DOI: 10.31038/EDMJ.2025923

Abstract

Objective: To investigate the status quo of pregnant women’s attitude towards childbirth and the use of we-media to browse childbirth-related information, and to analyze the correlation between the two.

Methods: The Chinese version of female childbirth Attitude questionnaire was used to conduct a questionnaire survey on 304 pregnant women who were conveniently sampled from a Grade 3 A hospital in Hangzhou and recruited online.

Results: The score of women’s attitude toward childbirth during pregnancy was (90.30 ± 14.65), and the characteristics of the use of we-media to obtain maternity information showed diversification. The frequency and duration of we-media use were positively correlated with the score of the attitude toward childbirth. In terms of the use motivation, the attention of specific content may have a negative impact on different dimensions of women’s attitude toward childbirth.

Conclusion: The more frequently and longer pregnant women browse pregnancy-related information on we-media platforms, the more likely they are to hold negative attitudes towards childbirth. It is suggested that we media be used to disseminate more authoritative content of childbirth education to help women deeply understand the physiological process of childbirth, so as to reduce the fear of the unknown.

Keywords

Pregnant women, Childbirth attitude, We media use, Influencing factors

Introduction

Childbirth is a major turning point in a woman’s life and has a profound impact on her physical and mental health [1]. As a special physiological and psychological stage for women, pregnancy has increased the demand for maternal and child health information [2]. In recent years, we-media platforms have increasingly become an important channel for pregnant women to obtain maternity information due to their characteristics of immediacy, interaction and decentralization [3]. Childbirth attitude refers to an individual’s subjective cognitive, emotional and behavioral tendencies towards childbirth, including fear of childbirth, childbirth pain, childbirth mode choice and views on the use of medical interventions. A positive attitude towards childbirth contributes to maternal confidence and reduces the risk of postpartum depression [4]. Birth attitudes are shaped by a variety of factors, including personal subjectivity, traditional factors such as family support [5,6], and by the emerging media environment [7]. However, the quality of information on we-media platforms is uneven, and false or inaccurate maternity information may exacerbate the anxiety and fear of pregnant women, thus affecting their attitude towards childbirth [8]. Previous studies have shown that media exposure is associated with women’s childfear behavior [9], but there is still a lack of research on the relationship between we-media use and women’s attitude toward childbirth during pregnancy. Therefore, the purpose of this study is to explore the correlation between we-media use and pregnant women’s attitude towards childbirth, in order to provide a scientific basis for optimizing pregnant women’s access to information, improving their attitude towards childbirth and enhancing their childbirth experience.

Methods

This study was conducted from July to October 2024, through a combination of online and offiine methods, and adopted the snowball method recommended by friends to recruit research subjects. The researcher published a post on rednote to recruit research subjects, attracted potential participants by providing professional nutrition knowledge during pregnancy, and recruited them offiine simultaneously. Pregnant women who underwent prenatal check-up in a third-level A hospital in Hangzhou were selected as research objects by convenient sampling method. They were then encouraged to recommend their friends or relatives to participate, thereby gradually expanding the study sample. Inclusion criteria: ① in the gestation period; ② Age ≥18 years old; ③ In the past six months, I have used the small Red book platform to browse the content related to childbirth; ④ Normal cognitive function, with basic communication and writing skills; ⑤ Know about this study and agree to participate in the study. Exclusion criteria: ① Pregnant women with a history of mental illness. Before collection, obtain approval from the hospital Ethics Committee (No. ZN- 20240327-0098-01). The research team sent the two-dimensional code of the questionnaire was distributed to the study subjects through the questionnaire star link, and the research purpose, content and informed consent were set as required reading items. Participants could read and agree before filling in the questionnaire; The system sets that each IP address can be entered only once to avoid repeated entries. Adopt the form of anonymous independent filling, for regular answers, the answer time is too short less than 3min questionnaires will be excluded. After the survey, the collected questionnaires will be reviewed. A total of 310 questionnaires were sent out in this survey.

Measurement

General Information Questionnaire

Based on the literature review and combined with the purpose and content of this study, the design was self-designed, including general information such as age, ethnicity, education level, household registration type, marital status, expected delivery mode selection, delivery information sources, and use of we-media.

Chinese Version of Women’s Attitudes Towards Birth Questionnaire (WATBQ)

The Chinese version of the Female Childbirth Attitude Questionnaire was compiled by Stoll et al. [10] in 2014. The questionnaire consists of 22 items, including four parts: views on pregnancy and childbirth, views on delivery techniques, views on cesarean section and views on physical changes after delivery. Likert6- level scoring method was adopted, with scores ranging from 1 to 6 for “strongly disagree” to “strongly agree”. The higher the score of each dimension, the more negative the attitude towards childbirth in this dimension. The Chinese version of the Women’s Childbirth Attitude Questionnaire (WATBQ) was developed by our research team in strict accordance with the Brislin model. After cross-cultural adjustment, the Chinese version of the female childbirth attitude questionnaire included 22 items in 5 dimensions: views on childbirth, views on complications, views on delivery techniques, views on caesarean section and views on body changes after childbirth. The Cronbach’s α coefficient of the questionnaire was 0.890, and the retest reliability was 0.824, with good reliability and validity.

Data Analysis

All data were entered into Excel by double checking. SPSS 27.0 software was used for data processing and analysis. For categorical variables, frequency and percentage were used to describe them, and Chi-square test and Fisher exact test were used for comparison. The mean ± standard deviation was used for descriptive statistical analysis of the study variables conforming to the normal distribution. With the scores of childbirth attitude questionnaire as the dependent variable, single factor analysis was performed by t test and variance analysis. Pearson correlation analysis and Point-biserial correlation analysis are used for correlation analysis.

Results

General Information About Women During Pregnancy

A total of 304 pregnant women who met the eligibility requirements completed the survey, of which 78 were recruited online through rednote and 226 were recruited offiine in hospitals, as shown in Table 1.

Table 1: Demographic characteristics of the study participants (n=304).

Women’s Childbirth Attitude Score During Pregnancy

The results showed that the total score of pregnant women’s attitude towards childbirth was (90.30 ± 14.65), and the scores of each dimension were shown in Table 2.

The Result of Characteristic Clustering of Pregnant Women’s Delivery Attitude Score

Table 2: Total and dimension scores of childbirth attitude questionnaire (n=304).

