Zadok (2016), in his preparation of couples for birth, uses a board where participants write down associations related to childbirth. Positive words like child, anticipation, and blessing appear on the board. But more typical are words like: pain, fear, loss of control, and death. These associations stem from childhood, as birth is always presented to us as suffering, and the media portrays it that way. Awareness, humility, patience, and dedication are four interconnected elements that help women in birth preparation start trusting their bodies and gain the necessary knowledge and confidence. A woman who doesn’t feel safe or senses danger is likely to have a long and painful labor. As healthcare professionals, we are the ones who must enable women in the delivery room to feel safe and trust us. Support and a sense of security make labor faster. Fear and anxiety, on the other hand, slow it down and make it more painful. During labor, emotions and the environment affect the secretion of hormones that have a major impact on the birth. A woman who doesn’t feel safe will secrete a lot of adrenaline, making the labor slow and painful. Muscles contract under the influence of adrenaline, and all energy goes to our limbs. The body is also more sensitive to pain. Adrenaline secretion helps us avoid danger, and we must ensure that as little as possible is secreted during labor. A woman who feels safe in the environment where she is giving birth will secrete oxytocin and endorphins, which help her labor progress smoothly. Muscles are relaxed under the influence of these hormones, and energy is sent to the uterus, which further increases oxytocin secretion (Durham, 2016). To prevent adrenaline secretion in the delivery room, we must ensure the woman feels safe, loved, and protected, that she has a sense of control and supportive people by her side. We must also provide her with privacy.

Fear is an emotion that arises when a person feels their values are threatened, while at the same time thinking they cannot adequately face or stand up to the object or situation that threatens them (Milivojević, 2008).

Psychological characteristics in pregnancy

Pregnancy is a unique period of two individuals joining into one. For a first-time mother, it doesn’t just mean a new state or situation, but a period of intense development of identity from woman to mother. Different authors name pregnancy differently. Pregnancy can be a critical phase leading to a new level of personality integration and development. It is equivalent to the crisis that occurs with every pregnancy.

Every pregnancy brings changes not only in the emotional but also in the cognitive field. Buckwalter and colleagues found that changes in cognitive functioning and emotions occur during pregnancy due to altered hormonal balance. These changes don’t just appear during pregnancy but also over a longer period after birth, manifesting as mood swings and difficulties in memory and learning (Steblovnik, 2009).

Pregnancy can be a stressful period for a woman. Stress is particularly pronounced in the first trimester, when the pregnant woman fears whether the baby will be healthy, wonders if she’ll be able to be a mother, and fears about social capabilities arise. The next period is the time before birth, due to fear of pain and possible birth complications, and in the third trimester, when fear of the birth itself appears (Blejec and Strgulc, 2009).

Mixed and unstable emotional reactions and states are common during pregnancy, not just feelings of happiness and satisfaction. Many women fear the fetus isn’t normal, worry about what the birth will be like, and feel they’ve become unattractive during pregnancy. On one hand, pregnancy makes a woman happy, especially if it’s wanted; on the other, she is filled with many doubts. A variety of feelings is common in pregnant women, but the feeling of fear shouldn’t prevail. Frequent low moods, excessive worry, and moodiness give the woman a sense of mental tension. And if she experiences pregnancy as a crisis, then birth represents the peak of that crisis.

Birth marks the end of the pregnancy period, during which the woman felt that she and the child were one. Birth can be the most beautiful experience in a woman’s life if it goes without complications and according to her expectations (Steblovnik, 2009). It is the culmination of pregnancy and a very unpredictable event. During birth preparation, every pregnant woman hears countless birth stories from her immediate surroundings.

They receive information about long and painful births, so a pregnant woman’s fear of pain is based only on storytelling. The more negative things she has heard about birth, the more emotionally unstable she will be and the fear will remain unconquered. It’s important that the better a pregnant woman prepares physically and mentally for birth, the better she will handle it (Čeh and Matko, 2007). A woman can manage fear and pain through her own activity, and only then can she establish a real connection and relationship with the child after birth (Steblovnik, 2009).

