Pregnancy and Childbirth Fear of Women from Poland, Greece, Turkey, Belarus, and Russia

Background/Objectives: Pregnancy and childbirth in many women cause various situations, from physical to emotional. The analysis of selected factors affecting pregnancy and childbirth in a group of women from Poland, Greece, Turkey, Belarus, and Russia and self-assessment of their impact on fear of pregnancy and childbirth. Material and Methods: A total of 2017 women were surveyed, including 584 pregnant women, 528 postpartum women, and 906 non-pregnant and never-pregnant women. The study used an original questionnaire, including questions on socio-demographics and the history of pregnancy and childbirth. The material status of the respondents was assessed using the Family Affluence Scale. Results: The age range of respondents was 19–50. The surveyed women most often reported (p < 0.001) fear (n = 928) and excitement (n = 901). A positive correlation was found between anemia, infections, and fear in women from Belarus. No correlation was found between low, average, or high material status and the perception of pregnancy in women from the studied countries. Significantly (p < 0.001), women from Turkey had more children (p < 0.001) than women from other countries. With the exception of Russia, statistical correlations were shown between the feeling of fear of pregnancy and childbirth and the way the previous/current pregnancy was delivered and the experience of an artificial/natural miscarriage in the past. In general, 630 women had given birth vaginally, and 283 women had given birth by cesarean section. In the group of currently pregnant women, 22 women had had natural miscarriages in Belarus, 37 in Poland, 27 in Greece, 29 in Turkey, and 9 in Russia. Conclusions: When thinking about pregnancy, respondents in all groups most often felt joy and excitement, as well as fear and excitement, about childbirth. Natural miscarriage was experienced most frequently by women in Poland and Greece and induced in Belarus. The largest number of women who had cesarean section were from Poland and Belarus.


Introduction
Motherhood is recognized as one of a woman's most significant roles, often regarded as the central and dominant element of womanhood.It is a time of discovering one's capabilities, strengthening perseverance and efficacy, learning a new role, and assuming more responsibilities.
During pregnancy, women may experience various situations, from physical to emotional, which affect both the mother's and baby's health [1].Thus, needs and concerns arise related to their bodily sensations, changes in lifestyle, and fears about the possibility of miscarriage [2].
The timing of childbirth causes many concerns.The mother's knowledge and expectations often influence childbirth.One of the most common feelings reported by pregnant women concerning childbirth is fear.This increases the perception of childbirth as a traumatic and painful process [3].Many women demand a cesarean section delivery, believing it to be safer and more comfortable for them and the baby [4].
There is also a noticeable upward trend in the rate of cesarean sections worldwide, with an average increase of 9% between 2000 and 2015 [5].On individual continents, the changes are distributed differently: in Western Europe, it was 7.3%; in Eastern Europe and Central Asia, 15.4%; in Northern America, 7.7%; and in the Middle East and Northern Africa, as much as 10.6%.In Poland, the rate of cesarean sections is one of the highest in Europe, at 42.2% [4].
In recent years, Poland has seen a change in fertility patterns, a decline in the number of births in all reproductive age groups, and a decrease in the absolute number of births [6].The fertility rate for Poland in 2023 was 1.467 births per woman, a 0.62% increase from 2022.The fertility rate for Belarus in 2023 was 1.736 births per woman, a 0.29% increase from 2022.The fertility rate for Russia in 2023 was 1.825 births per woman, a 0.05% increase from 2022.The birth rate for Greece in 2023 was 6.930 births per 1000 women, a 2.56% decline from 2022.The fertility rate for Turkey in 2023 was 1.994 births per woman, a 0.85% decline from 2022.In 2021, the rate was 1.33, and was thus below the EU average and well below the replacement level [7].
Several factors influence birth rates, impacting population growth and demographics [8][9][10][11].Generally, higher levels of wealth and education are associated with decreased fertility rates.Educated individuals often delay childbirth and have fewer children.As more women participate in the workforce, they tend to have fewer children due to career demands and lifestyle choices.Urban areas often exhibit lower birth rates compared to rural regions.Urbanization leads to smaller families and different lifestyle priorities.It is well known that increased maternal age is linked to lower fertility.First-time mothers today tend to be older, contributing to declining birth rates.Birth rates are dynamic and influenced by a complex interplay of social, economic, and cultural factors.
Also, fear of childbirth may affect the birth rate.Fear of childbirth is a natural reaction for many expectant mothers.Women often experience uncertainty about the labor process.They often fear that something might go wrong or be painful.Pregnant women are increasingly exposed to the view that pregnancy and childbirth are intrinsically dangerous, requiring medical monitoring and management.Societal pressures that dictate appropriate behaviors during pregnancy are applied to women.These changes have resulted in an increased perception of risk for pregnant women [6,8].
It is essential to learn about the birthing process and attend childbirth preparation classes [12].Many women worry about significant weight gain during pregnancy [13].Women are often afraid that they will be less attractive to their partner after giving birth.Some women worry that there may be complications with the baby.Fear of pregnancy is known as tokophobia [14].It is a specific anxiety disorder where individuals experience an irrational and excessive fear related to pregnancy and childbirth.Women with this phobia may avoid becoming pregnant altogether or opt for a cesarean section to avoid vaginal birth.Some women may experience sleep disturbances, panic attacks, and nightmares.
It is suggested that some women are more susceptible to fear of childbirth than others.The etiology of tokophobia is multifactorial and can be associated with different factors such as susceptibility to anxiety or depression [15] and other psychiatric disorders, wellbeing in interpersonal relationships [16], and traumatic experiences of former births [17].Some women described themselves as lonely or with low self-esteem [18].The need for psychiatric care and the presence of traumatic stress symptoms are reported outcomes together with prolonged labor, use of an epidural, and obstetric complications.
To our knowledge, similar studies comparing factors affecting pregnancy and childbirth in women from Poland, Greece, Turkey, Belarus, and Russia are unavailable.
No similar studies have been conducted in Belarus or Russia.Several studies are from Poland [19][20][21].Only a few studies from Turkey and Greece have assessed fear of childbirth and pregnancy.A Turkish study from 2020 found that 82.6% of the women had a fear of childbirth [22].Economic status, parity, previous birth experience, and preferred delivery method affected the fear of childbirth among women.In a Greek study [23], a Validation of the Childbirth Attitudes Questionnaire was used, and 145 latepregnancy women participated.Eighty percent of women reported that they would intend to have a normal vaginal delivery, while 20% of participants stated that they preferred cesarean section.
In this study, we tried to compare factors that could affect pregnancy and childbirth in women from Poland, Greece, Turkey, Belarus, and Russia.