According to the total score of the childbirth attitude questionnaire and the average scores of items in each dimension, the pregnant women were divided into 2 clusters by K-means clustering. The distribution of the two groups was average, and the clustering effect was good. Table 3 shows the average scores of the two clusters in the total score of the childbirth attitude questionnaire and items in each dimension. There are significant differences in their mean values, reflecting different characteristics. Therefore, Cluster1 is named “Negative childbirth Attitude Group” and Cluster2 is named “positive childbirth Attitude Group”. In this study, there were 152 pregnant women in the positive childbirth attitude group and the negative childbirth attitude group, each group accounted for 50%.

Table 3: Comparison of two clusters across five dimensions.

**P<0.01

Univariate Analysis of Pregnant Women’s Attitude Towards Childbirth

The results showed that there were 5 variables related to women’s attitude towards childbirth, including household registration type, monthly income per capita, gestational week, number of pregnancies and pregnancy education. For details, see Table 4.

Table 4: Univariate analysis of childbirth attitudes by demographic factors (n=304).

^at-value and ^bF-value

Multiple Linear Regression Analysis of Pregnant Women’s Attitude Towards Childbirth

Five indicators with statistical significance in the univariate analysis were taken as independent variables, and the total score of pregnant women’s attitude towards childbirth was taken as dependent variable. The results of multiple linear regression show that the type of household registration, per capita monthly income of the family, the number of pregnancies and pregnancy education affect their attitude towards childbirth, as shown in Table 5.

Table 5: Multivariate linear regression analysis of childbirth attitudes (n=304).

R=0.826, R²=0.682, after adjusting R²=0.673, F=79.028, P<0.001

We-media Use in Pregnant Women

In this study, the average weekly frequency of non-medical we- media platforms used by pregnant women to browse childbirth- related information, the time of each use of non-medical we-media platforms to browse childbirth-related information, and the use of we- media platforms to browse childbirth-related content were counted. For details, see Table 6.

Table 6: Social Media Usage Characteristics of Participants

Correlation Between Pregnant Women’s Childbirth Attitude and We-media Use

The results of correlation analysis showed that the total score and each dimension of female childbirth attitude were significantly positively correlated with the frequency of use of we-media (r=0.431, P < 0.01) and duration of use (r=0.435, P < 0.01). In terms of motivation, browsing diet and lifestyle recommendations during pregnancy through we-media platforms was only positively correlated with the perception dimension of complications (r=0.136, P < 0.05), while the risks and benefits of browsing common interventions and technologies that could be used during pregnancy and delivery were significantly positively correlated with the total score of childbirth attitudes and the perception dimension of cesarean section (r=0.211, P < 0.05). P < 0.01), browsing other women’s childbirth experience was significantly positively correlated with the total score of female childbirth attitude (r=0.230, P < 0.01), and there was no statistical difference between the preparation for childbirth and browsing the process and possible problems of childbirth through we-media platforms and the total score and all dimensions of female childbirth attitude (P < 0.05). See Table 7 for details.

Table 7: Correlation analysis between social media usage and childbirth attitudes (r-value, n=304).

*P<0.05, **P<0.01

Discussion

Status Quo of Childbirth Attitude of Pregnant Women

The cluster analysis results of this study revealed that the negative childbirth attitude group scored 102.05 ± 8.55, while the positive childbirth attitude group scored 78.55 ± 8.94. The total childbirth attitude score among pregnant women was 90.30 ± 14.65, falling between the two groups but closer to the negative attitude group. Analysis identified key concerns among pregnant women, including fears about physical harm from childbirth, intensity of labor pain, potential harm to the fetus, and possible complications during delivery. These concerns align with findings from a prior study conducted in the United States [11].

Within the “Perspectives on Pain and Loss of Control” dimension, Item 1 (“I worry childbirth pain will be too intense”) had the highest score, indicating that pain is one of the most pressing concerns for pregnant women. Research by Joshi et al. [5] demonstrated that younger, educated career women place greater emphasis on pain management during childbirth, which aligns with the demographic characteristics of participants in this study. Additionally, the high scores for Item 5 and Item 7 reflect anxieties about fetal safety and childbirth complications, respectively. This underscores pregnant women’s heightened focus on the safety and outcomes of delivery, likely influenced by media coverage of childbirth complications and an inherent anxiety toward uncertainty, consistent with findings by Kurz et al. [12].

In contrast, the lower scores for Item 13 and Item 15 suggest that most women remain cautious about the use of obstetric technology and prefer natural childbirth. Aligning with Stoll et al. [10], this indicates that while pregnant women increasingly demand medical management during delivery, they simultaneously value the importance of natural childbirth and tend to opt for non-interventional approaches in the absence of medical indications. Women’s predominantly negative perceptions of childbirth, particularly the higher scores in the “Perspectives on Obstetric Technology” dimension, reveal a reliance on medical interventions during labor. These results are consistent with the survey of outpatient pregnant women reported by Pan Feng et al. [13], reflecting high trust in modern medical technology. Therefore, we should focus on the management of maternal pain and provide personalized psychological support. Medical staff should pay attention to the pain of childbirth, and formulate personalized care plan after timely evaluation of the pain degree. It is recommended that medical workers provide pregnant women and their families with comprehensive delivery information support, including labor progress, pain management and coping strategies, so as to enhance the sense of security and physical control of pregnant women.

Status Quo of We-media Use in Pregnant Women

This study investigated the frequency, duration, and motivations of pregnant women’s use of non-medical self-media platforms to access childbirth-related information. The results indicate that over one-third of participants (34.2%) used self-media platforms 3-4 days per week, reflecting a proactive attitude toward seeking childbirth- related information. However, the proportion of daily users (3.6%) was relatively low, which may be attributed to time constraints and selective information-seeking behaviors in their daily lives.

Regarding usage duration, 2-3 hours per session was the most common (29.9%), a finding significantly higher than the average 2.38 hours per week spent on pregnancy-related websites reported in the study by Wallwiener et al. [14]. This discrepancy may stem from differences in content and interaction styles: self-media platforms often provide richer interactivity and instant feedback, potentially increasing engagement and prolonging usage time. Only 3.6% of participants spent over 4 hours per session, suggesting that most pregnant women moderate their browsing time to avoid anxiety caused by information overload.

