A Systematic Review of Tocophobia Rate Before and During the COVID-19 Pandemic

Abstract

Introduction: Childbirth is a phenomenon that causes stress to future mothers. The fear of childbirth is complemented by the fear that prevails all over the world due to the COVID-19 pandemic. Childbirth alone entails many risks; adding to them the COVID-19 outbreaks lead to a considerable amount of uncertainty that affects the psychology of pregnant women.

Aim:The present study aims at comparing the rate of tocophobia before and during the COVID-19 pandemic through a systematic review of studies published before and during the COVID-19 pandemic.

Methods:The methodology used in this study comprised an advanced search in several scientific databases and the recovery of relevant quantitative studies.

Results:The review included a total of 18 research papers published in English from January 2009 to April 2023, which examined the phenomenon of tocophobia before and during the COVID-19 pandemic.

Conclusion:This systematic review shows that tocophobia was more prevalent after the outbreak of the COVID-19 pandemic (ranging from 4.8%-20.8% before the COVID-19 pandemic and 10.6%-62% during the COVID-19 pandemic). It seems that the increase in tocophobia rate after the onset of the COVID-19 pandemic ranged from 6.4% to 54.3%. According to our review, tocophobia constitutes a major source of anxiety, especially during the COVID-19 pandemic. Therefore, governments should take appropriate action, especially in times of the COVID-19 pandemic, to ensure a more secure and friendly hospital setting for pregnant women.

Keywords:tocophobia, fear of childbirth, fear of labor, fear of birth, childbirth related fear, childbirth related anxiety, covid-19, fear in pregnancy and childbirth.

INTRODUCTION

Pregnant women, especially first-time mothers, frequently experience anxiety, concern, or fear regarding childbirth, with varied degrees of severity (1). During the postnatal period, women have a three times greater probability of being diagnosed with anxiety disorders than depression (2). Unlike perinatal depression, however, little focus has been put on the study of anxiety during the perinatal period so far (3). Fear of giving birth varies from little to strong and phobic dread, but the challenge is to determine when fear of childbirth turns into "tocophobia". Avoidance behaviors are typical of phobia. Although perinatal psychiatrists are few, a systematic clinical interview may be used for the psychiatric assessment of women, but this is not standard practice in maternity care (4, 5). Women with fear of childbirth are typically diagnosed with generalized anxiety disorder during a psychiatric evaluation; hence, fear of childbirth falls under the umbrella of anxiety disorders (6, 7).

For some women, fear of childbirth is so severe that it interferes with their daily lives and mars their pregnancy experience. Women with tocophobia experience feelings of loneliness, guilt, and humiliation due to a perceived stigma, because pregnancy is often regarded as a happy period in their lives and they may consider it inappropriate to share their anxieties with their partners or midwives (8). In extreme cases of tocophobia, women utilize strict contraceptive measures to avoid pregnancy, endure psychosexual difficulties, may choose to terminate a healthy pregnancy, conceal, or deny pregnancy (8).

The prevalence of tocophobia during the last 11 years before the COVID-19 pandemic (2009-2020) approximately ranged from 5% to 21% (9-11). For approximately 10% of women, however, the fear of childbirth is so intense that it could potentially lead to disorders, negative consequences on the birth of the fetus, unpleasant childbirth experiences, desire for a cesarean delivery, emergency cesarean section or even avoidance of pregnancy (9-11).

