Tokophobia: A dread of pregnancy

Abstract

Tokophobia is a pathological fear of pregnancy and can lead to avoidance of childbirth. It can be classified as primary or secondary. Primary is morbid fear of childbirth in a woman, who has no previous experience of pregnancy. Secondary is morbid fear of childbirth developing after a traumatic obstetric event in a previous pregnancy. A case of tokophobia with depression who responded to fluoxetine is being described.

Pregnancy is a major physical, psychological, and social event in every woman's life. Instead of being a joyful experience, pregnancy may become a worrisome and fearful event in few patients and the fear may assume a pathological dimension and becomes a disorder worth recognition and treatment. Majority of women are able to cope up with fear and anxieties by self-help efforts, social support, and medical help. However, when it becomes pathological dread, it is called tokophobia. It is also known as “maieusiophobia” or “parturiphobia.” It was first described in literature by Knauer in 1897.[1]

Tokophobia is a pathological fear of pregnancy and can lead to avoidance of childbirth.[2] It can be classified as primary or secondary. Primary tokophobia is morbid fear of childbirth in a woman, who has had no previous experience of pregnancy. The dread of childbirth may start in adolescence or early adulthood. Although sexual relations may be normal, several different methods of contraceptive use to delay the pregnancy is often scrupulous.[2,3] Generally pregnancy is avoided because of fear of labor. Some suffering women go for abortion, caesarean, or adoption.[2] Secondary tokophobia is defined as morbid fear of childbirth developing after a traumatic obstetric event in a previous pregnancy. However, it could also occur after an obstetrically normal delivery, miscarriage, stillbirth, or termination of pregnancy. Less commonly, prenatal depression may be present with tokophobia. About 20-78% of pregnant women report fears associated with the pregnancy and childbirth.[4,5] However, 13% of non-gravid women report fear of childbirth sufficient to postpone or avoid pregnancy.[4] Fears are more common and more intense in nulliparous than in parous women.[6,7]

CASE REPORT

A 43-year-old married housewife of high socioeconomic status presented to the psychiatry out-patient department with a 2 years history of morbid dread of pregnancy. This started 2 years after marriage when she contacted a gynecologist for menstrual irregularity. She asked the physician about the complications of pregnancy. On hearing the dreaded complications like having a deformed fetus, change in body figure, eclampsia, caesarean, and even death, she developed excessive fear of pregnancy. When also informed that no contraceptive method is fully protective, she started avoiding sexual contact with husband. On stopping all sexual activity, she gradually developed sad mood, hopelessness, helplessness, worthlessness, difficulty in falling asleep, weeping spells, loss of appetite and suicidal ideation. She also started having less interaction with husband, parents, and other relatives. Even after being counseled by relatives and two obstetricians, she could not get rid of the fear of pregnancy. There was no past or family history of mood disorder, schizophrenia, epilepsy, or drug dependence. Her vitals, routine investigations, and physical examination were normal.

On mental state examination, she was a tidy, cooperative lady of pyknic build. There were no disturbances in orientation or memory. Her mood was sad with reduced psychomotor activity and monotonous low volume speech. There were ideas of hopelessness and worthlessness and also, feeling of guilt and suicidal ideation. There was no formal thought disorder. Insight and judgment were intact.

She was diagnosed as a case of tokophobia with major depressive disorder. She was started on fluoxetine, 20 mg once daily and clonazepam 0.5 mg at night and counseling (including psycho education) weekly for about 2 weeks but there was no improvement. The dose of fluoxetine was increased to 40 mg daily and over the next 4 weeks, there was reduction in her morbid fear of pregnancy along with symptoms of depression. She started having normal sexual activity. At follow-up after 3 months while still on medication, there was no recurrence of symptoms.

DISCUSSION

Pregnancy and anxiety related to childbirth are very common in women. The various hypotheses put forward to explain fear of childbirth include disturbance in neurohormonal homeostasis (i.e., disturbance in mechanisms regulating anxiety),[8] social communication (relationships with women who had undergone traumatic births),[9] fears related to medical care (ineffective pain control, fear of loss of control or death, and lack of confidence in team providing care),[10] psychosocial factors (e.g., younger age, low education, and social disadvantage), and psychological factors (e.g., low self-esteem, lowered pain sensitivity, revival of traumatic memories of childhood or psychiatric disorders commonly depression or anxiety).[2,11] Better the support system, lesser is the antenatal stress load. Most of the women with fears seek support from their spouses, mothers, sisters or other family members, while some look to friends and colleagues for support.[9] Sjögren and Thomassen[10] had shown that support for women with severe fear of delivery resulted in a 50% reduction in the rates of caesarean section births for psychosocial indications. Cognitive behavior therapy (Because of short duration, lack of deep analysis, and focus on a specific symptom) and psychotherapy (aimed at controlling emotions and feelings) give satisfactory results.[4,11,10] Pharmacotherapy is used to treat anxiety, depression or underlying psychiatric disorder.[2,3] The present case had depression and responded to fluoxetine. Prenatal and antenatal education[11,10] and antenatal screening tests certifying normalcy[12] is an effective way to alleviate fears. Preventive programs for management of pregnancy-related fears should be implemented in modern obstetrics. This would facilitate satisfactory delivering experience.