In terms of motivations, pregnant women primarily sought content related to diet and lifestyle (e.g., nutritional guidance, exercise routines), highlighting their strong focus on personal and fetal health. This aligns with findings from a Chinese study [15]. A separate Korean study further revealed that pregnant women prioritize daily life adjustments during early pregnancy and shift toward fetal development information in the second trimester [16]. Additionally, childbirth preparation and browsing others’ experiences were significant motivators, consistent with research by Fleming et al. [17] and Bjelke et al. [18], indicating that women seek to enhance their preparedness through shared narratives.

The diversity of information needs underscores the dual role of self-media platforms: while they serve as vital resources for pregnant women, they also raise concerns about information credibility. To address this, we recommend that healthcare professionals leverage the strengths of self-media—such as videos, infographics, and other multimedia formats—to establish scientifically validated information- sharing mechanisms. By disseminating evidence-based childbirth knowledge, these efforts can help pregnant women develop rational perceptions of delivery, alleviate prenatal anxiety, and empower them to embrace this critical life event with confidence.

Correlation Between Pregnant Women’s Childbirth Attitude and We-media Use

This study employed Pearson correlation analysis and Point- biserial correlation analysis to explore the relationship between pregnant women’s social media usage and their childbirth attitudes. The results revealed a positive correlation between both the frequency and duration of self-media use and childbirth attitude scores. This suggests that frequent and prolonged exposure to self-media content dominated by negative narratives may foster negative cognitive biases toward childbirth, thereby shaping psychological expectations and attitudes. Notably, Serçekuş et al. [19] found that 14.8% of women reported heightened fear of childbirth due to online information, underscoring the potential adverse influence of self-media content on maternal perceptions. Such effects may stem from the prevalence of fear-inducing stories, exaggerated emphasis on delivery risks, and sensationalized portrayals of complications on these platforms.

Further analysis of usage motivations showed that browsing dietary and lifestyle advice on self-media platforms was only weakly correlated with the “Perspectives on Complications” dimension (r = 0.136, P < 0.05). While such content may improve awareness of complications, it fails to positively influence overall childbirth attitudes and might inadvertently amplify concerns about risks. Conversely, accessing information about medical interventions (e.g., risks and benefits of cesarean sections) was significantly correlated with both total childbirth attitude scores and “Perspectives on Cesarean Section” (r = 0.211, P < 0.01). This aligns with evidence that mass media amplifies perceived birth risks [20] and often frames cesarean sections as life-saving interventions [21], potentially driving women to prioritize perceived safety over natural delivery.

Interestingly, no correlation was found between childbirth attitudes and activities such as childbirth preparation or browsing information about potential delivery complications on self-media. This implies that mere information access or preparatory behaviors may not suffice to shift entrenched attitudes. Therefore, this study recommends that internet regulatory authorities strengthen oversight of health-related content and standardize the dissemination mechanisms for pregnancy and childbirth information in media environments. By establishing an authoritative childbirth knowledge dissemination platform—serving as a hub for information exchange—the public can access accurate and reliable childbirth-related information. Concurrently, efforts should be made to balance childbirth narratives on self-media platforms, minimizing the sensationalization of negative content. These measures aim to empower women to develop positive perceptions of childbirth and gradually reshape societal stereotypes surrounding the delivery process.

Strengths and Limitations

This study offers novel insights into the interplay between self- media consumption and childbirth attitudes among pregnant women, providing a foundation for improving maternal support systems. By integrating both online and offiine recruitment strategies, the sample captured diverse demographics, enhancing the generalizability of findings.

However, the study has limitations. Its cross-sectional design precludes causal inferences, and the reliance on self-reported data introduces potential response bias. Additionally, the focus on a single geographic region (Hangzhou) and the exclusion of women with psychiatric histories may limit external validity. Future longitudinal studies should explore how interventions—such as curated educational content on self-media—could shift attitudes over time.

Conclusion

Pregnant women who frequently and extensively engage with self- media platforms for childbirth-related information are more likely to develop negative attitudes toward delivery. Specific content types, such as discussions of medical interventions or others’ childbirth experiences, further exacerbate these concerns. To mitigate this, regulatory bodies should enforce stricter oversight of health-related content on self-media, promoting scientifically accurate and balanced narratives. Healthcare institutions should leverage these platforms to disseminate authoritative guidance, empowering women with knowledge to reduce fear of the unknown. Future research should investigate how content quality, source credibility, and algorithmic curation on self-media shape maternal perceptions, enabling targeted strategies to foster positive childbirth experiences.

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DOI: 10.31038/EDMJ.2025922

Abstract

The transition from pregnancy to childbirth and then to parenting is a time of rapid physiological, psychological, and social change, as a key turning point in the transformation of women’s roles, childbirth plays a vital role in the smooth establishment of mother-infant relationships. This paper based on the attachment theory, introduces the concepts of maternal-fetal attachment, childbirth experience and maternal-infant attachment, and systematically reviews the correlation between maternal-fetal attachment, childbirth experience and maternal-infant attachment, so as to provide theoretical basis and practical guidance for formulating relevant perinatal health care policies.

Keywords

Maternal-fetal attachment, Childbirth experience, Maternal-infant attachment, Relevance

In recent years, the parent-child relationship has been rethought as research in developmental psychology has polarized toward the two poles of the life course (“one old, one young”). Research has shown [1] that the parent-child relationship begins to form gradually during pregnancy and manifests itself in the form of maternal-fetal attachment. The term Maternal-Fetal Attachment (MFA) describes the emotional bond between a mother and her unborn fetus during pregnancy. During the perinatal period, establishing an emotional bond with the fetus and the newborn is one of the most important tasks of the mother [2]. However, the transition from pregnancy to labor and delivery and then to parenting is a process of rapid physiological, psychological, and social change for women, and labor and delivery, as a key turning point in the transformation of women’s roles, plays a crucial role in the successful establishment of the mother-infant attachment relationship [3]. In view of this, the childbirth experience may play a mediating role between mother-fetus attachment and mother-infant attachment. Currently, the national literature has only found studies on the current status of maternal-fetal attachment, labor and delivery experience, or a single variable of mother-infant attachment and its influencing factors. Therefore, based on attachment theory, this paper reviews the correlation between maternal-fetal attachment, labor and delivery experience, and mother-infant attachment, with a view to providing a theoretical basis and practical guidance for the formulation of relevant perinatal health policies, so as to enhance maternal labor and delivery experience and maintain mother-infant relationships.

