Pregnancy and child birth are significant life events in which physical, emotional and psychological changes occur. While childbirth is considered a natural physiological event, there is a lot of anxiety and fear in relation to labor and delivery for many women. Fear of childbirth (FOC), or tokophobia has become an important public health concern due to its association with adverse maternal and neonatal outcomes, elective cesarean section, lengthy labor, postpartum depression, and negative birth experiences [1]. The maternal fear can vary from a slight feeling of anxiety to high psychological distress that can affect daily life and antenatal well-being. Over the last few years there has been an increased focus on gaining an understanding of the factors associated with fear of childbirth and the identification of women who could be at risk during pregnancy.

Fear of childbirth is a phenomenon that encompasses biological, psychological, social and obstetric factors. The fear may stem from uncertainty and lack of experience in primigravidas, and traumatic or negative previous birth experiences in multiparous women [2]. Past experiences are an important factor in determining mothers’ perceptions and expectations for the next birth. Pregnant women who have had with severe pain in labor, obstetric complications, emergency interventions, poor communication with health service staff, lack of emotional support, and disrespectful maternity care are more likely to experience greater fear of childbirth in subsequent pregnancies [3]. On the other hand, positive birth experiences with supportive healthcare, effective pain management, and a successful vaginal delivery can help mitigate maternal anxiety and boost confidence in future births.

Fear of childbirth is common in some groups and health care environments. In international studies it has been found that about 20-25% of pregnancy women face moderate fear and nearly 6-15% are experiencing severe fear of child birth all over the world [4]. Variations in prevalence might be explained by sociocultural beliefs, education level, health care system, and obstetric practices. Lack of awareness of maternal mental health issues and lack of psychological support during pregnancy are some of the factors that affect the under-recognition of childbirth-related fears in low and middle-income countries including Pakistan. Although there have been improvements in obstetric care, maternal psychological well-being is often overlooked in favour of physical health outcomes.

Frequently, childbirth fear is reported to be a strong predictor of future childbirth fear in women who have previously had traumatic birth experiences. Women who have an emergency cesarean section, instrumental vaginal delivery, postpartum hemorrhage, prolonged labor, stillbirth or neonatal complications often experience lingering emotional distress and anxiety during future pregnancies [5]. These experiences can cause a sense of helplessness, a lack of control and mistrust of health care providers. Studies have shown that women who have previously had traumatic delivery are more likely to ask for cesarean delivery as elective surgery in future pregnancy, because of fear of same complication or pain during labor [6]. This is one of the factors leading to the increasing rate of cesarean delivery worldwide with its additional burden on health care and morbidity to mother.

Psychological theories also indicate that childbirth experiences are influenced by subjective maternal perceptions of and responses to medical events. Women's experience of pain during labor, their interactions with health care providers, their dignity and participation in decision-making are all significant factors in their satisfaction with the birth [7]. Negative perceptions can continue after childbirth and impact upon maternal self-esteem, mother–infant bonding, and reproductive decisions. Those women who feel that giving birth was traumatic have a higher risk of developing postpartum depression, post-traumatic stress disorder (PTSD), and a fear of future pregnancies [8]. Thus, delivering better birth experience has become a crucial element to respectful maternity care and quality obstetric services.

There are also a number of demographic and obstetric factors that have been linked to fear of childbirth. Fear and anxiety during pregnancy have been associated with younger maternal age, low level of education, low socioeconomic status, unplanned pregnancy, inadequate counseling during the antenatal period and lack of social support [9]. Also, women who have had a history of infertility, miscarriage or poor pregnancy outcomes may have increased worries about the safety of mother and fetus. Mother's expectation and fear are also shaped by cultural expectations and the stories of society about child birth. Many societies tell women frightening stories about pain and problems in childbirth from family members, friends or the media that can increase women's 'pregnant' anxiety before birth.

