Queen Elizabeth Psychiatric Hospital, Birmingham
Department of Psychiatry, University of Birmingham
Correspondence: Dr K. Hofberg, Department of Psychiatry, University of Birmingham, Queen Elizabeth Psychiatric Hospital, Mindelsohn Way, Birmingham B15 2QZ; e-mail: kristina.hofberg{at}virgin.net
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ABSTRACT |
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Aims To classify tokophobia for the first time in the medical literature.
Method Twenty-six women noted to have an unreasoning dread of childbirth were interviewed by the same psychiatrist, who was not the treating doctor. A qualitative analysis of these psychiatric interviews was performed.
Results Phobic avoidance of pregnancy may date from adolescence (primary tokophobia), be secondary to a traumatic delivery (secondary tokophobia) or be a symptom of prenatal depression (tokophobia as a symptom of depression). Pregnant women with tokophobia who were refused their choice of delivery method suffered higher rates of psychological morbidity than those who achieved their desired delivery method.
Conclusions Tokophobia is a specific and harrowing condition that needs acknowledging. Close liaison between the obstetrician and the psychiatrist in order to assess the balance between surgical and psychiatric morbidity is imperative with tokophobia.
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INTRODUCTION |
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"If they are primiparous, the expectation of unknown pain preoccupies them beyond all measure, and throws them into a state of inexpressible anxiety. If they are already mothers, they are terrified of the memory of the past and the prospect of the future."
It is well known that pregnancy may be a time of considerable anxiety, with symptoms escalating in the third trimester (Lubin et al, 1975). Women in the 1990s still suffer from the fear of death during delivery (Fava et al, 1990). When this specific anxiety or fear of death during parturition precedes pregnancy and is so intense that tokos (childbirth) is avoided whenever possible, it is a phobic state called tokophobia.
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METHOD |
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Twenty-seven women were referred for the study, one declined to be interviewed. The remaining 26 women were seen over a two-year period in their homes by the same psychiatrist, who was not the treating doctor. No structured interview was used in this preliminary study. The authors developed an interview that combined narrative histories with specific direct questions for obtaining information. The authors were investigating trends in presentation and past history that may identify women with tokophobia. They were not investigating an already-established illness pattern. Direct questions were used to elucidate diagnoses of depressive episodes, anxiety disorders and post-traumatic stress disorder (PTSD) using ICD-10 (World Health Organization, 1992). Detailed enquiries were made about the obstetric history, including all pregnancies, contraceptive methods and sexual relationships. The relationship with each baby was examined. Questions about childhood sexual abuse and rape were investigated.
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RESULTS |
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Primary tokophobia
Eight women in the sample had a dread of childbirth that pre-dated
pregnancy, that is, primary tokophobia. The dread of child-birth started in
adolescence. Sexual relationships were normal but contraceptive use was
scrupulous, some of these women using several methods of protection. Four of
the eight women planned their pregnancies despite their intense fears. Two had
an overwhelming desire to be a mother and saw that role as their raison
d'être. These feelings overpowered their
avoidance but did not allay their fear.
One woman conceived only after she had arranged a lower segment Caesarean section (LSCS) for the delivery of her first baby. Most women strongly desired an elective LSCS. Maternal morbidity was evident during these pregnancies (see Table 1).
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Outcome of primary tokophobia pregnancies
Four women achieved their ideal delivery, bonded well with their babies and
enjoyed excellent psychological health. Three women endured vaginal deliveries
against their will; all three suffered postnatal depression, two suffered
symptoms of PTSD and two had delayed bonding with their infants. One woman
chose to deliver vaginally despite her intense fears (she was also terrified
of needles, hospitals and doctors). She had an emergency LSCS, and suffered
postnatal depression.
Secondary tokophobia
Secondary tokophobia occurs after a traumatic or distressing delivery.
Fourteen women in the sample had developed a dread of childbirth after a
previous delivery. Ten had experienced instrumental or operative deliveries
for foetal distress; two others had suffered severe pain and perineal tearing.
Twelve stated that during the delivery they believed that they would die or
that the baby had already died. Maternal morbidity was evident and undetected
for many months in ten women (see Table
2). One woman who accidentally conceived again organised a
termination of pregnancy rather than face another delivery. The dilemma for
these women was that the family felt incomplete but the women were terrified
of a further delivery.
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Nevertheless, 13 of these women proceeded with further pregnancies. Eight were planned where a sibling was wanted for the first baby. Two women suffered miscarriages (before going on to complete a pregnancy to term) and one had an ectopic pregnancy; all three felt enormous relief when these pregnancies did not result in delivery. All 13 women were extremely anxious during their pregnancies with the recurrent, intrusive belief that they were unable to deliver their babies (see Table 3).
