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Sixty seconds on . . . tokophobia

BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3933 (Published 17 September 2018) Cite this as: BMJ 2018;362:k3933

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.

28 September 2018
Lucy N Lewis
Medical Student
Dr Selina Nath-Post-doctoral research associate and Professor Louise Howard-NIHR Research Professor
University of East Anglia, Department- Norwich Medical School
Section of Women’s Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, De Crespigny Park, London SE5 8AF, UK.