Effects of virtual reality on fear of birth, length of labor, and fetal well-being: a randomized controlled trial

Introduction

With the changing needs of humans and the advancement of technology, digital health services have gained importance in the transformation of healthcare, as in every other field. In line with the Sustainable Development Goals (SDGs) of the United Nations (UN) (2015), the use of digital health applications has accelerated to promote a healthy and quality life for every individual [1]. Digital health services, which have become important for modern health systems worldwide, have expanded to include scientific technologies such as artificial intelligence, wearable technologies, mobile applications, and telemedicine [2]. The most commonly used wearable technology is virtual reality (VR) glasses. VR glasses transport people from their current environment, immersing them in another environment where they can interact with objects within that environment [3], 4]. Because of this feature, VR glasses have emerged as a prominent tool for distraction in the field of healthcare.

The World Health Organization (WHO) advocates for creating a healing environment in health-promotion practices to enhance quality of life and address healthcare challenges. A healing environment can be defined as a physical and emotional setting intentionally designed to promote well-being and recovery by engaging the senses through elements such as natural light, soothing sounds, access to nature, green spaces, and art [5], 6]. Research indicates that one in three women experience psychological trauma during childbirth, even in the absence of physical injury, which can lead to depression, fear of childbirth, reduced breastfeeding, and long-term health issues [7]. Virtual reality (VR) applications have been identified as a tool for cultivating a healing environment by incorporating different layers of sensory experiences such as light and sound, as well as virtual elements including nature, green spaces, and art to enhance overall sensory engagement [3], 5]. Beyond these psychological and sensory benefits, its potential influence on physiological processes during labor has not yet been sufficiently explored. The use of various strategies that focus on the healing environment and relaxation therapy to enhance health, relieving physical symptoms, reduce anxiety, and manage fear plays a significant role in the development of physical birth environments that support the psychological and emotional processes of labor [4], [8], [9], [10], [11], [12], [13], [14].

The focus of SDG-3 – securing healthy lives and promoting well-being at all ages – a new global strategy, has been expanded. This goal goes beyond the survival of women and babies regarding birth, focusing not only on ensuring that they survive birth complications but also on ensuring that they reach and achieve their true strengths and abilities for health and well-being [6], 15]. Women’s birth-related experiences are shaped by subjective, psychological, and physiological processes affected by environmental factors. Prolonged labor, as an important physiological challenge, may negatively affect maternal well-being and neonatal outcomes [16]. Such experiences vary individually: For some women, birth is an exciting and beautiful event, while for others, it is a stressful, tiring, and unpredictable experience [6], 17]. Birth-related experiences are associated with various factors and emotional dimensions of care, affecting the overall maternal condition and fetal health [4]. The WHO has published new recommendations on intrapartum care for all pregnant women and newborns, from pregnancy to birth and the postpartum period. These recommendations go beyond preventing the risk of death and disease and include optimizing the health and well-being of women and babies [6], 18]. In this context, it is important to consider interventions that may positively affect not only maternal experiences but also neonatal outcomes.

The assessment of the fetal health status, severity of contractions, duration of labor, uncertainty of the process, negative birth experiences, and practices implemented after admission to the delivery room can cause stress, fear, and anxiety [4], 19], 20]. Reassuring women and providing supportive care during labor can reduce their fears, ensure the maintenance of fetal well-being, and provide them with a positive birth experience [21], 22]. According to a study conducted among OECD countries, 1 in 10 women who have not given birth prefers cesarean delivery due to the fear of birth [23]. While the fear of birth remains a worldwide problem, there is currently no definitive solution to reduce such fear and foster a positive birth experience. Moreover, although VR has been explored mainly in terms of psychological outcomes, there is a growing need for studies evaluating its impact on labor physiology and neonatal outcomes. The effects of VR applications on the fear of birth and fetal well-being remain unknown. Therefore, the aim of this study was to evaluate the effects of using VR glasses on the fear of birth, duration of labor, and intrapartum fetal well-being.