On March 11, 2020, the coronavirus outbreak has been declared a global emergency by the World Health Organization (12). Since infection management, medicine and immunization against COVID-19 came to the fore (13, 14), psychological and social issues such as fear and anxiety have been overlooked. Once the effects of the coronavirus infection became known, the original rejection of COVID-19 gave way to worry and anxiety (15). Later, it was found that people were afraid of getting infected or infecting their friends or family members (16). Fear of COVID-19 can be mainly seen in individuals who work in healthcare, education, customer service, public transportation, security and other fields where they often come into contact with customers (17). As a result, it was expected that these people's despair, anxiety, and stress levels would rise because of their excessive dread (18). Individuals' severe fear of COVID-19 is further enhanced by chronic illnesses or the presence of infected relatives and family members. Individuals will find it hard to respond to the COVID-19 outbreak and other situations calmly and reasonably if their dread of COVID-19 increases (16). COVID-19 pandemic confronted pregnant women with several concerns and reflections regarding their own health as well as that of their fetus and family, such as fear of contagion, lack of social connectedness because of social isolation, limited pregnancy care as well as other social and financial issues. The anxiety that pregnant women experience during COVID-19 pandemic has significant repercussions for the young mothers’ quality of life and the pre- and post-natal development of their offspring. Therefore, this should be considered as a serious matter that requires further scrutiny (19). For this reason, we decided to evaluate the degree of tocophobia before and during COVID-19 pandemic.

Study aim

The aim of the present study was to make a comparison of the phenomenon of tocophobia before and during the COVID-19 pandemic through a systematic review of studies published before the onset of COVID-19 and during the COVID-19 pandemic, in order to address the impact of COVID-19 pandemic on tokophobia rate.

METHODS

Eligibility criteria

Study eligibility criteria comprised quantitative surveys but not reviews and qualitative studies. Articles had to include pregnant women experiencing tocophobia, published before the onset the COVID-19 and during the covid pandemic. Articles had to use a valid questionnaire for measuring tokophobia.

Review eligibility criteria – As a result of the lack of translation resources, only articles in English were accepted in this systematic review. The study was not limited to a specific geographic area. Research limitations were related to the year of the research. The articles had to be published between January 2009 and April 2023.

Literature search strategy

A systematic search in two medical and psychological electronic databases, PubMed and Scopus, was carried out at the beginning of May 2023. The literature search was conducted in English only. The specific search strategies were created by KG, an author with previous experience in systematic review searching. An appropriate Medical Subject Heading (MeSH terms) and associated text words were used to develop a robust search strategy. Different search terms were used to cover the concept of tocophobia such as: fear of childbirth, fear of labor, fear of birth, childbirth related fear, covid-19, childbirth related anxiety, fear in pregnancy and childbirth. For the concept of COVID-19 pandemic we used covid-19, Coronavirus, Covid-19 outbreak, SARS-CoV-2, Coronavirus Disease. The two concepts and the associated text words were combined using operators (AND/OR). A search was carried out for key concepts and synonyms thereof in titles, abstracts, keywords, and texts.

Study selection

Titles and abstracts were closely examined to determine whether they met the eligibility criteria. Abstracts on the search topic were included in the full-text screening. Next, the reviewer pairs concluded the degree to which these articles fulfilled the criteria, and if they were deemed relevant, data were extracted and recorded to be included in this review.

Data extraction

With the help of an already developed pilot data extraction form, the following information was extracted using a standard structured form: author, year, study location (country), study design, scale used, sample size and prevalence. A summary of each publication included in this review and the key findings of each study (Tables 1 and 2) were extracted and recorded to prepare research data synthesis.

Quality assessment of the reviewed articles

A structured format adapted from Greenhalgh (20) was used to assess 18 studies with regard to their methodological quality. The present systematic review was carried out according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines (21). The methodological quality of the included studies was assessed based on the extent to which they met the following criteria: 1) data documenting the random recruitment of participants; 2) response rate .70%; 3) data documenting that each variable, such as tocophobia (severe fear of childbirth), was measured using standardized validated instruments (third criterion); and 4) control for confounding to avoid systematic bias. Data on the measurement of each variable were derived from the studies that were finally included using standardized validated instruments (third criterion) and met at least two of the three other methodological quality criteria.

Data synthesis

A summary and explanation of the key findings and the features of each study are provided, and they are indicated in Tables 1 and 2. A narrative synthesis approached the relationships and the findings within and between the included studies.