Attachment

Attachment Theory (Attachment Theory) was first proposed in the 1960s by the British psychologist John Bowlby [4]. Bowlby defined Attachment as a biologically based innate system that guides individuals to stay close to an attachment figure when faced with a threat to protect themselves from harm [4]. Based on this, a special and strong emotional connection is formed between mother and child [5] (Bonding). Emotional bonding is an important theme within attachment theory. During the development of attachment theory, emotional bonding and attachment are two important concepts that need to be differentiated emphatically.

Maternal-infant Bonding (MIB) refers to the process of communication between mother and infant through behavior and emotion [6], which is mainly reflected in the sense of intimacy between mother and infant and the mother’s confidence in caring for the infant [7], as well as in the mother’s love for the infant and her sense of the infant’s uniqueness and importance, which is a kind of unidirectional emotional bonding, specifically referring to the mother’s emotions towards the infant. This bond is a unidirectional emotional bond, specifically referring to the mother’s feelings toward the infant. On the other hand, Maternal-infant Attachment (MIA) is a special and strong emotional connection between infants and their primary caregivers (usually mothers) established through emotional communication and behavioral interactions [8], which is a bi-directional emotional connection between mothers and infants, and is a phenomenon that can only be manifested by infants when they have developed the ability to express their emotions about separation and reunion. Therefore, mother-infant attachment has a specific developmental time period, with attachment establishment occurring from 6 weeks of birth to 6 to 8 months, with clarity of display occurring from 8 months to 18 months, and reaching the period of reciprocal relationships by 24 months [4]. In summary, it is possible to describe the mother-infant relationship as emotional bonding before 8 months. After 8 months it is described as attachment. However, the existing literature has not been subdivided by scholars on the concepts of mother-infant emotional connection and mother-infant attachment, which are usually referred to as mother-infant attachment.

With the development of attachment theory, some scholars pointed out that when a mother becomes a pregnant mother, she is also emotionally attached to the fetus in her womb. Therefore, maternal-fetal attachment was extended. Cranley [9] first defined maternal-fetal attachment as “the behavioral and emotional relationship of a pregnant woman interacting with her unborn fetus”. Based on Cranley’s conceptualization, Muller and Mercer proposed that the definition of maternal-fetal attachment should also include the mother’s imagination of the unborn fetus [10]. In addition, Condon proposed that maternal-fetal attachment consists of five key attributes: knowing the fetus, being with the fetus, protecting the fetus from physical or emotional harm, attending to the needs of the fetus, and avoiding separation from the fetus, with love being the core of maternal-fetal attachment [11]. Although scholars define maternal-fetal attachment differently, they agree that maternal-fetal attachment is a multidimensional structure that includes the mother’s thoughts, behaviors, emotions, and attitudes, and is an emotional connection that the mother creates to the fetus in the womb.

The Importance of the Childbirth Experience in Attachment Research

Currently, there is no uniform definition of the concept of childbirth experience. Salmon et al. [12] first proposed that childbirth experience is a multidimensional phenomenon based on women’s emotions and perceptions of childbirth, including three dimensions: emotional distress, physical discomfort, and satisfaction. Larkin [13] used a conceptual analysis approach to define the childbirth experience as a unique life event experienced by a woman, including the subjective mental and physiological processes, which are influenced by society, environment, organization, and policies, and this concept is agreed upon by most scholars. Childbirth, as an important turning point in the transformation of women’s roles, plays a crucial role in the successful establishment of the mother-infant relationship [14]. Positive birth experiences can empower women through labor and delivery, promote personal growth and self-knowledge, which in turn enhances women’s self-esteem, sense of responsibility, self-efficacy and self-confidence levels, actively participate in self and infant care and interaction, and promote the establishment of the mother-infant relationship [15]. In contrast, negative birth experiences, such as post-traumatic stress disorder after childbirth, can undermine the continued development of the mother-infant relationship. Kennell and Klaus et al. have shown [16] that after a negative birth experience, mothers may become preoccupied with their own physical and emotional needs and reduce their interactions with their infants, thereby weakening the mother-infant relationship. Smorti et al. have shown [17] that the birth experience can significantly affect the the relationship between prenatal and postnatal attachment. as the emotional bond between mother and infant evolves from pregnancy to postpartum. Given this, labor and delivery experiences may play a mediating role between mother-fetus attachment and mother-infant attachment. However, there is a lack of national research related to the inclusion of the labor and delivery experience in the domain of attachment.

Correlation Between Maternal-Fetal Attachment, Birth Experience and Mother-Infant Attachment

Research on the Correlation Between Maternal-Fetal Attachment and Mother-Infant Attachment

At this stage, there is a lack of research on the correlation between maternal-fetal attachment and mother-infant attachment in China, and the existing literature has only found studies on the status of maternal-fetal attachment or mother-infant attachment as a single variable and its influencing factors. Overseas research on the correlation between maternal-fetal attachment and mother-infant attachment first began in the 1980s, with studies focusing on the United States, Australia, Italy, and other European countries, and the existing literature suggests that the emotional bond between mothers and their infants continues to develop from pregnancy to the postpartum period. Prospective studies measuring maternal-fetal attachment and mother-infant attachment separately at different points in time have found that maternal-fetal attachment predicts mother-infant attachment and positively influences mother-infant attachment. A longitudinal study in an Australian region found [18] that stronger maternal-fetal attachment in the third, sixth, and ninth months of pregnancy predicted stronger postpartum mother-infant attachment in the eighth week of the infant’s life. Italian scholars Cataudella [1] investigated using the Maternal Antenatal Attachment Scale (MAAS) and the Maternal Postnatal Attachment Scale (MPAS), respectively, and showed that in mid-pregnancy, The results showed that pregnant women who showed a stronger emotional connection with their fetus in late pregnancy had a higher level of attachment to their infants in the postpartum 3 months. German scholars Dubber [19] measured maternal-fetal attachment and maternal-infant attachment at 32 weeks of late pregnancy and 3 months postpartum, and found that there was a significant negative correlation between maternal-fetal attachment and postpartum maternal-infant attachment disorder, i.e., the higher the level of mother’s attachment to the unborn fetus during pregnancy, the fewer postpartum attachment disorders. In addition, researchers investigating different populations have come to similar conclusions. Hildingsson [20] investigated 172 women with fear of childbirth and found that low levels of maternal-fetal attachment showed impaired mother-infant bonding, in which depressive symptoms played a mediating role. American scholars Karina [21] and others investigated 124 pregnant women with unintended pregnancies using the Prenatal Attachment Inventory (PAI) and the Mother-to-Infant Bonding Scale (MIBS) and found that maternal-fetal attachment would have an independent and positive effects on postpartum maternal-infant attachment, with higher levels of maternal-fetal attachment during pregnancy being a protective factor for postpartum maternal-infant attachment among women with unintended pregnancies. The positive association between maternal-fetal attachment and mother-infant attachment can be confirmed regardless of the measurement tool used. Thus, maternal-fetal attachment lays the foundation for postpartum mother-infant attachment. Early identification of maternal-fetal attachment disorders during pregnancy is especially critical in order to prevent possible attachment problems in the early postpartum period. Monitoring maternal-fetal attachment levels during pregnancy and providing timely interventions for possible maternal-fetal attachment problems in pregnant women can be considered to further enhance the quality of maternal-infant attachment in the early postpartum period.

