Introduction
Childbirth is an exciting event for a mother [1-3], but sometimes it can be accompanied by worry and anxiety for various reasons which can develop the fear of childbirth (FOC) [3‌، 4]. FOC is an unreasonable fear of labor in most pregnant women [5-7]. Most women, especially primiparous women, experience a natural FOC due to being unfamiliar with the labor process [8]. It is estimated that at least one out of five pregnant women has severe FOC, and 6-13% of women experience severe and debilitating fear of FOC [9]. The results of a meta-analysis estimated its global prevalence to be 14% [7-11]. In Iran, it is estimated that 5-20% of women have FOC [9]. Abnormal FOC is accompanied by daily anxieties, nightmares, and obvious physical symptoms. The biggest consequence of FOC is the mother’s request for elective cesarean section, which can include all the consequences of cesarean section [12، 13]. 
Research has shown that 6-10% of FOC cases are associated with severe and debilitating consequences. Sometimes, severe FOC leads to avoiding or denial of pregnancy [12، 13]. Women with FOC may have a more complicated labor process and are usually hospitalized in the latent phase and can experience a longer labor [12، 13]. This causes more fatigue and anxiety for mothers, and the probability of medical intervention in labor will increase [12، 13]. Being exposed to emotional imbalance, depression, intensification of fetal movements, premature birth or miscarriage are among the complications of FOC that affect the baby. At the same time, complications such as anemia, hyperactivity, irritability, and malnutrition are more common in children whose mothers suffered severe FOC. Among the other causes of fear of childbirth, it has been pointed out the inability or disturbance in marital relations and the decrease in the sexual satisfaction of the wife [12، 13]. The causes of FOC may include the inability or disturbance in marital relations and the decrease in the sexual satisfaction [12، 13]. A study on 85 Swedish women with different socioeconomic characteristics to investigate the causes of FOC showed that women’s previous experiences of childbirth, the existence of unstable personality, anxiety disorders, and less social communication were the most important predictors of FOC and the desire for cesarean section [14]. 
Therefore, predicting factors of FOC can be psychological factors [13-15]. These factors can affect women’s personal lives and be related to their behaviors and performance [16]. In some studies, psychological disorders have been identified as predictors of 83% of abnormal functions in women [12-15]. Since the control or management of the FOC is very important, and psychological disorders can be related to many behaviors [11، 14، 15], examining the psychological factors related to the intensity of FOC can provide more comprehensive information for interventions. A scoping review study can give us access to several studies in this field. This type of review studies, by identifying the evidence and clarifying key concepts or definitions, aims to recognize and analysis the in knowledge [17]. 
To our knowledge, no scoping review or systematic review has been conducted in this field. Therefore, the present scoping review study aims to determine the psychological factors related to the severity of FOC.

Materials and Methods
This is a scoping review study, which was conducted in five stages according to the JBI approach. These steps are: 1) Identifying the research question, 2) Searching the related studies, 3) Selecting relevant studies, 4) Charting and summarizing the data, and 5) Reporting the results [17]. In the first step, the question was determined as: What are the psychological factors related to the intensity of FOC? For searching the related studies, following keywords were used in Persian and English: Relationship, psychological factors, Fear of childbirth, predictive factors, women, severity. These keywords were used along the Boolean operators (AND, OR). The search was performed in Google Scholar, PubMed, Scopus, Cochrane Library, Science Direct, Web of Science, Scientific Information Database (SID), IranDoc, and MagIran. All online articles published from 2010 to May 3, 2023 were searched. The reference list of identified articles was also manually searched to find more related studies. The process of selecting the final articles was done independently by two researchers (first and last authors). 
The inclusion criteria were determined based on the PECO approach: Population (pregnant women), exposure (intensity of FOC), comparison (women with no FOC), and outcome (psychological factors). The observational studies (case control, cohort, descriptive, cross-sectional, and analytical), studies that investigated the relationship between psychological factors and the intensity of FOC, those met the PECO criteria, and those whose sample size and their results were clear were included in the study. The studies that did not meet the mentioned criteria, those published in a language other than English and Farsi, and those with unavailable full texts were excluded from the study. The quality of articles was examined using the AXIS checklist. It is mostly used to examine the quality of studies in the field of medical sciences. The items of this checklist have been developed based on a combination of evidence-based data, epidemiological data, experience of scholars, and experience of Delphi participants. This tool examines five standard sections under the titles of introduction, methods, results, discussion, and other information [18‌، 19] (Table 1).



