Tokophobia

Tokophobia also called maieusiophobia or parturiphobia, is a pathological fear of pregnancy and can lead to avoidance of childbirth ¹. Fear of childbirth interfering with the woman’s daily functioning is a severe form of tokophobia and referred to as a pathological fear ². Tokophobia was first described in literature by Knauer in 1897 ³. Tokophobia can be classified as primary or secondary ¹. Primary tokophobia is morbid fear of childbirth in a woman, who has no previous experience of pregnancy. The dread of childbirth may start in adolescence or early adulthood. Although sexual relations may be normal, several different methods of contraceptive use to delay the pregnancy is often scrupulous ⁴. Generally pregnancy is avoided because of fear of labor. Some suffering women go for abortion, caesarean, or adoption ⁵. Secondary tokophobia is morbid fear of childbirth developing after a previous negative or traumatic experience of childbirth, sometimes related to posttraumatic stress disorder (PTSD) ⁶. However, it could also occur after an obstetrically normal delivery, miscarriage, stillbirth, or termination of pregnancy. Less commonly, prenatal depression may be present with tokophobia ⁷. About 20-78% of pregnant women report fears associated with the pregnancy and childbirth ⁸. However, 13% of non-gravid women report fear of childbirth sufficient to postpone or avoid pregnancy ⁸. Fears are more common and more intense in nulliparous (a woman who has never given birth) than in parous women ⁹.

The prevalence of tokophobia in Western countries is over 20% ¹⁰. An Australian study found that 48% of women reported moderate tokophobia and 26% exhibited strong fear of childbirth ¹¹. Pathological “disabling” fear of childbirth ¹ is felt in about 6%–10% of the pregnant women ¹². Studies have shown that fear of childbirth has a significant impact on delivery outcome ¹³, resulting in a dramatic increase of cesarean births ¹⁴.

The better the support system, the lesser is the antenatal stress load. Most of the women with fears seek support from their spouses, mothers, sisters or other family members, while some look to friends and colleagues for support ¹⁵. Sjögren and Thomassen ¹⁶ had shown that support for women with severe fear of delivery resulted in a 50% reduction in the rates of caesarean section births for psychosocial indications. Cognitive behavior therapy (because of short duration, lack of deep analysis, and focus on a specific symptom) and psychotherapy (aimed at controlling emotions and feelings) give satisfactory results ⁸. Pharmacotherapy is used to treat anxiety, depression or underlying psychiatric disorder ⁵. Prenatal and antenatal education ¹⁷ and antenatal screening tests certifying normalcy ¹⁸ is an effective way to alleviate fears. Preventive programs for management of pregnancy-related fears should be implemented in modern obstetrics. This would facilitate satisfactory delivering experience.

Tokophobia causes

Pregnancy and anxiety related to childbirth are very common in women. The cause of tokophobia is multifactorial and can be associated with different combinations of predisposing factors such as susceptibility to anxiety or depression ¹⁹ and other psychiatric disorders ²⁰, well-being in interpersonal relationships ²¹, experience of sexual abuse and traumatic experience of former birth ²². Some women described themselves as lonely ²³ or with a low self-esteem ²⁴. In addition, a sociocultural context exists that influences perception and expression of fear of childbirth suggesting a social and personal background ²⁵.

The various hypotheses put forward to explain fear of childbirth include disturbance in neurohormonal homeostasis (i.e., disturbance in mechanisms regulating anxiety) ²⁶, social communication (relationships with women who had undergone traumatic births) ¹⁵, fears related to medical care (ineffective pain control, fear of loss of control or death, and lack of confidence in team providing care) ¹⁶, psychosocial factors (e.g., younger age, low education, and social disadvantage), and psychological factors (e.g., low self-esteem, lowered pain sensitivity, revival of traumatic memories of childhood or psychiatric disorders commonly depression or anxiety) ¹⁷.

Risk factors for tokophobia

Important risk factors for tokophobia are anxiety and depression ²⁷. Storksen et al.  ¹⁹ found that depression is a better predictor than anxiety.

It has also been established that sexual activity before and during the current pregnancy is a good predictor of fear for childbirth. There are significant differences in experiencing tokophobia between women with and without a satisfactory sexual activity ²⁸. Scientists found that sexual satisfaction deteriorated for some women during the current pregnancy compared to the pre-gravid period. Compared with the period before conception, women have intercourse less frequently, are less satisfied, and have more sexual problems during the 2nd and 3rd trimester.

Fear of loss of control was a significant predictor of fear of childbirth, right after fear of experiencing intolerable pain. Fear is also significantly associated with having a preferred mode of delivery ¹⁴ and as shown in this study ²⁸, women who would definitely opt for a vaginal delivery were the least afraid in comparison to those that would definitely choose a cesarean section. Higher the fear, the more they tend to have cesarean section. It is also interesting that despite advances in medicine and modernization, fear of death during parturition does still exist.

Tokophobia treatment

Several studies found a 6% incidence of pathological tokophobia requires clinical treatment ¹³. The better the support system, the lesser is the antenatal stress load. Most of the women with fears seek support from their spouses, mothers, sisters or other family members, while some look to friends and colleagues for support ¹⁵. Sjögren and Thomassen ¹⁶ had shown that support for women with severe fear of delivery resulted in a 50% reduction in the rates of caesarean section births for psychosocial indications. Cognitive behavior therapy (because of short duration, lack of deep analysis, and focus on a specific symptom) and psychotherapy (aimed at controlling emotions and feelings) give satisfactory results ⁸. Pharmacotherapy is used to treat anxiety, depression or underlying psychiatric disorder ⁵. Prenatal and antenatal education ¹⁷ and antenatal screening tests certifying normalcy ¹⁸ is an effective way to alleviate fears. Preventive programs for management of pregnancy-related fears should be implemented in modern obstetrics. This would facilitate satisfactory delivering experience.

References

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