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Eleven women were seen in the postnatal period; two were still pregnant but had arranged an LSCS (see Table 4). Nine of the postnatal women arranged an LSCS, all felt that they had avoided the fearful situation of tokos. Two women had not obtained an operative delivery: one had had a successful vaginal delivery and good psychological outcome, although she retained residual symptoms of PTSD from her first delivery; the other suffered postnatal depression, PTSD and a bonding disorder with her baby. One woman was separated at birth from her baby, who was ill. She suffered bonding delay.
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Tokophobia as a symptom of depression
Four women developed a phobic dread and avoidance of tokos as a
symptom of depression in the prenatal period. In each woman this was
characterised by a recurrent intrusive belief that she was unable to deliver
her baby and, if made to, would die. Of these four women, the first two were
primiparous; both felt shocked at the realisation of pregnancy and both became
depressed. One sought a termination of pregnancy even though the pregnancy was
planned. The other began to exercise strenously in the hope of inducing a
miscarriage rather than endure a vaginal delivery. Both were treated
psychologically and recovered spontaneously in the middle trimester of
pregnancy. The second two women already had children; both had experienced
vaginal deliveries that they perceived as untraumatic. Both of these
subsequent pregnancies were planned. In the context of relationship
difficulties and depressive illness both women failed to bond with their
foetus and became adamant that they could not deliver their babies. The care
shown in previous pregnancies was lacking. One woman responded well to
antidepressants in the prenatal period and arranged an LSCS. She bonded well
with her baby and had no further episode of depression. The second woman
declined antidepressant medication in pregnancy and was refused an LSCS. She
described a traumatic vaginal delivery, with continued depression postnatally
and a feeling of detachment from her baby.
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DISCUSSION |
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Tokophobia and termination of pregnancy
Two women in the study terminated a pregnancy because they could not face a
delivery. In both cases the baby was much wanted. Another woman described how
she was offered a termination of pregnancy when she had begged for an LSCS. A
proportion of termination of pregnancies may be requested by women who suffer
from tokophobia and want a baby but cannot understand their own strong
aversion to parturition. In the absence of an empathic professional listener
or relevant medical literature, their only choice may be to terminate the
pregnancy.
Tokophobia and hyperemesis gravidarum
In this study, women with tokophobia had a high rate of hyperemesis
gravidarum (5/8 of those with primary tokophobia, 5/14 of those with
secondary tokophobia). A psychological component to hyperemesis
gravidarum has been postulated. This may be relevant to tokophobia, when
rejection of pregnancy, failure to bond with the foetus, attempts to obtain a
termination of pregnancy and terror at an impending delivery may occur.
Tokophobia and PTSD
PTSD is increasingly being recognised as a consequence of childbirth
(Ryding et al, 1997).
Among subjects with tokophobia the incidence of PTSD was high, and was
associated with traumatic delivery (secondary tokophobia) and denial of the
delivery method of choice (primary tokophobia).
Tokophobia and depression
In this sample depression was a frequent cause and consequence of
morbidity. Postnatal depression was associated with refusal of the delivery
method of choice and with traumatic and distressing deliveries.
Tokophobia and sterilisation or vasectomy
Ten women in the sample had completed a sterilisation or were on a waiting
list for either sterilisation or vasectomy for their partner, this proportion
of couples seeking permanent contraceptive methods shows that they are
over-represented in this sample. Ekblad
(1961) addressed the issue of
fear of pregnancy as a reason for requesting sterilisation. Some childless
women presenting for sterilisation may be tokophobic and respond to a
psychological approach to dealing with the phobia.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Fava, G. A., Grandi, S., Michelacci, L., et al (1990) Hypochondriacal fears and beliefs in pregnancy. Acta Psychiatrica Scandinavica, 82, 70-72.[Medline]
Lubin, B., Gardiner, S. H. & Roth, A. (1975) Mood and somatic symptoms during pregnancy. Psychosomatic Medicine, 37, 136 -146.[Abstract]
Marce, L.V. (1858) Traite de la Folie des Femmes Enceintes, des Nouvelles Accouchees et des Nourrices. Paris: Baillière.
Ryding, E. L., Wijma, B. & Wijma, K. (1997) Posttraumatic stress reactions after emergency cesarean section. Acta Obstetrica et Gynecologica Scandinavica, 76, 856 -861.
World Health Organization (1992) The Tenth Revision of the International Classification of Diseases and Related Health Problems (ICD-10). Geneva:WHO.
Received for publication November 30, 1998. Revision received June 15, 1999. Accepted for publication June 16, 1999.