Childbirth is viewed as an unpredictable event by some women and can evoke feelings of fear and anxiety. Fear of childbirth can range from apprehension to intense fear (tokophobia), with serious consequences for maternal well-being and health [1-3]. Previous studies have identified high levels of fear of childbirth in 20% of women [3]. High levels of fear were more commonly reported by young, unemployed, less educated women and by those experiencing their first pregnancy [4, 5]. In addition, fear of childbirth is associated with an increased number of caesarean sections, prolonged labour, and difficulties in bonding with the baby [6, 7].

The main causes of fear include perception of the unknown, pain, perineal trauma, lack of involvement in decision-making during labour, abandonment during labour, child’s health, mother’s health, and neonatal death [3, 8, 9]. In multiparous women, surgical deliveries or previous traumatic experiences were the strongest predictors of childbirth fear [10].

It is important to note that the characteristics and anxieties of healthcare professionals affect birth outcomes. For example, Yee et al. studied the cognitive and affective traits of 94 obstetricians (OBs) in the United States and reviewed the birth outcomes of 1,502 women who received care from these OBs [11]. OBs with high anxiety and low coping scores had a significantly lower vaginal birth after caesarean rates among patients eligible for a vaginal birth after caesarean, compared to OBs with low anxiety and proactive coping skills. Conversely, healthcare providers can help reduce fear and anxiety among childbearing women. Trust can reduce fear [12]; however, to support childbearing women who have a fear of childbirth, health professionals must be willing to analyse and acknowledge their own fears, as personal opinions and feelings can affect the manner in which care is provided [11, 12]. During childbirth care, a provider’s fear of birth can result in unnecessary interventions and can cause the provider to discourage patients from having a natural birth.

Previous studies on the preferences of young women from eight countries revealed that preferences for a caesarean section without medical indication are primarily driven by fear of childbirth [13]. Some strategies to address fear include health education in schools and during the prenatal period [14, 15], debriefing or counselling to discuss previous negative experiences [16], intensive cognitive-behavioural therapy [17], and yoga [13, 18]. Partners are also affected by fear and, therefore, must be included in the diagnosis of and interventions for fear [19].

Some instruments are available to measure fear of childbirth [20-24]. However, there are no validated scales to evaluate pre-pregnancy fear of childbirth in women and men in Brazil.

The assessment of fear of childbirth and the early identification of modifiable factors contributing to this fear can be useful for the development of interventions directed at health professional trainees working in obstetrics and to improve the quality of care for the next generation of maternity care recipients. For these reasons, this study aimed to conduct the cross-cultural adaptation and psychometric testing of the Childbirth Fear Prior to Pregnancy (CFPP) scale for use in Brazil.

The equivalence between the original version of the CFPP scale and the version adapted to Portuguese culture was evaluated, and changes were suggested for the cross-cultural adaptation to be used in the Brazilian context. Words that are not commonly used in Brazil were replaced with more appropriate words (Table 1).

Changes made to the Portuguese version to develop the Brazilian version are shown in bold in the ‘Brazil version’ column.

The use of the term ‘parto’ was carefully considered, as for some experts, it refers specifically to the moment of childbirth. In item 1, the English version of the CFPP scale included the term ‘labour’, which refers to ‘trabalho de parto’. The use of the term ‘trabalho de parto’ instead of ‘parto’ in item 1 was approved by 90% of the experts. In items 3, 6, and 7, the word ‘parto’ was replaced with ‘trabalho de parto’ and ‘nascimento’, as the terms “labour and birth” were included in the original version. This change was also approved by 90% of the experts. All other changes were approved by 100% of the experts. The committee agreed that the items were relevant to the measurement of fear of childbirth and easy to understand, confirming the content and face validity of the Brazilian version of the CFPP scale.

No participant had difficulty completing or understanding the Brazilian version of the CFPP scale. The students found the CFPP scale easy to understand and believed that it contained items that accurately assessed fear of childbirth, with no further suggestions for changes. The mean time to complete the CFPP – BR was five minutes.

Of the 146 nursing students participating in the psychometric analysis stage, 58.2% attended public universities, and 41.8% attended private universities. There was a predominance of female participants (86.3%, n = 126), with a mean age of 21.2 years. Most participants were without a partner (54.1%, n = 79), identified as white (67.1%, n = 98), did not have a paying job (73.9%, n = 108), did not study women’s health (69.2%, n = 101), and never assisted in a delivery (54.1%, n = 79).

The Spearman correlation test revealed a moderate correlation between the items and a strong correlation of the sum of all items with individual items of the Brazilian CFPP scale (Table 2).

Inter-item and item-total correlations were measured using the Spearman correlation test. Values >0.45 demonstrate strong one-dimensional analyses. CFPP, Childbirth Fear - Prior to Pregnancy.

The KMO was 0.83, and Bartlett’s test revealed p < 0.001. The scree test with scree plot visualisation and Horn’s parallel analysis indicated a one-dimensional solution (Fig. 1).

