Tocophobia (Tokophobia)

What is Tocophobia (also called ‘Tokophobia’)?

The term ‘Tocophobia’ (or Tokophobia) refers to a severe fear of childbirth and/ or pregnancy. This is sometimes also called severe Childbirth Anxiety (CA) or Fear of Childbirth (FOC).  (1, 2)

The word ‘Tokophobia’ originated from Greek ‘tokos’ meaning childbirth and ‘phobia’ meaning intense fear.

Although this is often used in the context of pregnant women, this also occurs in non-pregnant women and in men. Sometimes women with this condition may avoid getting pregnant, using scrupulous methods of contraception or opt for repeated abortions (termination of pregnancy). (1)

In 1797, Dr Osiander from Germany wrote about suicidal ideation of women resulting from the intense fear of childbirth. (1) Dr Louise Victor Marcé, a French psychiatrist, described the fear of childbirth in 1858 (3,4):

“If they are primiparous, the expectation of unknown pain preoccupies them beyond all measure and throws them into a state of inexpressible anxiety. If they are already mothers, they are terrified of the memory of the past and the prospect of the future.”

However, the term ‘Tokophobia’ was first introduced (5) in the medical literature by Hofberg and Brockinton in the year 2000 in their article entitled, ‘Tokophobia: An unreasoning dread of childbirth’ published in The British Journal of Psychiatry. (3)

Is it unusual to have some worries about pregnancy/ childbirth?

It is normal to have some fear and concerns regarding pregnancy and childbirth (especially among the first-time mothers). In fact, having a certain amount of fear may have a protective effect since mothers may be triggered to seek advice and maternity care often based on fears. i.e. in the case of reduced fetal movements, going for a check-up and reassurance.  Common fears reported by women with tocophobia may be related to a fear of the unknown, labour pain and safe arrival of the child. (1) Causes for tocophobia can be complex, however; including vicarious trauma through family or friends, previous traumatic experience in the hospital or previous traumatic birth, a history of rape or sexual abuse, and lack of trust in the hospital staff. Women may catastrophize labour pain.

Research has shown that about 80% of pregnant women could have such fear and worries (6). Most women can cope themselves, sometimes just with reassurance and support from their pregnancy care providers.

However, women with tocophobia have an extreme and intense fear and anxiety (often associated with phobia symptoms such as panic attacks, insomnia and nightmares) that they need specialist care and would like to avoid childbirth (although very often they would like to become a mother). Therefore, this is a distinct clinical condition.

How common is the tocophobia?

There is no internationally agreed clinical definition of tocophobia, therefore, the prevalence varies in different studies depending on the criteria used to measure this condition (7). The reported incidence is about 6-10% of women during pregnancy. However, a recent scientific paper has indicated that tocophobia could be prevalent as high as 14% pregnant women and seems to be on the rise since the year 2000. (7)

What are the different types of Tocophobia?

Tocophobia was first classified in the medical literature by Hofberg and Brockington (3) into three groups:

Primary tocophobia (no previous experience of pregnancy)

If this intense fear of childbirth occurs to a woman before her first pregnancy, then this is called ‘Primary Tocophobia’. This could start as early as adolescent period and could be associated with previous sexual abuse, witnessing a traumatic birth of someone else or traumatised by watching a video on childbirth without adequate explanation. (2, 3, 5)

 

Secondary tocophobia

If a woman develops tocophobia following a previous pregnancy, then this is called ‘Secondary Tocophobia’. This may follow a traumatic birth (Caesarean or vaginal) experience of stillbirth, miscarriage or termination of pregnancy. (2, 3, 5)

 

Tocophobia as a symptom of depression

When a woman (regardless whether she had a previous pregnancy or not) has co-existing depression and recurrent intrusive thoughts that she would die if she tries to deliver the baby.

There is growing evidence that fear of childbirth is associated with depression and depressive personalities. (8,9)

Risk factors (2) for Tocophobia:

Tocophobia is found to be more prevalent in the following conditions:

 

 –  Mental health conditions such as anxiety, depression, Obsessive Compulsive Disorders (OCD)

 –  Previous sexual abuse (as vaginal examination during labour could trigger previous painful memories)

 –  Traumatic birth experience

 –  Witnessing a traumatic birth/ hearing stories of family and friends

 –  First pregnancy (primigravida)

What could be the possible underlying factors of tocophobia?

Liji Thomas, MD in her article (‘Causes of Tokophobia’) described the following as the underlying causes of this intense fear of the childbirth:

  –  Sense of ‘loss of control’

  –  Fear of losing privacy and dignity

  –  Fear of pregnancy/ delivery complications or significant harm to the child

  –  Lack of social support

  –  Fear of not having adequate pain relief/ not getting safe medical care

Are there conditions that mimic or even co-exist tocophobia (Differential diagnosis)?

The presence of the following clinical conditions could mimic tocophobia or they may co-exist with the tocophobic state (1) :

  –  Blood-injection-Needle phobia

  –  Hospital phobia

  –  Vaginismus

  –  Fear of vaginal examination

  –  Social anxiety disorders (encounter with unfamiliar people during labour)

  –  Panic disorder

Can Childbirth-related videos/ reality TV shows affect the perception towards birth?

