Sixty seconds on . . . tokophobiaBMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3933 (Published 17 September 2018) Cite this as: BMJ 2018;362:k3933
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What is tokophobia?
Tokophobia, commonly known as a severe, pathological or disabling fear of childbirth, is defined differently across studies. Whilst historically the term has been associated with the avoidance of pregnancy due to a phobia of childbirth (1), more recently it has been recognised as an extreme and severe fear response, expressed mainly by pregnant women to the prospect of childbirth.
What are the prevalence rates?
The lack of consistency over the way it is defined creates a lack of clarity about prevalence rates. While rates in Western countries have been identified as over 20% (2), an Australian study has quoted a rate of 48% for moderate tokophobia and 26% for strong (3). Other studies referring to a ‘pathological and disabling fear of birth’ have used a range of 6-10% to highlight the prevalence (4, 5). There is also the additional lack of clarity over whether these figures relate solely to pregnant women, or if they include women who have never entered maternity services due to the avoidance of pregnancy. Not all women with tokophobia are pregnant women.
Is it on the increase?
Because of the varied definitions it is difficult to say if the numbers of women experiencing an extreme and severe fear are increasing. In addition, the benchmarking of tokophobia rates is further complicated by the fact that it has only recently been described in the academic literature in any great detail. What is noticeable however is that clinically, practitioners are encountering increasing numbers of women with varying levels of anxiety and fear about the prospect of giving birth. This may be due to women feeling more able to report their fears, or an increasing awareness on behalf of practitioners about perinatal mental health more broadly. So, whilst practitioners seem to be encountering women who are more able to talk about their fears, and not all of these women will be recognised clinically as ‘tokophobic’, a number of cases will require additional clinical support beyond that of routine maternity care.
What can be done to help women with problematic levels of fear?
Our goal is always to ensure women get the right support at the right time, and having a pathway of care which identifies a level of fear and anxiety which is problematic, or has the potential to become problematic, and provides an appropriate level of support and treatment is key to helping women. We presented at the British Science Festival to discuss our collaborative work with health professionals, specialist practitioners and service users on the development of a fear of birth care pathway, in response to a need for early detection and treatment of fear that goes beyond ‘normal’ levels. A significant part of the presentation focused on the importance of measuring fear and being able to understand and identify when it deviates from an expected level to a problematic level.
What does the evidence say?
It is vital that the available options within the pathway are evidence based and reflect research findings presented in scientific peer reviewed journals. With this in mind, from looking at some of the fear of childbirth literature, we can suggest that the media’s treatment of birth in general, both mainstream and social, may be playing a part in setting birth up as a negative experience (6, 7, 8, 9). Despite the attention-grabbing headlines from the British Science Festival, it is not advisable that women stop sharing their birth stories. We have found that like-minded peer support mechanisms, including the use of parenting forums, have been extremely helpful for women who experience perinatal mental health problems (10). Clearly, there is a tension here, the question being –how do you meet the needs of both groups of women? Those who want to tell their stories and find it helpful and cathartic and those who, we know from the evidence, have become more fearful as a consequence of reading and hearing them.
Fear of childbirth exists on a scale, there are varying levels from normal to pathological. Perinatal mental health researchers and service providers need to work collaboratively to develop pathways of care to ensure that all women who experience a fear of childbirth that affects daily functioning and negatively impacts upon pregnancy get the right support in a timely manner, so that their psychological and pregnancy needs are met. Professor Julie Jomeen and myself are midwives, lecturers and researchers. Professor Jomeen has over 20 years of research expertise which has distinct relevance to contemporary clinical practice and service development. Together we have a national/international reputation for research and strategy work in perinatal mental health supported by a strong record of publication, conference and invited papers. The main messages coming out of this work should be that by providing high quality care for all women, we can diminish the chances of women developing tokophobia after their first birth and also the amount of negative birthing stories that women are sharing.
1. Hofberg K, Brockington I. Tokophobia: an unreasoning dread of childbirth. Br J Psychiatry 2000; 176: 83-5.
2. Demsar K, Svetina M, Verdenik I et al. Tokophobia (fear of childbirth): prevalence and risk factors. J Perinat Med 2018; 46 (2): 151 – 154. doi: 10.1515/jpm-2016-0282
3. Fenwick J, Gamble J, Nathan E et al. Pre and postpartum levels of childbirth fear and the relationship to birth outcomes in a cohort of Australian women. J Clin Nurs 2009; 18 (5): 667 – 77. doi: 10.1111/j.1365-2702.2008.02568.x
4. Kjærgaard H, Wijma K, Dykes A et al. Fear of childbirth in obstetrically low-risk nulliparous women in Sweden and Denmark. J Reprod Infant Psych 2008; 26: 340 – 50.
