Catriona Jones, Faculty of Health Sciences, University of Hull (@Free_wheeler68)
Fear of childbirth is conceptualised along a continuum, with women who are almost free of fear at one end, and women with severe or disabling fear (known as tokophobia) at the other. For some women, severe fear of childbirth can have debilitating effects. Some women will avoid pregnancy, even though they might want to have children. For those who do become pregnant, the condition can overshadow pregnancy and affect the choices they make for labour and birth. They have specific risks in relation to their clinical state, including severe levels of anxiety and depression and the risk of post-traumatic stress disorder (PTSD) (NHS London Clinical Networks, 2018). For some women, self-harm and suicide risk may increase as pregnancy progresses, and increasing proximity to delivery is associated with increasing anxiety. Risks to the baby/fetal risk include termination of pregnancy, potential difficulties with bonding and attachment and potential problems associated with on-going anxiety in pregnancy, such as the negative impact on emotional and developmental outcomes in the longer term (NHS London Clinical Networks, 2018).
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. Practitioners have greater awareness of the impact of anxiety on pregnancy and childbirth and are more likely to encourage women during antenatal consultations, to discuss any fears or anxieties. Whilst practitioners seem to be encountering women who are more able to talk about their fears, not all of these women will be recognised clinically as tokophobic, however a number of cases will require additional clinical support beyond that of routine maternity care.
Across the fear of childbirth literature, there is a lack of consistency over the way tokophobia is defined, and this adds to a lack of clarity about prevalence rates. While rates in Western countries have been identified as over 20% (Demsar et al, 2018)), an Australian study has quoted a rate of 48% for moderate tokophobia and 26% for strong (Fenwick et al, 2009)). Other studies referring to a ‘pathological and disabling fear of birth’ have used a range of 6-10% to highlight the prevalence (Kjærgaard et al, 2008; Searle et al, 1996). There is 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.
Women with extreme disabling levels of fear warrant referral to specialist midwifery or perinatal mental health services. The aim of the referral is to help them to address the anxiety/fear in a supportive manner. In areas where specialist services are available, women are referred by their midwife or obstetrician, for support and/or psychological treatment and to help coordinate their care. This process takes time, and it is vital that referrals are made in the earlier stages of pregnancy, in order to ensure that the work of the specialist services can make meaningful differences to the women’s condition. Anecdotal and research evidence indicates that women need timely referrals for treatment and support facilitated by a pathway of care. This has been shown to improve the experience of pregnancy, childbirth and the postpartum period significantly (NHS London Clinical Networks 2018). Where a pathway of care is available, and timely referral is made, women are offered a clear plan of care for pregnancy and birth, they are provided with consistency of care, and have input from a specialist midwife. Women can be provided with opportunities to visit the birth environment and meet labour ward staff, develop a birth plan which includes decision making about how the baby will be born, and where necessary, engage in the necessary psychological interventions from a mental health team.
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, the fear of childbirth literature does indicate that the media’s treatment of birth in general, both mainstream and social, may play a part in setting birth up as a negative experience (Stoll et al, 2014; Fenwick et al, 2010; Fleming et al, 2014; Sheen & Slade, 2017). However, it is important that women share their birth stories, and social media can provide a very useful platform for them to learn from each other. Like-minded peer support mechanisms, including the use of parenting forums, have been found to be extremely helpful for women who experience perinatal mental health problems (Jones et al, 2014). Clearly, there is a tension: how can the needs of both groups of women be met – 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. Research into this aspect of perinatal mental health is ongoing.
Fear of childbirth exists on a scale, there are varying levels from normal to pathological. Perinatal mental health researchers and service providers should 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.
References
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.
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
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. doi.org/10.1016/j.midw.2008.10.011.
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): doi.org/10.1080/02646838.2014.886104
Hofberg K, Brockington I. Tokophobia: an unreasoning dread of childbirth. Br J Psychiatry 2000; 176: 83-5.
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.
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.
Searle J. Fearing the worst – why do pregnant women feel at risk? Aust N Z J Obstet Gynaecol 1996; 36: 279 – 86.
NHS London Clinical Networks. Fear of childbirth (Tokophobia) and traumatic experience of childbirth: Best practice toolkit 2018; NHS London.
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.
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.