Comparison of the effect of internet-based and in-person cognitive behavioral therapy on the fear of childbirth in primiparous pregnant women: a randomized controlled trial

Fear of childbirth (FOC) is a significant factor contributing to requests for elective cesarean sections. This study aimed to compare the effectiveness of internet-based cognitive behavioral therapy (ICBT) versus in-person cognitive behavioral therapy (CBT) on fear of childbirth and delivery mode preference among primiparous pregnant women. In this randomized controlled trial, 72 primiparous pregnant women with high fear of childbirth (based on the Wijma Delivery Expectancy/Experience Questionnaire [W-DEQ-A]) were randomly allocated into three equal groups: in-person CBT, internet-based CBT (ICBT), and a control group. The interventions were delivered in eight 60–90-minute sessions. Data were collected using demographic questionnaires, W-DEQ-A, and a delivery mode preference question at three time points: before, immediately after, and one month after the intervention. Data were analyzed using repeated measures ANOVA, chi-square, and one-way ANOVA in SPSS version 25. At baseline, groups were similar in W-DEQ-A scores. Both in-person CBT and ICBT significantly reduced total scores and most subscales compared with the control group, with large effect sizes. In-person CBT showed greater improvement than ICBT in total score, lack of self-efficacy, and lack of positive anticipation, while other subscales were comparable. Effects persisted at follow-up. Both interventions also increased preference for vaginal delivery, especially in the in-person CBT group (8.7% to 60.9%), whereas no statistically significant change was observed in the control group over time. Analysis accounting for repeated measures confirmed these group-level differences over time. These findings demonstrate that both CBT modalities effectively reduce fear of childbirth and positively influence delivery mode preference. Both in-person and internet-based CBT effectively reduce fear of childbirth and improve related psychological outcomes. In-person CBT shows slightly greater benefits in self-efficacy and positive anticipation, while other domains are similarly improved by both modalities. Effects persist at follow-up, and both interventions increase preference for vaginal delivery. These findings support integrating CBT, particularly blended or flexible approaches, into routine prenatal care to enhance maternal psychological well-being and childbirth outcomes.