In pregnancy, fear of birth and of congenital fetal defects are quite common. These known fears are the basis for the development of more severe mental distress and disorders, especially if triggering factors are present (e.g., poor social status, illness of the mother or fetus, death). Increasingly, however, there is a fear of contact with the health service. The cause is distrust and fear of inappropriate treatment by the health service. The woman is afraid she will be mutilated in the hospital or treated and managed against her will.

Therefore, the pregnant woman’s readiness is crucial, and pregnancy is long enough to prepare for the birth itself. This way, she will have pleasant memories of it to pass on to her children. Fear of birth is a fear of the unknown and causes many negative feelings during pregnancy, which can lead to postpartum depression (Steblovnik and Novak-Antolič, 2009).

Fear of childbirth or TOCOPHOBIA

Fear is a constant companion of birth. Research shows that one in ten women studied reports fear of birth during pregnancy (Otley, 2011). The nature of fear changes over time. In the 17th century, mothers preparing for birth were mostly preparing for death. Therefore, it was interpreted more as a fear of death than a fear of birth or pain. Nowadays, for some women, tocophobia represents fear in pregnancy; more commonly, women interpret this word as fear of birth, which is also the meaning of the word. The word “tocos” or “tokos” means ‘birth’ in Greek. According to the general assumption, the cause is fear of pain and other fears, such as loss of control during labor, the hospital environment, and the inability to bond with the newborn.

We distinguish between primary and secondary fear of birth. Primary fear occurs in women who have never given birth before. Women report fear of pain, while fear of a C-section represented a potential fear. Secondary tokophobia represents fear of the act repeating, which the woman becomes aware of through a first traumatic experience (vaginal birth or C-section), as found in qualitative studies. Hofberg and Brockington list tokophobia as a psychological disorder, like postpartum depression and post-traumatic stress syndrome after sexual abuse. While some women become sufficiently aware of the fear, others become unstable toward the end of pregnancy because of the baby they are facing. This manifests as an imbalance in the nature and intensity of the fear of the birth itself. Here, sociological readiness and awareness of the transition from partner to responsible mother are evident (Mander, 2007).

Research has shown that fear of birth most often manifests as insomnia and depression, emotional instability after birth, a sense of wrong personality, a negative birth experience, requesting a C-section, and the use of epidural analgesia (Otley, 2011).

Factors of fear of childbirth

Fear factors can be divided into several areas: biological, psychological, social, cultural, and secondary. The following subchapters describe the most common factors for fear of birth.

• Biological factors

An interesting fact is that fear depends on the environment where a woman grows up. Culture and personal confidence in one’s own abilities are important, as these traits reduce the fear of birth. The number of cases of fear of birth is high, especially among women who had an emergency birth, and stories also include negative experiences and fear of pain. In hospitals, they also report suffering, shame, loss of control, and power. The most common reasons for fear are a lack of trust and negative feelings regarding individual decisions (Otley, 2011).

Fear of pain as a biological factor increases toward the end of pregnancy, is greatest during the early phase of labor, and the level of fear coincides with the pain assessment. Even epidural analgesia does not reduce fear. According to research, women who reported fear of birth during pregnancy are indeed more afraid during labor. However, there is no link between fear and the expectation of pain at birth. Results also showed that women with higher levels of anxiety or fear more often received pudendal and epidural blocks during labor. Likewise, fear is greater in women who received epidural analgesia (Alehagen et al., 2006). Pain dictates the behavior of pregnant or laboring women, and it also increases fear and causes other negative emotions, along with worry (Rocha et al., 2011).

