What is Tokophobia?

Although pregnancy and childbirth can be a joyful time for many expectant parents, for others, it is a time filled with fear, anxiety and panic. As many as 80% of pregnant women report experiencing fear in anticipation of childbirth. However, for some people, that fear can develop into tokophobia.

It is approximated that between 2.5% and 14% of expectant parents experience tokophobia every year. Today, we are going to look at tokophobia in more detail, including the common causes, symptoms and possible treatments.

What is tokophobia?

Tokophobia is a pathological fear of pregnancy and childbirth. The fear can be so extreme that it leads to complete avoidance of pregnancy and childbirth, even in those who want to have children. Alternatively, a person with tokophobia may request a caesarean birth, instead of a vaginal birth.

Tokophobia can be classified in two ways:

• Primary Tokophobia:
  An extreme fear of childbirth in someone who has no previous experience of childbirth. This can develop at any time in your life, including during your first pregnancy.
• Secondary Tokophobia:
  An extreme fear of childbirth that develops, usually, after a traumatic childbirth during a previous pregnancy. Secondary tokophobia can also occur in people who have experienced a stillbirth, miscarriage, or failed fertility treatment. In some cases, secondary tokophobia can occur after a previous pregnancy where there was no trauma.

Tokophobia is a type of specific phobia. A specific phobia is a lasting, overwhelming and unreasonable fear of a specific object, situation, activity or person, in this case, an overwhelming fear of childbirth. To be classified as a phobia, your fear of childbirth must be irrational, overwhelming and persistent.

Pregnancy and childbirth are major life events and result in significant physiological and psychological changes. While some people have a positive reaction to and experience of pregnancy, for others it can be a time of great stress, fear and anxiety. Being fearful and apprehensive about childbirth can be completely normal and something that many people experience.

However, these fears can usually be alleviated by learning more about childbirth, speaking to their doctor or midwife, speaking to family and friends and joining pregnancy and birthing groups. If your fear of childbirth is overwhelming and irrational, meaning no amount of positive information or reassurance can calm you and it impedes your desire to have a baby or give birth naturally, you may be experiencing tokophobia.

In some people with tokophobia, their fear is so extreme that they avoid sexual activity to ensure they cannot get pregnant.

If a person with tokophobia does become pregnant, they may:

• Request an elective caesarean birth.
• Refuse to engage with doctors, midwives and other medical staff.
• Experience extreme fear, anxiety and panic throughout the pregnancy.
• Have difficulty bonding with their baby.
• Choose to have an abortion.
• Choose to put their baby up for adoption because of the lack of emotional connection to their pregnancy.

Although most commonly experienced by the person who is pregnant, tokophobia can also occur in the non-pregnant parent. They may feel a lack of control and fear for the safety of their partner and baby during the birth.

The non-pregnant parent can experience fear relating to the labour and delivery processes, the potential medical treatments, the possibility that they may need to make life-changing decisions and their overall capability to cope with the situation.

Tokophobia can be related to other phobias and mental health conditions, including:

• Post-traumatic stress disorder (PTSD), following a previous traumatic childbirth.
• Previously experiencing postnatal depression or postpartum psychosis.
• Parent anxiety – the feelings of fear, anxiety or stress related to being a parent.
• Thanatophobia – an extreme fear of death or dying.
• Nosocomephobia – an extreme fear of hospitals.
• Latrophobia – an extreme fear of doctors or medical tests.
• Haemophobia – an extreme fear of blood.
• Haphephobia – an extreme fear of being touched.
• Paedophobia – an extreme fear of children.

How common is tokophobia?

Feelings of fear and anxiety about giving birth are extremely common, with as many as 80% of pregnant women experiencing negative emotions in the lead-up to childbirth. Negative feelings in relation to childbirth occur on a spectrum, from low levels of fear to severe fear that can impact a person’s ability to function in their day-to-day life or significantly affect their decision-making.

