In this study, the fear of anesthesia for cesarean section among Palestinian pregnant women and the factors associated with fear were determined. To the best of our knowledge, this is the first study of its type in Palestine.

In this study, the majority of pregnant women expressed fear of anesthesia. In previous studies, women expressed more fear of anesthesia compared to males (Mavridou et al. 2013; Kilinc and Ozer 2017; Ruhaiyem et al. 2016). The findings of this study indicated that pregnant women who received a university education expressed a higher fear of anesthesia compared to women who received a school education only. Probably, pregnant women who received a university education could be more knowledgeable of the risks associated with anesthesia compared to less educated women (McMullan 2006).

The findings of this study showed that pregnant women who lived in rural areas expressed higher fear compared to those who lived in urban areas. In Palestine, women who live in rural areas often maintain stronger social relationships with neighbors and the surrounding society. Discussing and sharing experiences with other women who might have undergone anesthesia for cesarean delivery could have increased awareness of women about the risks associated with anesthesia. Previous studies have shown that health literacy and health information-seeking behavior affected fear of medical procedures including anesthesia (Suka et al. 2015).

In this study, self-rating satisfaction with social life was negatively associated with fear. Probably, the pregnant women who were not satisfied with their social life experienced higher levels of stress, anxiety, and fear in their lives. This could also affect their fear of medical procedures like anesthesia. Additionally, the pregnant women who have had cesarean section delivery under anesthesia expressed higher fear compared to those who did not have cesarean section delivery. Probably, this could be explained by the past/negative experiences that the women might have experienced before (Carvalho et al. 2005). Therefore, it was not surprising that women who feared anesthesia preferred normal delivery over cesarean delivery.

The findings of this study highlighted the need to address the fear of anesthesia among women scheduled for cesarean section deliveries. In this study, the majority of the women expressed fear of classic concerns reported in previous studies conducted elsewhere (Mavridou et al. 2013; Kilinc and Ozer 2017; Ruhaiyem et al. 2016; Dursun et al. 2011). It is noteworthy to mention that anesthesiologists, gynecologists and obstetricians, nurses, midwives, and other providers of antenatal and perioperative healthcare services should address the fear of anesthesia among women who might be candidates for cesarean delivery.

The following strengths can be considered when interpreting the findings of this study. First, this was the first study to assess the fear of anesthesia for cesarean section among Palestinian pregnant women. The findings reported in this study could be informative to providers of antenatal and perioperative healthcare services. Second, a large number of pregnant women were included in this study. Additionally, the pregnant women were diverse in terms of demographic characteristics. The large sample size and diversity of the demographic characteristics of the pregnant women should have improved the representativeness of the entire pregnant women in Palestine and the external validity of the findings. Third, the demographic variables collected in this study allowed comparing the different groups of pregnant women based on their demographic variables. Fourth, the questionnaire that was used in this study was pilot-tested for test-retest reliability and internal consistency.

On the other hand, this study had some limitations. First, the study was conducted in a cross-sectional design. Cross-sectional studies lack temporality and the ability to establish causal relationships. Although associations between the characteristics of pregnant women and fear of anesthesia were identified, no causal relationships could be established. Second, the pregnant women were recruited using a convenience sampling approach. This nonprobability sampling approach is associated with selection bias. However, the sample of pregnant women who were recruited in this study was diverse in terms of demographic characteristics like age, marital status, place of residence, educational level, and employment status. Third, the data collected in this study were self-reported by the pregnant women. Self-reported data and experiences are subject to recall and desirability bias.