All living beings are entitled to the desire to start a family, and the physical action of falling pregnant and giving birth to a baby is a human right. However, for individuals living with tokophobia, this right can feel conflicting. Tokophobia is experienced as an extreme fear of pregnancy and birth (Ayers, 2014; Demšar et al, 2018; Nath et al, 2020). It can develop at any point across adolescence and adulthood and can affect men as well as women (Scollato and Lampasona, 2013; Ganapathy, 2015; Masoumi and Elyasi, 2021). Individuals living with tokophobia may feel an overwhelming fear of pregnancy and birth, despite the desire to become a mother or a father (Hofberg and Brockington, 2000; Hofberg and Ward, 2007; Anniverno et al, 2013). The fear can feel so extreme that some individuals may not feel able to entertain thoughts or discussions about starting a family. This can have significant implications on their relationships with their partners, potentially leading to relationship breakdowns (Ayers et al, 2006; Ayers, 2014; Fenech and Thomson, 2014; Delicate et al, 2020). Some women's fear of birth can be so severe it can lead to termination of pregnancy, despite their baby being wanted (Hofberg and Brockington, 2000; Hofberg and Ward, 2007; Nanjundaswamy et al, 2019; Jomeen et al, 2021).
There are a range of life events that could trigger the onset of this condition, some of which may include vicarious trauma regarding traumatic pregnancies and/or births, sexual abuse, a previous history of mental health problems and childhood attachment difficulties (Otley, 2011; Gutteridge and Richens, 2020). Research indicates that women who live with tokophobia who fall pregnant are more likely to request caesarean sections as their preferred mode of delivery because of how fearful they are about giving birth vaginally (Bewley and Cockburn, 2002; Otley, 2011; Betrán et al, 2016; Nilsson et al, 2018; Korabiusz et al, 2019). Nevertheless, there is a dearth of research on tokophobia (Onley, 2008; Aksoy et al, 2016; Wootton et al, 2020; Nunes, 2021). Furthermore, those training for careers in mental health, nursing and medicine do not necessarily receive specific training about the condition, meaning that tokophobia may often be overlooked or misunderstood. Research by Hofberg and Brockington (2000) found that women terminated their pregnancies, despite wanting their baby, because they were not able to have a caesarean section. The authors indicated that the absence of an empathic listener and relevant medical literature on the condition were factors that could have influenced the women's decisions to terminate their pregnancy because of tokophobia. As such, health professionals play a vital role in helping people with tokophobia to feel empowered to continue with their pregnancy and in finding ways to manage their anxiety (Ayers, 2014).
There is a rich evidence base of studies that examine the psychological and physical needs of women with perinatal mental health difficulties. Within this, anxiety disorders are considered (O'Hara et al, 2014; Ayers et al, 2015; Kingston et al, 2015). However, there is a significant lack of research exploring the impact of living with tokophobia (Aksoy et al, 2016; Wootton et al, 2020; Nunes et al, 2021), with even fewer studies exploring the implications for relationships and how men may experience the condition differently from women (Ayers, 2014; Moran et al, 2021). It is likely that living with tokophobia can lead to severe psychological distress, including depression, anxiety, low self-esteem and symptoms of traumatic stress (Ayers, 2014; Slade et al, 2019). Women with tokophobia are also more likely to develop post-traumatic stress disorder following childbirth (Schwab et al, 2012; Ayers, 2014; Isbit et al, 2016; Vignato et al, 2017). Women and men living with the condition are at risk of feeling misunderstood, which has implications for increasing mental health difficulties and experiencing strong feelings of guilt regarding their identity as a women/man, pregnant women/expectant father or new mother/father. For those with tokophobia who have recently had a baby, it could also impact on their bonding and attachment with their newborn (Otley, 2011; Gutteridge and Richens, 2020; Nunes et al, 2021).
As a condition, tokophobia falls under the umbrella term for specific phobias in diagnostic manuals including the International Classification of Diseases and the Diagnostic and Statistical Manual of Mental Disorders (DSM). Therefore, it does not hold its own diagnostic criteria in its own right. The National Institute for Health and Care Excellence (NICE, 2020) provides a guide for clinicians in England and Wales recommending gold standard interventions used to treat a range of mental health conditions. This also includes guidance for how to support women with a range of perinatal mental health problems. Tokophobia is featured very briefly in the NICE (2020) guidelines on treating specific mental health problems in pregnancy and the postnatal period. As such, pregnant women and expectant fathers presenting with tokophobia may not necessarily receive an evidence-based psychological intervention to help them with their symptoms because of a lack of attention to and awareness of this condition.