Educational interventions based on Bandura’s self-efficacy theory (i.e., the theory of self-efficacy, which recognizes the diversity of human abilities) are essential for reducing fear of pain and the birth itself. It works by encouraging pregnant women to increase their self-efficacy and reduce pain and fear in the first two stages of labor. Midwives should include this theory in their educational interventions (Ip et al., 2009).

Results of research by Kjærgaard and colleagues showed a link between a woman’s age and fear. The older the women are, the greater the fear. Women who are afraid of the pregnancy itself also feel fear during labor. The finding regarding fear in late pregnancy could contribute to additional preventive work with women who conceived late, at least in the area of psychological support (Kjærgaard et al., 2008). Rouhe and Salmela-Aro (2011) and Nieminen et al. (2009) also state that age has a certain influence on fear.

• Psychological factors

Studies on personality variable characteristics highlighted depression, anxiety, and low self-esteem. These are factors that influence the fear of birth. Women who are afraid mostly have lower self-esteem, lack confidence in their abilities, and are afraid of the hospital. Here, midwives must show a particularly high level of understanding, instill strong will, and provide stronger support. Saisto and Halmesmaki (2003) even stated that some women have strong abdominal pain precisely because of anxiety (Otley, 2011).

A study from Helsinki states that women who already have some mental health issues have a greater fear of birth than women with no history of mental problems. This is a retrospective study involving a total of 2,405 women who had a fear of birth, while 4,676 women represented the control group. Data were entered into the medical birth register and hospital register between 1990 and 2008. The prevalence of psychiatric care was recorded based on the use of psychiatric medications and episodes of individual psychiatric illnesses. They also considered episodes reported by women when they were not hospitalized. Women who were afraid of birth often had psychiatric care, including medication therapy. The most common diagnoses were mood disorders and anxiety. In women with previous mental problems, fear was predictably expected in advance; women were afraid in as many as 95% of cases. At-risk women could be included in special groups to overcome fear during pregnancy (Rouhe and Salmela-Aro, 2011).

The common thread of the following research was to find a link between a stable personality or stable personality traits and fear during birth and late pregnancy, while also considering birth experiences. They used an open questionnaire that women filled out twice: between the 34th and 37th week of pregnancy and in the 1st week after birth. A comparison was made between two groups: 85 women for whom fear of birth was predicted and who had support from a professional group dealing with fear of birth, and another group from so-called routine births. The first group of women had more problems with anxiety. These were women with poorer social adjustment who described fear and pain more intensely than women in the control group (routine births). Also, this group of women described the birth experience more positively than negatively. Methods for treating fear should therefore be adapted to the personality traits of the individual (Ryding and Wirfe, 2007).

• Social factors

Social factors primarily include the age of the women. Those who are pregnant very young are most at risk. Also those with a low level of education and from poor areas or those who have a poor relationship with their partner. These women belong to a vulnerable group. They need a different form of help, and therefore the midwife must have a special approach. Sometimes women from this risk group also need psychological help (Otley, 2011).

Kjærgaard and colleagues, as well as Ryding and Wirfe, also state in their research that poor socio-economic status is a high fear factor. Poor social status is represented by irregular work, occasional schooling, heavy smoking, and unemployment among women (Kjærgaard et al., 2008).

Also the experience of childhood sexual abuse negatively affects birth. Women who have been abused are more afraid of birth (Lukasse, 2011). This claim is also stated by a Danish study conducted using two open questionnaires. Women were grouped into: never experienced abuse, mild (16.1%), moderate (9.9%), and severe physical violence (9.2%). In the most severely abused group, as many as 95% reported fear of birth, while only half (47% less) of women who had no such experience did (Schroll, 2011). Klaus states that about one in four women experiences sexual abuse. Such a history causes not only fear of birth but also problems in relationships with partners and healthcare professionals. It also affects her ability and attachment to the child. Therefore, it’s important for healthcare professionals to recognize or ask about a history of sexual abuse. This requires good cooperation and the establishment of mutual trust so that the woman can reveal her fears and her story. Only in this way can we avoid re-traumatization (Klaus, 2010).