You may experience fear and anxiety in relation to childbirth for several reasons, such as:

• The hormonal changes that you experience during pregnancy.
• Hearing frightening stories from other people about childbirth.
• A lack of confidence in or a fear of hospitals and doctors.
• Having a low pain threshold.
• Having a poor or no support system.
• Already having anxiety, depression or a panic disorder.
• Being afraid of the unknown.

However, if self-help techniques, social support, the learning of information and medical support do not help to alleviate these worries, the fear may be pathological, and you may have tokophobia.

Because some people with tokophobia never seek treatment for their phobia or purposefully avoid becoming pregnant, accurate figures about the prevalence of tokophobia are not available. Research suggests that between 2.5% and 14% of people are affected by tokophobia, although some studies put this figure as high as 22%. The statistics vary so significantly because some researchers only account for people with severe tokophobia, whereas others consider people with varying degrees of severity. Determining the difference between tokophobia and a fear of childbirth can be difficult.

Who is at risk of tokophobia?

Although anyone can develop tokophobia, certain risk factors can increase the likelihood of you developing tokophobia.

Some of the risk factors include:

• If you have a history of anxiety, depression or panic attacks.
• If you have another condition related to tokophobia, such as PTSD or nosocomephobia.
• Previously experiencing sexual abuse, sexual assault, sexual violence or rape.
• Having a lack of support from a partner or family and friends during pregnancy.
• Becoming pregnant at a young age.
• Having a previous traumatic pregnancy or childbirth experience.
• Being exposed to the fear of childbirth during childhood or adolescence.
• A close family member also having tokophobia.
• A lack of information or knowledge about pregnancy and childbirth.
• Being a naturally anxious or nervous person.

However, even if you have one or more of the above risk factors, this does not mean you will develop tokophobia. A person with no risk factors who has never had a negative or traumatic experience relating to pregnancy or childbirth can still develop the condition.

On the contrary, someone who had a previous traumatic pregnancy and has a history of anxiety and depression may never develop tokophobia.

How to deal with tokophobia

Although medical treatment is available, there are certain coping strategies you can learn to help you deal with, alleviate or prevent the symptoms of tokophobia.

Some people with tokophobia may think the best way to deal with their phobia is to avoid situations where their symptoms may manifest. However, this may not be the most effective long-term strategy, as it may prevent you from having a child and can result in more severe symptoms if you are ever faced with a childbirth situation, for example, if a close family member or friend becomes pregnant or a childbirth scene is shown during a TV show or film.

Learning how to deal with your tokophobia and implementing coping strategies can help you to relieve the symptoms of your phobia more effectively.

If you are pregnant or thinking of becoming pregnant, some of the most effective coping strategies include:

• Discuss how you are feeling with your doctor or midwife or a close family member or friend as they may be able to provide reassurance and help to ease your worries.
• Form a birthing plan that helps you feel in control and helps you to prepare for your labour. This can include your pain management strategy, your medication and treatment preferences and your preferred delivery method.
• Avoid hearing negative or traumatic birthing stories, as these can worsen your symptoms. Instead, speak to people who you know had a positive birthing experience.
• Enrol in prenatal classes, such as labour and birthing classes, prenatal exercise classes and prenatal support classes. This can help you to feel more prepared for the birth and can help you connect with other expectant parents.
• Speak to a psychologist or other mental health professional who can help you identify the root cause of your phobia and learn coping strategies.
• Try meditation or hypnobirthing, as these can help you to relax during your pregnancy and labour.
• Learn facts and information about pregnancy and childbirth, as having the relevant knowledge can help you to recognise that the risks are low.
• Practise self-care, including ensuring you get enough sleep and eating a healthy, balanced diet.
• Practise deep breathing techniques.
• Learn visualisation techniques to help keep you calm or reduce your feelings of anxiety.
• Tour the hospital and birthing areas in advance so that you know what to expect.
• Reduce stress in your everyday life.
• Remind yourself that your fear is not rational, and the risks are low.
• Join a support group to connect with other people who have experienced tokophobia.

