Pregnancy is a desirable and anticipated outcome of marriage in most young women. However, it is also a time when many fears and anxieties crop up, and this is especially true in the third trimester. One of these fears is regarding their death from complications of childbirth. However, women usually draw strength from social or family support, or spiritual resources, which help them to proceed cheerfully despite these worries.
When this specific anxiety or fear of death during childbirth leads a woman to avoid pregnancy and delivery even before she has any experience of the same, it is termed tokophobia. This phobic state may affect women from any age between childhood and old age. Knauer first described this condition in 1897.
While up to four of every five pregnant women report that they have some fear of pregnancy and delivery, only about 6% have the disabling fear which is termed tokophobia. Non-pregnant women, in contrast, describe themselves as extremely fearful of pregnancy (so much so that they seek to avoid or postpone getting pregnant, or terminate pregnancy) in 13% of cases. The fear of pregnancy may start in early adulthood or even in adolescence. As a result of this emotional state, affected women typically show extreme care in the use of contraceptive methods, usually adopting more than one, to avoid pregnancy, even though they have normal sexual relations.
It is interesting to know that up to 13% of expectant fathers also show tokophobia. Such men may contribute to raising doubt in the minds of their partners as to their capacity to go through labor and delivery successfully. This kind of fearful anticipation and hypervigilant attitude may reduce the woman’s self-confidence. The male partner may be driven by fear of childbirth to discourage their partners from attending childbirth classes. They are highly reluctant to envisage normal childbirth, and are often strongly in favor of a Cesarean section.
Both primary and secondary tokophobia have been described. Primary tokophobia is defined as the abnormal fear of pregnancy in a woman who has never become pregnant. In contrast, secondary tokophobia is, more often, secondary to a previous traumatic childbirth experience.
Both are more common in nulliparous women (pregnant women who have never borne children) than in multiparous women (who have already borne one or more children). It is also more intense in this category of women.
Tokophobia may result from a neurohormonal imbalance in the woman, resulting in trait anxiety. In such a condition, anxiety becomes unregulated.
Other mechanisms responsible for Tokophobia include:
- Fear resulting from hearing stories of difficult deliveries from friends or colleagues, or other social contacts
- Fears of not receiving good medical care, which includes adequate pain control, having control over medical decisions relating to one’s case, and being able to trust the medical team in charge of one’s care
- Psychosocial factors including relative youth, poor education, or low socioeconomic background
- Psychological factors such as low self-esteem, increased sensitivity to pain, and evocation of childhood traumas during the pain of childbirth, or the presence of psychiatric disorders such as depression or anxiety
In most cases of tokophobia, the woman avoids getting pregnant. The fear of experiencing labor pains in a nulliparous woman may drive her to undergo an abortion. Many other first-time mothers request an elective Cesarean section if they continue the pregnancy to term. In some cases, the woman prefers to look into adoption instead of risking becoming pregnant, a condition known as voluntary childlessness.
Secondary tokophobia may occur after a woman suffers some trauma during the course of a previous delivery, but not always. In many cases, it follows a delivery which was normal from a medical point of view. It may also have its onset after a stillbirth, or a miscarriage, or a termination of pregnancy. Some women with prenatal depression may also develop a morbid fear of pregnancy.
Support from the woman’s spouse, family, or close friends can reduce the level of prenatal stress and thus prevent severe tokophobia. Even women who have already developed this phobia may be able to overcome their desire for a Cesarean section instead of a normal delivery if they are supported both medically and psychologically.
Providing education for the parents prior to pregnancy and delivery, and doing appropriate tests to reassure the mother that the pregnancy is progressing normally, are also useful in preventing or treating tokophobia.
Several forms of psychotherapy including talk therapy and cognitive behavioral therapy (CBT) have been found to be successful in managing tokophobia. CBT takes a shorter time, does not probe deep into the past, and aims to change one single behavior as a result of changing a single thought pattern.
Antidepressants are sometimes used if the tokophobia is due to or is contributed to by psychological disturbances such as prenatal anxiety or depression.
Audit and modification of labor and delivery programs
The mother’s fears should be acknowledged and she should be cared for during both pregnancy and labor, so as to ensure that the process is as secure as possible, preventing future fear of childbirth.
Reviewed by Afsaneh Khetrapal BSc (Hons)