Doctors, midwives, nurses, and other professionals involved in maternal healthcare are key in minimizing worries and ensuring positive childbirth experiences. Emotional support, appropriate antenatal education, effective communication, pain management technique and respectful maternity care during labor have been found to increase women satisfaction and decrease childbirth related anxiety [10]. This has been shown to be effective in women with high levels of fear of childbirth in the form of midwife-led counselling programmes and psychological interventions, for example, cognitive behavioural therapy [11]. Antenatal screening will help to identify women who are at high risk so that interventions and care plans can be made at the right time.

Maternal mental health is an under-researched field in the reproductive health research in developing countries including Pakistan. The majority of obstetric services concentrate on preventing physical complications and death; psychological considerations of childbirth are not particularly considered. For Pakistani women, other obstacles can include restricted decision making in health care, lack of information about childbirth, crowded health care facilities, and lack of emotional support during childbirth [12]. All these can have a negative impact on women's birth experiences and can contribute to fear during their next pregnancy. Moreover, there is a lack of local multicenter study to assess the association of previous birth experiences with fear of childbirth in Pakistani women.

Hence, it is important to understand how the previous child birth experiences affect the fear of the mothers for developing targeted interventions to enhance the psychological well-being of mothers and obstetric outcomes. Women who experienced negative birth experiences might benefit from more receiving antenatal counselling, psychological support and individual birth planning to decrease fear and increase confidence in the labour experience. When it comes to birth, if fear can be addressed, this could also lead to a decrease in unindicated cesarean section requests and to positive maternal experiences. Furthermore, modifiable health care-related factors (e.g., provider communication and labor support) can help improve the quality of maternity care.

The study was designed to assess the effect of past birth history on fear of childbirth in pregnant women visiting antenatal clinics, a multicenter study was conducted at Creek General Hospital and SESSI Landhi Hospital, Karachi. The results of this study can assist health care providers in identifying women who are at risk psychologically and suggest supportive interventions for future pregnancies that will enhance mental health and childbirth experiences.

Study Design and Setting

This was a retrospective observational study conducted at Sapthagiri Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, a tertiary care teaching hospital. Institutional Ethics Committee approval was obtained prior to data collection (SIMSRC/ EC-35/PG-08/ 2025-26). The study was conducted in compliance with the Declaration of Helsinki.

Inclusion and Exclusion Criteria

Consecutive patients aged 18 years and above who underwent primary unilateral or bilateral TKA between January 2023 and January 2026 were included. Patients undergoing revision arthroplasty, those with incomplete preoperative data, and those with prior ipsilateral knee surgery were excluded.

mFI-5 Calculation

The mFI-5 was calculated for each patient using five preoperatively documented variables: (1) diabetes mellitus (any type requiring medical management), (2) hypertension (on antihypertensive therapy), (3) congestive heart failure (documented on echocardiography or clinical records), (4) chronic obstructive pulmonary disease (spirometry-confirmed or treated), and (5) functional dependence (requirement of assistance for activities of daily living). Each variable was scored 0 (absent) or 1 (present), and the composite mFI-5 score ranged from 0 to 5. Patients were categorised as non-frail (mFI 0–1), moderately frail (mFI 2), or severely frail (mFI ≥3), consistent with published classification thresholds [7,8].

Outcome Measures

Primary outcomes were: (1) any postoperative complication, (2) ICU admission, (3) 30-day readmission, and (4) 30-day mortality. Specific complications recorded included surgical site infection (SSI), deep vein thrombosis (DVT), pulmonary embolism (PE), and urinary tract infection (UTI). Secondary outcomes included length of hospital stay (LOS in days) and functional recovery as measured by the Knee Society Score (KSS) at baseline and at 3-month follow-up.

Statistical Analysis

Continuous variables are expressed as mean ± standard deviation (SD) and were compared across frailty groups using the Kruskal-Wallis test, with Mann-Whitney U test for binary group comparisons. Categorical variables are expressed as frequency and percentage and were compared using the chi-squared test or Fisher's exact test as appropriate. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for binary outcomes comparing frail (mFI ≥2) versus non-frail (mFI 0–1) patients. Spearman's rank correlation was used to assess associations between mFI score and continuous outcomes. A p-value of <0.05 was considered statistically significant. All analyses were performed using Python (SciPy v1.11, pandas v2.0).