Initial search yielded 1473 articles. Six articles were also found by manual search. After removing duplicates, unrelated articles were identified by reading titles and abstracts. After removing unrelated articles, 27 remained. Nine studies were removed after reading their abstracts and 8 were removed after reading their full texts. Finally, 9 articles were selected for the review (Table 2) and their information including name of the authors, year of publication, study area, study purpose, sample size, tool, study variables, and results were extracted (Figure 1)








Results

Participants
The participants in the studies were pregnant women or women who had given birth (in the post-partum period). They were in reproductive age and their age range was from 15 to 48 years. The entry criteria for women were reading and writing literacy, willingness to participate in the study, pregnancy, or having FOC according to the standard tool. In some studies, to control the effect of confounding factors such as age, level of education, history of attending educational and counseling classes related to the management of FOC, and having psychological disorders in the last 6 months, were considered as exclusion criteria. The total number of participants in the 10 studies was 3909 [20-28].

Data classification
By reviewing the texts, the findings from 10 observational (descriptive-analytical) articles were placed in three groups based on the answer to the main research question. The first group included four articles that assessed the relationship between FOC and depression (P<0.05 in all studies) [5، 22، 24، 27]. The second group included six articles that assessed the relationship between FOC and anxiety (P<0.05 in all studies) [20, 2, 23, 25-27]. The third group included three articles that assessed the relationship between FOC and self-esteem (P<0.05 in all studies) [21، 22، 28].

Prevalence of FOC
The overall prevalence of severe FOC in the general population ranged from 5.3 to 11.13%, and the overall prevalence of high FOC was 36.7%. The prevalence of severe FOC was 7.4-12.4% in primiparous women and 4.3-9.7% in multiparous women [1-10].

Depression
Depression is related to the development and severity of FOC [5، 22، 24، 27] Although pregnancy often creates joy, it is stressful for most women. One out of every 8 people suffers from depression and this number is almost twice as high for women [29-31]. Adapting to or accepting the motherhood role for a woman may be stressful and be a prelude to the onset of depression. The presence of depression can have many negative effects on the mother, fetus/baby, or the family [31، 32]. The FOC, which occurs in women before giving birth, may be related to depression. Four studies investigated the relationship between depression and FOC [5، 22، 24، 27]. In these studies, pregnant women or women who had given birth were included, and the level of depression was evaluated with the Beck depression inventory (BDI), the center for epidemiological studies-depression (CES-D) scale, and the Edinburgh postnatal depression scale (EPDS). In all these studies, depression and FOC had a direct and significant relationship with each other. In one study, the odds ratio was stated as OR=4.2 [27].

Anxiety
Anxiety disorders are common during pregnancy and account for a large share of health problems [29]. FOC can be the result of provoking factors such as anxiety [29, 30]. The results of the studies show that the prevalence of anxiety disorders during pregnancy is higher than 30%, which may have adverse effects on obstetric, fetal, and neonatal outcomes. Hormones caused by having anxiety, such as adrenal steroids, catecholamines, and corticotropin-releasing hormone, have effects such as asphyxiation, premature termination of pregnancy, halted fetal growth, or immune system dysfunction. In six studies, the relationship between FOC and anxiety during pregnancy has been mentioned [5، 20، 22, 24, 27]. Their results reported a significant relationship between them. The range of P was reported from 0.001 to 0.043. The instruments used to measure anxiety in these studies were the Spielberger state-trait anxiety inventory (STAI) and clinical interview.

Low self-esteem
Self-esteem is a part of a person’s self-concept, which includes cognitive, behavioral, and emotional aspects. It is the sense of personal value and self-worth [33]. According to Rosenberg, it is “the experience of being competent to cope with the basic challenges of life and being worthy of happiness”. Self-esteem derives from the difference between the perceived self and the ideal self, such that a high difference between the two leads to low self-esteem [34]. Aklechi showed that low self-esteem causes behaviors such as reduced performance, feelings of inadequacy, feelings of loneliness, and self-destructive behaviors [35]. In this study, 3 articles investigated the relationship between FOC and self-esteem [21، 22، 28]. The tools used in these studies were the Rosenberg self-esteem scale (RSES), the Wijma delivery expectancy/experience questionnaire (W-DEQ), and the childbirth attitude questionnaire. In all these studies, the relationship between low self-esteem and FOC was reported to be positive and significant (P<0.05). In one study, in addition to indicating a significant relationship, it was reported that the group with no self-esteem was 1.7 times more likely to have FOC than the group with self-esteem [28].

