Maternal fear associated with pregnancy and childbirth

1. Is it common to have fear associated with pregnancy and childbirth?
Pregnancy and childbirth are usually associated with joy and excitement but can also bring about fear and anxiety to some. Fear can be of different degrees. A relatively new medical term called ‘tokophobia’ is used for severe fear of childbirth.

In a study involving 882 pregnant women in Ireland (1), the overall prevalence of severe fear of childbirth and high fear of childbirth were found to be 5.3% and 36.7% respectively. First-time mothers had significantly higher prevalence of high fear of childbirth compared with those who had delivered before (43% versus 33.6%). In another study involving 329 Finnish pregnant women using a different research questionnaire, 78% expressed some degrees of fear towards childbirth (2).

In Hong Kong, we have previously looked into this using the same questionnaire of the Finnish study (3). Three hundred low-risk Chinese pregnant women attending a public obstetrics unit were recruited. All participants expressed some degrees of fear towards pregnancy and childbirth. Twenty-two percent of participants had considered an elective cesarean section due to fear of childbirth.

Therefore, even among low-risk pregnant women, fear towards pregnancy and childbirth is frequently experienced.

2. What are women mostly afraid of?
In our study (3), the 4 main objects of fear are:

• ‘process of childbirth’
• ‘child’s and mother’s wellbeing’
• ‘problems with health care staff and lack of control over events’ and
• ‘family life after delivery’.

Our findings were similar to the Finnish study (2) but their study has also identified ‘caesarean section’ as an additional main object of fear.

3. What are the risk factors and underlying causes of fear?
The Irish study (1) has identified ‘first-time mothers’, ‘single marital status’, ‘low perceived informational support’ and ‘depression’ as risk factors for high fear of childbirth. 

In our study (3), the four factors identified as causes of fear for the overall subjects were:

• ‘negative stories’
• ‘negative attitude or mood’
• ‘alarming information’
• ‘family or medical history’

For those who have delivered before, the 2 most significant factors were:

• ‘negative experience of the baby’s health’
• ‘negative experience with previous pregnancy and childcare’.

4. What could be the manifestation of fear?
For both the Finnish and our local study (2,3), The five areas identified were:

• ‘stress symptoms’
• ‘wish to avoid pregnancy and childbirth’
• ‘alterations in daily activities’, 
• ‘feeling of uncertainty and lack of enjoyment’
• ‘wish to have a caesarean section’

In another large prospective study in Denmark, 25,297 women in their first pregnancy with spontaneous labour were assessed (4). Fear of childbirth in early (16 weeks) or late (31 weeks) pregnancy was shown to be associated with an increase in emergency caesarean section. The main reason was slow progress of labour. This observation of longer duration of labour process among women with fear of childbirth has also been made by another study in Norway (5). The underlying cause is unknown.

5. Management of fear of childbirth

• Some form of fear of childbirth is common. There is no need to hide or feel incompetent;
• Important to identify the objects of fear and to express them to your health-care providers;
• Health-care providers should identify the underlying risk factor(s) or cause(s) for the fear and hopefully counselling can help. It is also important to suspect depression as the cause;
• Some data have suggested the benefit of antenatal counselling either on one-to one basis or in groups (6-7);
• It is also important to realise that some women may still have high fear of childbirth and negative birth experience despite counselling (8). Given the association between fear of childbirth and prolonged labour (5) and emergency caesarean section (4), women with high or severe fear of childbirth should be given the choice of elective caesarean section if they so prefer after adequate counselling.