The Bottom Line

A fear of childbirth (and pregnancy) is common.  Although not much evidence-based information exists on how to best manage this fear, it appears the best strategy is for women to receive valid and accurate information from reliable sources regarding the labor and delivery process – as well as pregnancy itself. 

Women who are experiencing an intense fear of pregnancy or childbirth need to find an HCP they are comfortable with so they can express their questions, fears, and concerns in a safe and nonjudgmental place.

If women are really uncomfortable, they can write it down or email their HCP their topics of concern so HCPs can bring them up at their next appointment.

Women should also be aware of the different types of HCPs that can assist them during pregnancy to include midwives, doulas, registered nurses, and licensed counselors.

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Background

Fear of childbirth is common; even though women have been delivering babies since the beginning of humans, labor is still unpredictable, can change on a whim, and women can often feel like they have lost control. Further, for women who have never experienced labor pains before, the unknown is scary. 

Research has shown that about 80% of pregnant women have some level of fear, worry, and/or anxiety regarding pregnancy and/or childbirth.

Additionally, it is estimated that about 6% to 10% of pregnant women report severe nightmares related to their fear of childbirth.

However, some women have such intense and extreme fear and anxiety that it affects numerous aspects of their lives, to include avoiding pregnancy even though they strongly desire to have a child. During pregnancy, this can result in panic attacks, nightmares, and even depressive symptoms. This level of fear is considered a distinct clinical condition called tokophobia (‘tokos’ meaning childbirth).

The prevalence of tokophobia is hard to estimate but may be around 6% to 20% of pregnant women. It has been formally recognized since 1797 and can be categorized as primary or secondary:

Primary tokophobia is the fear that occurs in pre-pregnancy, and can begin as early as adolescence as women first begin to hear negative stories that surround labor.

Secondary tokophobia tends to develop after a traumatic obstetric event such as a miscarriage or stillbirth.

Causes

Women can be afraid of labor and delivery – and pregnancy – for numerous reasons. The most common reasons include a fear of the unknown and/or sense of ‘loss of control’.

Others reasons include a fear of:

  • No information, or no understanding of what is happening

  • Labor pain

  • Loss of privacy/dignity

  • Pregnancy/delivery complications or significant harm to the baby

  • A traumatic experience related to pregnancy

  • Lack of social support

  • Inability to give birth

  • Physical damage or tearing

  • Having a baby with birth defects or disabilities

  • Distrust of hospital staff

  • Motherhood in general

  • Cesarean delivery

  • Traumatic memories due to prior sexual assault

  • Death

Women may also have pre-existing concerns that can worsen during pregnancy. These may include: a fear of needles, fear of hospitals, fear of vaginal examinations, and social anxiety and panic disorders.

Complications of Fear

When a fear of labor is particularly severe, it is possible this fear could worsen certain physiological aspects of labor.  It is estimated that approximately up to 10% of women may experience such an intense fear of labor and delivery that it disrupts the labor process.

Women also shouldn’t be afraid of being afraid.

A certain amount of fear is considered healthy and can help women stay awake and alert to not only cope with the pain of labor, but maintain the energy necessary to push (Köroğlu et al. 2017).

Hormones that are activated during labor as a result of stress and fear increase complications for both mother and baby.

The hypothalamus portion of the brain forms a response to fear in the body by releasing hormones. However, this can reduce, and even prevent the release of hormones required for labor. 

Oxytocin, a hormone required for contractions, is secreted from the pituitary gland/hypothalamus. Therefore, any additional stimuli from the hypothalamus could suppress the secretion of oxytocin.

Additionally, epinephrine and norepinephrine (adrenaline and noradrenaline) are “fight or flight” hormones. Under any stressful situation that causes fear, anxiety, and/or excitement, these hormones are secreted from the adrenal glands which activates the sympathetic nervous system.

When the sympathetic system is activated, breathing becomes much faster, heart rate increases, blood pressure rises, and major blood vessels tighten.  Therefore, blood flow may decrease to certain organs, such as the uterus, which then cannot contract regularly. The baby may also receive less oxygen. These changes can also cause shaking and dizziness which could distract women from focusing, breathing slowly, and pushing.

However, these complications can be prevented.  The above effects illustrate how important it is that women talk to their HCP to manage any and all their concerns about their pregnancy.

If women learn more about pregnancy and labor and delivery, and understand the processes and the options available to them, their fears may lessen, which in effect may lessen labor pain, labor complications, labor duration, oxytocin use, cesarean section rates, and newborn complications as well as postpartum psychological problems.

Another type of complication from tokophobia includes unnecessary abdominal surgery (cesarean section).

A growing number of women are requesting delivery by “elective” cesarean section (c-section) without a conventional medical reason, or “cesarean delivery upon maternal request”. These types of deliveries have doubled over the past decade, with up to 18% of all c-sections done at the mother’s request.