Study of the Correlation Between Maternal-Fetal Attachment and Labor Experience

Currently, only 3 foreign studies on the correlation between labor and delivery experience and maternal-fetal attachment have been retrieved. Two of them suggest that maternal-fetal attachment contributes to the emergence of postpartum labor-related PTSD symptoms. The results of a cross-sectional study in Turkey [22] showed a negative correlation between maternal-fetal attachment and postpartum labor-related PTSD symptoms. Higher maternal-fetal attachment scores were associated with fewer postpartum labor-related PTSD symptoms. The results of a study by Italian scholars such as Tani [23] showed that the quality of maternal-fetal attachment was negatively associated with negative labor experiences (use of oxytocin and analgesics and duration of labor). In addition, labor-related PTSD symptoms can positively affect maternal-fetal attachment in PMSMs. In 2019, Norwegian scholar Susan [24] administered a questionnaire to 1, 493 PMSMs on labor-related PTSD symptoms at 17 weeks and maternal-fetal attachment levels at 32 weeks, and showed that women with labor-related PTSD symptoms who became pregnant again had a more higher levels of maternal-fetal attachment. However, there is only one study on this subject, and the results need to be further confirmed.

A Study of the Correlation Between the Experience of Childbirth and Mother-Infant Attachment

Findings on the relevance of the birth experience to mother-infant attachment are not consistent, with most studies suggesting that negative birth experiences for mothers, such as posttraumatic stress disorder after childbirth, disrupt the development of the mother-infant bond. In 2020, a Japanese regional study using the Postpartum Bonding Questionnaire (PBQ) surveyed 130 mothers at 1 and 4 months postpartum and showed a positive correlation between posttraumatic stress disorder after childbirth and failure of the mother-infant bond at 1 month postpartum [25]. Ponti found [26] that postpartum PTSD symptoms caused by traumatic birth experiences negatively impacted mother-infant attachment, either directly or indirectly through postpartum depression. American scholars such as Dekel [27] showed that women with postpartum PTSD symptoms had lower mother-infant attachment scores than women without postpartum PTSD symptoms, and that postpartum PTSD symptoms can hinder the establishment of mother-infant attachment. However, there is also a study that states that negative birth experiences can improve the mother-infant relationship. American scholar Babu [28] used the Maternal Attachment Inventory (MAI) to investigate 2205 women who gave birth during the COVID-19 pandemic and 540 women who had given birth before, and found that a large proportion of mothers who had traumatic birth experiences during the COVID-19 pandemic triggered the mother’s s psychological growth, leading to an improvement in the mother-infant relationship. In addition, a few studies have indicated no association between the two. 2022, Iranian scholars Moniri [29] found no statistically significant relationship between birth experience and mother-infant attachment using the Postnatal Bonding Questionnaire (PBQ) and the Childbirth Experience Questionnaire (CEQ) in 228 pregnant women at 6 weeks postpartum. There was no statistical significance between the two. In conclusion, the contradictions between the above results may be due to differences in year, country, measurement tools applied, and time point of mother-infant attachment measurement.

The Mediating Role of the Childbirth Experience in Maternal-Fetal Attachment and Mother-Infant Attachment

Currently, foreign literature on the relationship between labor and delivery experience, maternal-fetal attachment, and mother-infant attachment suggests that labor and delivery experience plays a mediating role in maternal-fetal attachment and mother-infant attachment. However, only 2 relevant literatures were retrieved. The results of Smorti [17] and other studies showed that traumatic birth experience plays a mediating role between maternal-fetal attachment and mother-infant attachment. Adverse maternal-fetal attachment is a risk factor for traumatic birth experience, which in turn hinders the development of mother-infant attachment. Damato et al.’s study [30] found that maternal-fetal attachment indirectly affects mother-infant attachment, with the birth experience being an important variable that influences the relationship between the two. Positive maternal-fetal attachment improves a woman’s ability to cope with labor and promotes a positive birth experience, which in turn facilitates the development of positive mother-infant attachment. Due to the limited amount of literature, further research is needed.

Summary

There may be a certain connection between maternal-fetal attachment, mother-infant attachment, and labor and delivery experience. At present, the existing domestic research only focuses on maternal-fetal attachment, maternal-infant attachment, and childbirth experience individually for current research or multifactorial analysis, and there is a lack of relevant research linking the three. The existing foreign studies start from the negative birth experience, such as postpartum post-traumatic stress disorder symptoms, future research can be analyzed in depth from the perspective of positive birth experience, to explore the mediating role of positive birth experience between maternal-fetal attachment and mother-infant attachment, and at the same time, combined with the intervening factors to develop precise intervention strategies, to provide a theoretical basis and practical reference for the development of perinatal health care policies, to establish This will provide a theoretical basis and practical reference for the formulation of perinatal health care policies, establish a deep emotional connection between mother and fetus, promote positive labor experience, improve labor outcomes, and maintain the mother-infant relationship.

