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HomeEditor's PickTokophobia levels rise, linked to early births – US study

Tokophobia levels rise, linked to early births – US study

Preterm births have, for the first time, been linked to tokophobia – a pathological fear of childbirth – with an online survey finding that in the early days of the Covid-19 pandemic, it affected most American women: 62% of pregnant respondents reported high levels of fear and worry about childbirth.

Earlier studies have linked preterm birth to psychosocial stress, but this survey, of nearly 1 800 women, is the first to find an association with tokophobia, according to Dr Zaneta Thayer, an anthropologist at Dartmouth College, who led the research.

When Thayer had asked students in her evolution class what words sprang to mind when they thought of childbirth, almost all of them were negative: pain, screaming, blood and fear, The New York Times reports.

Then she asked if any of them had ever seen a woman give birth. Most had not.

Curious about how cultural attitudes and expectations affect the physical experience of childbirth and its outcomes, Thayer began a study to assess the prevalence of tokophobia, with surprising results – published in the journal Evolution, Medicine and Public Health.

Some level of apprehension about childbirth is universal. It may be an adaptive behaviour favoured by evolution that prompts women to seek out assistance and emotional support during labour, said Karen Rosenberg, professor of anthropology at the University of Delaware.

“Other animals may give birth in a social context, but humans are the only primates that actively and routinely seek assistance at birth,” said Wenda Trevathan, a senior scholar at the School for Advanced Research in Santa Fe, an anthropology think tank.

Extreme pathological fear may be maladaptive, however, causing some women to have unnecessary Caesarean sections or to refrain from becoming pregnant.

The new study has limitations. The prenatal and postpartum data were collected during the first 10 months of the pandemic, when the healthcare system was under extreme duress. The sample was not nationally representative, consisting of a disproportionate percentage of white and higher-income women.

Half of the women had never given birth, and more than one-third had experienced high-risk pregnancies.

More than 80% them said that because of the pandemic, they were worried they would not have the support person they wanted in the hospital with them while in labour, that their baby might be taken away if they were diagnosed with Covid, or that they might infect their baby if they had the virus.

Black mothers, who face almost three times the risk of dying from pregnancy-related complications, were almost twice as likely to have a strong fear of childbirth as white mothers.

“Black women are more likely to have complications or die in childbirth,” one pregnant woman said in her response, adding that her concern was heightened because she was not assured she would have a relative or advocate in the hospital with her because of Covid. “Who’s going to speak up for me?”

Women with tokophobia were almost twice as likely to have a preterm birth, or a baby born before 37 weeks of gestation, the study found. Preterm babies are more likely to have health problems and are at higher risk for disability and death, often spending time in neonatal intensive care.

The connection does not prove a causal relationship between fear and preterm birth. But the risk of preterm birth among women with high levels of fear and worry remained high even after adjustments were made for other factors, such as Caesarean sections.

The study also found links between fear and higher rates of postpartum depression and the use of formula to supplement breastfeeding. It did not find an association between tokophobia and a higher rate of C-sections or low birth weight among newborns.

Thayer said that fear of childbirth might be “an under-appreciated contributor to health inequity”.

“Women who fear unfair treatment and discrimination in obstetrical settings possibly have greater fear of childbirth, which could increase complications across the perinatal period,” she said.

In the US, black women experience more preterm births than any other race or ethnic group; the rate is about 50% higher than that of white women. About 14% of black infants are born preterm, compared with slightly more than 9% of white and Hispanic infants.

Fear of childbirth was higher among all socially disadvantaged women, including lower-income women and those with less education. Women who were single, those who were receiving care from an obstetrician and those who were having their first child, were also more likely to be more fearful.

Women with high-risk pregnancies and those suffering from prenatal depression were also more likely to fear childbirth, Thayer found.

Study details

Childbirth fear in the USA during the Covid-19 pandemic: key predictors and associated birth outcomes

Z M Thayer, S A Geisel-Zamora, G Uwizeye, T E Gildner

Published in Evolution, Medicine, and Public Health on 13 April 2023


Background and objectives
Childbirth fear, which has been argued to have an adaptive basis, exists on a spectrum. Pathologically high levels of childbirth fear is a clinical condition called tokophobia. As a chronic stressor in pregnancy, tokophobia could impact birth outcomes. Many factors associated with tokophobia, including inadequate labor support, were exacerbated by the Covid-19 pandemic.

We used longitudinally collected data from a convenience sample of 1775 pregnant persons in the USA to evaluate the association between general and Covid-19 pandemic-related factors and tokophobia using the fear of birth scale. We also assessed associations between tokophobia, low birth weight and preterm birth when adjusting for Caesarean section and other covariates among a subset of participants (N = 993).

Tokophobia was highly prevalent (62%). Mothers who self-identified as black (odds ratio (OR) = 1.90), had lower income (OR = 1.39), had less education (OR = 1.37), had a high-risk pregnancy (OR = 1.65) or had prenatal depression (OR = 4.95) had significantly higher odds of tokophobia. Concerns about how Covid-19 could negatively affect maternal and infant health and birth experience were also associated with tokophobia (ORs from 1.51 to 1.79). Tokophobia was significantly associated with increased odds of giving birth preterm (OR = 1.93).

Conclusions and implications
Tokophobia increases the odds of preterm birth and is more prevalent among individuals who are black, have a lower income, and have less education. Tokophobia may, therefore, be an underappreciated contributor to inequities in US birth outcomes. The pandemic likely compounded these effects.


Evolution, Medicine, and Public Health article – Childbirth fear in the USA during the Covid-19 pandemic (Open access)


The New York Times article – Many women have an intense fear of childbirth, study finds (Restricted access)


See more from MedicalBrief archives:


A woman dies every two minutes in pregnancy or childbirth: UN report


Surge in the number of C-sections around the world


Racism blamed for more black maternal deaths – UK report


SA Society of Obs/Gynaes: Pandemic having ‘dire consequences’ for women


Delta variant increases COVID-19 risks for pregnant women






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