Intended for healthcare professionals

Rapid response to:


Sixty seconds on . . . tokophobia

BMJ 2018; 362 doi: (Published 17 September 2018) Cite this as: BMJ 2018;362:k3933

Rapid Response:

Re: Sixty seconds on . . . tokophobia

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.
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):
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

26 September 2018
Catriona Christine Graham Jones
Senior Research Fellow/Lecturer in Midwifery
Professor Julie Jomeen
University of Hull
Faculty of Health Sciences, University of Hull