Majority of US Women Have Tokophobia, a Fear of Childbirth, According to New Survey

New research reveals that many women in the United States suffer from tokophobia, an extreme fear of childbirth, particularly exacerbated by the COVID-19 pandemic. Despite being well-studied in other countries, such as Scandinavia where screenings are common for pregnant women, there has been a lack of research on tokophobia in the US.

Dartmouth researchers conducted a study in April that looked at factors predicting fear of childbirth and how the pandemic impacted rates of tokophobia in the US. “Our results showed really high rates of childbirth fear in our sample,” said first study author Zaneta Thayer, PhD, associate professor of anthropology at Dartmouth College. “Since there’s no pre-pandemic US data, we cannot compare our data to that context, but we know that the rates are very high compared to other international studies on the subject that have been published pre-pandemic.”

These high rates of tokophobia may also reflect the generally distressing birthing environment in the US, where maternal mortality rates reached an all-time high in 2021. “Our findings illustrate that pregnant people are stressed in the US birth environment and that they are not getting the emotional support they need,” said Thayer. “And the COVID-19 pandemic just added to those fears.”

To determine the rates of tokophobia in the US, researchers analyzed data from the COVID-19 and Reproductive Effects (CARE) study, a survey that examined how COVID affected pregnant people’s healthcare experiences and wellbeing. Prenatal data came from 1,775 participants, some of whom also shared postpartum data, between April 2020 and February 2021 – during the height of the pandemic. Researchers gave each participant a score on the fear of birth scale (FOBS) to identify clinical tokophobia. The majority of women surveyed – 62% - were found to have tokophobia. Black women in particular were significantly more likely to have a fear of childbirth compared to white mothers.

Participants in the lowest household income category, with the least amount of education, and who had high-risk pregnancies or pre-existing health conditions also had higher rates of tokophobia. Fear that COVID would impact their health, the health of their infants, or their overall birthing experience was common, with many worried that an unborn child would be affected if the mother tested positive for the virus or that a baby would be taken away at birth if a parent tested positive. Potentially having to give birth alone was also a common source of fear, with 86.9% of participants reporting concerns that they would not have extra support during labor.

People who experienced tokophobia were 91% more likely to have a preterm birth, or birth before 37 weeks of pregnancy. However, an infant’s birth weight did not seem to be affected by fears of childbirth. “When the fear response is triggered during labor, it may affect progression, length, and delivery outcomes,” said Sharon Ben-Rafael, PsyD, a clinical psychologist with expertise in prenatal mental health.

Though more research is needed to determine how and why tokophobia impacts birth outcomes, researchers noted that this study and previous research suggests any kind of maternal stress can impact gestation length, as well as other pregnancy outcomes.

“Active depression and anxiety in pregnancy are associated with shorter pregnancies, lower birth weights, [and] higher risks of complicated deliveries and admissions to the NICU,” Dr. Robakis said, adding that it’s also associated with “developmental changes in the baby’s brain as well as measurable long-term impacts on children’s emotions and behavior.”

Ben-Rafael added that tokophobia has the potential to affect childbirth-related choices regarding medical care. Dr. Robakis noted that tokophobia especially requires treatment if it gets to that point—for example, if that intense fear drives decisions like having a C-section.

The high rates of tokophobia in the U.S. aren’t necessarily surprising to experts, as America is fraught with health disparities, including for expectant parents.

“The fact that we have no national system of public health insurance makes childbirth much more fraught here than elsewhere,” Dr. Robakis said. “Between variable healthcare coverage and no mandated national paid maternity leave, having a baby puts many new parents under significant financial strain.”

Inequities in the U.S. healthcare system—including racism in obstetric care for Black mothers, according to study authors—may also help explain the high rates of tokophobia in historically underrepresented groups.

Statistically, minorities face more birth-related deaths. Black women are three times more likely to die from a pregnancy-related cause than white women. People of color are more likely to be uninsured than their white counterparts, creating a bigger divide in available resources.

“I would speculate that tokophobia could be a not-totally-illogical response to the reality of the birth outcomes landscape,” Dr. Robakis emphasized.

A small step toward alleviating tokophobia in the U.S. may be to include screening and treatment for it as standard maternal health care. “Prior research has shown that treating childbirth fear can reduce it and improve confidence in one’s ability to give birth,” Thayer said in the news release.

More research on fear of childbirth in the U.S. would also be beneficial to help inform healthcare providers about care and treatment options.

In the meantime, people who know they have a strong fear of childbirth should bring it up to their physician who may be able to provide help, or resources to find another healthcare professional who has experience treating and managing tokophobia with tools like cognitive behavioral therapy (CBT).

“Trepidation about childbirth is very common,” Dr. Robakis said, “but [you should] probably start thinking seriously about treatment if the fear becomes impairing.”