The only thing that surprised Karen McDermott more than her unexpected sixth pregnancy was the terror and anxiety that gripped her when she thought of giving birth again.
Karen, now 39 and living in Perth, had felt nervous but mostly excited during the pregnancies of her three girls and two boys. But preparing to go into labour again left her feeling “haunted” for nine anguished months.
“I focused a lot on what could go wrong,” she says. “I didn’t want my luck to run out as I’d had five healthy children. I listen to my instinct, and I had an unsettling feeling for months. I was afraid of giving birth.”
While Karen says her anxiety disappeared as soon as her newborn daughter was in her arms (albeit six days overdue), during the pregnancy, her concerns were dismissed.
“My obstetrician laughed when I voiced my feelings. I did too, as it seemed so strange. I mentioned it to my mum and sister, and even my partner, but they didn’t seem to take it on board.
“I had always been the brave one, getting on and giving birth with just some gas and air. But this time I was happy to wait — every extra day was a day when I didn’t have to give birth.”
When does a normal fear of childbirth become tokophobia?
Fear of childbirth is normal, but since at least 2000, the term “tokophobia” has been used in medical literature to describe a fear so intense women may seek abortions, elective caesarean sections — or avoid falling pregnant altogether, despite wanting to be mothers.
An underlying mental illness such as anxiety or depression can also make women vulnerable to tokophobia.
In its primary form, a woman who has never given birth before feels a “morbid” fear of pregnancy and childbirth, while secondary tokophobia is a fear of giving birth again after a traumatic birth experience.
But there is little understanding as to when a normal fear of childbirth becomes pathological in a culture where, as author Tara Moss put it in 2012, childbirth is presented as something to be “survived”.
Some studies point out media coverage and reality television focused on birth skews heavily towards what can go wrong.
And, as comedian and writer Jessi Klein wrote recently in the New York Times, pain is accepted as part of the process: “No one ever asks a man if he’s having a natural root canal”.
A 2012 study from India noted that 13 per cent of women experience a fear of childbirth sufficient to postpone or avoid pregnancy.
But tokophobia is not in the Diagnostic and Statistical Manual of Mental Disorders (DSM), partly because there is still not much awareness — and many cases go untreated as a result.
Brisbane obstetrician Dr Gino Pecoraro says tokophobia is gaining ground in medical literature, but is less well-known in the community.
“Many people are aware that some women have a difficult time with pregnancy and childbirth,” Dr Pecoraro says. “But [awareness of tokophobia] may only occur as a result of a personal experience, or after hearing about someone else’s experience.”
Dr Pecoraro says a woman is tokophobic when the fear disrupts everyday life.
“It becomes pathological when it starts to interfere with normal functioning — [for example] if a woman can’t bear the thought of pregnancy, but wants a child, and this is causing relationship stress and difficulty coping with daily living, like sleeplessness,” he says.
A woman suffering from a pathological fear usually needs psychiatric or psychological help to cope with her distress.
“Not all women have the same concerns, fears or anxieties,” says Dr Pecoraro. “A one-size-fits-all approach is rarely the way to go. As with all pregnant women, the best care is individualised to best meet that woman’s needs.”
Fear management could reduce number of traumatic births
Importantly, as new research from the National Institute of Complementary Medicine at Western Sydney University (WSU) suggests, fear of birth can be managed.
In fact, fear management is crucial to the reduction of traumatic births, which occur when a woman experiences complications or her birth plan goes awry, says WSU midwifery professor and the study’s co-author, Hannah Dahlen.
“Women describe themselves repeatedly in studies as feeling like a piece of meat on a slab [during childbirth],” Professor Dahlen says.
“It’s such an awful, disembodied image, where you’re reduced to the blood and bone, and not a being.
“[But] our study has found that evidence-based complementary medicine techniques [including massage, yoga and acupressure] for pain relief can reduce medical intervention rates, and meaningfully reduce the fear around childbirth.”
Secondary tokophobia often develops alongside post-traumatic stress disorder (PTSD), following a traumatic birth. Clinical psychologist Heather Irvine-Rundle, who treats dozens of women with PTSD at her Sydney practice, says traumatic births are producing “dead women walking”.
“These women have nightmares and regular flashbacks to the birth, blame their body for what happened, and they were told if they just meditate, they’ll have a joyous birth,” Ms Irvine-Rundle says.
“What happens in a ‘normal’ birth can be traumatic because it’s so different from what you expect it to be.
“[But] we don’t understand what a ‘normal’ birth is. There are hundreds of complications that can go on for women during childbirth, and Australia has hardly any support for traumatic births,” she says. “Doctors say, ‘you had a baby in the end, what are you worried about?'”
While traumatic births do not always result in secondary tokophobia, Ms Irvine-Rundle says they often do.
Indeed, a 2004 study found the dislocation between a woman’s expectations and the reality of childbirth could be due to a clinical perception of trauma as “routine”.
And a global report commissioned by the World Health Organisation (WHO) last year showed positive mental health during pregnancy was linked to a woman’s wellbeing in childbirth.
But trauma might be regarded clinically “routine” because the wellbeing of the baby is considered more important than that of the mother — it’s why midwives say part of the solution to managing fear involves helping women feel in control during birth.
Traumatic births could be contributing to rise in elective C-sections
Still, a growing number of women are choosing C-sections to avoid vaginal delivery, a trend medical professionals say is unsurprising. Some of these are women who feel too anxious to go through with a vaginal birth.
Queensland mum Carla Greenfield, 27, found the vaginal birth of her first child Lachlan traumatic, suffering a massive haemorrhage and losing consciousness after he was delivered.
“When I came to [after losing consciousness], a doctor had both hands inside my uterus in an attempt to stop the blood flow. I screamed louder than I had in labour. It was like crowning all over again, but worse, with a second degree tear which hadn’t even had the chance to be stitched,” Carla says.
Carla scheduled a caesarean section for her second, but struggled with the recovery. She developed tokophobia after falling pregnant a third time, but delivered her daughter via a successful vaginal birth after caesarean (VBAC).
“I was terrified a lot. I now feared the C-section recovery and labour complications,” she says.
However, women seeking C-sections as a result of their fear of childbirth can encounter stigma — partly because health professionals consider natural birth less risky and better for the baby than a C-section.
The World Health Organisation recommends no country should have a rate above 15 per cent, but Australia’s hovers around a third of all births.
New South Wales mother Jess planned her C-section after a traumatic first birth, but was still asked during labour if she’d like to deliver naturally.
“Midwives would make remarks such as, ‘natural birth is a gift, though’, or ‘I don’t know why anyone would willingly choose a C-section, are you sure?'” she says.
“I wouldn’t say they were judgmental, but I don’t think they fully understood the depth of my fear.”