Subjects and methods

Measurement tools

The personal information form, covering socio-demographic characteristics and pregnancy history, was completed by both the VR and control groups within the first hour of entering the delivery room. The clinical record form documented labor details, including cervical dilation, contraction patterns, fetal heart sounds, time of birth, and time of placental delivery. The time of placental delivery was recorded as part of routine labor monitoring. The NST monitoring form documented the pregnant women’s emotional state through observational notes during the procedure, as well as the NST results, including fetal heart rate baseline, variability, accelerations, and any decelerations. These parameters were evaluated by the researchers.

Fear of birth was measured using the W-DEQ-A and W-DEQ-B. Developed by Wijma et al. in 1998, the W-DEQ-A has a Cronbach’s alpha of 0.93 [26], 27], and the Turkish version, evaluated by Körükcü et al. in 2012, has an alpha of 0.89. The scale, which assesses women’s expectations about birth, includes 33 items scored on a 6-point Likert scale (0–5), with scores ranging from 0 to 165. Higher scores indicate greater fear, with thresholds for mild (≤37), moderate (38–65), severe (66–84), and clinical (≥85) levels of fear [28].

The W-DEQ-B, developed by Wijma et al. (1998), measures women’s fear of birth with a Cronbach’s alpha of 0.93. The Turkish version, evaluated by Korukcu et al. (2016), has a Cronbach’s alpha of 0.84. The 32-item scale uses a 6-point Likert scale (0–5), with scores ranging from 0 to 160, where higher scores indicate greater fear. It includes six subscales: concerns about contractions, positive behaviors, loneliness, positive emotions, birth, and the baby [29].

Ethical considerations

Approval for the conduct of the study was obtained from the Akdeniz University Clinical Research Ethics Committee (decision number: KAEK-524) (decision date: 07.07.2021) and for the use of the W-DEQ-A and W-DEQ-B from the chief physician of the Akdeniz University Hospital and Assoc. Dr. Öznur Körükcü. In addition, verbal and written consent were obtained from women who agreed to participate in the study.

Data analysis

The data obtained in the study were analyzed using the free trial version of the Statistical Package for the Social Sciences for Windows 25.0. Descriptive statistics (i.e., numbers, percentages, means, and standard deviations [SDs]) were used to present the data. An independent-sample t-test was conducted to test whether the quantitative variables obtained from two unrelated samples differed significantly from each other. The chi-square test was performed to test whether there was a significant difference between the two groups. p-values below 0.05 were considered significant.

Results

The initial study sample consisted of 204 pregnant women. Of them, 60 were excluded because they did not meet the inclusion criteria. The pregnant women were randomly allocated into either the control group (n=72) or the VR group (n=72). Each group comprised 36 primiparous women and 36 multiparous women. Figure 1 shows the CONSORT flow diagram of the study.

Figure 1:

Consort flow chart.

The average age of primiparous women was 24.28 years (VR group) and 23.47 years (control group). For multiparous women, it was 26.50 years (VR group) and 26.69 years (control group). About 38.9 % of primiparous women in the control group and 55.5 % in the VR group were at or beyond 40 weeks of gestation. For multiparous women, 41.7 % in the control group and 36.1 % in the VR group were at or beyond 40 weeks. Approximately 47.2 % of multiparous women in both groups had low educational levels, and 80.6 % of multiparous women in the control group were housewives. Over 80 % of primiparous women in both groups desired their pregnancy (Table 1).

Discussion

This study demonstrated that the use of VR glasses during labor shortened the duration of the active phase of labor, and reduced the fear of birth among the pregnant women. It is reasonable to expect that VR-based distraction will be most beneficial during the active phase, when pain, stress, and anxiety are most intense. However, no improvement was observed in NST parameters such as fetal movements and accelerations in the VR group. On the contrary, both parameters were significantly higher in the control group, suggesting that VR did not have a positive impact on fetal activity during labor. Fetal reactivity during NST may be governed by physiological processes that are less directly influenced by brief, intrapartum VR exposure, whereas maternal affect (stress/anxiety) is more amenable to modulation in the active phase.

