003cp\u003e(26 recommendations)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 83px;\" align=\"left\"\u003e\n\u003cp\u003e7 recommendations for reforming the structure of health services,\u003c/p\u003e\n\u003cp\u003e5 recommendations for motivating employees and\u003c/p\u003e\n\u003cp\u003e14 recommendations for policy making in the field promote normal vaginal delivery.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 72px;\"\u003e\n\u003ctd style=\"height: 72px;\" align=\"left\"\u003e\n\u003cp\u003eSocial support and formation of peer groups\u003c/p\u003e\n\u003cp\u003e(9 recommendations)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 72px;\" align=\"left\"\u003e\n\u003cp\u003e9 recommendations for social support of women suffering from fear of childbirth, forming and setting up peer groups for pregnant women\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 59px;\"\u003e\n\u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n\u003cp\u003eEvaluation methods of clinical guideline\u003c/p\u003e\n\u003cp\u003e(5 recommendations)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 59px;\" align=\"left\"\u003e\n\u003cp\u003e5 recommendations for Indicators for monitoring and evaluating the results of interventions.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eBased on the standard score of AGREE-II checklist, the minimum and maximum scores were related to the domains of Applicability (80/86%) and Scope and Purpose (93/21%), respectively. The scores given by specialists to the clinical practice guideline in other domains ranged between 86/57 and 92/06%. In the end, in the final evaluation of the clinical guide, the evaluators declared their judgment about the quality of the guide and 100% of them recommended the use of the clinical guide. 72.2% strongly recommended the use of the clinical guide and 27.8% conditionally recommended the use of the clinical guide. (Minor changes in parts of the clinical guide were recommended based on the suggestions provided by the evaluators). Overall, the quality of the clinical practice guideline of managing the fear of childbirth was estimated as desirable.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eEvidence-based recommendations and expectations of pregnant women and healthcare team members developed the clinical guideline for managing the fear of childbirth. One hundred and ninety recommendations within seven areas in the Iranian culture context were made. Recommendations in the first three areas, regarding education, counseling, diagnosis, and treatment, are specifically designed for clients. The next two areas contain recommendations for empowering health providers and the health service delivery system. 14 recommendations of the clinical guide in two other areas are related to social services and evaluation methods. This guideline is applicable based on the levels of health care in the health system. The health system of our country functions as a coherent network at three levels and the Ministry of Health and Medical Education stands at the top level. The first level includes sectors in which the first and largest level of contact between the society and healthcare system occur. These sectors include health houses and rural and urban health centers, in addition to health posts. The second level includes sectors which are able to provide healthcare services at a more specialized level. They include district health centers as well as district general hospitals under the supervision of medical sciences universities. Healthcare services at specialized levels occur at the third level of the health system of the country. This level includes the province health center and specialized hospitals under the supervision of medical sciences universities (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Concerning the structure of the health system of the country and access to resources, this guideline can be applied at all three levels. That is, it can be implemented in primary care, intermediate care, and finally, hospitals (emergency departments, delivery, postpartum and palliative care), as well as hospital-integrated services to community-based home care. Considering the negative effects of the fear of childbirth on the attitude of women of reproductive age to the issue of having children, attention has been paid to the needs of women before pregnancy. So that the first field is dedicated to training, counseling, screening and necessary interventions in the pre-pregnancy period. Mycroft et al also emphasize in the guide to tokophobia and Traumatic Experience of Childbirth on identifying and providing educational and counseling services to non-pregnant women with a negative attitude towards childbirth(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Several clinical guidelines have mentioned the issue of providing mental health services to pregnant mothers during the perinatal period and have provided specific recommendations for the diagnosis and management of cases with mental health disorders(\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). This is despite the fact that the issue of fear of childbirth has only been addressed in the guide to fear of childbirth (tokophobia)(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). In the third area, providing respectful services to mothers during admission, in the first and second stage of childbirth and postpartum are mentioned as recommendations related to making childbirth pleasant. Increasing the mother's participation, self-confidence, independence of action and satisfaction in the process of physiological childbirth can make childbirth pleasant for the mother and the family and reduce the desire of the mother to perform a cesarean section. By the World Health Organization, the intrapartum