Vaginal vs. Cesarean Delivery

Although cesarean section carries a higher risk of certain complications than vaginal delivery, it is not accurate to simply ask whether vaginal delivery or cesarean section is safer.  The safety of each comes down to many factors regarding an individual woman and her pregnancy.  While vaginal delivery could be the safest option for one woman, a cesarean may be necessary for another (the reverse is also true).

A fear of vaginal delivery is one of the reasons women specifically request a c-section, even when they do not need one. Some women believe that a c-section is safer (not always) and causes less pain (not always) than vaginal delivery.  Women may also wish to avoid tearing, contraction pain, and postpartum urinary complications (c-section does not always prevent the latter).

A c-section has many additional complications and women need to be made very aware of all risks and benefits associated with each type of delivery, specific to that woman’s pregnancy and overall health through a discussion with their HCP

HCPs appear to agree, however, that if a woman’s overall physical and mental well-being will benefit significantly with an elective c-section, and the fetus’ health is in good status, then she should receive one.  More information on elective c-section can be read here.

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Management

There is a lack of research regarding tokophobia, and therefore the best management techniques are unclear, and even the definition itself is inconsistent.

However, since one of the leading causes of a fear of childbirth and pregnancy is likely incomplete or misleading information, it is assessed that patient education, along with adequate social and emotional support, may be the best method. Further, better education has been linked to decreased pain perception, since women who are better informed have less stress, fear, and anxiety during labor.

Reality and unscripted television programs and YouTube videos that over-dramatize the birthing process, word-of mouth negative childbirth experiences, and false, negative, and fear-mongering stories on the internet can all potentially lead to an extreme fear of childbirth in some women.  Women need valid sources of information to correct the falsehoods that serve as the basis of their fear and anxiety.

Childbirth preparation classes are very valuable for most women, can be both public or private, and educate pregnant women and their spouses about labor and birth as well as many other aspects of pregnancy and newborn care.

At least one study indicated that in some women who received an enhanced 2‐hour childbirth education class at a maternity hospital had more relieved fears of childbirth in comparison to a standard childbirth education class.

Women should be careful when researching pregnancy and childbirth online; they should aim for valid and reliable sources, and be wary of social media stories that can sometimes be overly dramatic.

Women need to talk to their HCP about any concerns they have during pregnancy, in an attempt to determine what aspects of pregnancy, labor and delivery, or postpartum (parenting) concerns them the most, so the HCP can provide additional information with the goal of relieving those concerns.

For example, it is possible that after an in-depth discussion of the risks and benefits of vaginal delivery versus elective cesarean section with an HCP, some women may change their minds and prefer vaginal delivery instead, once they learn more about each type of delivery from a valid and reliable source.  Women may also fear labor pain less when they understand the safety of pain management options, to include epidurals.

It is critical that women find an HCP they are comfortable with. A strong perception of support and control during delivery reduces fear of childbirth and providers who understand this can help women avoid the possibility of birth trauma due to fear and anxiety.

Research has also indicated that adding motivational interviewing (MI) psychotherapy as an adjunct therapy to prenatal care may be very helpful for some women. MI psychotherapy promotes behavioral change and helps women through conflicting emotions about pregnancy and childbirth. MI psychotherapy, particularly group therapy, was shown to reduce the level of general anxiety of pregnant women.

HCP Support

Studies have shown that when women have pain during labor, it is highly important for them to have support from the HCPs who care for them.  Labor and delivery nurses are invaluable. They are trained to assess each woman as an individual; they also understand that the woman's pain is how she perceives it and that women deal with pain in different ways.

Midwives can also provide counseling to women as well and be made more available for discussion than some obstetricians.

Doulas are specifically trained to assist with pain and other emotional support during pregnancy, to include labor and delivery.

Some midwives, doulas, and nurses are also trained in the sensitivities of women delivering who were prior victims of sexual assault.

Read more information on these types of health care providers.

Psychotherapy, hypnosis, cognitive and behavioral exercises are also used as methods in coping with fear of labor.

Research has also shown that women who have a fear of childbirth can benefit from hearing positive stories from other women.

Actions

Women who are experiencing an intense fear of pregnancy or childbirth need to find an HCP they are comfortable with so they can express their questions, fears, and concerns in a safe and nonjudgmental place. If women are really uncomfortable, they can write it down or email their HCP for later discussion.

Women should also consider who their health care team members are, include people who will support them, and surround themselves with women who can offer them comfort when they need it, as well as positive advice and emotional support.

Women should make sure they are also reading valid and reliable information on the internet, recognizing that all women have different experiences related to pain, complications, symptoms, labor, and delivery.

Women should also try to find prenatal classes in their area, or ask their HCP for recommendations. Prenatal classes can be taught in groups, online, in private, and with partners.

Women should also consider sharing and submitting their experience below regarding their current fears of pregnancy or childbirth, or how they overcame those concerns. This could be very helpful for other pregnant women currently experiencing these fears.

Resources

What is Cognitive Behavioral Therapy? (American Psychological Association)

Hypnobirthing*

*Meant as a resource and not an official endorsement.

References

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