The Relationship Between Perceived Social Support in Pregnancy and Self-Efficacy for Childbirth Fear-A Cross-Sectional Study in Arak City , 2017

Methods: This cross-sectional study was conducted on 180 pregnant women. Sampling was done on convenience and health centers were selected randomly. After receiving written consent, the standard questionnaire of perceived social support and the self-efficacy for childbirth fear was given to pregnant women. The questionnaires were collected immediately after completion. After collecting the data, the information was entered into the spss18 software and the Pearson test was used for data analysis.


INTRODUCTION
Childbirth is a multidimensional process with physical, emotional, social, physiological, cultural and psychological dimensions and is regarded as a critical experience in the life of a woman [1].Delivery as the most stressful physical and mental incident for women affects physiological and psychological indices of women pregnancy and childbirth [2].Factors such as labor pain, previous labor experience, previous gynecological problems, including emergency cesarean section, mother personality characteristics such as anxiety, low self-esteem, marital dissatisfaction, lack of social support and low self-efficacy are related to mother's fear of childbirth [2 -4].If a pregnant woman feels that she can deal with stress well, she may be overcome the adverse effects of stress on her health and her fetuses, such as an increase in chances of cesarean section, increased labor pain, negative childbirth experience, impairment in the process of delivery, postpartum mental illness and breastfeeding problems [5 -7].One of the important factors for the coping behavior in stressful situations is self-efficacy.Self-efficacy consists of two components: "Expected Outcome" and "Expected Self-efficacy".Expected outcome refers to the individual's belief that a particular behavior leads to a specific outcome.Expected self-efficacy refers to the individual's belief in his ability to succeed in behavior and the extent to which he controls the circumstances [6 -8].Bandura believes that self-efficacy affects all aspects of behavior and emotional activities such as anxiety, stress, and patterns of thought [9].One of these stressful situations is delivery.Self-efficacy of childbirth is one of the effective factors in coping with this stressful situation and the implementation of behaviors consistent with labor pain [10,11].On the other hand, social support has a significant effect on reducing stress, depression, and distress, and directly associates with social skills and reduction of the duration of the disease.
Perceived social support is the subjective perception of the individual that the people who matter to me are alongside me and I can count on their help when in need.Social support enables the individual to self-care, moderate the response of people to stress and protect people from the threatening effects of stress.The sense of support in pregnancy can reduce pregnancy-related depression and stress [12,13].Considering that many types of research have been done on social support, few studies have been conducted on the relationship between perceived social support and self-efficacy for childbirth fears, so researchers decided to do this research with the aim of the relationship between the perceived social support in the primiparous women and self-efficacy for childbirth fear.

MATERIAL AND METHODS
This cross-sectional study was conducted in Arak University of Medical Sciences in 2016.According to the Cochran formula, 95% confidence interval and P = q = 0.5 were selected as default; the error value was 0.04 and 180 people were considered.The last trimester pregnant women were studied in Arak clinics.After obtaining permission from Arak University of Medical Sciences, sampling was done randomly from selected health centers.The health center lists were prepared from the East, West, North and South and Arak center.After drawing, five centers (one center from each region) out of 40 entered the sampling.After that, pregnant women referred to the health centers were included in the study based on convincing sampling.Women who had the inclusion criteria, after obtaining written consent entered the sampling.Inclusion criteria were women who had a pregnancy without complications, were not opting for divorce, and had a gestational age greater than 35 weeks.In this study, a standard questionnaire of perceived social support and self-efficacy for childbirth fear was filled.Social support was assessed using the standard 12-item questionnaire of perceived social support on a five-point Likert scale from strongly agree to disagree strongly.The questionnaire consisted of three sub-scales of perceived support from family, friends, and others (health providers).According to Salmi et al., Cronbach's Alpha coefficient of three dimensions of social support received by family, friends and close relations was 89%, 86% and 82% respectively [14].The questionnaire of self-efficacy for childbirth fear included 14 items, and it was scored on a Likert scale ranging from never to very high (score 1 to 4).A high score showed high selfefficacy [10].After expressing the research goals, these two questionnaires were distributed among samples in the health clinics, and they were immediately collected after completion.After collecting data, the data were entered into the spss18 software and Pearson test was used for data analysis.