care clinical guideline for a positive childbirth experience was published in 2018 with 56 recommendations. WHO recommends respectful maternal care (RMC), effective communication, companionship during labor, and continuity of care for a positive birth experience(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The recommendations of this clinical guideline are classified into three-time stages for providing care (peripartum, intrapartum and postpartum). In other studies, interventions to increase self-confidence or improve women's childbirth conditions have had positive results regarding making childbirth more pleasant(\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). In order to improve the structure of providing services to pregnant women in health systems, recommendations have been designed in the next two areas of the guideline. Educational empowerment of health providers and improving the system of providing health services to pregnant women are issues that were raised due to the low quality of health service provider systems. It is necessary to reform the service delivery system in order to improve the quality of care in the field of women's health, and the current structure should be revised and the performance procedure should be modified. Some studies in Iran have shown that the low quality of health services for women and the lack of proper education for them leads to a lack of belief in health services. It not only causes a decrease in the motivation of service providers, but also creates unmet needs of clients and their dissatisfaction with health services(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Regarding the educational empowerment of the health team, some studies stated that the necessary capacities to enable them to play the role they are responsible for in the system with high efficiency and effectiveness should be created by using appropriate training(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). For this reason, paying attention to the educational needs of employees in order to improve the quality of training courses was brought up. The lack of a specific screening protocol for the fear of childbirth and its administration in pregnancy is an important factor in the low performance of the health team in this field. The establishment of new regulations by health system policymakers with the aim of changing the approach of identifying high-risk cases and operational solutions to remove obstacles to NVD will lead to a change in the service path for pregnant women. Researchers have suggested that protocols based on theories of health education be designed, implemented and evaluated in healthcare systems(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). In these protocols, women who receive psychoeducation along with usual care methods will experience more positive pregnancy and birth experiences. Psychologically based interventions can play an effective role in reducing FOC during pregnancy and even childbirth. Therefore, creative and counseling-based methods should be used to improve women's psychological conditions by health care teams(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Social support and the formation of peer groups is another area of clinical guidance for the management of fear of childbirth. Considering the special conditions of pregnancy, women need multifaceted support, including family and community support in the form of cultural and welfare services. These supports reduce the psychological burden caused by pregnancy and with companionship, empathy and attention to the woman's needs from other people, are effective in reducing fears during pregnancy. In studies, increasing social support leads to a decrease in the fear of childbirth in primiparous women and an increase in their satisfaction with childbirth(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). In addition to positive effects during pregnancy and childbirth, social support also has beneficial effects after childbirth. Studies have shown that women who received supportive measures during pregnancy had less depression than others in the postpartum period(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). In recent years, more emphasis has been placed on that a significant part of health behaviors is the result of learning from others, and in particular, the effects of peer groups. Thus, the use of a peer education approach, which is considered a behavior change strategy, can be applied in this regard(\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e).In a peer education approach, the peers communicate with other peers and transfer the information effectively thus affecting their counterparts(\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).The results of studies have shown that peer education has an effect on reducing the FOC in pregnant women. The mean scores of mothers\u0026rsquo; fear in the peer education group after the intervention decreased compared to their mean scores before the intervention(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Considering the positive effect of peer groups in reducing fear of childbirth, recommendations were designed on this basis in this clinical guide. Considering the importance of evaluation in determining the positive performance of a process and the degree of success in achieving the goals, recommendations for its evaluation methods were designed in the last area of the clinical guide.