Fund Program

The Ministry of education of Humanities and Social Science project(22YJAZH148).

References

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DOI: 10.31038/EDMJ.2025921

Abstract

Objective: To explore the adherence influencing factors of anticoagulant medication adherence in patients with atrial fibrillation under the perspective of behavioral economics, and to provide a reference basis for constructing an anticoagulant medication adherence improvement program for patients with atrial fibrillation.

Methods: A descriptive qualitative study was designed, semi-structured interviews were conducted with 13 patients with atrial fibrillation, and thematic analysis was used to analyze the data and refine the themes.

Results: The factors influencing medication adherence to anticoagulants in patients with atrial fibrillation can be categorized into five themes: representative bias, psychological accounts, social norms, time inconsistency preference, and optimism bias.

Conclusion: Anticoagulant medication adherence in patients with atrial fibrillation is affected by a variety of factors, and behavioral economics can be applied to the study of management strategies for patients with chronic diseases, such as atrial fibrillation, and intervention strategies can be proposed from the perspective of psychology to improve patients’ adherence to medication.

Keywords

Atrial fibrillation, Anticoagulants, Adherence, Behavioral economics, Qualitative research

Atrial Fibrillation (AF) is one of the most common arrhythmias in clinical practice. According to the results of the seventh national census published by the National Bureau of Statistics of China [1], there are at least 6.9 million AF patients in China, and the number and prevalence of AF is expected to increase even more significantly in the future as the life expectancy of human beings increases. Stroke is the most common and serious complication of AF, and studies have shown [2], that 20% to 30% of ischemic strokes are caused by AF, and patients with ischemic stroke caused by AF have a higher rate of death and disability than non- AF patients, and require 0.5 times higher medical costs.

Oral anticoagulant therapy is the treatment of choice for stroke prevention in atrial fibrillation recommended by today’s national and international guidelines. In addition to reducing stroke risk and stroke severity in patients with AF, oral anticoagulant therapy also reduces the risk of AF-associated dementia [3], Oral anticoagulant therapy is the treatment of choice for stroke prevention in atrial fibrillation recommended by today’s national and international guidelines. In addition to reducing stroke risk and stroke severity in patients with AF, oral anticoagulant therapy also reduces the risk of AF-associated dementia [4], and adherence decreases with increasing age. Therefore, it is crucial to understand the factors influencing adherence to anticoagulant medication in patients with atrial fibrillation.

Behavioral economics is a combination of economics, psychology, sociology and other disciplines developed a cross-disciplinary, used to describe the decision-making behavior of individuals [5], in the study of human decision-making behavior, behavioral economics focus is not on the correctness or incorrectness of the decision itself, but rather to make a decision on the individual’s cognitive and psychological activity behavior. Behavioral economics theory uses cognitive mode and reflective mode preferences to help individuals make rational choices [6], showing more advantages in intervening in people’s decision-making behavior, which is not easy to cause individuals to resist the psychology, and the cost is low, which can promote individuals to make better decisions.

Therefore, this study introduces the behavioral economics perspective into the study of factors influencing treatment adherence in patients with atrial fibrillation, and adopts a qualitative research approach, aiming at obtaining more comprehensive factors influencing adherence in patients with atrial fibrillation, with a view to providing references and lessons for scholars in China to develop strategies for the management of adherence to anticoagulant drugs in patients with atrial fibrillation.

Objects and Methods

Objects

Purposive sampling method was used to select patients with atrial fibrillation who met the criteria for natriuresis from February to August 2024 in a tertiary hospital in Hangzhou City as the interview subjects. The study was reviewed by the Ethics Committee. Inclusion criteria: (1) Age >18 years old. With good language skills; (2) taking oral anticoagulants for >6 months; (3) voluntary participation in this study. Exclusion criteria: (1) presence of mental illness, hearing impairment, or intellectual disability; (2) inability to accept audio recording during the interview; (3) serious physical condition that prevented cooperation with the interviewer. Sampling was carried out following the principle of maximizing differences, and the sample size was used until the information was saturated. Thirteen interview subjects were finally included, 8 male and 5 female; ages 38 to 80 (57.38±10.744); 6 patients with junior high school or lower education and literacy, 4 high school, 2 secondary school or college, and 1 university; 9 patients currently residing in the city and 4 currently residing in the countryside; 4 patients living alone, 9 patients not living alone; 8 patients using urban and rural residents’ health insurance, and 5 used employee health insurance; 5 patients were on warfarin and 8 patients were on new oral anticoagulants; years of illness ranged from 1 to 10 years (5.15±2.672); 4 patients had a number of combined other diseases ≤1, 4 patients had a combination of 2 other diseases, and 3 patients had a combination of 3 or more other diseases.

Methods

Preparation of Interview Outlines

According to the research purpose, theory, and related literature research content of this study, the preliminary outline of the interview was drawn up after consulting the experts, and the outline was revised according to the preliminary literature research and the results of the pre-interviews of the two cases, and the outline of the interview was finally determined: (1) How has long-term use of anticoagulant medication brought about an impact on your life? (2) What are the current therapeutic drugs? (3) What factors do you focus on during the medication process? (What factors would make you feel that the drug is working) (4) Have you ever missed or stopped taking your medication on your own, and what was the reason? What did you do when you realized that you missed a dose? (5) Do you have any concerns when taking anticoagulants? (6) What difficulties have you encountered in the use of your medication? Who would you like to bring in to support you in these difficulties? (7) What are some of the factors that prevent you from adhering to your medication? (8) What do you think would help you to be more adherent to your anticoagulant medication? (Family members/healthcare professionals/patients/ society) (9) Do you usually know something about medication? Which aspects of knowledge do you pay more attention to? In what way do you usually learn about the disease?

Methods of Data Collection

The researcher conducted the qualitative interviews by contacting suitable interviewees in advance and booking the time and place for the interviews. Face-to-face semi-structured interviews were used, each interview lasted 30-45 minutes, and the whole interview process was audio-recorded. The interviews were conducted by the same researcher who had systematically studied qualitative research, and the researcher communicated with the interviewees in the form of questioning and answering according to the interview outlines, and adjusted the order of the outlines and asked follow-up questions according to the interviewees’ answers, in order to collect as much information as possible in the interviews.