• Cultural factors

Horror stories about births are a significant fear factor, especially for first-time mothers and those who describe their first birth as negative. They get this kind of information from friends, family, and also from the media. Stories heard from health professionals are of particular importance. A woman feels a lack of knowledge, if not inferiority in her own knowledge, and slowly begins to doubt her body due to all the changes occurring (Otley, 2011).

The more interventions and procedures women see, the more they see it as proof that birth is actually dangerous, and the more fear surrounds them. The midwife’s task in these cases is to protect the woman from fear. She must give every woman special attention and care, and offer information that will evoke positive energy and a positive experience of the birth itself.

The susceptibility of pregnant women to certain inappropriate information about birth is of great importance. We are in an era of abundant information about birth, and the media often treats birth in a lay manner, which leads to inadequate information and a consequent increase in fear. The mission of midwives and other health professionals is to provide health education within parenting classes and dispensary activities. Only in this way can women be properly informed during their antenatal period (Čeh and Matko, 2007).

• Previous experiences and control

Fear manifests due to a lack of power. Cheung et al. (2006) found a significant negative determinant between maternal anxiety and feelings of control, which point to fear. Particularly emphasized is the fear of losing control during labor. Studies have shown that if a woman feels in control of the birth, then anxiety is negligible. Ryding et al. (2007) state that 61% of women report fear and worry because they feel they are unable to make decisions. Geissbuehler and Ebrhard (2002) found that women fear losing control, especially worrying about inappropriate behavior during labor. Fisher et al. (2006) state something similar, including fear of losing control, both physically and emotionally.

By incorporating improved, professional communication, emphasizing the importance of information, and focusing on a respectful and responsible attitude toward women based on their individual needs, midwives will eventually minimize the fear of birth (Otley, 2011).

Kjærgaard et al. (2008) and Ryding and Wirfelt (2007) claim that women with previous negative experiences have a greater fear of birth. Fear can increase with operative interventions during birth, with depression, and other anxiety symptoms. Fear usually also depends on whether the woman is a nullipara, primipara, or multipara. Nulliparas had a higher score than others. Women who had previously given birth by C-section also had a higher fear score compared to those who had previously given birth vaginally. Fear was greater in women who had previously given birth with the help of vacuum extraction compared to those who had a natural, non-instrumental birth. Fear is also greater in women who previously had an emergency C-section than a planned one (Nieminen et al., 2009). Likewise, nulliparas reported a higher level of fear than multiparas before birth, but after birth, even nulliparas did not report intense fear.

Results indicate that in nulliparas, fear is always present to some extent; more concerning is the presence of fear of birth in multiparas (Fenwick et al., 2008). Research has shown that the biggest factor for fear of birth in a multipara is a negative birth experience. For the occurrence of severe fear in a primipara, it’s past childhood abuse (Lukasse et al., 2010).

Some believe that tocophobia could be prevented with a C-section, so they introduced this factor as a reason for a C-section. Based on this, a Swedish gynecologist-obstetrician with a psychotherapeutic orientation conducted a study on 100 women who had a fear of birth. The research showed that most women accepted a C-section to avoid vaginal birth. Their birth experience was just as good as those who chose vaginal birth. Ryding and her colleagues (1998) took a similar study for comparison, but from a midwifery perspective, where the results were less encouraging. Women with a fear of birth were satisfied with the care and support provided, but their birth experience was negative compared to the control group. Some authors believe that the routine performance of C-sections with an indication of tocophobia is concerning (Mander, 2007).

When a woman is afraid, she usually suggests a C-section (Lukasse, 2011; Rocha et al., 2011; Nilsson and Lundgren, 2007; Nerum et al., 2006). Lukasse (2011) states that women who have been abused more often suggest a C-section. Those who had a C-section before suggested it again in 7.6% of cases. Reasons for suggesting a C-section are fear of vaginal birth, fear of instrument-assisted birth, and a previous C-section (Nieminen et al., 2009).