RESULTS

Study selection

The original search produced 58 titles. Titles and abstracts were assessed regarding their relevance to the review objective. After the assessment of titles and abstracts, 40 references were excluded as they were deemed irrelevant to the objective of the study. Finally, 18 articles were selected to be included in the present study (Figure 1). The 18 studies included in this systematic review are referred to in Tables 1 and 2.

Characteristics of included studies

Study location, design and sample – Two of the 18 studies took place in Poland (32, 36), three in Turkey (31, 34, 38), one in China (37), one in the Netherlands (35), and one was conducted online in Italy (33). Also, two (2) of the 18 studies took place in Sweden (23, 25), one in Canada (22), one in Norway (24), one in Australia (26), one in Slovenia (27), one in Ireland (28), one in Iran (29) and two in USA (30, 39). Sixteen (16) of the included studies had a cross-sectional design and two (2) had a longitudinal design. Samples of all approved studies consisted of pregnant women who experienced tocophobia before and during the COVID-19 pandemic. Eleven of the 18 studies, which included pregnant women who experienced tocophobia before the COVID-19 pandemic between 2009-2020 (Table 1), provided data on tocophobia rate long before the onset of COVID-19 pandemic. Three studies considered pregnant women with tocophobia right before and during the COVID-19 pandemic and compared the two pandemic and pre-pandemic groups (33-35), while four studies (36-39) assessed women with tocophobia during the COVID-19 pandemic and did not have a comparison group. The size of the survey samples ranged from 90 to 1775 participants (Tables 1 and 2).

Instruments of tokophobia – The Wijma Delivery Expectancy Questionnaire (WDEQ-A) was administrated in the vast majority of the included studies (22-32, 34, 35), while the labor anxiety questionnaire (KLP-II) in one study (36), the State Trait Anxiety Questionnaire for additionally assessing anxiety (STAI) in one study (36), and the Childbirth Attitude Questionnaire (CAQ) in one study (37). The Fear of Birth Scale (FOBS) was used in two studies (38, 39) and COVID-ASSESS questionnaire in the study conducted by Ravaldi (33).

Outcomes: prevalence of tocophobia before and during the COVID-19 pandemic

This review aims to compare the prevalence of tocophobia before and during the COVID-19 pandemic. For examining the changes in tocophobia rate, we classified the findings of our research into studies that assessed tocophobia rates during the COVID-19 pandemic (Table 2) and studies that assessed tocophobia before the onset of pandemia (Table 1), which documented the tocophobia rates before the COVID-19 pandemic. The rates of tocophobia were compared between the studies published during the COVID-19 pandemic and short or long before its onset.

The prevalence of tocophobia across several countries before the COVID-19 pandemic during 2009-2020 ranged between 4.8%-20.8%. However, during the COVID-19 pandemic, tocophobia rates ranged between 10.6%-62%. Therefore, it can be noted that there was an increase in the rate of tocophobia after the onset of COVID-19 pandemic comparing to the available data on the rate of tocophobia before the onset of COVID-19 pandemic. More specifically, tocophobia rate in Central European countries such as Poland increased by 6.4% (24.8% during the first phase and 18.4% before the pandemic) during the first phase of the pandemic and by 13.2% (31.6% during the second phase and 18.4% before the pandemic) during the second phase of the pandemic (32, 36) in comparison to the period prior to the pandemic. Moreover, in the USA, tocophobia rate was 7.7% before the COVID-19 pandemic (30) and 62% after its onset (39). This difference indicated an important increase of 54.3%.

According to studies with two comparative samples measuring tocophobia just before and after the onset of the COVID-19 pandemic, tocophobia rates ranged between 7.5%-24% in the samples right before the pandemic and between 10.6%-49% in those after the onset of the pandemic. From the three studies with two comparative samples right before and after the onset of the pandemic, only one research (33) showed an increase in tocophobia rate. More specifically, in the study performed by Ravaldi et al, the tocophobia rate increased by 41.5% between before and after the onset of COVID-19 (7.5% before the COVID-19 pandemic and 49% during the pandemic) (33). However, in the study conducted by Soysal et al there was no significant difference in the fear of childbirth between the pandemic and pre-pandemic groups (34), while in that performed by Zilver et al the tocophobia rate decreased between the pandemic and prepandemic groups (35).