Aim of the Study
The study's main aim was to analyze factors that may affect the perception of pregnancy and childbirth in a group of pregnant and postpartum women from Poland, Greece, Turkey, Belarus, and Russia.

Material and Methods
The study was conducted with approval from the Bioethics Committee APK.002.587.2021,Białystok, Poland.All participants provided written informed consent for participation.Participation was voluntary and anonymous.Participants could withdraw from the study at any point without feeling obligated to continue.Personally identifiable data were not collected.
The sample selection was purposive.A cross-sectional study was carried out amongst the 2017 women surveyed, including pregnant and postpartum women who were not pregnant and had never given birth from Poland, Greece, Turkey, Belarus, and Russia.The sample selection was purposive.The pregnant women were recruited from Obstetrics Departments, the postpartum women were recruited from General Practice Clinics, and the group of women who had never given birth and were not pregnant included female students and university workers in the studied countries.Surveys were collected between November 2021 and December 2022 during the COVID-19 pandemic.This could have affected the collection of the surveys.The questionnaires were given to the participants by the authors of the study.All completed questionnaires from Greece, Turkey, Belarus, and Russia were sent to Poland.A statistician analyzed the data from the questionnaires.
The inclusion criteria were as follows: pregnant and postpartum women over 18 years of age who could communicate in the mother language of the country where they were contacted were included in the study.
The exclusion criteria were as follows: women were excluded if they were under 18 years of age and could not communicate in the mother language of the country where they were contacted.