RESULTS
Results showed that the mean age of women was 29.166 ± 5.814.The minimum age of women was 17 years, and the maximum was 43 years.Other demographic characteristics are presented in Table 1.The Mean score of selfefficacy for fear of childbirth and perceived social support is showed in Table 2.The present study showed that there was no significant correlation between Family perceived social support (r = -0.071,P= 0.17), friends perceived social support (r = 0.069, P=0.17), and others such as health providers (r= -0.078, P=0.29) in self-efficacy for childbirth fear.Other results were included in Table 3.

Self-efficacy of fear childbirth P*
Family perceived social support r = -0.0710.17 Friends perceived social support r = 0.069 0.17

DISCUSSION
This study showed that there is no significant relationship between perceived social support and self-efficacy for childbirth fear.The reason may be that we studied the sense of support, not real support.Studies show that real support influences fear and self-efficacy.The correlational research was done on childbirth fear, and social support in 180 lowrisk pregnant women referred to Mashhad's health centers and their husbands who were selected by multi-stage sampling method.The frequency of pregnant women with childbirth fear was 3.68%, and the rate of those who did not fear childbirth was 7.31%.The results showed that there is a significant difference in the social support of the husband in the childbirth preparation classes between women with childbirth fear and those who did not fear childbirth [14].In some previous studies, the role of social support on self-efficacy has been examined.A study showed that multiparous women who did not have husband support had a lower level of childbirth self-efficacy than primiparous women who did not have husband support.Women who have already experienced childbirth may have thought about the value of having a trusted support person in labor [15].Fleming et al. reported that multiparous women who are alone in labor (lack of husband support) have low self-efficacy and high anxiety.On the contrary, the primiparous women enter an environment that requires the caring and support of labor staff, and therefore their dependence on a supporting partner is unnecessary for the success of childbirth [16].
Pregnant women seem to have a greater sense of support than non-pregnant women, while a study showed that this difference was not significant [17].A study also found that social support was a predictor of childbirth fears and the increase of support reduced the fears [18].Fisher et.al.showed that social relationships, informal support networks for pregnant women and strong support of midwives could strengthen the women's belief in the fact that labor is a physiological and controllable process.As a result, this psychological feeling can reduce the fear of childbirth [19].The difference between the present study and the studies showing the reduction of fear and stress with social support is that in their studies, the actual support meaning the presence of supporters was investigated when necessary, while in this study, the individual's perception of those who can help her when necessary was studied which is a subjective phenomenon.The study results of Badaghi showed that there is a reverse relationship between anxiety, depression, and stress in pregnant women and social support [20] while in the study of Shishehgar et.al., there was no significant relationship between social support and stress in pregnancy [21].The difference between the present study and the studies mentioned above was that the pregnant women's stress was studied in the above studies, while in the present study, childbirth fear was examined.A study by Salomonson et al., which was conducted in Sweden in 2013 entitled "Perceived self-efficacy and childbirth fear in primiparous women," showed that when there is no preference for cesarean section, self-efficacy has a direct relationship with labor fear.It means that the reduction of self-efficacy increases the labor fear.Also, it was shown that increased self-efficacy in women during pregnancy could be effective in reducing the fear of childbirth and these programs can be part of a pregnancy-based educational program for women [22].In this study, the general self-efficacy of mothers was examined, which was different from the present study, because in this study, fear self-efficacy was used and its relationship with perceived social support was measured.

CONCLUSION
It seems that the individual's subjective assessment of her supporters during her pregnancy does not associate with self-efficacy for labor fear which is subjective as well.It seems that health providers should ask people with whom the pregnant mother has a direct relationship such as husband, to involve actively in the process of supporting during pregnancy.

CONTRIBUTOR STATEMENT
The main idea was proposed by Fatemeh Zarin.The initial draft was prepared by Fatemeh Zarin and Katayon Vakilian and the final draft was prepared by Vakilian.