\u003c/p\u003e \u003cp\u003eIn summary, applying this clinical guideline can help caregivers of the health system to move towards an integrated mental health care plan for pregnant women in our healthcare system. midwives can be in the core of the Maternal mental health team. Maternal mental health team consists of qualified healthcare providers who are all working under supervision of the Reproductive health specialist. Through holistic view, they can constantly examine the psychological needs of mothers, including fear of childbirth alongside their other needs and provided standard care to pregnant women by focusing on the process of identification, psychoeducation, follow-up and referral.\u003c/p\u003e \u003cp\u003eBenefiting from the NICE guideline, grading the evidence, and critical appraisal of the clinical practice guideline by the AGREE-II have been the strong points of this study.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe guideline obtained from this research with regards to fear of childbirth can be employed for management, policymaking, educational, and research purposes, and be effective in enhancing the quality of services provided to pregnant mothers. Considering the increasing rate of C-section caused by fear of childbirth in Iran it is expected that with implementing of guideline, women would have greater tendency to undergo natural delivery. Further, implementation of the guideline will help gain awareness about the benefits and obstacles of executing this guideline across the Iranian population. Indeed, we could also provide this guideline to policymakers and planners, so that they would use it as a standard for Promotion of natural childbirth. Nevertheless, in this regard the grounds for implementing national protocols of management fear of childbirth such as human and financial resources as well as hospitalization environment should be provided. Since there is no comprehensive guideline in WHO or presented by other countries for management fear of childbirth, this study was designed to compose guideline in Iran based on a multiphase study. Tis guideline can be also considered in other parts of the world as well.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNICE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Institute for Health and Care Excellence\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFOC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFear of childbirth\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNVD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNormal Vaginal Delivery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCOREQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConsolidated criteria for Reporting Qualitative research\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePRISMA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePreferred Reporting Items for Systematic Reviews and Meta-Analyses\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNGC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Guideline Clearinghouse\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eG-I-N\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGuideline International Network\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNHMRC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Health and Medical Research Council\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSIGN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eThe Scottish for Clinical Guidelines Network\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAGREE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAppraisal of Guidelines for REsearch \u0026amp; Evaluation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRMC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRespectful Maternal Care.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval to conduct this study (IR.SHMU.REC.1399.135) was granted by the Ethics Committee of Shahroud University of Medical Sciences, Iran. Written informed consent will take from each participant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset supporting the conclusions of this article is available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors contributed to the conception and design of the study. AB drafted the first version of the manuscript. ZM, NJ, and MK revised the manuscript. MR critically reviewed the manuscript for important intellectual content. All authors approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis paper was extracted from a reproductive health PhD thesis, approved by the research session of Shahroud University of Medical Sciences with code 873. Therefore, I would like to thank the Vice Chancellor for Research of Shahroud University of Medical Sciences.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSalomonsson B, Gullberg MT, Alehagen S, Wijma K. Self-efficacy beliefs and fear of childbirth in nulliparous women. J Psychosom Obstet Gynecol. 2013;34(3):116\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFenwick J, Toohill J, Creedy DK, Smith J, Gamble J. Sources, responses and moderators of childbirth fear in Australian women: a qualitative investigation. Midwifery. 2015;31(1):239\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFisher C, Hauck Y, Fenwick J. How social context impacts on women's fears of childbirth: a Western Australian example. Soc Sci Med. 2006;63(1):64\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO'Connell MA, Leahy-Warren P, Khashan AS, Kenny LC, O'Neill SM. Worldwide prevalence of tocophobia in pregnant women: systematic review and meta‐analysis. Acta Obstet Gynecol Scand. 2017;96(8):907\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhwepeya M, Lee GT, Chen S-R, Kuo S-Y. Childbirth fear and related factors among pregnant and postpartum women in Malawi. BMC Pregnancy Childbirth. 2018;18(1):1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSwift EM, Gottfredsdottir H, Zoega H, Gross MM, Stoll K. Opting for natural birth: A survey of birth intentions among young Icelandic women. Sex Reproductive Healthc. 