Measures
The study used a diagnostic survey method involving an original questionnaire about age, marital status, place of residence, education, material status, and associations of respondents regarding pregnancy and childbirth (joy, excitement, fatigue, helplessness, fear, hospital, house, and loneliness) with and health problems in the last year.In the group of pregnant and postpartum women, the respondents were additionally asked about the number of children, spontaneous and induced abortions, duration of the delivery, total number of deliveries, type of the last delivery, and participation in childbirth classes.
The material status of the respondents was assessed using the Family Affluence Scale (FAS) [24].The FAS was developed within the 'Health Behaviour in School-Aged Children: WHO Collaborative Cross-National Study' (HBSC), which aims to collect comparative data on adolescent health and its determinants.The scale is a socioeconomic proxy for family wealth in studies where reliable, objective information about family wealth is impossible to obtain.This questionnaire includes the following questions: Does your family own a car, van, or truck?(Scores 1-No, 2-Yes one, and 3-Yes two or more).Do you have a bedroom for yourself?(Scores 1-No, 2-Yes).How many computers do your family own (including laptops and tablets, not including game consoles and smartphones)?(Scores 1-None, 2-One, 3-Two, and 4-Two or more).How many bathrooms (room with a bath/shower or both) are in your home?(Scores 1-None, 2-One, 3-Two, 4-More than two).Does your family have a dishwasher at home? (Scores 1-No, 2-Yes).How often did you and your family travel out of [insert country here] for a holiday/vacation last year?(Scores 1-Not at all, 2-Once, 3-Twice, and 4-More than twice).A simple sum score is the starting point for computing relevant socioeconomic indices.The Cronbach's α of the scale is 0.643.

Statistical Analyses
The statistical analysis was performed based on the Statistica 13.0 PL software.The Shapiro-Wilk test was used for the test of normality.A t-test was used to compare the means of the two groups.The chi-square test was used for sample sizes of five and larger.This test was used to compare the percentages between countries.The correlations between variables were calculated using Spearman's rank correlation analysis.We used the interpretations of the r values: poor correlation is r = 0.1-0.2;fair is r = 0.3-0.5;moderate is r = 0.6-0.7;and very strong is r = 0.8-0.9.Statistically significant differences were defined at p < 0.05.

Results
The study involved 2017 women, including 584 pregnant women, 528 postpartum women, and 906 women who were not pregnant and had never given birth from Poland, Greece, Turkey, Belarus, and Russia.Married women dominated all study groups.The mean age of 19.2 ±19 years for women who had never given birth in Belarus was significantly (p < 0.001) lower compared to Poland (33.5 ± 33) and Turkey (28.3 ± 26).In the pregnant group, it was 29.2 ± 29 years in Belarus, 30.4 ± 30 in Poland, 34.7 ± 33 in Greece, 27.7 ± 27 in Turkey, and 27.7 ± 29 in Russia.In the postpartum group, it was 28.7 ± 29 years in Belarus, 31.0 ± 30 in Poland, 37.6 ± 36 in Greece, 28.1 ± 28 in Turkey, and 28.1 ± 28 in Russia.All groups and countries were significantly (p < 0.001) dominated by urban residents, with an overall number of 1699 vs. 318.In Poland, respondents with a master's degree significantly (p < 0.001) dominated (n = 201) compared to other countries.Statistically, the largest number of students were from Russia, n = 262, compared to other countries (Table 1).1-women who have never given birth and are not pregnant, 2-pregnant women, and 3-postpartum women; Spearman's rank correlation test.

