Archives of Women's Mental Health (2023) 26:713–715

https://doi.org/10.1007/s00737-023-01362-9

SHORT COMMUNICATION

Tocophobia: a nosological quagmire

Verinder Sharma1,2,3 · Sapna Sharma4

Received: 17 May 2023 / Accepted: 2 August 2023 / Published online: 7 August 2023
© The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature 2023

Abstract
Fear of childbirth exists on a continuum of severity, and the most severe form is commonly referred to as tocophobia.
Although a rare entity, tocophobia is a common reason for requesting an elective cesarean section. It is generally considered
a specific phobia but is not recognized by the Diagnostic and Statistical Manual of Mental Disorders (DSM) as a diagnostic
entity. To improve the assessment and treatment of tocophobia, research is warranted to clarify its relationship with com-
monly occurring psychiatric disorders in pregnancy.

Keywords Tocophobia · Childbirth · Diagnosis · Anxiety · Post-traumatic stress disorder

Introduction of tokos (“childbirth”) whenever possible. FOC is associ-

Concerns about pregnancy and childbirth are common,
especially among nulliparous women. Fear of childbirth
(FOC) exists on a continuum of severity, and the most severe
form is referred to as tocophobia. A systematic review and
meta-analysis found a pooled prevalence of 14% (95% CI:
0.12–0.16) among pregnant women, but the rates of toco-
phobia varied between 3.7 and 43% (O’Connell et al. 2017).
In the absence of a clear, consistent definition of the disor-
der, tocophobia in this review was defined using various
measures including patient interviews. A study using the
Structured Clinical Interview for DSM-IV-TR estimated a
population prevalence of 0.032% (95% CI: 0.0044–0.23)
(Howard et al. 2018; Mayor 2018). Hofberg and Brockington
who first reported tocophobia in medical literature defined
the condition as specific anxiety or fear of death during
parturition preceding pregnancy, which leads to avoidance
* Verinder Sharma
vsharma@uwo.ca
1
Department of Psychiatry, Western University, London,
Ontario, Canada
2
Department of Obstetrics & Gynecology, Western University,
London, Ontario, Canada
3
Parkwood Institute Mental Health, Mental Health Care
Building, St. Joseph’s Health Care, 550 Wellington Road,
London, Ontario, Canada
4
Department of Obstetrics and Gynecology, McMaster
University, Hamilton, Ontario, Canada
ated with the termination of pregnancy, use of epidural,
prolonged labor, obstetric complications, assisted birth,
and elective cesarean births. Approximately 7–18% of indi-
viduals with tocophobia ask for an elective cesarean section
(Kanellopoulos and Gourounti 2022). There are also reports
of its association with vaginismus, hyperemesis gravidarum,
anxiety, post-traumatic stress disorder (PTSD)(Ayers et al.
2016), intrusive thoughts, and delayed bonding. Tocophobia
is a challenging condition to treat. A Cochrane review of
seven studies involving 1357 patients with high to severe
FOC including tocophobia questioned the effectiveness of
non-pharmacological interventions in the treatment of high
to severe fear of childbirth and accompanying depression.
Tocophobia and psychiatric disorders
There is no empirically derived definition of tocophobia
and its differentiation from other psychiatric disorders (e.g.,
major depressive disorder, anxiety disorder, or PTSD) that
can present as excessive fear of childbirth. Tocophobia is
classified as a phobic anxiety disorder, unspecified in the
ICD-10-Clinical Modification (ICD-1-CM); however, it is
not recognized as a diagnostic entity in DSM-5. It is con-
sidered a primary diagnosis if symptoms precede pregnancy
as in nulliparous women or secondary if symptoms follow
a traumatic or distressing delivery. Tocophobia can also be
a symptom of depression during or after pregnancy. It has
been validated against a DSM-5 diagnosis of specific phobia