Methods of Data Analysis

The qualitative interview data were transcribed verbatim within 24 hours of the end of the interview, and the audio recordings were listened to repeatedly to ensure the accuracy of the transcription and to supplement the interviewee’s tone of voice, etc., in conjunction with the interview transcripts. The transcribed text was then imported into Nvivo 12.0 software for management, coding, and analysis. Both transcription and analysis of the data were carried out independently by two researchers, and when disagreements existed, they were discussed and a third researcher was asked to reach a consensus. Thematic analysis was used to analyze the interview data, and data collection was synchronized with data analysis.

Findings

By analyzing and distilling the interview data of 13 patients with atrial fibrillation who were undergoing oral anticoagulant therapy, the influences on adherence to anticoagulant therapy in patients with atrial fibrillation were finally summarized into five themes.

Theme 1: Influenced by Representativeness Bias

Due to insufficient knowledge of AF and anticoagulants, patients are easily influenced by the experiences or descriptions of people around them and use the situation of a small sample to infer the situation of a large sample, thus ignoring the a priori probability, leading to poor decision-making and discontinuing medication on their own. Some patients with weak awareness of medication safety will choose whether to take medication based on their own experience, and some subjects found that a small number of people around them taking anticoagulants still experienced vascular adverse events, then they will ignore the a priori probability, and will question the efficacy and safety of anticoagulant drugs a priori: N4: “Isn’t there still a person who has taken the medication or had a cerebral infarction, a lot of, nothing to do with this medication. ” There were also subjects who believed that if other patients did not take anticoagulants without vascular adverse events, then they themselves could not adhere to the medication: N13: “There is a person in our village who also has a bad heart, for many years, did not take the medication, and now he has not had an attack.”

Complex Knowledge of Atrial Fibrillation and Anticoagulants

The reason for patients’ representative cognitive bias is partly because the knowledge related to atrial fibrillation and anticoagulants is too complex, and there are many drugs and foods that tend to react with anticoagulants, and it is difficult for patients who lack a professional medical background to fully grasp them, N1: “Atrial fibrillation those are professional knowledge, doctors they only know, and I haven’t read much, so how can I remember it. ” N6: “The doctor also talked to me about it, the usefulness of this medicine and so on, but after two days I forget.”

Lack of Access to Specialized Knowledge

Secondly, it is because patients lack channels to obtain specialized information. Some patients lack the subjective initiative to obtain disease-related knowledge, the doctor is the only way for most patients to obtain professional knowledge, N3: “The doctor told me how to eat how I eat, I do not understand.” “The doctor said is not very detailed, side effects and so on I do not quite understand, Baidu asked to see you do not dare to believe.” N8: “Still trust the doctor a little more, that is to say that the knowledge of the Internet may not be accurate.”

When the doctor failed to meet the needs of patients to obtain knowledge related to medication, some patients in order to obtain professional advice will choose to go online to seek help, however, the medical information on the network is difficult to distinguish between true and false, mixed, when the patient is difficult to identify the correct information, it will be blindly seeking medical treatment, N10: “I saw on TV, the kind of health program sold, said that the cardiovascular benefits, I would like to buy to try. I just want to buy it and try it.”

Theme 2: Influenced by Psychological Accounts

Patients will pre-divide the expenditure of the funds they have into several categories such as travel, medical care, daily expenses, etc. When the actual expenditure of patients for the treatment of atrial fibrillation exceeds their own psychological budget, there is a probability that they will choose to be non-compliant. Most atrial fibrillation patients are middle-aged or elderly and suffer from multiple chronic diseases, requiring long-term use of three or more medications. With the progression of the disease, the economic burden brought by long-term medication gradually increases, leading to negative emotions towards medication, thus affecting patients’ compliance with medication. n2: “If I take one box of dabigatran a day, I’ll take that imported box of 160, and that’s 6 boxes a month, and that’s a thousand boxes. If I take one box of Dabigatran a day, and I take that imported box of more than 160, that’s 6 boxes a month, that’s a thousand dollars.”

However, some patients still insist on taking medication even when their medical expenses exceed their psychological accounts, probably because medical expenses are different from daily expenses and are related to the safety of patients’ lives, so even if they spend more money, some patients still insist on taking treatment. N8: “The medication is definitely a little bit expensive, and there’s no way to cure the disease, the doctor said to keep taking it. ”

Theme 3: Influenced by Social Norms

Social norms are a standard of behavior for social members in a social group, which can constrain and guide individual behavior by influencing the decision-making behavior of social members [7]. The influence of social norms on the medication-taking behavior of patients with atrial fibrillation (AF) depends on the ability to be aware of other patients with AF taking their medication, understanding what to do as a patient with AF, and the perception of other people if they do not take their medication on time.

When patients with atrial fibrillation perceive social norms, i.e., realize that other patients with atrial fibrillation take their anticoagulant medications consistently and have a good prognosis, they realize the importance of adhering to their medications and the consequences of not adhering to their medications. However, most of the patients in this study did not take the initiative to communicate with other patients about their condition and did not know about the treatment of other patients. N10: “I usually don’t know much about the treatment of other patients and I don’t communicate with others about their condition.” N11: “What kind of medicines other people take, how many boxes a month, this kind of thing is after all other people’s privacy, and I don’t feel too good to ask.”

Some patients recognize that not taking medication as prescribed will bring greater financial and living burdens to their families, and out of a sense of responsibility to their family members, this group of patients has a high level of compliance, N12: “If I don’t stick to the medication, I’ll spend more money if I’m re-hospitalized, and my family will have to take time off from work to come to stay with me in bed.” However, there are also some patients who are not able to realize what patients with atrial fibrillation should do to comply with the doctor’s instructions, and increase or decrease their medication on their own according to their own experience, N5: “It feels that atrial fibrillation is not as serious as other heart diseases, and that I have to have an operation or something.” N2: “Originally the amount of two tablets at a time, I changed it to one tablet at a time by myself, sometimes a bit of chest tightness other than that there is no discomfort.”