Patient Demographics and Frailty Distribution

Ninety-nine patients met the inclusion criteria. The mean age was 64.7 ± 7.6 years (range 48–86 years), and 58 patients (58.6%) were female. The distribution of mFI-5 scores was as follows: 17 patients (17.2%) scored 0, 39 (39.4%) scored 1, 35 (35.4%) scored 2, 5 (5.1%) scored 3, and 3 (3.0%) scored 4. Overall, 56 patients (56.6%) were classified as non-frail (mFI 0–1), 35 (35.4%) as moderately frail (mFI 2), and 8 (8.1%) as severely frail (mFI ≥3).

The most prevalent frailty-defining comorbidities were hypertension (60.6%, n=60) and diabetes mellitus (54.5%, n=54), followed by COPD (9.1%, n=9), functional dependence (9.1%, n=9), and congestive heart failure (4.0%, n=4). Baseline demographic data are summarised in Table 1.

Table 1: Baseline Demographics and Comorbidities by Frailty Group

Primary Outcomes

Postoperative complications occurred in 9 patients (9.1%) overall. No complications were recorded in the non-frail group, compared to 4 (11.4%) in the moderately frail and 5 (62.5%) in the severely frail group (p<0.001). Complication types included DVT in 4 patients (4.0%), SSI in 3 (3.0%), UTI in 2 (2.0%), and PE in 1 (1.0%).

ICU admission was required in 15 patients (15.2%). Rates were 7.1% (non-frail), 22.9% (moderate), and 37.5% (severe), with a statistically significant difference across groups (χ²=7.518, p=0.023). Thirty-day readmission was recorded in 9 patients (9.1%), exclusively in the frail cohort: 11.4% in the moderate group and 62.5% in the severe group versus 0% in the non-frail group (p<0.001). There were no 30-day deaths in the cohort.

Binary comparison of frail (mFI ≥2, n=43) versus non-frail (mFI 0–1, n=56) patients demonstrated that frailty was associated with a 4.47-fold increase in odds of ICU admission (OR 4.47, 95% CI 1.29–15.49; p=0.021). Both complication and readmission rates were significantly higher in the frail group, with no events in the non-frail group (Fisher's exact p=0.0003 for both).

Table 2: Postoperative Outcomes by Frailty Group

Table 3: Frail vs Non-frail — Binary Comparison of Key Outcomes

Length of Hospital Stay

Mean LOS increased significantly with frailty score: 5.5 ± 1.2 days (non-frail), 6.1 ± 1.8 days (moderate), and 8.6 ± 1.4 days (severe) (Kruskal-Wallis H=17.799, p=0.0001). Spearman's correlation confirmed a significant positive association between mFI score and LOS (r=0.212, p=0.035).

Functional Outcomes

Preoperative KSS was similar across frailty groups (104.9, 108.0, and 107.9 for non-frail, moderate, and severe respectively; p=0.12). At 3-month follow-up, mean KSS was 188.2 ± 28.6 (non-frail), 184.3 ± 24.0 (moderate), and 176.8 ± 22.1 (severe). No statistically significant difference in 3-month KSS was observed (Kruskal-Wallis H=3.991, p=0.136), and mFI score did not correlate with KSS improvement (Spearman r=−0.029, p=0.779).

Table 4: mFI-5 Score Distribution and Outcome Rates

This study evaluated the mFI-5 as a preoperative risk stratification tool in 99 consecutive TKA patients at a tertiary orthopaedic centre in Bengaluru. The principal finding is that higher mFI-5 scores are significantly and independently associated with postoperative complications, ICU admission, 30-day readmission, and prolonged hospital stay. Notably, no complications or readmissions occurred in non-frail patients, while severely frail patients experienced complication and readmission rates exceeding 60%. These findings strongly support routine integration of the mFI-5 into preoperative TKA assessment.