Results
Assessment of material status 1 with the FAS allowed us to conclude that the average material status was high (above 5 points) in all groups and countries (Table 1).The largest number of women with a very low material status was in Belarus, with a low and average material status in Turkey, and a high material status in Poland.However, in the study group, women with a high material status dominated with 72%.
No correlation was found between low, average, or high material status in the FAS and the perception of pregnancy in women from Belarus.Similarly, no correlation was found between low, average, or high material status in the FAS and the perception of pregnancy in women from Poland, Greece, Turkey, and Russia.
Respondents were asked what associations they had with regard to pregnancy.Among the women who had never been pregnant, those from Belarus and Russia most often (p < 0.001) reported excitement (n = 43 and n = 80, respectively), while in Poland and Greece they most often mentioned joy (n = 108 and n = 96, respectively).Pregnant women from Belarus, Poland, and Greece reported joy more often (n = 130, n = 145, and n = 102) than others.Details are shown in Table 2.      1-women who have never given birth and are not pregnant, 2-pregnant women, and 3-postpartum women (several answers could be chosen); Spearman's rank correlation test (r = −0.480;### p < 0.001; r = −0.247;### p < 0.001).
Respondents were asked to list the diseases affecting them during the survey.In the group of pregnant and postpartum women from Poland, the most common diseases were infections, diabetes, and anemia.In women from Belarus, they were infections and anemia.A positive correlation was found between anemia, infections, and fear in women from Belarus.Details of the results are shown in Table 3.   * several answers could be chosen; 1-women who have never given birth and are not pregnant, 2-pregnant women, 3-postpartum women; Spearman's rank correlation test ( # r = 0.160, p = 0.01; ## r = 0.497, p = 0.005 positive correlation with fear).
Respondents were also asked what associations they had regarding childbirth.For women who had never been pregnant, those from Greece (n = 84) and Russia (n = 72) mentioned fear significantly (p < 0.001) more often than other women.Pregnant women from Belarus (n = 102) and Turkey (n = 78) reported excited significantly more frequently.A total of 64.2% of pregnant women reported childbirth fear.Postpartum women from Belarus (n = 63) and Turkey (n = 67) reported excitement.In general, women from Belarus (n = 199) and Turkey (n = 234) more often (p < 0.001) reported that childbirth evoked excitement.Generally, all women from the five surveyed countries reported fear (n = 928) and excitement (n = 901) most often (p < 0.001).Details are shown in Table 4.   1-women who have never given birth and are not pregnant; 2-pregnant women; 3-postpartum women * several answers could be chosen.Spearman's rank correlation test, ### p < 0.001 .
Pregnant women at the time of the survey had an average of 1.4 ± 0.7 children in Belarus, 1.4 ± 1.1 in Poland, 2.0 ± 0.9 in Greece, 3.1 ± 1.4 in Turkey, and 1.1 ± 1.2 in Russia.Significantly, women from Turkey had more children (p < 0.001) than others.Details are shown in Table 5.     1-women who have never given birth and are not pregnant; 2-pregnant women; 3-postpartum women.Independent samples t-test p < 0.001 vs. other groups (Belarus, Poland, Greece, and Russia).
Significantly (p < 0.001), the highest number of births were reported both by pregnant and postpartum women from Poland and the lowest from women from Russia (Table 6).Respondents who had given birth previously or were in the postpartum period were asked to specify the type of delivery.The highest percentage, 29 (30.5%)natural births, were reported by women from Russia, and the lowest was 63 (20.4%) from Poland.Significantly (p = 0.002), women from Greece reported 72 (31.3%) cesarean sections compared to 10 (10.5%) from Russia.In total, 283 women gave birth by cesarean section, a few more than the 264 women who gave birth naturally.Details are shown in Table 7. Postpartum respondents were asked to report how long their delivery lasted.The duration of childbirth was significantly (p < 0.001) the longest in Greece compared to other countries.In Belarus, it lasted 5.8 ± 3.8 h; in Poland, 5.6 ± 3.6; in Greece, 10.8 ± 8.9; in Turkey, 4.6 ± 4.3; and in Russia, 5.3 ± 4.2 h.
The women surveyed were also asked whether they had experienced a spontaneous abortion.In the group of pregnant women, 22 had had spontaneous abortions in Belarus, 37 in Poland, 27 in Greece, 29 in Turkey, and 9 in Russia.There were no induced abortions in the group of subjects from Turkey.Induced abortions occurred in 12 women in Belarus, 11 in Greece, 6 in Poland, and 2 in Russia.The results are shown in Table 8.We also analyzed relationships between the respondents' associations regarding pregnancy and the method of an earlier delivery.
In the Polish group, among women who were currently pregnant and had previously given birth naturally, significant relationships were found with the feeling of excitement (R = 0.254; p = 0.008), anxiety (R = −0.207;p = 0.032), and the feeling of loneliness (R = −0.251;p = 0.026), and in women currently intending to give birth by cesarean section with a sense of helplessness (R = −0.193;p = 0.046).
In the group from Belarus, significant correlations were found only in terms of perceived loss, both in the group of pregnant women who had previously given birth vaginally (R = −0.441;p = 0.0002) and those currently after vaginal delivery (R = −0.451;p = 0.0001).
In the Greek group, a significantly negative relationship was found in the area of fear felt in the group of women currently after natural childbirth (R = −0.377;p = 0.000).
In the Turkish group, significant negative relationships were found in terms of perceived fear in pregnant women after induced labor (R = −0.706;p = 0.000) or cesarean section (R = −0.312;p = 0.039).No significant correlations were found among Russian women.The results are shown in Table 9.  Next, the respondents' associations regarding pregnancy were analyzed between women who had and who had not experienced a natural miscarriage in the past.
In the group of currently postpartum women from Belarus, significant negative correlations were also found for fear (R = −0.266;p = 0.001) and sense of helplessness (R = −0.492;p < 0.001).The results are shown in Table 10.
Table 10.Respondents' associations regarding pregnancy between women who have and who have not had a natural miscarriage in the past.The respondents' associations regarding childbirth were also analyzed between women who had and who had not experienced an artificial miscarriage in the past.
In the group of pregnant women, significant differences were found between miscarriage in the group from Belarus and the feeling of joy (R = 0.228; p = 0.02) and fatigue (R = −0.341;p < 0.001) in the face of fear (R = −0.278;p = 0.004) and loss (R = −0.197;p = 0.044), and in the Russian group with fear (R = −0.551;p < 0.00).
Additionally, in the group of women from Greece who were currently pregnant, significant differences were found between a previous artificial miscarriage and excitement (R = 0.205; p = 0.035) and fatigue (R = −0.286;p = 0.003).Details are shown in Table 11.The respondents' associations regarding childbirth and the method of earlier delivery were also analyzed.Significant differences were only found in the group of women from Poland, including those who were currently pregnant and had given birth vaginally, with excitement (R = 0.254; p = 0.008) and joy (R = −0.207;p = 0.032) and those who had given birth by cesarean section (R = 0.222; p = 0.021).Women who had just given birth had a feeling of helplessness (R = 0.193; p = 0.046).The results are shown in Table 12.

