Background <p>Pregnancy and childbirth involve significant psychological and physiological changes in women. Some pregnant women experience intense anxiety, which may lead to serious concerns that contribute to the development of fear of childbirth. This study aimed to determine the mediating role of fetal health anxiety in the relationship between fear of childbirth and preferred mode of delivery among pregnant women.</p> Methods <p>This descriptive and correlational study was conducted with 241 pregnant women who attended outpatient clinics and polyclinics in two cities in the Black Sea Region. The data were collected between September and December 2025. Data were collected using the Personal Information Form, the Anxiety subscale of Depression Anxiety Stress Scale-21, the Fetal Health Anxiety Inventory, the Tokophobia Assessment Questionnaire, and the Pregnant Women’s Preferences for Mode of Delivery Questionnaire. Data were analyzed using descriptive statistics, Pearson correlation, Cronbach’s alpha reliability analysis, linear regression, and mediation analysis. Statistical significance was set at <i>p</i> &lt; 0.05.</p> Results <p>The mean age of the participants was 29.70 ± 4.80 years. Among the pregnant women, 22.8% reported mild anxiety and 11.6% reported moderate anxiety. Fear of childbirth was positively and weakly correlated with anxiety (<i>r</i> = 0.175), positively and moderately correlated with fetal health anxiety (<i>r</i> = 0.395), and negatively and moderately correlated with preferred mode of delivery (<i>r</i> = − 0.374) (<i>p</i> &lt; 0.001). Fetal health anxiety showed a positive and moderate correlation with anxiety (<i>r</i> = 0.433) and a negative and moderate correlation with preferred mode of delivery (<i>r</i> = − 0.336) (<i>p</i> &lt; 0.001). Fear of childbirth and fetal health anxiety were significantly associated with preferred mode of delivery (<i>R</i> = 0.427, R² = 0.183, F = 17.656, <i>p</i> &lt; 0.001), explaining 18% of the variance. According to standardized regression coefficients, fear of childbirth (β = −0.286) and fetal health anxiety (β = −0.210) were significant predictors of preferred mode of delivery. Analysis of the t-test results for the regression coefficients indicated that fear of childbirth and fetal health anxiety were significant predictors of pregnant women’s preferences for mode of delivery. The findings further showed that fear of childbirth had a significant negative effect on preferred mode of delivery (β = −0.286).</p> Conclusions <p>Fetal health anxiety mediates the relationship between fear of childbirth and preferred mode of delivery, contributing an additional indirect effect to the influence of fear of childbirth on preferred mode of delivery.</p>