There was no significant difference noted in the total duration of labor of the primiparous and multiparous women between the control and VR groups in the present study. In the study by Akin et al. (2021), it was found that VR application was ineffective in shortening the duration of the first and second stages of labor [27]. In the study by Ebrahimian et al. (2021), the first and second stages of labor were shorter in the VR group than in the control group. Conversely, Gökduman Keleş and Altinkaya (2022) found no significant difference in the duration of labor of primigravida women between the control group and the group that used VR glasses. In our trial, total labor time did not differ despite a shorter active phase, because total duration aggregates the latent, active, second, and third stages; in the absence of changes in the other stages, a reduction confined to the active phase alone is unlikely to yield a statistically significant difference in total labor time.

In the present study, the active phase of labor was shorter in the VR group than in the control group. Similarly, in a randomized controlled study using VR during labor, the active phase was found to be shorter in the VR group than in the control group [8]. In the study by Estrella-Juarez et al. (2023), the first stage of labor among mothers who received VR application and music therapy was shorter than that among mothers who received the control intervention [30]. Karacan and Akköz Çevik (2022) also reported congruent findings in their study conducted among 114 primiparous pregnant women who used VR glasses and applied breathing exercises [31]. The authors found that the active phase of labor was shorter for mothers who used VR glasses than for those who received the control treatment. This resulted in a reduction in the level of stress hormones due to the increased comfort experienced by pregnant women during labor. The shortened duration of the active phase of labor observed in the VR group may be related to improved maternal comfort and reduced stress, which are known to promote endogenous oxytocin release during labor [6]. Although oxytocin levels were not measured in this study, previous literature suggests that psychological well-being and relaxation can positively influence labor progression through hormonal pathways. Taken together, these data support a stage-specific effect: VR appears most beneficial when pain and anxiety peak (active phase), whereas effects in other stages may be limited. This stage-specific effect may be attributed to the fact that stress, pain, and anxiety peak during the active phase of labor. As the need for distraction and psychological support is greatest in this critical period, the impact of VR becomes more pronounced. This mechanism may explain why VR is particularly effective in the active phase, while its influence appears limited in the earlier or later stages of labor.

Factors such as psychological well-being, anxiety, and stress can affect the NST results of pregnant women [32], 33]. In this study, significant differences were found in the numbers of fetal movements and accelerations between the VR and control groups. Previous studies have shown that reduced anxiety and increased maternal relaxation may lead to more frequent fetal movements and accelerations during NST [32], 34]. However, in the present study, fetal movements and accelerations were not consistently higher in the VR group. In fact, in primiparous women, both parameters were higher in the control group. These findings suggest that while VR may reduce anxiety and fear of birth, its effects on fetal reactivity during labor may not follow a predictable pattern and could be influenced by additional physiological or contextual factors. Accordingly, VR’s psychological benefits may not uniformly translate into changes in fetal activity indices recorded during intrapartum monitoring.

The fear and stress experienced by women during labor cause the level of cortisol secreted to increase [35]. In the present study, the primiparous and multiparous women in the VR group experienced less fear of birth than did those in the control group. Although no study using VR was found in the literature review to report reduced fear of birth, the results are consistent with those of studies examining the effects of distraction and relaxation techniques on the fear of birth. In their study, Klabbers et al. (2019) found that the level of fear of birth decreased after haptotherapy compared with that after the control intervention [36]. Conversely, Koyuncu and Bülbül (2021) discovered that women who did yoga had lower levels of fear of birth [37]. Additionally, in a study examining the effects of hypnosis during and after pregnancy, it was found that the W-DEQ-A scores were lower in spontaneous vaginal birth [38].

The main purpose of managing the fear of birth among women is to either eliminate their uncertainties about birth or help them accept these uncertainties and reduce their concerns about birth [21]. In this study, the women’s concerns about labor pain were fewer in the VR group than in the control group. In the study by Akin et al. (2021), the perceived labor pain and anxiety levels were found to be lower in the intervention group where ultrasound images of babies were shown using VR glasses than in the control group. Other studies have also shown that watching videos using VR devices during birth reduces pain and anxiety [10], 11], 19]. Numerous non-pharmacological techniques, including breathing exercises, massage, aromatherapy, music therapy, and hypnobirthing, have been shown to reduce labor-related pain and anxiety [8], 22]. These methods work primarily by promoting relaxation and diverting attention away from pain. Virtual reality (VR), as a modern distraction technique, combines immersive visual and auditory stimuli to create a multi-sensory experience. This approach may enhance the effectiveness of traditional methods by fully engaging the user’s attention and altering pain perception through cognitive distraction [11]. The concentration of benefit during the active phase aligns with this mechanism, as cognitive load and nociceptive input are highest and thus most modifiable at that time.