Discussion
Our study was performed during the COVID-19 pandemic, a difficult time for all people, particularly pregnant women.The COVID-19 epidemic led to increased fear, stress, and anxiety among pregnant women.They often perceived childbirth during this time as a threat to their well-being and health [20,25,26].A study funded by the National Institutes of Health found that women who gave birth during the pandemic, especially in communities with COVID-19 outbreaks, were more likely to experience traumatic childbirth.This included symptoms of intense anxiety or post-traumatic stress disorder triggered by the birthing experience [27].Pregnant women were very often worried about the virus's impact on their pregnancy and unborn babies.These negative factors could also impact our results.
Our findings are in agreement with previous reports on childbirth fear.In the present study, 64.2% of pregnant women reported childbirth fear.In a study from Slovenia, 75% of pregnant women reported low to moderate tokophobia, whereas 25% exhibited high or very high fear of childbirth [28].A European study of 6870 pregnant women in Belgium, Iceland, Denmark, Estonia, Norway, and Sweden demonstrated that 11% of pregnant women reported severe childbirth fear [29].There were significant differences between the countries for prevalence of severe fear of childbirth, varying from 4.5% in Belgium to 15.6% in Estonia for primiparous women and from 7.6% in Iceland to 15.2% in Sweden for multiparous women.
Cultural norms regarding motherhood and birth shape women's perceptions regarding what birth is and how it should be managed.Several studies have found differences between cultures in terms of women's preferences regarding cesarean sections [30,31] and levels of fear of childbirth [29,32].A systematic review of 490 full-text articles on the fear of childbirth was assessed for analysis [32].It was found that various definitions and measurements of fear of childbirth were used.The most frequently used scale was the W-Delivery Expectancy/Experience Questionnaire with various cut-off points describing moderate, severe/intense, and extreme/phobic fear.Furthermore, rates of severe fear of childbirth measured in the same way varied in different countries.The reasons why the fear of childbirth might differ are unknown.
In the current research, women who had never been pregnant, most often in the groups from Belarus, Poland, Greece, and Russia, reported fear more frequently, and in Turkey, excitement.Pregnant women from Belarus and Turkey reported excitement and fear more frequently than women from Poland and Greece.Women from Belarus and Turkey reported excitement in the postpartum group, as did women from Poland and Greece.When analyzing the responses of all the women from the five countries surveyed, fear was dominant at 46%.
In the present study, women frequently indicated excitement and joy evoked by pregnancy and childbirth.Our results are in accordance with previous studies [33 -35].When parents experience more significant meaning in life, satisfaction of their basic needs, more significant positive emotions, and enhanced social roles, they are happy and joyful [35].Childbirth is an intense and transformative psychological experience that generates a sense of empowerment.The benefits of this process can be maximized through physical, emotional, and social support for women, enhancing their belief in their ability to give birth and not disturbing their physiology unless necessary.
To reduce the anxiety and stress associated with pregnancy and childbirth, women can attend childbirth classes to prepare them for motherhood and to help improve their psycho-physical condition.Contact with other pregnant women allows them to bond with women struggling with the same pregnancy symptoms or doubts.
Childbirth education classes are antenatal support services offered to pregnant women or couples to increase their knowledge regarding pregnancy, labor, delivery, breastfeeding, parenthood, and newborn care [12].
In the current study, most women surveyed did not attend childbirth classes, which may be related to the fact that schools are virtually non-existent or exclusively paid for in some countries.
Hildingsson et al. [36] researched the length of births without medical interventions between 2008 and 2013 in four Scandinavian countries.This study found that labor from the first uterine contractions to the birth of the child took an average of 14 h in primiparous women and 7.25 h in multiparous women.In the current study, labor lasted between ½ h and 42 h, including an average of 5.8 h in Belarus, an average of 5.6 h in Poland, an average of 10.8 h in Greece, an average of 4.6 h in Turkey, and an average of 5.3 h in Russia.