During an interview in 2007, the renowned English actress, Helen Mirren, said that she was so traumatised by watching an educational film on childbirth in the school during her early teens that she decided never to have children in her life. (Ref) . There are some scientific data to suggest that reality TV programmes (showing childbirth process) could lead to extreme fear of childbirth(2). However, there is a need for more research on this topic.

Is there any ‘test’ available to diagnose tocophobia?

Tocophobia may be assessed using various different assessment tools. The most commonly used validated tool is the Wijma Delivery Expectancy Questionnaire Part A (W-DEQ A). This was originally produced in Swedish but translated in different languages including English, Italian and Turkish. There are 33 questions to assess the emotional and cognitive expectations of the delivery process. Fear of Birth Scale (FOBS) and the Childbirth Attitudes Questionnaire are some other assessment tools. FOBS has an advantage due to its simplicity (2, 7). Tocophobia is included under 2015 ICD (International Classification of Disease) -10-CM Diagnosis Code F40.9 Phobic anxiety disorder, unspecified. (2)

Pregnant women should be asked about their concerns regarding the childbirth process during their first (booking) visit and also subsequent consultations by health professionals (10). Also, fear of childbirth is a continuum and may change or worsen at any point, therefore, women may develop increasing fear during their pregnancy. It is important to remember that sometimes women find it difficult to discuss their childbirth fears at early stages of pregnancy and could disclose nearer the time of birth. Therefore, healthcare professionals should create opportunities to express their thoughts and feelings throughout the pregnancy and provide necessary support.

What are the symptoms of tocophobia (2)?

 –  Insomnia

 –  Panic attacks

 –  Nightmares

 –  Seeing pregnant mothers/ reading childbirth-related stories can trigger symptoms

What are the impacts of tocophobia on the women during the pregnancy and beyond (2, 10)?

It is important to remember that the symptoms/ clinical presentations might vary from one person to the other:

 –  She may find antenatal consultations difficult (therefore can leave the clinic suddenly)

 –  She could attend and seek medical consultations repeatedly for reassurance

 –  Depression (Antenatal/ postnatal)

 –  Posttraumatic stress disorder

 –  Decision for abortion (termination of pregnancy)

 –  Request for Caesarean section (sometimes they find it difficult to disclose symptoms early, or book late and request  Caesarean section nearer to the due date)

 –  Difficulty in bonding and attachment with the child

 –  Affect marital relationship

 –  Traumatic birth experience

 –  Sense of failure

 –  Prolonged labour, increased need for CS: Adrenaline hormone (released as a result of anxiety and stress during labour) has been thought to slow down uterine contractions (11) (which is important for steady progress in labour), therefore resulting in prolonged labour and emergency Caesarean Section (8)

What is the outlook of the society on tocophobia?

Stephanie Calman in her article in The Guardian (UK) described how the women with tocophobia are often made to feel as a failure by the society. She was even called “Too posh to push” by her friends. Sadly stigma, shame and myths still exist regarding the tocophobia and this is mainly due to the lack of awareness. As a result, many women hesitate to speak out and suffer in silence.

It is vital that the society acknowledges tocophobia as a health condition and understands that anyone could be affected by this. It is also very important that health professionals create an opportunity for the expectant mothers to discuss their fear and anxiety related to the childbirth process. Failure to identify them could have an impact on the future psychological wellbeing of the woman, marital relationship and bonding/ attachment with the child.

What is the treatment of tocophobia?

The treatment needs to be individualised and varies on the severity of the symptoms and any coexisting condition. In absence of internationally agreed treatment of tocophobia, the basic principles of care and support (2, 10) are as follows:

 –  Listening and understanding their fear and concerns are vital.

 –  ‘Turning fear into trust’ (10): Developing a trusting relationship and continuity of care could play an important role in addressing myths surrounding childbirth

 –  Treatment of phobia: eg CBT (its goal is to change patterns of thinking or behaviour behind people’s difficulties in order to change the way they feel)

 –  Treatment of any co-existing anxiety/ depression/ OCD/ other mental health condition

 –  ‘Psycho-educative’ counselling programmes

 –  The caesarean section may be necessary in some cases.

 –  Debriefing consultation for women with previous traumatic birth

 –  Practicing mindfulness

 –  Self-hypnosis in labour

 –  Aurora clinic: this is a multidisciplinary clinic in Sweden (consisting of a midwife, Obstetrician, psychologist and psychiatrist) to support women with tokophobia during pregnancy (12)

What is the role of an Elective (planned) Caesarean section in women with tocophobia?

Although there are many risks associated with the Caesarean section, many women with tocophobia request this procedure even if there is no other medical (obstetric) reason to do so. It is important to remember that it is vital to treat anxiety and phobia (and other psychological symptoms) adequately related to tocophobia regardless of the decision regarding the delivery (vaginal or Caesarean section). Therefore, the NICE guideline (2011) suggests that if a woman requests a planned Caesarean Section (for her intense anxiety regarding childbirth) then she should be referred to the perinatal mental health team to treat her anxiety. The caesarean section could be offered to her if she feels that this is the only acceptable option for her after a detailed discussion and support (13).