Telling your doctor or midwife about your fears as early as possible is recommended. You can then be referred to a psychologist or mental health specialist who can help to support you throughout the pregnancy. Being aware of your phobia will also ensure all medical staff who come into contact with you during your pregnancy are understanding of your condition and treat you accordingly.

If following your treatment you are still experiencing tokophobia, you can speak to your doctor to request a planned caesarean birth.

What triggers tokophobia?

Tokophobia can be triggered by a variety of different things. You may have one single trigger or multiple factors that trigger your phobia.

Some of the most common triggers that can result in you developing tokophobia are:

• A fear of pain.
• A fear of losing control.
• A fear of the unknown.
• Uncertainty or a lack of information about pregnancy and childbirth.
• Fearing for the life or wellbeing of your unborn baby.
• A fear of birth-related complications, including pre-eclampsia, vaginal injuries and death.
• A lack of trust in doctors and other medical practitioners.
• Hearing scary or traumatic birthing stories.
• Feeling a lack of control or that you are pressured into having a vaginal birth.

If you have tokophobia, there are many different things that can trigger your symptoms. Different people have different triggers, depending on the severity and cause of their phobia.

The most common triggers for a tokophobia episode are:

• Finding out you are pregnant, whether planned or unplanned.
• Attending your first medical appointment for pregnancy.
• Undergoing a medical examination.
• Hearing about childbirth.
• Watching a TV show or film where a character is pregnant or giving birth.
• Hearing traumatic birth stories from other people.
• The hormonal changes experienced during pregnancy.
• Planning your birthing experience.
• Reaching pregnancy milestones.
• Having sexual intercourse.
• Waiting for your period or your period being late.
• Someone close to you, such as a family member or friend, becoming pregnant.

What are the symptoms of tokophobia?

The symptoms of tokophobia can differ from person to person. Some people may experience mild symptoms, whereas others experience severe symptoms. Some people with tokophobia also find that their symptoms vary in different situations, depending on the perceived danger, their current wellbeing and mental state and their coping strategies.

Some people also only experience symptoms in relation to themselves and their own pregnancy and childbirth. Other people experience symptoms of tokophobia in other situations, such as if a family member or friend becomes pregnant or they see childbirth on the TV.

Although the symptoms of tokophobia can differ in different people, they are often similar to the symptoms of anxiety or panic attacks.

The symptoms can be both physiological and psychological and often include:

Physiological Symptoms:

• Sleep disturbances.
• A rapid heart rate or heart palpitations.
• Difficulties in breathing, such as hyperventilating, rapid breathing or shallow breathing.
• Tightening in the chest or chest pains.
• Shaking or trembling.
• Feeling dizzy or light-headed.
• Elevated blood pressure.
• Sweating, hot flushes or chills.
• Nausea, vomiting or diarrhoea.
• A dry mouth.
• A choking sensation.
• Confusion or disorientation.
• Numbness or tingling in your body.
• Severe headaches.
• Freezing or feeling unable to move.

Psychological Symptoms:

• Experiencing nightmares about childbirth.
• Avoiding becoming pregnant.
• Avoiding all sexual contact.
• Refusing to give birth naturally.
• Avoiding all medical and pregnancy-related appointments.
• Extreme fears relating to the risk of pain, injuries, birth defects, stillbirths or maternal death.
• Feelings of dread throughout the pregnancy.
• Not bonding with your baby or feeling emotionally detached.
• Feeling disconnected from your partner or other family members or friends.
• Trying to hide your pregnancy, avoiding talking about your pregnancy or living in denial about being pregnant.
• Immediate and overwhelming feelings of fear and panic when faced with childbirth or pregnancy.
• Feeling like you cannot breathe.
• An inability to control your feelings of fear, anxiety or panic.
• A fear of death or dying.
• A sense of impending doom.

What causes tokophobia?

There are multiple reasons why a person could develop tokophobia. It could be that your condition has one clear cause, or that multiple factors have contributed to you developing tokophobia.