Discussion
The present research has investigated the psychological factors related to the severity of FOC. The FOC naturally exists in all women and it is a natural thing, but if it is worsened by the influence of any other factor, it can become a problem and cause the consequences. In this regard, it is necessary to examine the psychological factors affecting the FOC in women to prevent the worsening of FOC and the creation of uncontrollable fears [2-6]. In the current research, 10 related studies were reviewed. Depression, anxiety, and low self-esteem were the examined psychological factors related to FOC, which have been introduced in a wide range of studies [20-28]. FOC can occur before, during, or after childbirth. Currently, it has increased in the world [37, 38]. Spic et al. in 2010 [20]investigated the level of anxiety and FOC using reliable questionnaires. They found that the severity of FOC was higher in women who suffer from anxiety. This relationship was reported as positive and statistically significant. Demsar [5] and Akhlaghi [22] conducted descriptive-analytical studies in Slovenia and Iran, respectively, to determine the level of anxiety in pregnant women with moderate to high FOC, and reported a direct and significant relationship between anxiety and FOC. Çıtak Bilgin in 2020 [26] and Kananikandeh in 2022 [25] by examining the level of anxiety and the FOC in pregnant women in Turkey, also reached a consistent result. They reported that higher anxiety in pregnant women causes their greater FOC.
Depression is an important psychological factor that is related to many human affairs [38] such as FOC in pregnant women. Four descriptive-analytical studies investigated this relationship. In 2012, Storksen investigated 1642 women at 32-38 weeks of pregnancy using W-DEQ and EPDS tools, and found that the level of depression in women with FOC was much higher than in women with no FOC [39]. Akhlaghi [22] also found the same result in Iran. Molgora in 2017 [24] and Demsar in 2018 [5] also confirmed the relationship of depression with FOC.
Many decisions of people in life are affected by their self-esteem [39]. According to Rosenberg, low self-esteem can worsen psychological disorders. He suggested that strengthening and increasing self-esteem is one of the ways to save people from psychological disorders [39، 40]. The FOC, which is developed by mental disorders in pregnant women, can be related to the self-esteem of women. In 2021, Raudasoja studied 125 primiparous women in Finland using the RSES and W-DEQ. He found that self-esteem in pregnant women can predict the level of FOC [28]. The results of Hamama-Raz in 2017 [21] and Akhlaghi in 2012 [22] are also in line with these findings. 
In the reviewed studies, despite the difference in the value of correlation with FOC, there was no information contradiction. In future studies, this point should be taken into account by examining the degree of correlation between related factors and FOC to understand the intensity and strength of each factor.

Conclusion 
Some psychological factors have a direct and significant relationship with the intensity of FOC in pregnant women including depression, anxiety, and low self-esteem, which can be the predictors of FOC. By improving self-esteem and reducing depression and anxiety of pregnant women through intervention programs by experts, the FOC and its complications can be reduced. Although the articles meeting the inclusion criteria were identified and reviewed in this study, some published studies may have been missed due to the lack of access to all databases (e.g. PsychoInfo). In addition, due to heterogeneity between studies in terms of the used instruments, conducting a meta-analysis was not possible. Despite these limitations, this review study has some practical implications for the healthcare system. The results can help health professionals, psychologists and psychiatrists, midwifery experts, consultants, and gynecologists in developing the necessary educational programs and designing clinical trials for pregnant women.

Ethical Considerations

Compliance with ethical guidelines
This study was approved by the ethics committee of Mazandaran University of Medical Sciences (Code: IR.MAZUMS.REC.1402.185). All ethical principles were considered in this study.

Funding
This study was funded by the Deputy for Research and the Student Research Committee of Mazandaran University of Medical Sciences (Code: 17908).

Authors' contributions
Initial draft preparation: Kosar Miraei Mohammadi and Mobina Moghassemi; Search and investigation: Kosar Miraei Mohammadi and Zeinab Hamzehgardeshi; Data collection: Kosar Miraei Mohammadi, Elahe Rahimian and Forogh Najafi; Review, editing, and final approval: All authors.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank the Deputy for Research and the Student Research Committee of Mazandaran University of Medical Sciences for their financial support.

 

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