Fear of birth is becoming increasingly recognised as a clinical issue that can have profound effects on the mother and her experience of pregnancy and birth. Failure to identify women with fear of birth could lead to them feeling isolated and unsupported, and affect their psychological health and the health of their baby. There is, however, much confusion around terminology and no consensus on what constitutes fear (Richens, 2016), which makes it very difficult when attempting to assess prevalence and incidence of fear of birth or tocophobia.
Following a recent episode of Call the Midwife, there was a flurry of tweets on social media regarding the case of the woman depicted in the programme. These tweets confirmed the lack of understanding of fear of birth, tocophobia and post-traumatic stress disorder (PTSD).
The episode showed a woman having her second baby. This was not a planned pregnancy, and it became clear that she did not want to birth this baby, due to a previous traumatic forceps birth that resulted in flashbacks. The trauma and effects of the first birth were so severe that the woman had considered a termination. The question raised was, does this woman have secondary tocophobia, or PTSD?
The concept of fear of birth was introduced in 1980s (Areskog, 1981). Before this, fear of birth was not legitimised as a medical condition, as anxiety and fear were recognised as part of the transition to motherhood. Today, nearly four decades later, fear of birth is something that is better understood and accepted.
In the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association (APA), 2000) the following statement was added, which highlighted the effect of stressful situations:
‘Stressful situations in which a person had experienced, witnessed, or was confronted with an event that involved actual or threatened death or serious injury, or a threat to physical integrity of self or others.’ (APA, 2000: 467)
The same year, tocophobia was described and classified as:
‘When this specific anxiety (fear of parturition) or fear of death during parturition precedes pregnancy and is so intense that tokos (childbirth) is avoided whenever possible, this is a phobic state called “tokophobia”.’ (Hofberg and Brockington, 2000: 83).
It has been suggested that PTSD is a retrospective phenomenon following birth trauma (Leeds and Hargreaves, 2008). While it is recognised that PTSD is a separate psychological disorder to fear of birth, PTSD may be a consequence of a previous birth experience (Ayers, 2007), and it is possible that PTSD may coexist with a fear of subsequent pregnancy/birth, resulting also in secondary tocophobia.
The fact remains, however, that there is no agreed definition and there is often confusion when terms are used interchangeably. This suggests that there is a continuum of fear of birth, with anxiety at one end and tocophobia at the other.
Is is therefore essential that midwives acknowledge and understand tocophobia, fear of birth and PTSD and know how to support women experiencing these conditions.
Tocophobia is a complex condition, and women need to be supported by a range of health professionals, including perinatal mental health specialists.
To define fear of birth, it is important to try to understand what it is and how it has entered mainstream midwifery practice. Clinically, it is important to distinguish the differences between anxiety, fear of birth and tocophobia, so that, as with any medical condition, the problem can be identified and an effective treatment plan developed. A key challenge now is to differentiate between and diagnose anxiety, fear of birth and tocophobia, so that the most effective treatment can be provided to women. Assessing the differences between the conditions will be the first step towards the development of validated screening tools for diagnosis.
Note – this article appeared originally in the British Journal of Midwifery, March 2018, Vol 26, No 3
Acknowledgments: Centre for Nursing and Midwifery UCLH Fellowship Award
Areskog, B. Uddenberg, N. Kjessler, B. Fear of childbirth in late pregnancy. Gynecol Obstet Invest. 1981;12(5):262-6
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th text revision edn). American Psychiatric Association. Washington DC: 2000
Ayers S. Posttraumatic Stress Disorder. In: Cockburn J. Pawson ME (eds). Psychological Challenges in Obstetrics and Gynaecology:The Clinical Management. London: Springer Verlag; 2007: 131–40
Hofberg K, Brockington I.Tokophobia: an unreasoning dread of childbirth.A series of 26 cases. Br J Psychiatry. 2000; 176(1): 83-5
Leeds L, Hargreaves I.The psychological consequences of childbirth. J Reprod Infant Psychol. 2008; 26(2):108-22
Richens Y. Investigation into fear of birth using a mixed methods design. PhD Thesis, University of Manchester; 2016