The main causes of tokophobia are:

• Previously experiencing sexual abuse, sexual assault or rape
  A traumatic experience such as sexual abuse or rape, whether in childhood or adulthood can result in a person developing tokophobia. The traumatic experience can result in a fear of experiencing vaginal pain, losing control, undergoing medical examinations or of other people seeing or touching their vaginal area. If you have experienced sexual assault, sexual abuse or rape at any point in your life, getting help and support from a reputable organisation such as Rape Crisis or The Survivors Trust can help you to process and overcome your experience and deal with the negative impact it may be having on your life and mental health, including your tokophobia. You can also contact the police on 999 or 111 or by visiting your local police station to report the assault or abuse.
• Having issues with your reproductive system
  Previously experiencing gynaecological problems, including pain, injury, infections and birth defects, can result in an individual experiencing fear and anxiety in situations relating to their gynaecology, including in relation to childbirth.
• Experiencing a previous traumatic birth
  In secondary tokophobia, your phobia develops as a result of a previous traumatic pregnancy and childbirth experience. This may deter you from having future children or result in a traumatic second pregnancy.
• Hearing traumatic or scary birth stories
  An informational learning experience can result in you developing tokophobia, even though the experience didn’t happen to you. Hearing a frightening story from a family member or friend involving a traumatic birth, an injury to the mother or child or even a death during childbirth can result in extreme fear.
• A learned phobia
  If someone close to you, such as a close family member, has tokophobia, you can develop the condition yourself, in what is known as an observational learning experience. A learned phobia is more likely to develop if you are exposed to it during childhood or adolescence or at a time when you are already experiencing anxiety.
• Exposure to information that scares you
  This information could come from many sources, such as books, the media, the internet or even your doctor or a pregnancy group you attend. An informational learning experience usually involves you learning facts or information that scares you. Failure to take into account the very low likelihood of these experiences happening to you can result in you developing a phobia of childbirth.

How is tokophobia diagnosed?

Tokophobia can be difficult to diagnose, as many people who are pregnant experience fear and anxiety in relation to childbirth. Differentiating a fear from a phobia can be difficult. Furthermore, tokophobia is often misdiagnosed as post-traumatic stress disorder (PTSD), and vice-versa, with many of the characteristics of the two conditions being similar.

Tokophobia can also be more difficult to diagnose than other phobias because it is classed as a specific phobia. This means it is a phobia of a specific object, place or situation, in this case, the fear of pregnancy and childbirth. The diagnostic criteria used for diagnosing phobias do not list all the specific phobias individually, meaning tokophobia may be assessed using the diagnostic criteria for specific phobias in general.

If you think you have tokophobia, you should seek medical advice as soon as possible, especially if you are already pregnant or would like to have a baby in the future. An early diagnosis allows you to seek treatment and reduce your symptoms more effectively and can help to reduce the impact that your phobia has on your life and your decision-making.

If you are unsure whether your fear of childbirth is severe enough to be classed as tokophobia, consider whether it:

• Impedes your ability to function in your everyday life.
• Has a specific negative impact on your quality of life.
• Causes you to avoid certain situations or places.
• Has a negative impact on your mental health or wellbeing.

Your first step when seeking a diagnosis will be to visit your GP. Your GP will ask if you have previously experienced a traumatic pregnancy or if you have a history of anxiety disorders, panic disorders or extreme fears. Your GP may look at your medical history and your family history and may also perform a physical exam.

They will also look at any other conditions you are diagnosed with and any medication or supplements you take to ensure your symptoms cannot be attributed to another source.

If your GP suspects you have tokophobia, you will likely be referred to a psychologist. The psychologist will conduct a psychological evaluation and assess your symptoms. They will aim to determine whether you are experiencing a phobia or a fear. As part of your assessment, the psychologist will ask about previous pregnancies, whether anyone close to you has experienced tokophobia or a traumatic pregnancy, and any other factors which could have contributed to your fears.