Proposed psychological model to support pregnant woman with tokophobia
This article discusses a psychological model that medical, health and mental health professionals working with pregnant woman and expectant fathers can use if they detect signs of tokophobia. It is worth noting that this can also be used for any individual with symptoms of the condition. To begin, it would be helpful for any professional working with pregnant women and their partners to be mindful of the signs to look out for that may indicate tokophobia. These signs may include (but are not limited to) the following:
- Individuals who cannot talk about seeing themselves pregnant or giving birth
- People who say they would like children, but indicate they are too scared to do so
- Emotional distress when talking about pregnancy or birth
- Avoidance of talking about pregnancy or birth
- Avoidance of attending antenatal appointments
- Arguments with partners regarding starting a family
- Nightmares regarding pregnancy or birth
- Intrusive thoughts and/or images about pregnancy or birth
- Relationship breakdowns regarding starting a family
- Thoughts of/requests to terminate the pregnancy because of fear of birth
- Guilt about any of the above.
There are a range of psychological models that can be used to understand mental health difficulties, including anxiety disorders and trauma. Indeed, a range of theories and models can be used to understand and make sense of tokophobia. Given individuals with tokophobia may be likely to have traumatic stress symptoms or post-traumatic stress disorder (Schwab et al, 2012; Isbit et al, 2016; Vignato et al, 2017), it could be helpful to conceptualise their presenting difficulties using a trauma informed model. Hobfoll et al (2007) developed a model for supporting those who have experienced traumatic events. The model suggests five empirically supported intervention principles, which include the promotion of a sense of safety, calming, a sense of self-and community efficacy, connectedness and hope. Health professionals, could draw upon Hobfoll's recommendations in supporting individuals with tokophobia using these principals. Table 1 outlines examples for how this model can be applied in clinical practice.
Table 1. Proposed model for supporting individuals with tokophobia based on Hobfoll et al (2007)
| Intervention principals* | Suggestions for use in clinical practice | Examples |
|---|---|---|
| Sense of safety | Show the person you are listeningUse calming and validating responses in talking to them about their fearsEncourage then to talk openly and honestly about how they are feeling*Offer regular appointments to review themTry to offer continuity, if possible, in terms of midwife and obstetrician in the antenatal period | ‘Thank you for sharing this with me’‘I am here for you’*‘It is ok to express feelings, such as sadness, anger, guilt, etc. This is a safe space for to do so without being judged’ |
| Calming | Normalise their responses†Tell them you will support them and want to help themGive encouraging statementsEncourage them to talk openly and honestly with you*Reassure them that whatever they tell you will not be judged | *‘It is normal to feel like this. Being pregnant and giving birth can feel frightening to many people and it is completely understandable that you are feeling like this’‘I can hear how hard this is for you’‘I am here for you’ |
| Sense of self and community efficacy | *Discussing any worries/concerns and empowering them to find manageable solutionsDiscussing what will help them to cope*Discussing referral to a qualified mental health professional for support | *‘What will help you to get through this?’‘How would you like me to help you through this?’ |
| Connectedness | Promotion of social supportPsychoeducation on self-care*Reflections on what they have done wellExplore whether they feel able to hear information about hypnobirthing and explain this can be offered one to one as well as a group setting | ‘Who would you like to support you through this?’‘How can they show you they are supporting you?’†‘What would others need to do in order for you to feel supported with this?’ |
| Hope | Discussions on how they can cope with how they are feelingEncouragement of positive coping behaviours and support*If talking to a pregnant woman with tokophobia, explore options that will help her to feel in control of how she can get through her pregnancy and birth | ‘What will be important to get through this?’*‘What will things looks like for this to feel achievable to get through?’*‘What will help you to feel more in control of your pregnancy and birth?’‘How ready do you feel to discuss ways to support you through the birth?’ |
There are a number of ways that medical and mental health professionals supporting individuals presenting with symptoms of tokophobia could intervene (Striebich et al, 2018; Delicate et al, 2020). Fisher et al (2006) state that positive relationships formed with midwives and wider support networks surrounding pregnant woman are important for supporting those with tokophobia. For health professionals working with pregnant women with this condition, the most important thing that can be done in the first instance is to listen and show support through use of empathic and validating statements. This will enable the individual with tokophobia to feel safe and contained. Discussion regarding a referral to a qualified and registered mental health professional with specialist experience in using evidence-based, gold standard interventions to treat a range of anxiety disorders and trauma, including cognitive behaviour therapy and eye movement desensitisation and reprocessing therapy would then be of most help (Ayers et al, 2007; Lynch, 2015; Cortizo, 2020). It can also be helpful to offer advice about exploring options for hypnobirthing sessions and in linking them in with midwifes with training in these techniques (Çankaya and Şimşek, 2021).