There is research data to suggest (14) that if the Caesarean Section is not granted under these circumstances, then there are higher risks of developing postnatal depression and posttraumatic stress disorders (PTSD).

Can men be affected with Tocophobia?

Scientific evidence is emerging to suggest that men can also suffer from tocophobia too. A study from Sweden showed that 13% of fathers could be affected. The father might worry about safety the of their female partner and the child during the delivery process, their parenting capacity, financial issues and responsibilities as the father. They may encourage their partners to request for a planned Caesarean Section (2). Treatment of tocophobia in men includes treatment of the anxiety and phobia, explanation and reassurance of the childbirth process, teaching them relaxation techniques and parenting education (15).

 

Conclusion

Tocophobia could be a very debilitating condition but with good supportive multidisciplinary care, an excellent outcome is possible. Many women (and men) could not speak out about their symptoms due to guilt and shame. It is a good practice to ask about any fear related to pregnancy and childbirth process both at booking and at subsequent antenatal visits. It is important to explore any such concern and address them with empathy and respect.

 

References

1) Wijma K, Wijma B. A woman afraid to deliver: How to manage childbirth anxiety. Bio-Psycho-Social Obstetrics and Gynaecology: A Competency-Oriented Approach. Springer International Publishing Switzerland (2017). (Link)

2) O’Connell M, et al., Tocophobia – the new hysteria? Obstetrics, Gynaecology and Reproductive Medicine (2015). http://dx.doi.org/10.1016/j.ogrm.2015.03.002

3) Hofberg, K., Brockington, I.F. (2000). Tokophobia: an unreasoning dread of childbirth. A series of 26 cases. The British Journal of Psychiatry, 176, 83- 85.DOI: 10.1192/bjp.176.1.83

http://bjp.rcpsych.org/content/176/1/83/full-text.pdf+html

4) Marce.L. V (1858) Traité de la folie des femmes enceintes, accouchées et des nouvelles des Nourrices. Paris: Bailliere

5) Alessandra, S., Roberta, L. (2013). Tokophobia: When Fear of Childbirth Prevails. Mediterranean Journal of Clinical Psychology 1(1), 1-18. Available online: https://www.researchgate.net/publication/307730913_Tokophobia_when_fear_of_childbirth_prevails

6) Melender HL. Experiences of fears associated with pregnancy and childbirth: A study of 329 pregnant women. Birth. 2002; 29(2): 101-111. (  https://www.ncbi.nlm.nih.gov/pubmed/12051188  )

7) O’Connell MA, Leahy-Warren P, Khashan AS, Kenny LC, O’Neill SM. Worldwide prevalence of tocophobia in pregnant women: systematic review and meta-analysis. Acta Obstet Gynecol Scand 2017 (https://www.ncbi.nlm.nih.gov/pubmed/28369672 )

8) Jaju S, Al Kharusi L, Gowri V. Antenatal prevalence of fear associated with childbirth and depressed mood in primigravid women. Indian journal of psychiatry. 2015 Apr;57(2):158

9) Räisänen S, Lehto SM, Nielsen HS, Gissler M, Kramer MR, Heinonen S. Fear of childbirth in nulliparous and multiparous women: a population‐based analysis of all singleton births in Finland in 1997–2010. BJOG: An International Journal of Obstetrics & Gynaecology. 2014 Jul 1;121(8):965-70.

10) Otley, H. (2011). Fear of childbirth: Understanding the causes, impact and treatment. British Journal of Midwifery, 19, 215–220. (  https://www.magonlinelibrary.com/doi/citedby/10.12968/bjom.2011.19.4.215  )

11) Alehagen S, Wijma B, Lundberg U, Wijma K (2005) Fear, pain and stress hormones during childbirth. J Psychosom Obstet Gynaecol 26(3): 153–65

12)Waldenström U, Hildingsson I, Ryding EL (2006). Antenatal fear of childbirth and its association with subsequent caesarean section and experience of child- birth. BJOG 113(6): 638–46 (  http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2006.00950.x/full  )

13) NICE (2011): Caesarean Section (CG 132). National Institute of Clinical Excellence (UK). Link: https://www.nice.org.uk/guidance/cg132/chapter/Key-priorities-for-implementation

14) Olieman et al. The effect of an elective cesarean section on maternal request on peripartum anxiety and depression in women with childbirth fear: a systematic review

BMC Pregnancy and Childbirth (2017) 17:195 (Link:

 https://www.ncbi.nlm.nih.gov/pubmed/28629393 )

15) Ganapathy T (2015) Tokophobia among first time expectant fathers. International Journal of Psychiatric Nursing 1: 99-106. Link: https://www.omicsonline.org/open-access/tokophobia-among-first-time-expectant-fathers-2167-1044-S3-002.php?aid=62201