Theme 4: Influenced by Inconsistent Time Preferences

Atrial fibrillation has a long course and develops slowly, and anticoagulation management requires long-term medication and adherence to healthy lifestyle habits, which costs a lot of time and money; however, anticoagulant medications are slow to work, and the benefits of adherence to medication are not immediately perceived, and patients have a poor sense of benefit from treatment in the moment, N9: “I took antihypertensive medication in the morning, and my BP came down that day, and I took rivaroxaban for a while It didn’t feel like it was helping.” In this case, patients with AF are faced with the intertemporal decision between investing large amounts of healthcare resources in the long term to improve cardiovascular status in the future, or investing a small amount of healthcare resources in the short term in exchange for a short-term reduction in overall healthcare expenditures and a reduction in the burden on the family, which, when encountered by patients with intertemporal decision- making, is influenced by the preference for temporal incoherence and can result in a tendency to choose the immediate reward of the undesirable behavior. choose the immediate rewards from bad behaviors and ignore the long-term benefits from healthy behaviors. N5: “Just then the frequency of checkups was very high, once a month, but now it may be slightly less, a few times a year, maybe because it was not very convenient during that time of the epidemic, and I just think that once a month is a bit of a hassle as well.” N6: “To check the hospital you have to go in and get blood drawn, you have to queue up, and then you have to wait for the results or something, half a day is gone, and my son has to go to work and doesn’t have that much time.”

Theme 5: Influenced by Optimism Bias

Even when recognizing that poor behavioral habits can affect their health, some patients remain optimistic that their risk of being harmed by such behaviors is lower than that of other patients, N3: “I didn’t even take any medication for my previous new crown, I made it through on my own, I’m in good shape with my resistance.” N7: “I’ll be fine with one or two less meals, I’m in good shape.” The reason for this is the influence of the optimism bias that one is less likely to have an obstructive vascular event than others [8].

Discussion

Enhancing Patient Health Education to Change Medication Beliefs and Perceptions

This study found that some patients with atrial fibrillation are affected by their own cultural limitations, health education is not in place and other factors, most patients do not have enough knowledge about atrial fibrillation and anticoagulant drugs, which leads to some patients questioning the efficacy and safety of anticoagulant drugs, resulting in some patients stopping their medication by themselves or increasing or decreasing the medication by themselves. Some studies have shown [9] that only when patients have a certain understanding of the drug, they can have positive beliefs about taking the drug, which will lead to the improvement of adherence. Behavioral economics theory suggests that human rationality is limited, and limited attention and memory are not enough to remember and process all the health information. Therefore, when conducting health education, the actual situation of patients’ literacy level and age should be considered, and the content of the education needs to be simple, direct, and relevant, in order to make the patients remember the information at the critical moment of decision-making. Some scholars have utilized vivid drawings and short words instead of complex medical knowledge to educate elderly patients with atrial fibrillation about anticoagulants, which effectively improved the anticoagulation compliance and self- management ability of elderly patients with atrial fibrillation [6] Tutorials such as brochures, educational videos, websites, software, lectures, and WeChat have also been proven to be an effective form of improving patients’ cognitive level, which suggests that clinical workers should combine diversified tutorials according to patients’ characteristics to improve the efficiency of the tutorials, improve the correct knowledge of anticoagulant drugs in patients with atrial fibrillation, reduce the uncertainty of the disease in patients with atrial fibrillation, and avoid representative cognitive bias and optimistic bias in the patients.

Promoting Socially Normative Behaviors to Change the Decision-making Environment

Behavioral economics theory suggests that individuals are influenced by the social environment in which they live and that their decision-making behavior is not only motivated by self-interest, but is also driven by group perceptions, whereby if other people act in accordance with a certain socially accepted behavioral norm, then that person is perceived as behaving appropriately, and conversely if they don’t, then they are disapproved [10]. However the extent to which an individual is influenced by social norms depends on the degree of interaction between the individual and the social environment. Social norms have been used by foreign scholars on studies of health promoting behaviors and have been remarkably successful [11]. In a study at the University of California, San Francisco, adolescents’ attitudes toward type 2 diabetes were effectively changed by establishing an online platform to promote mutual communication among adolescents, and organizing seminars and distributing public service advertisements to promote the dissemination of healthy behaviors, which showed that most of the adolescents were willing to change their poor living and dietary habits for the purpose of preventing diabetes due to the influence of their social environmen. This suggests that we can use the Internet and social media to promote and disseminate knowledge about atrial fibrillation and anticoagulant drugs, improve patient acceptance of anticoagulant drugs, and make standardized medication regimen a widely accepted social normative behavior for patients with atrial fibrillation; at the same time, the formation of a patient group of patients with atrial fibrillation, encouraging patients to communicate with each other, and inspiring patients to maintain a positive image of adherence to medication.

Fixing Current Preferences and Providing Extrinsic Motivation

Behavioral economics also refers to human time-inconsistent preferences as self-control problems, procrastination problems, problems with the short-term self and the long-term self, and when patients with atrial fibrillation have time-inconsistent preferences, they fail to adhere to their medication due to self-control problems, even if their knowledge of anticoagulant medication is correct [13]. Incentive strategy is the most widely used intervention strategy in studies on behavioral economics [14] for example, scholar Sebastian Linnemayr [15] used a small raffie incentive to intervene with young Ugandan AIDS patients, where weekly text messages would be sent to remind participants that antiretroviral therapy (ART) monitoring compliance would be eligible to participate in a raffie, and eventually ART adherence improved significantly; Barbara Riegel [16] used a telemedicine intervention, where patients were reminded to take their medication at a specified time every day via a smart device, and the medication record was monitored using an electronic bottle cap, and after 90 days of intervention, medication adherence improved significantly, and the rate of re-hospitalization was reduced significantly. This suggests that clinicians can improve anticoagulant medication adherence by motivating patients with atrial fibrillation to adopt healthy behaviors immediately through immediate rewards or regular feedback, and by translating long-term goals into multiple short-term goals, thereby overcoming individual time-inconsistent preferences.

Summary

This study started from the perspective of behavioral economics theory to explore the influencing factors of anticoagulant medication adherence in patients with atrial fibrillation, and ultimately refined the five themes of influencing factors, which suggests that clinical workers should pay attention to influencing the adherence to anticoagulant medication in patients with atrial fibrillation from multiple perspectives. In future research, behavioral economics can be applied to the study of management strategies for patients with chronic diseases such as atrial fibrillation, and intervention strategies can be proposed from the perspective of psychology to improve the subjective initiative of patients, as well as to improve the efficiency of long-term management of chronic diseases.

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