Given the lack of training professionals receive on tokophobia, it would be helpful for training on the condition to be built into courses that train professionals who will come into contact with pregnant woman, for example those studying for qualifications in midwifery, clinical psychology, psychiatry, obstetrics and gynecology. Having compulsory training modules on such courses would help future professionals to have an awareness of this condition, as well as know how best to support people living with the condition.
Discussion
Tokophobia can be extremely distressing for an individual to experience. The disorder can often leave individuals feeling misunderstood. This has implications for mental health difficulties within the perinatal period, including traumatic stress, post-traumatic stress disorder and difficulties bonding with their new baby. It affects men as well as woman. Pregnant women with tokophobia are more likely to request a caesarean section because of an overwhelming fear of vaginal delivery, therefore the condition can also lead to physical as well as mental health implications, as well as terminations of pregnancy.
Further research is needed to help medical, mental health and healthcare professionals to understand how best to support women and men presenting with symptoms of this condition. It is also important for educational establishments training medical, mental health and healthcare professionals in fields such as midwifery, obstetrics, gynecology, clinical psychology and psychiatry to include modules on the assessment, treatment and intervention of tokophobia. This would help protect the welfare of women and men living with this condition, as well as helping to protect parent–infant bonding and mental health in the perinatal period.
This paper proposes an adapted psychological model that may benefit professionals supporting pregnant woman, expectant fathers and their partners with tokophobia. The model proposed is based on a trauma model developed by Hobfoll et al (2007) and is one of many that could be used to think about how to understand and support individuals living with tokophobia. The use of open questions and the promotion of the five elements in the model could help health professionals helping those living with tokophobia to feel validated, contained (meaning psychological containment, where the aim is to help the person feel safe and secure with the clinician/professional who is supporting the person with tokophobia) and supported in feeling able to talk about pregnancy and in making decisions regarding their birth for those that are pregnant. However this paper is limited by the lack of research to test the usefulness of this model in clinical practice. Further research is needed in order to expand on this, in order to support anyone presenting with this condition.
Conclusions
The aim of this paper is to raise awareness of tokophobia in men and women, as well as offer a guide for professionals to support, validate and contain women (and men) living with this condition. It is hoped that this will lead those with tokophobia to experience a sense of safety, calmness, self-efficacy, connectedness and hope in working with professionals supporting them. This may, in turn, lead to them feeling more empowered and connected to not only continuing with their pregnancy, but also in becoming a parent and in planning their birth journey for those that are pregnant and living with this condition. This paper has also highlighted the importance for men to be acknowledged as being vulnerable to experiencing tokophobia, as well as women. It is hoped that this paper will help to enable those living with the condition to feel more heard and validated, as well as being guided to having mental health support during the perinatal period.
Key points
- Tokophobia is an overwhelming fear of pregnancy and birth that can lead to severe mental health difficulties in the perinatal period. It can affect men as well as women
- Individuals with tokophobia may also be at increased risk of traumatic stress symptoms or post-traumatic stress disorder
- It would be helpful for professionals working with pregnant women and expectant fathers to be mindful of key signs that may indicate tokophobia. This will enable the professional to link the individual with local support services
- Professionals supporting individuals with tokophobia may draw upon Hobfoll's model of psychological safety in promoting a sense of safety, calmness, a sense of self and community efficacy, connectedness and hope
- Educational establishments that train professionals to care for pregnant women and expectant fathers could build in teaching and mandatory training modules on tokophobia to help raise awareness of the condition, as well as helping them to understand how to support those with the condition