5. Searle J. Fearing the worst – why do pregnant women feel at risk? Aust N Z J Obstet Gynaecol 1996; 36: 279 – 86.
6. Stoll K, Hall W, Janssen P et al. Why are young Canadians afraid of birth? A survey study of childbirth fear and birth preferences among young Canadian University students. Midwifery 2014; 30 (2): 220 – 226. doi: 10.1016/j.midw.2013.07.017.
7. Fenwick J, Staff L, Gamble J et al. Why do women request caesarean section in a normal, healthy first pregnancy? Midwifery 2010; 26 (4): 394 – 400. doi.org/10.1016/j.midw.2008.10.011.
8. Fleming S, Vandermause R, Shaw M. First-time mothers preparing for birthing in an electronic world: internet and mobile phone technology J Reprod Infant Psychol 2014; 32 (3): doi.org/10.1080/02646838.2014.886104
9. Sheen K, Slade P. Examining the content and moderators of women’s fears for giving birth: a meta synthesis. J Clin Nurs 2017; 27 (13-14) 2523 – 2535: doi: 10.1111/jocn.14219.
10. Jones C, Jomeen J, Hayter M. The impact of peer support in the context of perinatal mental health. Midwifery 2014; 30 (5) 491 – 498: doi: 10.1016/j.midw.2013.08.003.
Competing interests: No competing interests
Fear of childbirth in Focus
As Mayor reports in ‘Sixty seconds on...’ (1), the extreme fear of childbirth or tokophobia has recently received much attention (2, 3). Whilst it is normal to experience fear of childbirth to some extent 4, tokophobia impacts women’s daily lives, and has been associated with depression, insomnia, longer labours, increased epidural use, previous Caesarean section and is a risk factor for Post-Traumatic Stress Disorder (PTSD) (5-7).
Our understanding of tokophobia has increased exponentially over the last three decades (8). Previous large epidemiological studies from Scandinavia have reported that fear of childbirth may be a predictor for women’s postnatal mental health. A large Swedish study (n=1,642) suggested that the majority of women with fear of childbirth had neither anxiety nor depression, but the presence of anxiety or depression increased the prevalence of fear of childbirth (9). An important finding from a large population-based Finnish study (n=788,317) was that in women without a history of depression or postnatal depression, women with high levels of fear of childbirth are almost three times as likely to experience postnatal depression, than those without or with low levels of fear of childbirth in the antenatal period (5-10). Furthermore, the strongest risk factor for fear of childbirth in one pregnancy is fear of childbirth in a previous pregnancy (11). Thus, all healthcare providers need to recognise and address fear of childbirth as early as possible.
The focus should be on working with women to reduce and manage their fear, rather than simply focussing on the mode of birth. Reasons for fear of childbirth can be complex, therefore, women need a personalised care plan. The Lancet series on perinatal mental health specifically identified non-psychotic mental health issues as an area which requires urgent action (13). Given the compelling evidence of the economic burden of perinatal mental disorders to society in the long term, we suggest that women’s emotional well-being needs to balance with the economic cost of delivery (12). The current challenge in maternity care is to provide women with a positive birth experience that allows women to emerge emotionally, psychologically and physically intact.
1. Mayor S. Sixty seconds on... tokophobia: British Medical Journal Publishing Group, 2018.
2. Jones C, Jomeen J. Fear of Childbirth. British Science Festival. University of Hull, 2018.
3. Moore S. Don't tell women to shut up about childbirth. Sharing Stories saves lives. Guardian 2018 13 September 2018. https://www.theguardian.com/commentisfree/2018/sep/13/women-childbirth-s...
4. Rondung E, Thomtén J, Sundin Ö. Psychological perspectives on fear of childbirth. Journal Of Anxiety Disorders 2016;44:80-91. doi: 10.1016/j.janxdis.2016.10.007
5. Raisanen S, Lehto SM, Nielsen HS, et al. 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 and Gynaecology 2014;121(8):965-70.
6. Adams S, Eberhard‐Gran M, Eskild A. Fear of childbirth and duration of labour: a study of 2206 women with intended vaginal delivery. BJOG: An International Journal of Obstetrics & Gynaecology 2012;119(10):1238-46.
7. Ayers S, Bond R, Bertullies S, et al. The aetiology of post-traumatic stress following childbirth: a meta-analysis and theoretical framework. Psychological Medicine 2016;46(6):1121-34. doi: 10.1017/S0033291715002706
8. O'Connell MA, Leahy-Warren P, Khashan AS, et al. Worldwide prevalence of tocophobia in pregnant women: systematic review and meta-analysis. Acta Obstet Gynecol Scand 2017;96(8):907-20. doi: 10.1111/aogs.13138
9. Storksen HT, Eberhard‐Gran M, GARTHUS‐NIEGEL S, et al. Fear of childbirth; the relation to anxiety and depression. Acta Obstetricia et Gynecologica Scandinavica 2012;91(2):237-42.