2017;11:41\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDemšar K, Svetina M, Verdenik I, Tul N, Blickstein I, Velikonja VG. Tokophobia (fear of childbirth): prevalence and risk factors. J Perinat Med. 2018;46(2):151\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eToohill J, Creedy DK, Gamble J, Fenwick J. A cross-sectional study to determine utility of childbirth fear screening in maternity practice\u0026ndash;An Australian perspective. Women Birth. 2015;28(4):310\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStoll K, Edmonds JK, Hall WA. Fear of childbirth and preference for cesarean delivery among young American women before childbirth: a survey study. Birth. 2015;42(3):270\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eR\u0026auml;is\u0026auml;nen S, Lehto S, Nielsen H, Gissler M, Kramer M, Heinonen S. Fear of childbirth in nulliparous and multiparous women: a population-based analysis of all singleton births in F inland in 1997\u0026ndash;2010. BJOG: An International Journal of Obstetrics \u0026amp; Gynaecology. 2014;121(8):965\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamama-Raz Y, Sommerfeld E, Ken-Dror D, Lacher R, Ben-Ezra M. The role of intra-personal and inter-personal factors in fear of childbirth: a preliminary study. Psychiatr Q. 2017;88(2):385\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSymonides A, Mogilnicka I, Krulak K, Kacperczyk J, Dobrowolska-Redo A, Romejko-Wolniewicz E. Understanding tokophobia phenomenon as a key to proper management. Microcephaly associated with Zika virus infection\u0026ndash;prevention, diagnosis and treatment. 2016:12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeaver J, Browne J, Aras-Payne A, Magill-Cuerden J. A comprehensive systematic review of the impact of planned interventions offered to pregnant women who have requested a caesarean section as a result of tokophobia (fear of childbirth). JBI Evid Synthesis. 2013;11(1):70\u0026ndash;122.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScollato A, Lampasona R. Tokophobia. When fear of childbirth prevails. Mediterranean Journal of Clinical Psychology. 2013;1(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHosseini VM, 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\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLarsson B, Hildingsson I, Ternstr\u0026ouml;m E, Rubertsson C, Karlstr\u0026ouml;m A. Women\u0026rsquo;s experience of midwife-led counselling and its influence on childbirth fear: A qualitative study. Women Birth. 2019;32(1):e88\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBahramnezhad F, Cheraghi MA. Realization of Clinical Guidelines in Providing Health Services. Hayat J. 2015;21(3):1\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnsari S, Rashidian A. Guidelines for guidelines: are they up to the task? A comparative assessment of clinical practice guideline development handbooks. PLoS ONE. 2012;7(11):e49864.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDennis C, Vigod S. PCMCH Guidance Document: Perinatal Mental Health, Guidance for the identification and management of mental health in pregnant or postpartum individuals Ontario\u0026rsquo;s Provincial Council for Maternal and Child Health. 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAustin M-P, Highet N. Mental health care in the perinatal period: Australian clinical practice guideline. 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNICE. Antenatal and postnatal mental health: Clinical management and service guidance. Leicester: British Psychological Society; 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMental Health Care in the Perinatal Period. the royal australian and new zealand college of obstetricians and gynaecologists Women\u0026rsquo;s Health Committee and approved by the RANZCOG Board and Council. March 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMycroft R, Taha S. Fear of Childbirth (Tokophobia) and Traumatic Experience of Childbirth: Best Practice Toolkit. NHS Pan-London Perinatal Mental Health Networks; 2018. p.\u0026nbsp;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Institute For Clinical. Excellence, Developing NICE guidelines: the manual.. Manchester. 2014.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. Development of the AGREE II, part 1: performance, usefulness and areas for improvement. CMAJ. 2010;182(10):1045\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsefzadeh S, Rezaee A. Health managment. 2012.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrganization WH. WHO recommendations on intrapartum care for a positive childbirth experience. World Health Organization; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eForster DA, McLachlan HL, Davey M-A, Biro MA, Farrell T, Gold L, et al. Continuity of care by a primary midwife (caseload midwifery) increases women\u0026rsquo;s satisfaction with antenatal, intrapartum and postpartum care: results from the COSMOS randomised controlled trial. BMC Pregnancy Childbirth. 2016;16(1):1\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeedya S, Fahy K, Parratt JA. The Milky Way educational and support programme: Structure, content and strategies. Women Birth. 2016;29(4):388\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGhanbari-Homaie S, Meedya S, Mohammad-Alizadeh-Charandabi S, Jafarabadi MA, Mohammadi E, Mirghafourvand M. Recommendations for improving primiparous women\u0026rsquo;s childbirth experience: results from a multiphase study in Iran. Reproductive health. 2021;18(1):1\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAllahqoli L, Rahmani A, GHANEI GR, Fallahi A, Hashemian M, Fallahi H, et al. Job Burnout from the Perspective of Health Educators: Challenges and Needs. 