Most women attend parenting classes and are (at least theoretically) prepared for birth in terms of pain, their own work, risks, and also something unknown—they don’t know exactly what awaits them during labor. On one hand, they are excellently prepared, but on the other, they don’t know if the scenario will unfold according to the learned plan. In most cases, it’s about a loss of control over the body at the time the water breaks and they are taken to the hospital, left to healthcare professionals who are essentially unknown to them. Loss of control over emotions manifests as crying that turns hysterical; sometimes women behave rudely toward their partner or medical staff. Some women, by losing control over their bodies, also lose control over their thoughts (Lederman and Weis, 2009).

Consequences of fear of childbirth

Fear can cause labor to progress abnormally. In frightened women, contractions become uncoordinated and ineffective due to high adrenaline secretion (Steblovnik, 2009). Adrenaline increases due to uterine activity, while cortisol is linked to pain (Alehagen et al., 2005). Thus, the cervix opens more slowly, pain increases, and so does fear (Čeh and Matko, 2007). Fear of birth negatively affects the pregnancy experience, the course of labor, the transition to parenthood (Salomonsson et al., 2010) and the mother’s relationship with the child (Melender H-L, 2002).

In women with anxiety disorders, such as fear of birth, there is an increased risk of adverse birth outcomes, premature birth, and higher neonatal morbidity. It is therefore important to recognize or get to know a woman’s fears and help her appropriately. (Lilliecreutz C et al., 2010)

If all of a woman’s emotional needs are not met during pregnancy, she is more afraid, which affects her self-esteem and changes her social image (Lyberg and Severinsson, 2010b).

To understand fear, it’s necessary to know that during birth, a woman experiences unique hormonal stress, which every individual experiences differently. In some, hormonal stress increases the risk of an emergency C-section. Laursen et al. (2009) state that fear of birth is greater when a woman knows the birth will not proceed normally. Laursen and colleagues found in their research that in women who are afraid of birth, there is an increased risk of labor dystocia, but not of fetal distress. Fear of birth also increases the possibility of a C-section (Laursen et al., 2009; Fenwick et al., 2009; Ryding et al., 1998).

A special impact is also had by emergency situations in pregnancy and at the time of birth. Women report feelings as if there isn’t enough room for them in the emergency room, and even when a midwife appears, they don’t feel any support. Such feelings also appear later in life; feelings of fear reappear, sometimes in a more intense form; they feel lonely and trapped in a strange fate, doubt their ability to give birth, and their confidence in motherhood decreases. A previous birth experience thus greatly influences fear in the next birth; the woman experiences it as a repeat trauma. The midwife’s task is to provide the woman with an individual space that is visually pleasant, spacious, and radiates warm karma and energy (Nilsson et al., 2010).

Ryding et al. (2007) state that women with greater fear of birth have worse experiences, either during a previous birth or due to bad experiences of hospitalization for other problems. Fear of birth manifests with feelings of stress and anxiety and interferes with daily activities. Fear is accompanied by a sense of loneliness and inferiority, incompetence, feelings of guilt and shame (Nilsson and Lundgren, 2007). Fear of birth also increases the possibility of postpartum depression, post-traumatic stress disorder, and negatively affects the role of motherhood (Fisher et al., 2006).

Fear of birth is a biological factor that influences the decline in birth rates or the postponement of the decision to have a child until later (Iglič, 2006).

The role of the midwife and other professionals with women who fear birth

Midwifery care for women with a fear of birth is emotional, demanding, and long-term (Salomonsson et al., 2010). A birth plan can help the laboring woman because it guides her toward the birth experience she chooses for herself. A birth plan is more effective if a midwife participates with her information, as it gives the woman insight into established practice and care. Some women feel stronger with a birth plan, but this isn’t true for everyone. Midwives must try to use language that is easily understandable for the woman to help ease her fear (Viccars, 2009).