10. Räisänen S, Lehto SM, Nielsen HS, et al. Fear of childbirth predicts postpartum depression: a population-based analysis of 511 422 singleton births in Finland. BMJ Open 2013;3(11):e004047-e47. doi: 10.1136/bmjopen-2013-004047
11. Storksen HT, Garthus-Niegel S, Vangen S, et al. The impact of previous birth experiences on maternal fear of childbirth. Acta Obstetricia et Gynecologica Scandinavica 2013;92(3):318-24.
12. Howard LM, Piot P, Stein A. No health without perinatal mental health. The Lancet 2014;384(9956):1723-24.
13. Howard LM, Molyneaux E, Dennis C-L, et al. Non-psychotic mental disorders in the perinatal period. The Lancet 2014;384(9956):1775-88.
Competing interests: No competing interests
Tokophobia is rare but fear of childbirth is common
Tokophobia is a specific phobia of childbirth i.e. an overwhelming, debilitating fear of childbirth, which can be so intense that childbirth is avoided (1). We recently investigated the prevalence of anxiety disorders in pregnancy (measured just after women’s first antenatal appointment), using the Structured Clinical Interview for DSM-IV (SCID-1) (2) and reported that they are common (3)– the population prevalence of anxiety disorders was 17% (95% CI 12% to 21%), including 8% (95% CI 5% to 11%) for specific phobia. We did not include data on the prevalence of tokophobia as it was rare but we can report here that the estimated population prevalence was 0.032% (95% CI: 0.0044 – 0.23) (for more details of study methods, see Howard et al 2018) (4).
However, the term tokophobia sometimes gets conflated with fear of childbirth. Fear of childbirth is a spectrum of fearful thoughts and feelings surrounding childbirth that exists on a continuum i.e fear of childbirth can consist of low (and normal) fear to severe fear that impacts on a woman’s daily functioning (5). Fear of childbirth is most commonly identified using the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ), a validated tool for measuring fear of childbirth, with a cut off of 85 differentiating between low fear and clinically severe fear of childbirth (6). Using this cut-off we estimated a population prevalence of severe fear of childbirth of 3.7% (95%CI: CI:2.1-6.6) in our inner-city London maternity population using this questionnaire at around 28 weeks gestation (7).
In addition to fear of childbirth being mistaken for tokophobia, some women may be mistakenly diagnosed with tokophobia after a traumatic birth when they actually have symptoms of PTSD (8). It is important to differentiate post-childbirth trauma related symptoms from primary tokophobia to establish the treatment needed (8).
Tokophobia is, therefore, a rare phobic disorder, whereas fear of childbirth exists on a continuum. Nevertheless whether tokophobia, PTSD or fear of childbirth at clinically significant levels are present, it is important to identify and support women through pregnancy, including psychological interventions where appropriate, and inform them about their delivery choices (8).
1. NHS. Phobias NHS health A-Z2016 [Available from: https://www.nhs.uk/conditions/phobias/.]
2. First, MB, Spitzer, RL, Gibbon, M, Williams, JB. Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Patient Edition. Biometrics Research, New York State Psychiatric Institute, 2002
3. Nath S, Ryan EG, Trevillion K, Bick D, Demilew J, Milgrom J, et al. Prevalence and identification of anxiety disorders in pregnancy: the diagnostic accuracy of the two-item Generalised Anxiety Disorder scale (GAD-2). BMJ Open. 2018;8(9):e023766.
4. Howard LM, Ryan EG, Trevillion K, Anderson F, Bick D, Bye A, et al. Accuracy of the Whooley questions and the Edinburgh Postnatal Depression Scale in identifying depression and other mental disorders in early pregnancy. Br J Psychiatry. 2018;212(1):50-6.
5.Wijma K. Why focus on 'fear of childbirth'? J Psychosom Obstet Gynaecol. 2003;24(3):141-3.
6. Wijma K, Wijma B, Zar M. Psychometric aspects of the W-DEQ; a new questionnaire for the measurement of fear of childbirth. J Psychosom Obstet Gynaecol. 1998;19(2):84–97.
7. Lewis L. Fear of Childbirth, mental health and delivery outcomes: a cohort study of women in an inner city maternity service, BSc dissertation, Kings College London, 2018.
8. NICE Antenatal and Postnatal Mental Health Guidance. https://www.nice.org.uk/guidance/cg192
Funding/support: The data collection reported here was funded by the National Institute for Health Research (NIHR) under the Programme Grants for Applied Research programme (ESMI Programme: grant reference number RP-PG-1210-12002) and the National Institute for Health Research (NIHR) / Wellcome Trust Kings Clinical Research Facility and the NIHR Biomedical Research Centre and Dementia Unit at South London and Maudsley NHS Foundation Trust and Kings College London. The study team acknowledges the study delivery support given by the South London Clinical Research Network. The senior author also has salary support from an NIHR Research Professorship (NIHR-RP-R3-12-011). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, the Department of Health
Competing interests: Prof Howard was chair of the NICE CG192 guideline. There are no other competing interests.