For several years, there has been a steady increase in cesarean sections [7].The report by Boerma et al. [6] shows that the number of births by cesarean section increased from 12% in 2000 to 21% in 2015.According to data from the EURO-PERISTAT report [37], the rate of cesarean sections in 2014 in Europe was about 27%.In Poland, it accounted for 42.2% of births and was one of the highest rates in Europe.In the current study, in the case of pregnant women in Belarus and Russia, delivery was more often natural, while in Poland and Greece, delivery was more often by cesarean section.Overall, 630 women gave birth naturally and 283 by cesarean section.
The number of abortions worldwide is increasing.Between 2010 and 2014, it was around 56 million, an increase of 6 million compared to 1990-1994, meaning that almost one in four pregnancies ended in abortion [38].However, the abortion rate, i.e., the number of abortions per 1000 women of reproductive age (15-44 years), decreased from 40 to 35.The abortion rate was found to be higher among married women, at 36 per 1000 women, against 25 per 1000 for unmarried women.
The current study found that no woman from Poland and Turkey had an induced abortion.In the pregnant group, 17 women in Belarus, 10 in Greece, and 3 in Russia had induced abortions, and in the postpartum group, 12 women in Belarus, 11 in Greece, and 2 in Russia had induced abortions.
An estimated 23 million miscarriages occur worldwide each year, which translates into 44 pregnancy losses per minute [39].The overall risk of miscarriage is 15.3% of all identified pregnancies.The consequences of miscarriage are both physical, such as bleeding or infection, and psychological.Psychological consequences include increased risk of anxiety, depression, post-traumatic stress disorder, and suicide.In Poland, approximately 10-15% of all pregnancies end in miscarriage [40].In the current study, in both the pregnant group and the postpartum group, women had between 1 and 3 natural miscarriages.
In the analysis of the relationships between the respondents' associations regarding pregnancy and childbirth, the method of previous childbirth, and previous experience of natural and/or artificial miscarriage, it was found that the respondents very often had a feeling of fear during pregnancy and after childbirth.
The professional literature emphasizes that childbirth is the main factor causing anxiety for pregnant women, and it may have various origins.Birth anxiety may be caused mainly by social learning; seeing or hearing about the problems of other women during childbirth, women begin to fear the occurrence of similar events in their case [41].Fear of childbirth significantly increases muscle tension and affects the perception of mental and somatic experiences, thus increasing pain, which is why reducing the fear of childbirth is so important [42].Negative memories of previous births is another factor causing fear of the next one [43].Anxiety may affect the course of childbirth, making labor difficult, contributing to obstetric complications, and increasing pain.
It should be emphasized that the experience of a traumatic childbirth may cause an acute stress reaction or post-traumatic stress disorder [44].The current study showed a relationship between a previous cesarean section delivery and the association of anxiety with pregnancy and childbirth in the group of pregnant and postpartum women in Poland, and in the group of pregnant women with the experience of a previous cesarean or induced delivery in Turkey.
The study by Størksen et al. [43] confirms the thesis that women who feel more anxious are more likely to try to deliver by cesarean section, explaining this by previous traumatic experiences during childbirth.In turn, research by Demšar et al. [28] shows that women with a higher level of fear of childbirth prefer delivery by cesarean section.In comparison, women with a lower level of fear prefer vaginal delivery or the route of delivery is not important for them.
Reducing fear of childbirth involves a holistic approach that considers cultural, emotional, and medical aspects.By fostering trust and understanding, professionals can positively impact birthing experiences.There are many factors that can reduce the number of caesarean sections [45].It is important to understand diverse cultural beliefs, practices, and expectations related to childbirth by medical staff.Health professionals should educate women on the benefits of natural delivery and the risks of cesarean sections.It is important to offer counseling and emotional support for pregnant women during prenatal visits.It is suggested that extra support for women should include sensitive education about the birth process, development of problem-solving skills, teaching coping strategies for labor, and affirming that negative childbirth events can be managed.