In the present study, the loneliness subscale score of both primiparous and multiparous women was found to be lower in the VR group than in the control group. In the literature review, no study was found to use a distraction method to reduce mothers’ feelings of loneliness during labor. However, in some studies, motivational interviews, education, and psychological interventions such as counseling reduced feelings of loneliness [39], 40]. These findings indicate the need for more studies using technological methods such as VR applications aimed at reducing feelings of loneliness. Reducing perceived loneliness may also be one pathway through which VR improves comfort and contributes to a shorter active phase, although this requires confirmation in future research.

In this study, the anxiety level of the primiparous and multiparous women regarding birth and their baby was found to be lower in the VR group than in the control group. In a previous study where VR was used as a distraction method, the birth-related anxiety levels were observed to be lower in the VR group [8]. In their study, Akin et al. (2021) reported that the anxiety level of pregnant women who watched videos using VR glasses was lower. While several non-pharmacological interventions aim to reduce fear and anxiety during labor, not all are equally effective across different subdimensions. For example, in a study by Vural and Aslan (2019), emotional freedom techniques and breathing awareness did not significantly affect the subdimension related to fear about the baby [41]. This highlights that certain interventions may have limited effects on specific aspects of childbirth fear. In contrast, the use of VR in the present study was associated with lower levels of fear related to both labor and the baby, suggesting that immersive distraction techniques may have broader psychological benefits.

While the fear of birth of the primiparous women in the VR group was at a moderate level (53.44), that of the primiparous women in the control group was at a clinical level (92.50) (Table 5). In the present study, both W-DEQ-A and W-DEQ-B scores were significantly lower in the VR group compared to the control group, among both primiparous and multiparous women. These findings indicate that the use of VR during labor may help reduce both anticipatory fear and the actual experience of childbirth-related fear. Although no previous study was identified that used the W-DEQ-B in evaluating VR interventions, other distraction-based methods such as cognitive behavioral therapy or yoga have been shown to reduce childbirth fear [20], 37]. These results support the potential of immersive technologies like VR in addressing psychological aspects of childbirth.

Beyond statistical significance, the findings of this trial may have important implications for clinical practice. Reducing childbirth fear and shortening the active phase of labor can enhance maternal comfort and potentially decrease the need for pharmacological interventions such as analgesics or anxiolytics. The absence of adverse effects further supports VR as a safe, acceptable, and easily implementable adjunct to routine intrapartum care. Given that the active phase is the most stressful stage for both women and healthcare providers, VR could serve as a practical, non-pharmacological tool to improve the birth experience and contribute to more positive maternal outcomes. Future research should also investigate implementation strategies and cost-effectiveness to guide integration of VR into standard practice.

Conclusions

Based on the findings of this randomized controlled trial, the use of VR glasses during labor significantly reduced the duration of the active phase and decreased the fear of childbirth among both primiparous and multiparous women. However, VR did not shorten the total duration of labor, which is an important outcome that highlights the need to interpret its benefits with caution. Although there were significant differences in NST parameters between the groups, the clinical implications of these differences remain uncertain, and no direct negative impact on fetal well-being was observed. No side effects or adverse reactions related to the VR intervention were reported by participants or observed by clinical staff. Taken together, these results suggest that VR may serve as a safe and effective non-pharmacological method to support maternal comfort during labor, primarily by reducing childbirth fear and facilitating a shorter active phase, rather than by shortening the overall labor process. Further studies with larger and more diverse populations are recommended to explore long-term effects, optimize content and duration of VR exposure, and examine potential physiological impacts more comprehensively.