Describing her reaction to a film on childbirth that was shown at her school, Dame Helen Mirren once commented: ‘I swear it traumatised me to this day. I haven't had children and now I can't look at anything to do with childbirth. It absolutely disgusts me’ (Shears, 2007).
One might infer that Dame Helen is a tocophobe: someone with a severe fear of childbirth. However, although tocophobia is defined as ‘an unreasoning dread of childbirth […] much of the published literature to date refers to tocophobia as a severe “Fear of Childbirth” rather than “an unreasoning dread of childbirth”’ (O'Connell et al, 2017: 908).
In the first systematic review and meta-analysis of the prevalence of tocophobia, O'Connell et al (2017) found the pooled prevalence to be 14%, with Scandinavia at 12%, the rest of Europe at 8% and Australia at 23%. They also noted that prevalence had increased since 2000.
According to O'Connell et al (2015), tocophobia was associated with young maternal age; maternal age greater than 40 years; high socioeconomic status; low education level; unemployment; single marital status and anxiety before or during pregnancy. With the maternal and infant risks of tocophobia including postnatal depression, reduced infant bonding and attachment, and long-term emotional effects on the infant, tocophobia is an important condition to address. O'Connell et al (2015) indicate approaches to management, but I found the title of the article: ‘Tocophobia—the new hysteria?’ intriguing.
O'Connell (2017: 808) suggests that ‘women with tocophobia may often request a caesarean section’, implying that some women may opt for (or insist on), a caesarean because they do not wish to undergo the perceived trauma of a vaginal birth. As Di Renzo (2003: 217) writes, ‘The “fatigue” of carrying a pregnancy is difficult to accept for some women, who, in addition, will not tolerate (or are afraid of) any pain or suffering in [birth].’
Di Renzo (2003: 217) suggests that the term ‘tocophobia’ is appropriate as an indication for a caesarean ‘Where there is a strong desire by a pregnant woman not to experience contractions even at the early first stage of labour, with the strong belief that, as a consequence, the pain may give rise to severe psychological disturbances.’
It seems at first glance that the woman's right to decide how her baby is born should be respected. However, as Selinger (2014: 859) argues, ‘The obstetrician also has rights to autonomy. They may feel it is unnecessary or inappropriate to perform major abdominal surgery when vaginal delivery is the default method of delivery.’
In the context of tocophobia, it is worth considering a thought offered by Koch (2017: 4) in his contemplation of disability: ‘[A] focus on the individual and his or her abilities should be secondary to the manner in which society provides the support required by all its members, irrespective of individual differences.’
Tocophobia may therefore not be sufficient grounds in a societal context to demand a caesarean. However, if we feel that a worthwhile contribution to public health can be achieved—as the World Health Organization (WHO) implies, by agreeing that caesarean sections ‘should ideally only be undertaken when medically necessary’ (WHO, 2015: 4)—then we must address the question of who benefits: ‘Is it the unborn baby and a reduction in their risk of brachial plexus injury? Is it the mother who had a previous vaginal delivery perceived by her as psychologically traumatic, and by carrying out an elective [caesarean section], the doctor removes her abject fear?’ Selinger (2014: 859)
O'Connell (2017: 809) commenting on midwifery in Sweden, noted that organised, sustained counselling is offered to women with tocophobia, suggesting if mental health issues are addressed, caesarean section need not be the default position. As she concluded: ‘If you want to go fast, go alone; if you want to go far, go together.’