Limitations of the Study
1.The study groups of women are relatively small for producing generalizable results.
The women surveyed were from five different countries: Poland, Belarus, Russia, Greece, and Turkey.It is well known that cultural norms, values, and beliefs influence individuals' behavior, decision-making, and perceptions.These factors can affect how people respond to surveys, questionnaires, or experimental conditions.2. It is worth assessing the felt anxiety using a standardized tool, such as the Childbirth Anxiety Questionnaire.Unfortunately, this tool was not validated in all surveyed countries, and the results could not be standardized.3. The study also did not include the form of childbirth preferred by the patients, which, as it turned out in the discussion, may not have depended on the fear of childbirth they felt, but instead on the expected form of childbirth.4. The sample size calculation was not done.5.The Cronbach's α of the FAS scale is 0.643, which indicates that it is not high.

Implications
Pregnancy and childbirth are two profound experiences that evoke a spectrum of emotions.Cultural norms regarding motherhood and birth shape women's perceptions regarding what birth is and how it should be managed.Women's experiences of pregnancy and childbirth can include all kinds of feelings, from joy to fear.Women's fear of labor and birth is an essential reason for the increasing number of requests for and rates of cesarean sections.We suggest that doctors and midwives should educate expectant mothers that cesarean sections can be crucial in specific medical situations.However, unnecessary surgical procedures should be avoided to minimize risks for both mothers and babies.
It is also worth emphasizing that reducing anxiety during pregnancy may have a positive impact on the course of childbirth.Anxiety occurs in the population of pregnant women regardless of the expected form of delivery, and its level may affect their preferences as to the form of delivery.Prevention of fear of childbirth is very important and can be implemented through antenatal classes, as well as through social support received by the pregnant woman.We also cannot ignore medical issues or offer psychoeducation and organize a psychiatric consultation.This seems particularly important when deciding on the form of childbirth.

Conclusions
When thinking about pregnancy, respondents in all groups most often felt joy and excitement about childbirth as well as fear and excitement.
Natural miscarriage was experienced most frequently by women in Poland and Greece and induced in Belarus.
Generally, the women surveyed did not participate in childbirth classes.The largest number of women gave birth naturally or by cesarean section in Poland and Belarus and the smallest number in Russia.
women; 2-postpartum women.Spearman's rank correlation test R, p values, NS-not significant.
women; 2-postpartum women.Spearman's rank correlation test R, p values, NS-not significant.

Table 1 .
Demographics of respondents.

Table 2 .
Associations of respondents regarding pregnancy.

Table 3 .
Diseases reported by respondents.

Table 4 .
Associations of respondents regarding childbirth.

Table 5 .
Number of children.

Table 6 .
Number of births to date survey.

Table 7 .
Type of last delivery.

Table 8 .
History of spontaneous and induced abortions.

Table 9 .
Respondents' associations regarding pregnancy and the method of previous/current delivery.

Table 11 .
Respondents' associations regarding childbirth between women who have and who have not had an artificial miscarriage in the past.

Table 12 .
Associations of respondents regarding childbirth and the method of earlier childbirth.
1-pregnant women; 2-postpartum women.Spearman's rank correlation test R, p values.* several answers could be chosen.