In conclusion, it could be argued that, comparing the tocophobia rates in all the abovementioned studies, tocophobia seemed to be increased between before and after the onset of COVID-19 pandemic by 6.4% to 54.3%, except for the study performed by Zilver et al, which showed a decrease in tocophobia rate, as previously mentioned (35), and that conducted by Soysal et al, which showed no difference in tocophobia rate (34).

DISCUSSION

According to the available data, the estimated prevalence of tocophobia in pregnant women before the COVID-19 pandemic is 4.8%–20.8% and this rate appears to be increased during the pandemic (10.6%–62%). According to our systematic review, the increase in tocophobia rate after the onset of the COVID-19 pandemic ranged from 6.4% to 54.3% The COVID-19 pandemic may negatively affect the emotional state of pregnant women, causing fear, stress and severe fear of childbirth. Also, it seemed that, in less developed countries, women may have had a greater fear of childbirth, as shown in the study of Matinnia et al, which makes sense, since local physicians have less knowledge and experience than those working in more developed countries (40). Several factors influence stress and fear of childbirth, including many social factors (40).

The COVID-19 pandemic had a major impact on tocophobia (19, 34). Consequently, it affected the psychology of pregnant women by increasing the fear of childbirth (19, 34), although it seemed to be more related to the general conditions prevailing in hospitals, and not to the birth process itself. Interestingly, the findings of a study conducted by Preis et al (41) found that, during COVID-19 pandemic, many women preferred to give birth outside the hospital setting, for example in a community setting or at home. In addition, during the COVID-19 pandemic, women who had a cesarean section, or were about to give birth by a cesarean section, were more afraid than those who were scheduled to give birth normally, since a cesarean section is usually an emergency solution in cases of difficult pregnancy (41-45).

It should be also noted that one study performed by Zilver et al, has shown that fear of childbirth (FOC) decreased during the first and second phases of the pandemic in comparison to the pre-covid era (35). A possible explanation might be that working from home during the pandemic put less pressure on everyday life and working life. Less physically demanding work, reduced work-related stress, optimal sleep duration and increased social support are possible explanations for lower levels of childbirth fear (35).

Study limitations

Some methodological limitations should be taken into account for the interpretation of this study findings. It is worth noting that the present review included only quantitative studies and articles in English. A better understanding of the effect of tocophobia might be limited to some extent, due to the exclusion of qualitative studies. In addition, studies published in languages other than English were not included, limiting the research findings of the present systematic review.

CONCLUSION

Childbirth is a phenomenon that causes stress to future mothers. The fear of childbirth is complemented by the fear that prevails all over the world due to the COVID–19 pandemic. An issue such as childbirth, which is governed by many factors of uncertainty caused by the COVID-19 pandemic, has a negative impact on pregnant women’s psychology. The present systematic review shows that fear of childbirth was more prevalent after the outbreak of the COVID-19 pandemic (4.8%–20.8% before the COVID-19 pandemic and 10.6%–62% during the pandemic). Comparing tocophobia rates in all of the above-mentioned studies demonstrated an increase in tocophobia rate, which ranged between 6.4%–54.3%. In any case, research shows that tocophobia is a real challenge during the perinatal period, and governments, especially in the current period of the pandemic, should take appropriate measures to create a safer hospital environment for pregnant women to feel safe.

Conflicts of interest: none declared.

Financial support: none declared.

FIGURE 1.

Flow-diagram of the search and selection process

TABLE 1.

The prevalence of tocophobia before the onset of the COVID-19 pandemic between 2009-2020 (22-32)

TABLE 2.

Prevalence of tocophobia during the COVID-19 pandemic (33-39)