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in only one study. The DSM-5 defines specific phobia as a
marked fear or anxiety about a specific object or situation
that lasts at least 6 months and is disproportionate to the
actual danger posed by the specific object or situation. Addi-
tionally, there is associated distress or functional impair-
ment, and the “disturbance is not better explained by the
symptoms of another mental disorder.” Due to the common
occurrence of mood and anxiety disorders in individuals
with specific phobias, the last diagnostic criterion can be
difficult to establish.
Substantial literature attests to the frequent association
of tocophobia with various psychiatric disorders. Hofberg
and Brockington found that 65% (17/26) of individuals
with tocophobia had depression during or after pregnancy.
All 8 women with primary tocophobia had anxiety, and
64% (9/14) with secondary tocophobia had PTSD symp-
toms. No standardized questionnaires were used to gather
data, but specific questions using the ICD-10 criteria were
asked to elicit clinical information using the ICD-10 cri-
teria. Storksen and colleagues studied the associations of
psychiatric disorders with FOC in 1642 pregnant women
attending public healthcare in Norway. FOC was present in
8% (137/1642) as measured by the Wijma Delivery Expe-
rience Questionnaire (W-DEQ). The Hopkins Symptom
Check List (SCL-25) was used to assess anxiety and the
Edinburgh Postnatal Depression Scale (EPDS) to evaluate
depression. Of those with FOC, 8.8% (145 of 1642) had
anxiety (SCL-25 ≥ 18), and 8.9% (146/1642) had depression
(EPDS ≥ 12). Most participants (56.2%) did not have anxi-
ety or depression; however, comorbid anxiety or depression
increased the prevalence of FOC (odds ratio 2.4, 95% confi-
dence interval 1.1–5.2, and odds ratio 8.4, 95% confidence
interval 4.8–14.7, respectively). Those with both anxiety and
depression had the highest prevalence of FOC (odds ratio
11.0, 95% confidence interval 6.6–18.3).
A population-based study from Denmark of 30,480 nul-
liparous individuals also found a significant association
between anxiety (odds ratio 4.8, 95% confidence interval
4.07–5.66) and depression 2.70 (2.23–3.26) (Laursen et al.
2008). FOC was assessed by asking the question “are you
anxious about the course of the upcoming delivery?” Those
who answered, “a lot” among three options, “not at all,” “a
little.,” or “a lot,” were considered to have FOC. Anxiety
was evaluated by asking the question, “during your preg-
nancy, have you been anxious and afraid for no reason?,”
and depression was assessed by asking, “have you felt down
and blue during your pregnancy?.” A Finnish study of 278
women found generalized anxiety was the strongest predictor
(β = 0.28, P < 0.001) of FOC (Saisto et al. 2001). A study
of 191 pregnant women attending a parenting and childbirth
center in Slovenia found a Center for Epidemiologic Studies
Depression Scale (CES-D) score best predicted FOC (β =
0.27, P < 0.01). An association was found between FOC and
13
V. Sharma, S. Sharma
mode of delivery, whereas cesarean birth was the preferred
choice in 7% of the participants (Demšar et al. 2018). A
study from Canada found a history of self-reported traumatic
cesarean birth rather than cesarean birth, in general, was
associated with fear of future cesarean births (Fairbrother
et al. 2018; Fairbrother and Woody 2007).
Another study found that anxiety sensitivity rather than
prenatal FOC significantly predicted postpartum depression
or PTSD (Ayers et al. 2016). A study of 788,317 singleton
births from Finland found depression was the strongest risk
factor (adjusted odds ratio, 6.35; 95% CI, 5.25–7.68 for FOC
in nulliparous women) (Räisänen et al. 2014). Calderani and
colleagues from Italy reported that women with psychiatric
disorders may be more susceptible to developing tocopho-
bia (Calderani et al. 2019). About one-fourth (25/106) had
a lifetime diagnosis of psychiatric disorder, and one-third
(33/106) had a family history of psychiatric disorders. Only
6 (5.7%) individuals had a psychiatric disorder at baseline,
and 9 (8.5%) met the DSM-5 diagnosis of specific phobia.
An Australian study of 1410 pregnant women also found
the W-DEQ and the EPDS scores were highly correlated
(Schwartz et al. 2015). Compared to women with normal
vaginal delivery, those requesting an elective cesarean sec-
tion had higher levels of depression and anxiety in preg-
nancy but had similar depression levels postpartum. A study
examining the effect of vaginal delivery in women asking for
elective cesarean section found women were at significantly
higher risk of PTSD and depression than women with nor-
mal vaginal delivery.
Improving the assessment and treatment
of tocophobia
Generally, specific phobia is a highly comorbid disorder with
high rates of other anxiety disorders and mood disorders
(Eaton et al. 2018). During the reproductive years, women
are at risk of various specific phobias including tocophobia.
In the absence of specific criteria, tocophobia is diagnosed
using various scales. The W-DEQ is the most used tool for
assessment and diagnosis. It is a 33-item Likert scale with
questions about expectations before childbirth (version A)
and experiences after delivery (version B). A cut-off score
of 85 reliably detects FOC meeting the DSM-5 criteria of
specific phobia. The Childbirth Fear Questionnaire (CFQ)
is a 40-item scale that measures nine frequently reported
dimensions of FOC. It has a good convergent and discri-
minant validity compared to other measures of FOC. The
Fear of Birth Scale (FOBS) is a visual analog scale consist-
ing of a single question, “How do you feel right now about
the approaching birth?” The two items are anchored with
the words “calm/worried” and “no fear/strong fear” (Haines
et al. 2011).
Tocophobia: a nosological quagmire 715
It is important to assess women with tocophobia for current
and lifetime psychiatric comorbidities using valid diagnos-
tic criteria. Frequent assessments are necessary due to the
variability of mood and anxiety symptoms during and after
pregnancy. Currently, there are no studies on the prevalence of
depression, anxiety disorders, obsessive-compulsive disorder,
or PTSD among individuals with tocophobia. Similarly, there
are no data on the prevalence of tocophobia among women
with commonly occurring psychiatric disorders during or
after pregnancy. This may in part be due to the current con-
ceptualization of tocophobia as a “psychological domain of
its own,” i.e., specific phobia. Future research should clarify
the diagnostic profile of women presenting with severe fear of
childbirth including current and lifetime psychiatric comor-
bidity. Similarly, studies are needed to assess the prevalence of
fear of childbirth among women with common perinatal psy-
chiatric disorders. Finally, randomized controlled trials using
validated instruments are necessary to investigate the efficacy
of pharmacological and non-pharmacological interventions on
birth satisfaction and psychiatric comorbidity.
In conclusion, FOC is common and lies on a continuum
of severity. Extreme fear termed as tocophobia is usually
accompanied by anxiety and depression during and after
pregnancy. Early identification of individuals with toco-
phobia is necessary to optimally deal with their request for
an elective cesarean section. More research is warranted to
examine the correlates and risk factors for tocophobia and its
treatment. Common concerns among women with tocopho-
bia include fear of episiotomy, blood-injection-injury pho-
bia, hospitals, physical pain, and lack of control. Treatment
needs to be tailored to address specific concerns as well as
comorbid anxiety and/or depression. An elective cesarean
section should be considered if anxiety about childbirth
remains elevated despite efforts to reduce it with pharma-
cologic and/or psychotherapeutic measures.
Funding The Academic Medical Organization of Southwestern
Ontario (AMOSO) provided funding for VS. The funder of the study
had no role in study design, data collection, data analysis, data inter-
pretation, or writing of the report.
Declarations
Conflict of interest The authors declare no competing interests.
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