Management of Tokophobia

Tokophobia is a mental issue which causes a woman to fear pregnancy and childbirth so intensely as to avoid undergoing them. Both primary and secondary tokophobia are known - primary tokophobia occurs before a woman ever experiences pregnancy, while the secondary form is found in parous women.

Understanding the causes

To manage tokophobia, the underlying etiology needs to be examined. This may include:

• Fear of pain, either mental or physical
• Fear of bodily injury to mother or baby
• Extreme shyness leading to reluctance to allow genital visualization or examination, especially in women who have a history of sexual abuse such as rape
• Previous childbirth perceived to be traumatic, with or without objective basis

Management

In mild primary tokophobia, it may be helpful to talk through the woman’s fears, ensure that false beliefs about childbirth are dispelled, and reassure her that she will receive adequate support in labor.

1. Multidisciplinary care

Women with a traumatic sexual history, which may have involved abuse or rape, will be best served by offering psychotherapy where they can talk through their negative feelings regarding pregnancy and childbirth, and reach solutions other than avoiding childbirth.

It is important to note that women who feared or were horrified by the idea of a normal vaginal delivery may develop post-natal depression, post-traumatic stress disorder (as already mentioned), and fail to bond properly with the infant, if they do not receive proper support during and following the pregnancy. A psychiatric evaluation is required following the obstetrician’s detection of such a fear, to confirm the diagnosis, and probe into any possible reasons for the condition. This will also aid in providing appropriate therapy, as well as help guide the obstetrician’s final decision as to the mode of delivery, the administration of anti-depressants when necessary, and the type of obstetric analgesia most appropriate, preventing further trauma and pain.

Preparing a birth plan

In some women, the fear is so strong that it resists all behavioral techniques or psychotherapy. This is especially so in nulliparous women (those who have not yet become pregnant). Such women may be willing to undergo pregnancy and delivery only if they can have an elective Cesarean section. On the other hand, when such women are forced to undergo vaginal delivery, they may become so stressed that they develop post-traumatic stress disorder following childbirth. This will result in the need for psychiatric help to cope with the condition.

Thus it is necessary to care for such patients from both the mental and obstetric angle, to ensure they receive the help needed. In many of these cases, empathic and professional counseling is successful in helping tokophobic women deal with their fear effectively enough to have a safe and satisfying vaginal delivery, without experiencing regrets or fear after childbirth.

Some solutions which may reassure the woman, when offered in good faith, include:

• Giving epidural analgesia earlier than usual, when requested by the woman
• Having a doula or birth attendant throughout the process of childbirth to reassure and advocate for the woman
• A signed contract with the consultant stating that if they require an instrumental delivery finally, they may opt out and receive a C-section instead. In some cases, a signed contract stating that they suffer from tokophobia and have the right to stop trying to deliver vaginally and receive a C-section at any time if they request it, is subject to the availability of operating room staff and facilities

2. Acknowledging and validating the fear

Women who have an incapacitating fear of becoming pregnant because they cannot go through with delivery need to be seen by a caring counselor. Such a person will be able to identify the woman’s genuine feelings without dismissing them or making them feel less feminine for not being able to do something that “all women do”. Such responses are usually heard, and drive a tokophobic woman deeper into guilt and depression, rather than strengthening her to fight the fear with any degree of success.

3. Support systems

Enlisting family support has a hugely positive impact, which can help a tokophobic woman go through childbirth without harm. Not only will responsible family physically help deal with the difficulties of pregnancy and the post-partum period, but they can impart enormous confidence when dealing with apparently hostile or uncaring medical staff. They can try to ensure that the woman gets the care she requires at each stage of labor.

Deciding to start another pregnancy is also a big issue for a woman with tokophobia. Partners should discuss the matter with genuine care and kindness for each other’s pain, but also seek professional help if, despite their shared desire for another child, the woman is irrationally and adamantly opposed to becoming pregnant again. A trusting and supportive relationship between the woman, her partner, and medical care providers, is essential to addressing tokophobia optimally. A woman with tokophobia who navigates one delivery well with this type of support often finds her problem is resolved, and goes on to have more children with much less difficulty.

References

1. http://www.aafp.org/afp/2005/0815/p697.html
2. https://www.infona.pl/resource/bwmeta1.element.elsevier-5ed582b6-2395-32b6-94e5-e8ab9bef75a4
3. https://www.allaboutcounseling.com/library/tokophobia/
4. https://www.ncbi.nlm.nih.gov/pubmed/10789333