Opinion: providing support can reduce many of the common fears experienced by women about pregnancy

By Maeve Anne O'Connell, Cardiff University

Childbirth is a fundamentally human and meaningful time. All women hope for a joyful, positive birth experience. However, the birth process is uncertain, so it is normal to experience anxiety, worries or childbirth-related fear.

An Irish study found that 37% of pregnant women had high levels and 5% had severe levels of childbirth fears. Levels of fear can fluctuate during pregnancy and usually increase as birth becomes imminent. Common fears experienced by women are safety concerns, fear of pain in labour, fear of the unknown, fear of being left alone in labour or fear for the baby's health. If women are prepared, supported in their choices and have respectful maternity care, fear can be reduced in pregnancies. Even an emergency situation which could be perceived as traumatic may be experienced as positive for the woman.

In ancient times, primordial fear served a purpose and a fight or flight response was triggered for survival. This type of fear may be counterproductive as there is a physiological response to the feared stimulus. The amygdala, or fear centre in the brain, releases stress hormones such as cortisol and adrenaline which can affect the ability to make decisions.

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From RTÉ Radio 1's Drivetime, two expectant mothers about their fears in relation to childbirth and Covid-19, and Professor Fergal Malone, Master of the Rotunda Hospital, talks about maternity care during the pandemic

This may happen for women experiencing high fear, impacting decision-making around labour and birth. For some women childbirth-related fear is extremely incapacitating. It negatively impacts sleep and can cause anxiety and depression. Avoidance behaviours characteristic of phobic states may be experienced. Antenatal appointments may be missed, engaging with conversation about the pregnancy or baby may be avoided, and preparation for birth or motherhood avoided because of feelings of disgust or fear of the process. It may be difficult to talk to their partner or family about and this may cause feelings of isolation.

A severe fear of childbirth is associated with lower birth satisfaction, negative birth experiences and Post-Partum Post Traumatic Stress Disorder. Infant bonding issues may be experienced. Fear of childbirth may also be passed on through generations from mother to daughter, affecting self-efficacy in the ability to give birth.

Fear can juxtapose a balance of risk avoidance and risk taking, meaning that some women will mitigate their risk by having more medical interventions and choosing Caesarean birth. Fearful partners may also influence birth choices. Nevertheless, fear may not resolve and women may still experience birth trauma or low birth satisfaction if adequate support is not perceived or if they have a negative encounter with a health care professional.

From RTÉ Radio 1's Today show, Professor Anthony McCarthy, Consultant Psychiatrist at the National Maternity Hospital, on mental health and pregnancy

Some women may fear unnecessary intervention, lack of control or not being involved in birth decisions. An Australian study found there were three groups of women: those who were 'fearful' had safety concerns and high levels of fear; those who 'take it as it comes’ and ‘self-determiners’ who had low levels of fear and perceived birth as a natural process. 

The term ‘tokophobia’ was coined in psychiatry in 2000. Primary tokophobia occurring in women who have never experienced childbirth. Indirect transmission through information such as horror stories of birth may trigger fear. Not surprisingly, there is an association with unplanned pregnancy, intimate partner violence, rape and sexual abuse. Pregnancy can evoke occult memories or flashbacks of abuse. Since one in three women has experienced sexual intimate partner violence, this may be common.

Helen Mirren identified as someone who experiences primary tokophobia through vicarious exposure to childbirth education in school at the age of 13. "I swear it traumatized me to this day," she told an Australian interviewer in 2007. "I haven't had children and now I can’t look at anything to do with childbirth. It absolutely disgusts me." For women who have experienced fear conditioning or learned association secondary to birth trauma, this has been classified as secondary tokophobia.

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From RTÉ Radio 1's Liveline, listeners talk about childbirth fears

A study estimated a prevalence of 14% tokophobia worldwide, with growing interest in the research field over the last decade. This estimate does not include the women at the phobic level of fear who were so fearful they chose not to get pregnant or had an abortion due to fear. A lack of consensus on definition was found and high heterogeneity amongst prevalence studies was noted.

What this tells us is that the issue is extremely complex. A variety of measures were used and the Wijma Delivery Expectancy Questionnaire, which is recognized as ‘gold standard’, is cumbersome, not easily understood by women and there is now doubt that it encompasses relevant concepts. The terms ‘tocophobia’ and ‘fear of childbirth’ remain poorly defined and are used to encompass a broad range of emotional challenges related to anxiety and fear in pregnancy. 

Fear of childbirth may also be passed on through generations from mother to daughter

Because of this confusion, the terms have become interchangeable by clinicians and the general public over the last decade. However, using the term tokophobia may not always be accurate or helpful in pregnancy. The fear may not be psychopathological or experienced by women requiring psychiatric assessment and treatment, but rather normal and rational, caused by medical routines, increased pressure on health systems, staffing issues and reduced availability of support. In two trials, for example, women who had midwifery support for fear of childbirth did not feel listened to or understood, as they felt their obstetrician was not sympathetic.

We need to normalise the conversation around childbirth fear. We need to take it seriously, be sensitive to individual needs and empower women to ensure a positive birth experience. Further research is needed to understand the causes of tokophobia in order to provide evidence-based interventions.

Dr Maeve Anne O'Connell is a Senior Lecturer in Midwifery at Cardiff University. 

The views expressed here are those of the author and do not represent or reflect the views of RTÉ