Fig. (1). Scree plot and Horn’s parallel analysis.

EFA indicated that all items were related to a single factor, with factor loadings and communalities >0.5 (Table 3).

Factor loading values >0.5 indicate a strong correlation of magnitude, and communality values >0.5 indicate adequate common variances between the items. CFPP, Childbirth Fear - Prior to Pregnancy.

The scores of the Brazilian CFPP scale were significant but had a weak correlation with the DASS-21 scores (r = 0.32, p < 0.001).

The Cronbach’s alpha coefficient of the Brazilian CFPP scale was 0.86. When any one of the ten items was excluded, the decrease in alpha value was <0.1.

The stability of the Brazilian version of the CFPP scale was measured using the test-retest method. The scores of the two survey administrations were similar (mean score of the first administration: 35.4; mean score of the second administration: 37.3). The ICC was 0.99 (p = 0.000).

Table 4 shows the students’ scores for fear of childbirth organised into quartiles. The proposed scores revealed moderate fear of childbirth in 50 participants (34.2%), low fear of childbirth in 39 participants (26.8%), absence of fear of childbirth in 31 participants (21.2%), and high fear of childbirth in 26 participants (17.8%).

To put the Brazilian scores into context, the third author provided comparable data from an international study of childbirth fear among university students, using the same scale to assess fear of childbirth. The sample included women and men from eight countries, and the results were stratified by the field of study. The proportion of students in the moderate and high quartiles were similar between Brazilian nursing students and students from other countries. In contrast, more Brazilian students reported no fear as compared to international students (Table 5).

The classifications were defined by the scores on the Brazilian version of the Childbirth Fear Prior to Pregnancy scale: absence of fear of childbirth = 10 ≤ x < 25; low fear of childbirth = 25 ≤ x < 35; moderate fear of childbirth = 35 ≤ x < 45; high fear of childbirth = 45 ≤ x ≤ 60.

The cross-cultural adaptation of the CFPP scale was conducted with methodological rigour, according to the recommendations of Beaton et al. [27]. We maintained the original content of the instrument and added specific characteristics related to Brazilian culture. The content and face validity of the instrument were verified via review by a committee of experts and nursing students.

The instrument presented good indicators of sample adequacy. Moderate inter-item and strong item-total correlations support the one-dimensionality of the Brazilian version of the CFPP scale. These results are similar to those obtained for versions of the CFPP scale adapted for other countries [25, 26]. All items were found to be highly correlated with a single factor and demonstrated high commonality, which indicated a favourable contribution of each item to evaluate the construct of fear of childbirth. These results suggest that the Brazilian version of the CFPP scale is one-dimensional, and our findings are similar to the results obtained for versions of the CFPP scale adapted for other countries [26].

The significant yet weak correlation between the scores of the Brazilian version of the CFPP scale and the DASS-21, a known scale to assess depression, anxiety, and stress, confirms the validity of divergent competitor criteria. This result also suggests that the two constructs are different. American university students showed greater correlations between the DASS-21 subscales and CFPP scale scores compared to students from other countries, indicating that fear of childbirth overlaps with other negative psychological conditions among American students. For Icelandic and German students, the correlation was lower between the two scales [26]. However, no correlation was found between the CFPP and DASS-21 scores among Portuguese university students [25].

The Brazilian version of the CFPP scale had a Cronbach’s alpha of 0.86, which indicates adequate reliability of the instrument [34]. This finding also corroborates the values described by Stoll et al. [26], and Ferreira and Teixeira (2020) [25] for the reliability of the English, Icelandic, German, Spanish and Portuguese versions of the CFPP scale. Furthermore, the test-retest ICC of the Brazilian version of the CFPP scale indicated the instrument’s stability.

The mean time to complete the Brazilian version of the CFPP scale was approximately five minutes, and 52% of the participants reported moderate or high fear of childbirth. These results are very similar to the results of the international sample (50% of health professional students reported moderate or high fear, and 54.1% of students studying other topics reported moderate or high fear).

The validation study of the original CFPP scale reported higher CFPP scores in English and American students, indicating more fear of childbirth in the United Kingdom and the United States. The lowest scores were obtained in German students, while students in Australia, Canada, and Iceland had scores similar to those of Brazilian students [26].

This study had some limitations. The participants were mostly women, which may have led to a bias in the results. Further research with the Brazilian version of the CFPP scale is necessary to complement the psychometric analyses. In addition, future studies on the scale administration for professionals already working in obstetrics are suggested, thereby complementing the validity studies.

In summary, the Brazilian version of the CFPP scale is a one-dimensional scale of 10 items that is a valid and reliable measure of fear of childbirth in young adults before pregnancy in Brazil. The scale demonstrated favourable psychometric properties that can be used to identify and target modifiable factors related to the development of fear of childbirth in both women and men. Identification of fear and the factors causing it can be used to develop specific educational strategies in nursing courses. Providing education about the fear of childbirth can help decondition the fear experienced by students and possible future parents.