Most of us are unfamiliar with a medical condition called tokophobia, which has been defined as “the pathological fear of pregnancy”, a term that derives from the Greek tokos, meaning “childbirth” and phobos, meaning “fear”. The condition is also known as maleusiophobia (from the Greek maieusis, literally meaning “delivery of a woman in childbirth” but referring generally to midwifery), parturiphobia (from the Latin parturire, meaning “to be pregnant”), and lockiophobia. The condition was first described in the literature by two German doctors, Oswald Knauer and A. Martin, in 1897. According to Dr. Kristina Hofberg, an expert in this topic, tokophobia is surprisingly common, affecting approximately one in six women.
The majority of women are able to cope up with the fear and anxieties of pregnancy with self-help efforts, social support, and medical help. What separates the little-known tokophobia from the usual anxieties of mothers-to-be is the depth of fear. Some tokophobes think they will die; others imagine something unbearable happening. The most common trait is a fear of vaginal birth, with no corresponding dread of caesarean sections (although some women find both prospects equally terrifying). For many, the idea of a baby growing inside them is deeply unsettling.
Primary tokophobia
This is a morbid fear of childbirth in a woman who has had no previous experience of pregnancy. The dread of childbirth may start in adolescence or early adulthood. Although sexual relations may be normal, she may painstakingly use several different methods of contraception to prevent pregnancy. Generally, pregnancy is avoided because of fear of labor. Some suffering women choose to have an abortion, elective caesarean section, or adoption.
Secondary tokophobia
This is defined as morbid fear of childbirth developing after a traumatic obstetric event in a previous pregnancy. However, it could also occur after an obstetrically normal delivery, miscarriage, stillbirth, or termination of pregnancy.
Julia, 28 years-old
“I was in my mid-20s when it occurred to me that the idea [of having kids] really has not grown on me at all,” wrote Julia, 28, who is disgusted by pregnancy. “The thought of being unfamiliar with my own body if it’s inhabited by a growing fetus gives me a lot of anxiety. A parasite growing in my body. Seriously. It just feeds from you, takes up space, sits on your bladder. Just get out.”
Case report described by Drs. Bhatia and Jhanjee
A 43-year-old married housewife of high socioeconomic status presented to the psychiatry out-patient department with a 2 year-history of morbid dread of pregnancy. This started 2 years after marriage, when she contacted a gynecologist for menstrual irregularity. She asked the physician about the complications of pregnancy. On hearing the dreaded potential complications (like having a malformed fetus, change in body figure, eclampsia, caesarean section, and even death), she developed excessive fear of pregnancy. When also informed that no contraceptive method is fully protective, she started avoiding sexual contact with her husband. On stopping all sexual activity, she gradually developed depression, hopelessness, helplessness, worthlessness, difficulty in falling asleep, weeping spells, loss of appetite and suicidal ideation. She also started having less interaction with her husband, parents, and other relatives. Even after being counseled by relatives and two obstetricians, she could not get rid of the fear of pregnancy. There was no past or family history of mood disorder, schizophrenia, epilepsy, or drug dependence. Her vital signs, routine investigations, and physical examination were all normal.
On mental state examination, she was a tidy, cooperative lady of rather weak body build. There were no disturbances in orientation or memory. Her mood was sad with reduced psychomotor activity and monotonous low volume speech. There were ideas of hopelessness and worthlessness and, also, feeling of guilt and suicidal ideation. There was no formal thought disorder. Insight and judgment were intact.
She was diagnosed as a case of tokophobia with major depressive disorder. She was started on medication and counseling weekly for about 2 weeks but there was no improvement. After an increase in the dose of medication, there was a reduction in her morbid fear of pregnancy along with symptoms of depression. She started having normal sexual activity. At follow-up, after 3 months while still on medication, there was no recurrence of symptoms.
Triggers of tokophobia
There are various hypotheses put forward to explain the crippling fear of childbirth: disturbance in neuro-hormonal equilibrium, cultural (for example, the mother passed down negative feelings about birth), experience of sexual trauma in the past, fears related to medical care (ineffective pain control, fear of loss of control or death, and lack of confidence in team providing care), psychosocial factors (e.g., younger age, low education, and social disadvantage), and psychological factors (e.g., low self-esteem, lowered pain sensitivity, revival of traumatic memories of childhood or psychiatric disorders commonly depression or anxiety).
The Oscar-winning actress Dame Helen Mirren admitted to suffering from tokophobia. She recently revealed her deeply held fear on an Australian television show, blaming a graphic video of childbirth shown to her as a 13-year-old schoolgirl for her childlessness ever since. “I swear it traumatized me to this day,” she said. “I haven’t had children and now I can’t look at anything to do with childbirth. It absolutely disgusts me.”
Prevention and treatment of tokophobia
The evidence indicates that the better the support system, the lesser will be the antenatal stress load. Most of the women with intense fear seek support from their spouses, mothers, sisters or other family members, while some look to friends and colleagues for support. Cognitive behavioral therapy and psychotherapy may provide satisfactory results. Pharmacotherapy can be used to treat anxiety, depression, or an underlying psychiatric disorder. Prenatal and antenatal education can be effective ways to alleviate fears. Finally, preventive programs for the management of pregnancy-related fears should be implemented in modern obstetrics to facilitate a satisfactory birthing experience.