Every midwife has a different approach; her duty is to establish trust and good mutual relationships. She must recognize the woman’s problems and try to reduce them by showing solutions, supporting, and encouraging her. The midwife must anticipate the needs of women during labor. For this way of working, supervision and successful management are essential. Fear often depends on previous bad experiences. It’s described as fear regarding reproductive health and post-traumatic stress disorder. The more a midwife shows supervision and leadership skills, the less fear the woman has (Lyberg and Severinsson, 2010).

Melender (2002) found that women in late pregnancy more often report anxious feelings; they are more afraid of hospitalization and being dependent on healthcare professionals than of the birth itself. The healthcare team must ensure the woman’s intimacy. Focusing on a positive course of labor and birth, as normal as possible, is a priority. But if it’s necessary to change the plan during labor, then the midwife should represent relief for the woman and her family and someone who provides appropriate information. Flexibility and adaptability should be included in the birth itself and its planning, and this should be a guarantee for a holistic approach and the fulfillment of the woman’s needs (Viccars, 2009).

The best way a midwife can help a laboring woman turn fear into trust is by honestly confronting the woman with the birth experience, so she understands the satisfaction that birth brings. Many women use the argument that they are more afraid of pain and that this seems like an acceptable reason for fear. They justify fear with arguments that every individual is a complex personality, has individual feelings, and that fear is not unacceptable (Otley, 2011). Alehagen et al. (2005) state that epidural analgesia is not as effective an analgesic as well-established trust with a midwife, even during pregnancy.

The midwife’s role is also to recognize individual needs for support when there is fear. Many midwives are aware that fear directly affects a woman’s state after birth, including her self-care. Midwives can help women more or less only based on experience, as (in the UK) there are no established guidelines on caring for a woman experiencing birth fears and how to support her. The reason probably lies in the fact that reducing or eliminating fear is not considered routine work (Otley, 2011).

Recognizing fear is essential in treatment. In Sweden, there is a clinic that deals with treating fear of birth and operates on the basis of a multidisciplinary team. The Swiss treatment system involves contact based on building trust. The system focuses on maximum continuity of care and offering the widest possible spectrum of medications. Without a specific transition, a woman who is afraid of birth is not entitled to a suggestion or wish for a C-section through the system. For example, in the UK, there are very few specialists in this field. The Hope Clinic in Birmingham offers women who fear birth psychological help, counseling, planning, and support during pregnancy, birth, and the postpartum period. Support is also offered by the “Birth Trauma Association,” both emotionally and practically, especially to multiparas who fear their next birth (Otley, 2011).

Swedish women report a high level of satisfaction regarding support for fear of birth; even after interventions, their opinion did not change. Still, they believe that despite well-organized support, fear is reduced but not eliminated. Treating fear is therefore successful to some extent. In the Swedish case, this involves psychotherapy, learning relaxation techniques, and other interventions (Ryding et al., 2003).

The author of the thesis concludes:

“Fear of birth is one of the most sensitive issues for a large number of women. Midwives are involved in all types of treatment. Special attention must be paid to women for whom it can be predicted that the risk of fear of birth is greater, mainly due to social or personality reasons or due to a past bad experience. The midwife’s role is crucial for neutralizing fears of birth. The key task is to establish trust, create a home-like environment, respect the wishes and needs of the pregnant woman, and give her a sense of encouragement and support with the help of her partner. First and foremost, of course, good information for the pregnant woman is necessary, because fear is a reflection of ignorance or lack of knowledge.

A change in philosophy and behavior is mandatory for midwives who used to look at birth fear as something completely normal. With greater attention, midwives could offer women better psychosocial support during the antenatal and perinatal periods. With a respectful attitude and by providing information, midwives will gain a privileged position to support women and provide knowledge regarding birth.”