Childbirth fear and mindset
The first relevant result is that there were hardly differences between the four groups: women with high childbirth fear and natural mindset, or medical mindset, and women with low childbirth fear and natural mindset or medical mindset. The only difference was a higher rate of having observed a birth in the group of natural mindset and low childbirth fear. Our cross-sectional study does not allow causal interpretations, but hypotheses can be drawn from these findings: It may be that women with low fear are more prone to expose themselves to watch a birth, or women who watch a birth may get a reframing of potential worries or vague ideas they had on birth before. While watching a birth, women are confronted with real life examples of what a birth can be like. Psychologically, aspects of model learning and holistic learning may apply hereby, be it a natural birth or medically supported birth. Model learning and holistic observation may both change the perception and knowledge on birth, from abstract or theoretical facts to realistic impression of what a birth may be like.
Relationships between childbirth fear, knowledge and mindset
Childbirth fear and mindset
Lower childbirth fear came along with rather natural mindset.
Even if the relationship is not very strong, the tendency fits to what has been found and hypothesized in the literature before [1, 4, 21].
Childbirth fear and knowledge
Childbirth fear occurred independent from the level of birth-related knowledge. This result is similar to an earlier correlative study which found that birth-related knowledge and childbirth fear were independent from each other . However, there are also contrary findings which report a negative association [25,26,27, 41]. The discrepancy of our present findings and findings indicating an association of knowledge and anxiety may be due to several aspects. First, cross-cultural differences must be considered, as both birth care and birth culture vary greatly between countries . The lack of standardized measures of knowledge means that the different levels of knowledge cannot be compared between samples and cannot be conclusively classified. In the randomized controlled trial  not only pure factual knowledge was taught, but also discussions and various exercises on relaxation and breathing techniques were conducted. Thus, in addition to increased knowledge, other factors that may have led to a reduction in childbirth fear, such as a sense of self-efficacy, social support, and the development of action skills, must be considered. Furthermore, studies on childbirth fear were able to show contrasting behaviors related to knowledge, indicating opposing associations; some women with childbirth fear specifically sought information, while others avoided it or worried about their knowledge .
The availability of individual knowledge elements in everyday life may also contribute to the independency of childbirth fear and knowledge. The birth-related mindset may lead to heuristic use of knowledge. Even if comprehensive knowledge can be mapped in the knowledge test, this does not mean that it is used for own birth-related decision-making.
Birth-related mindset and knowledge
There was hardly an association between birth-related mindset and birth-related knowledge. It is assumed that the birth-related mindset is based on different information . A higher birth-related knowledge could however be supportive for a rather natural mindset. Therefore, a natural view of births could be strengthened by giving psychoeducation and knowledge on normal childbirth [36, 43, 44].
The study is cross-sectional, which means that no causal conclusions can be made from the data.
In the present study, it was not assessed whether the women suffered from any mental disorder in general or even an anxiety disorder in particular. A mental disorder or particularly anxiety disorder might however impact on birth-related fear, in the sense that some of the women with high general anxiety or anxiety disorder might perceive childbirth anxiety as well. Similar observations have been made with other specific anxieties, such as specific work-anxiety accompanying general mental disorders in some patients . Also, half of women with specific phobias, including birth-related phobias were found to have other general (not birth-related) mental disorder .
In this study we used self-ratings to assess the degree of childbirth fear and natural and medical mind set. Self-reporting scores may not reflect actual emotions, nor report actual needs of a non-pregnant woman. For clinical diagnostic or decision making the full range of biopsychosocial diagnostics by health care professionals and physicians is necessary.
The knowledge test was developed for this study, in order to be an indicator of what the women know about birth (instead of what they think they know, in the sense of “I am convinced that I know a lot about birth”). Although the contents of the test and the correctness of answers have been prepared very carefully with several expert consultants, it may be that in different regions or different medical traditions other issues seem to be more important and other contents would have been asked or other answers offered.
Furthermore, our choice of instruments may influence the results in terms of childbirth fear rates. Alternative scales or also clinical interviews might be used in further research. An alternative self-rating questionnaire could be the Wijma Delivery Expectancy-Experience Questionnaire (W-DEQ)  which asks women about their expectations before the delivery (version A) and experience after delivery (version B).
Perspectives for practice and research
Prevalence and diagnostics
Most of the investigated non-pregnant women (43.6%) of our study had a natural mindset and at the same time low childbirth fear. The rate of 27% of our study participants with higher childbirth fear appears similar to the rate of 25.9% childbirth fear in non-pregnant female students which was found by Antic . Differences in prevalence estimations may be due to the different samples (pregnant, non-pregnant women), methodologies (structured interviews, self-rating questionnaires, different cut-off scores), and variance in cultural and sample characteristics [35, 36].
The rate of childbirth fear in our sample is similar to rates of general mental health problems in the general population which is constantly about 30%, covering different unspecific mental health problems . It may be that non-pregnant women with mental disorders who react with anxiety in several life situations, are also more likely to experience birth-related fear. Studies in pregnant women reported childbirth fear as associated with stress, depression, anxiety, or history of mental disorder [36, 37]. Also, fathers may be affected (13%) .
However, the pattern of relation of knowledge, mindset and childbirth fear may be very different in each single case. In clinical practice of specific cases, a thorough clinical investigation of the women is necessary. Especially in cases of phobic anxiety with clinical value and need for intervention a thorough anamnesis is mandatory. Self-rating questionnaires are useful for research and observation of symptom load in different samples or over the course of an intervention, but not for making a clinical diagnosis of childbirth fear.
Childbirth fear, mindset and birth-related knowledge in pregnancy counselling
As childbirth fear may occur in different pattern (i.e. with natural or medical mindset), such fears should be taken earnest and explored in non-pregnant women with desire for pregnancy. As birth-related mindset is related with knowledge, and women with natural mindset less often have childbirth fears, it may be fruitful to offer some facts about natural aspects of birth (e.g. such as the contents from the here developed knowledge test), or give the opportunity to observe educative birth videos or midwife-attended natural births in which overemphasize of medical interventions is omitted . This would be in line with intervention studies which give a hint that self-efficacy-oriented interventions, such as physicians education, and childbirth workshops for women or even couples , may increase women’s choice for spontaneous vaginal births (instead of choosing cesarian sections). Furthermore, some knowledge gaps were found in our sample concerning signs of beginning birth, and non-medical approaches to pain relief. These could be topics of interest in psychoeducation for non-pregnant women.
Our research – beside other  - has shown that also non-pregnant women can be affected from childbirth fears, and these are partly related with the birth-related mindset. Thus, further research should investigate whether and which aspects from existing non-medical educative interventions are useful and adaptable for non-pregnant women with desire for having children.