The overall complication rate of 9.1% in our cohort is consistent with published rates for TKA in Asian populations, which range from 5% to 15% [3,14,15]. The most common complication was DVT (4.0%), followed by SSI (3.0%), and PE (1.0%). The concentration of all complications within the frail subgroup aligns with the foundational observations of Velanovich et al. [7] and Subramaniam et al. [9], who first validated the mFI-5 in general and orthopaedic surgical cohorts respectively.

The 4.47-fold higher odds of ICU admission among frail patients (mFI ≥2) compared to non-frail patients is clinically significant and has direct implications for preoperative planning and resource allocation. In a resource-constrained environment such as ours, the ability to identify high-risk patients preoperatively enables optimisation of anaesthetic approach, enhanced recovery protocols, and ICU bed planning. This finding is congruent with the work of Bernstein et al. [10], who reported progressive increases in 30-day adverse events with increasing mFI-5 scores in total hip arthroplasty patients.

The absence of 30-day mortality in this cohort may reflect the relatively younger mean age (64.7 years), the elective nature of the procedure, and robust perioperative care practices. Prior studies have reported 30-day mortality rates of 0.1–0.3% for primary TKA [4,11]; the sample size of the present study may be insufficient to capture such low-frequency events. This should be acknowledged as a limitation.

An important and reassuring finding is that functional outcomes at 3 months, as measured by the KSS, did not differ significantly between frailty groups. This suggests that while frail patients carry a higher perioperative risk burden, those who recover from the acute postoperative period achieve functional gains comparable to non-frail patients. This is consistent with the recent meta-analysis by Gronbeck et al. [16], which found that frailty predicted perioperative morbidity but not mid-term functional outcomes after TKA. These data should inform shared decision-making conversations, reassuring frail patients that—with appropriate optimisation—functional benefit from TKA is achievable.

The high prevalence of hypertension (60.6%) and diabetes mellitus (54.5%) in our cohort reflects the epidemiological burden of metabolic disease in urban Karnataka. These two factors dominate the mFI-5 score in our population, a pattern distinct from Western cohorts where functional dependence and CHF are more prevalent contributors [7]. This finding highlights the importance of locally validated frailty threshold data; the binary mFI ≥2 cut-off for identifying clinically meaningful frailty appears appropriate in our cohort, but future studies should formally derive and validate ROC-based cut-off thresholds in Indian TKA populations.

The study has several limitations. The retrospective single-centre design limits generalisability. With a cohort of 99 patients, the severe frailty group (n=8) is small, rendering subgroup comparisons underpowered; findings in this stratum should be interpreted with caution. The mFI-5 does not capture nutritional status, bone mineral density, or cognitive frailty, which may independently influence TKA outcomes [17]. Follow-up was limited to 3 months; longer-term functional and radiological outcomes would be valuable. Finally, the absence of a comparator group undergoing THA or a control population without surgery limits causal inference.

Future directions include a prospective multicentre cohort study to validate mFI-5 thresholds specific to the Indian orthopaedic population, exploration of the mFI-5 in conjunction with nutritional and functional assessments, and examination of whether preoperative frailty optimisation programmes can attenuate the morbidity risk associated with higher mFI-5 scores.

The 5-factor modified frailty index is a simple, reproducible, and clinically meaningful tool for preoperative risk stratification in patients undergoing total knee arthroplasty. Higher mFI-5 scores are strongly associated with postoperative complications, ICU admission, 30-day readmission, and prolonged hospital stay. Frail patients (mFI ≥2) face a significantly greater perioperative risk burden than non-frail patients. Importantly, frailty does not preclude meaningful functional improvement at 3 months. We recommend routine preoperative mFI-5 calculation for all TKA candidates, with targeted optimisation strategies for those with scores ≥2.

DECLARATIONS

Ethics approval: Obtained from the Institutional Ethics Committee, Sapthagiri Institute of Medical Sciences and Research Centre (Ref: SIMS & RC/ EC-35/PG-08/ 2025-26).

Informed consent: Waived by the ethics committee for this retrospective study.

Funding: None declared.

Conflict of interest: None declared.

Data availability: Data available from the corresponding author on reasonable request.

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