They will also ask for information about:

• Your triggers.
• The type of symptoms you experience.
• When your symptoms first began.
• The frequency and severity of your symptoms.
• How much your fears and anxieties interfere with your everyday life or your decision-making (e.g. deciding not to have a child or electing for a caesarean birth).

To be diagnosed as having tokophobia, your symptoms will need to fit seven key criteria that make up the phobia diagnostic criteria:

1. The fear must be persistent, excessive and unreasonable. It can occur either when pregnant or not pregnant and can occur in relation to you or other people giving birth.

2. Exposure to triggers leads to an immediate anxiety response in the majority of situations.

3. The fear is excessive and disproportionate to the risk, and this is recognised by the individual.

4. The individual avoids places or situations relating to childbirth, for example avoiding becoming pregnant or having a vaginal birth. If faced with childbirth the individual will experience extreme fear, anxiety or distress.

5. The anticipation of childbirth and the avoidance behaviours associated with childbirth can have a significant impact on the individual’s day-to-day life.

6. The fear has lasted for a minimum of six months.

7. The phobia is not associated with another disorder or mental health condition.

If you fit these seven criteria, a diagnosis of tokophobia will be made and you will be offered relevant treatment.

How is tokophobia treated?

Treatments for tokophobia can vary depending on the severity of your symptoms and how significantly the phobia impacts your life and your overall health and wellbeing. Some people may not require treatment for their tokophobia. However, if your phobia is negatively impacting your daily life or impacts your decision to have a child or a vaginal birth, seeking treatment is recommended.

There are several different types of treatment available. Your doctor will create a treatment plan based on the severity of your phobia, your triggers, and the impact your phobia is having on your life.

The most common treatments for tokophobia are:

Cognitive Behaviour Therapy (CBT)

Cognitive Behaviour Therapy focuses on the thoughts and beliefs that centre around your phobia and how these affect you. CBT can help you change the way you think and feel and change any harmful or negative patterns of thoughts. CBT can also teach you coping strategies that you can implement if you are pregnant or become pregnant in the future.

As part of your CBT sessions you will:

• Discuss your triggers and symptoms.
• Explore what caused your tokophobia.
• Explore your fears in more detail.
• Learn how to recognise your negative thoughts and change the way you are thinking.
• Learn coping strategies.
• Learn calming strategies.

Hypnobirthing

Hypnobirthing aims to reduce the fear, anxiety and panic that you may feel in the lead-up to and during childbirth. It can also help you to manage your pain more effectively. Hypnobirthing uses a variety of relaxation and self-hypnosis techniques to prepare your body and mind for labour and childbirth.

As part of your hypnobirthing sessions, you will learn:

• Breathing techniques.
• Deep relaxation.
• Guided meditation.
• Visualisation.
• Positive suggestions and affirmations.

Rational Emotive Behavioural Therapy (REBT)

Rational Emotive Behavioural Therapy is another type of Cognitive Behaviour Therapy. It helps you to identify irrational and negative thoughts and unhealthy attitudes, emotions and behaviours related to pregnancy and childbirth. REBT is an action-oriented approach that helps you challenge irrational beliefs and manage the thoughts, emotions and behaviours related to childbirth in a more healthy way.

Medication

Depending on the severity of your symptoms, medication may also be recommended to treat the anxiety or panic attacks you experience as part of your condition. Medication may be used in conjunction with another type of treatment, such as CBT. Your doctor will take into consideration whether you are already pregnant or are planning to become pregnant soon before recommending medication.

Some medication that is used to treat tokophobia can include:

• Antidepressants.
• Anti-anxiety medication.
• Beta-blockers.

Relaxation and Visualisation

Learning different relaxation and visualisation techniques, such as mental imagery, guided imagery, deep breathing techniques, autogenic training and progressive muscle relaxation can help you to remain calm when faced with your triggers. Relaxation and visualisation techniques can help you remain calm if you are faced with childbirth in the future.