Tokophobia. Causes, symptoms and psychotherapy

The fear of childbirth is a mental health problem that involves a severe, excessive fear of pregnancy and the time of birth. This condition is also called "tocophobia" or, better said, birth phobia. This review is based on information from articles in the literature published between January 1, 2001 and November 1, 2021 in PubMed, ScienceDirect and Google Scholar using the following keywords: fear of childbirth, symptoms, causes, tools, psychological interventions. In this review, we discussed the types of fears women have about pregnancy and childbirth, the instruments that is used for assessing the fear of childbirth, and how to cope with and overcome this fear. According to the literature, the role of psychological counseling for women facing fear of childbirth is important in the optimal management of emotional symptoms associated with pregnancy.


INTRODUCTION
Fear of childbirth or tokophobia is a pathological fear or avoidance of childbirth, which has received little attention and has been neglected. This condition negatively influences the pregnant woman's life or the acceptance of her pregnancy. It leads to the extension of pregnancy duration or motivates requests for caesarean sections.
After birth, tokophobia may also delay bonding between the mother and the newborn, leading to breastfeeding difficulties and increasing the risk of puerperal depression. Tokophobia is associated with intrauterine growth restriction, low birth weight, changes in fetal heartbeat, and prematurity.
Fear of childbirth impacts negatively women's experience of birth and birthing outcomes [1,2]. Research on prevalence rates for fear of childbirth show extensive worldwide variation, ranging from 1.9 to 30% [3]. This may be due to genuine cultural differences, or a reflection of the lack of clarity in the definition of the term fear of childbirth and adequacy of measurement tools.
Several studies have found that several factors might increase FOC including advanced maternal age, high socio-economic status, insufficient antenatal education, obstetric complications, increased analgesic use in labor, postdate pregnancy, low self-esteem, and low level of acceptance of pregnancy. Earlier studies have shown that nulliparous women experience higher levels of fear than multiparous women before birth. However, recent studies indicate that there is no difference in levels of postpartum fear between these two groups.

Fear of the unknown
Mothers can experience fear of childbirth because they consider not knowing and manage what is going to happen. For instance mothers may feel unconfident and inefficient that they can give birth.

Fear of pain
First-time mothers fear labour pain but there are many ways they can relieve. Some antenatal classes, breathing techniques, meditation can help. Women who can relax and feel in control find it less painful.

Fear of interventions during labour
The key to managing the fear of childbirth is to know from the prenatal period information about what birth entails and some technical details to calm you down. Some solutions can be feel empowered and aware of what is happening. Women can do this by going to courses on childbirth, prenatal yoga, reading childbirth materials and talking to healthcare team.

Fear of not being in control
Uncertainty can increase as the pregnancy progresses, so it is important for women to have emotional and family support and discuss her needs with the doctor. Normal labor variates from average 8 hours for mothers who've given birth before to 12-24 hours in the case of a primipara. So, there is plenty of time to get to hospital. Doctors will assure the woman that qualified and experienced medical staff will be there [4].

TOOLS USED TO ASSESS THE FEAR OF CHILDBIRTH
Fear of childbirth can be assessed using a series of questionnaires or clinical interviews [5][6][7]. The most common tool used to assess the severity of this difficulty is W-DEQ A and W-DEQ B. The questionnaires consist of 33 questions scored on a Likert scale (zero to six) in order to assess women's thoughts about childbirth. future (W-DEQ A) and evaluation of postnatal experiences in the postnatal period (W-DEQ B) [8]. A score above 66 represents high fear of childbirth, and a score above 85 severe fear.
The Fear of Birth Scale (FOBS) is a clinical tool that identifies high levels of fear of childbirth [9]. The FOBS assesses the extent to which women are experiencing fear in relation to the approaching birth using a visual analogue scale.
The Oxford Worries about Labour Scale (OWLS) assesses worries around labour and delivery and report women's experiences of maternity care in England as part of a large survey [10].
The Slade-Pais Expectations of Childbirth Scale (SPECS) measures women's expectations of childbirth. The dimensions reflect areas about: the type of expectations held by women prior to birth, levels of control, pain, fear, support from partners and healthcare staff and positive anticipations of giving birth [11].

WAYS TO MANAGE THE FEAR OF CHILDBIRTH
One of the most important ways to counteract the fear of childbirth is psychological or emotional preparation during pregnancy and especially in the last trimester. Most women think about the birth experience in negative terms, which involves a lot of pain. In order to learn to control thoughts and emotions, which intensify as the time of birth approaches, pregnant women are recommended to learn about birth, how contractions work and how they will feel at different times of pregnancy; to learn self-control over one's own body and to know that pain during labor is different from any other pain.
Childbirth preparation courses [12] have a psychoeducational role for women who are preparing to become mothers. In these courses there are practical exercises for preparing perineal muscles and perineal massage techniques to increase muscle tone and tissue elasticity, and women learn useful information about labor, contraction management, positions to facilitate labor, types of anesthesia, types of procedures medical birth and the reasons why it may be necessary, but also about breathing, relaxation and massage techniques in optimal labor management.
Another way to deal with the fear of childbirth is haptonomy. This method focuses on emotional contact. Studies show that these emotional contacts contribute to the feeling of self-fulfillment and well-being [13]. By touching the womb, the mother has a conscious contact, recognizes the fetus, which leads to the creation of a secure attachment. This approach requires the use of the mother's and / or father's hands on the belly to feel the baby reacting to their touches. The parents do not explore only with their fingertips, but touch the whole belly, constantly moving their hand on the abdomen. At the same time, the parents must react to the movements of the fetus. Parents are encouraged to talk to their child. The voice of the mother and father is also part of this approach. Among the benefits on the fetus we can list the fact that it feels calmer, accompanied, confident; promoting the correct positioning of the baby for labor and future birth because it will be guided and the baby's heart rate is lower during birth.
Prenatal psychological counseling aims to connect the pregnant woman with her own body, reduce the emotional symptoms associated with pregnancy, such as prenatal anxiety, stress and depression, activate maternal resources and coping, create mental and emotional availability for the fetus and optimize mother-fetal attachment [14,15]. Among the methods used in prenatal psychological interventions are breathing techniques, relaxation, guided meditations, art therapy and the letter technique (letter to the baby or other mother afraid of birth).

CONCLUSIONS
Fear of childbirth has a negative impact on pregnancy and childbirth, being an explanation for cesarean birth requests. Also, this fear can lead to an insecure attachment between the mother and fetus, and later between the mother and the newborn, being associated with difficulties in breastfeeding and postnatal depression.
Studies show that there are many ways to manage the fear of childbirth and we can list the psychoeducational courses that prepare women for childbirth; haptonomy and psychological counseling. Together, these methods help the woman to transform the perception of a negative birth into a positive one. Also, preparing mentally and emotionally during pregnancy aims to reduce the emotional symptoms associated with pregnancy and create a secure prenatal attachment between mother and fetus.