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMasoumi SZ, Kazemi F, Oshvandi K, Jalali M, Esmaeili-Vardanjani A, Rafiei H. Effect of training preparation for childbirth on fear of normal vaginal delivery and choosing the type of delivery among pregnant women in Hamadan, Iran: a randomized controlled trial. J family reproductive health. 2016;10(3):115.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStriebich S, Mattern E, Ayerle GM. Support for pregnant women identified with fear of childbirth (FOC)/tokophobia\u0026ndash;a systematic review of approaches and interventions. Midwifery. 2018;61:97\u0026ndash;115.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAkg\u0026uuml;n M, Boz I, \u0026Ouml;zer Z. The effect of psychoeducation on fear of childbirth and birth type: systematic review and meta-analysis. J Psychosom Obstet Gynecol. 2020;41(4):253\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGargari MA, Esmailpour K, Mirghafourvand M, Nourizadeh R, Mehrabi E. Effects of Psycho-education Interventions on Perceived Childbirth Fear and Anxiety by Pregnant Women: A Systematic Review and Meta-analysis. 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJaghargh MV, Alizadeh KH. Determining the Predictive Factors of Fear of Childbirth Based on Personality Traits, Social Support and Emotional Regulation among Nulliparous Pregnant Mothers in Bandar Abbas. 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSadeghi Aval Shahr H, Moosavi Sahebalzamani S, Jahdi F, Neisani Samani L, Haghani H. Relationship between Perceived Social Support in First Pregnancy with Birth Satisfaction in Primigravid Women Referred to Shahid Akbar Abadi Hospital. Prev Care Nurs Midwifery J. 2014;4(1):54\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpoozak L, Gotman N, Smith MV, Belanger K, Yonkers KA. Evaluation of a social support measure that may indicate risk of depression during pregnancy. J Affect Disord. 2009;114(1\u0026ndash;3):216\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAZH N, YOUNESIAN M, Fili A, ABBASI MA. The study of supportive activities during pregnancy on postpartum depression. 2006.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUnited Nations Population Fund and Youth Peer Education Network. Training of Trainers Manual: From theory to practice in peer education. Arlington: United Nations Population Fund; 2014.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpeizer IS, Magnani RJ, Colvin CE. The effectiveness of adolescent reproductive health interventions in developing countries: a review of the evidence. J Adolesc Health. 2003;33(5):324\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRahmani R, Moghadam FY, Hadizadeh-Talasaz F, Reza M. The effect of peer education on fear of childbirth in pregnant women: A randomized clinical trial. International Journal of Women\u0026rsquo;s Health and Reproduction Sciences. 2019.\u003c/span\u003e\u003c/li\u003e\u003c/ol\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":"fear of childbirth. Clinical guideline. Tokophobia. management. multi-method. ","lastPublishedDoi":"10.21203/rs.3.rs-2220461/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2220461/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Despite the importance of fear of childbirth and the necessity of implementing appropriate care methods to increase women's willingness to childbearing and their more tendency to perform natural childbirth, there is no clear process in this field in the care programs of the country's health system. The present study was designed with the aim of developing a guideline for managing the fear of childbirth in the current context.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This is a multi-method study which was conducted in five stages within the framework of the National Institute for Health and Care Excellence (NICE) guideline. A research committee consisting of five focal and 16 secondary members was formed. The stages included determining the scope of the study, developing guideline (a qualitative study and a systematic review, triangulation of the data, and producing a preliminary draft), consultation stage (validation of the protocol Using nominal group method), as well as revision and publication stages.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe clinical guideline of Managing the fear of childbirth with 190 evidence-based recommendations was developed in seven main areas, including the Pre-pregnancy period, pregnancy period, making childbirth more pleasant, training empowerment of employees, improving the service delivery system, social support and clinical guide evaluation methods.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e We are hoping by applying this clinical guideline in maternal health care settings to move towards an integrated care plan for fear of child birth in the context of our health system. Health care organizations should support to form multi-specialty teams to care for mothers with fear of childbirth. Through holistic care, they can constantly examine the psychological needs of pregnant mothers, including the fear of childbirth, along with their other needs, and manage them correctly.\u003c/p\u003e","manuscriptTitle":"Full title: Managing the fear of childbirth, developing a care program: a multi-method study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-11-04 21:12:27","doi":"10.21203/rs.3.rs-2220461/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":"5ae4269a-29b9-487d-be9d-3eff2cb8d8c6","owner":[],"postedDate":"November 4th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-11-08T11:29:31+00:00","versionOfRecord":[],"versionCreatedAt":"2022-11-04 21:12:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2220461","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2220461","identity":"rs-2220461","version":["v1"]},"buildId":"omnImTCwR2MFx8CMYfrG7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}