Monday, June 10, 2013

FEAR - contributing to labor interventions and PTSD

It is called tocophobia .  

It affects 1 in 10 women.

And it seems to be ignored by maternity care literature.

Yet, an amazing study done between 2006 and 2007 in Sweden's Karolinska Institutet, shows that psychoprophylaxis does help in some cases.

What is tocophobia?  From the Greek word tokos meaning childbirth and phobos, meaning fear, tocophobia is the fear (irrational) of childbirth.  Women and men can experience tocophobia and can experience a fear of dying, fear of pain, fear of lack of pain relief and fear of deformity of the newborn.  Occasionally tocophobia is culturally associated, such as when negative feelings toward childbirth are passed from mother to daughter or after seeing a film depicting childbirth early in life with no support or educational explanation.

In the medical literature, tocophobia or severe fear of childbirth (SFOC) is seen addressed more in
psychological journals or those from Europe than in the North American continent.  Maternal confidence and self efficacy are common threads in discussions of tocophobia or SFOC.  From the Nethersole School of Nursing in Hong Kong, the author writes that the efficacy-enhancing educational intervention should be further developed and integrated into childbirth education interventions for promoting women's copying ability during childbirth. Not only did the educational intervention promote a woman's self-efficacy but also reduced their perceived pain and anxiety in the first two stages of labour.

Further research in the literature demonstrates that prenatal anxiety was significantly related to self-efficacy for childbirth in late pregnancy, labor pain, number of hours at home in labor and admitting cervical dilation, and interventions used during the labor.

Kathy McGrath demonstrates that fear has its place in birth and new mothers can benefit from it:

Giving birth is meant to shake us right down to our roots so that we come out of it changed and ready to take on the daunting tasks of mothering a new baby. When birth goes well, from an emotional as well as a physical perspective, we come out of it empowered, awed, and humbled. When it does not go well, we can enter motherhood feeling disappointed, disillusioned, and disempowered. The stakes are high.

As childbirth educators and doulas, we need to approach this fear with caution and respect.  Not only does fear of childbirth result in extended length of labor, arrested labors, increased using of induction or augmentation, cesarean delivery, instrumental delivery but SFOC can affect mothers during the postpartum period as well with an increased risk of post-traumatic stress disorder (PTSD).  Fear and lack of control are elements contributing to PTSD.

SFOC is not addressed in the typical office visit.  Childbirth education classes are often discouraged.  Why are women's fears being ignored?  Why do we send new mothers, traumatized by a difficult birth that validated their prenatal feelings of fear, home alone with little or no support?

Give expectant mothers an atmosphere where they can feel safe in sharing their fear(s), where they feel they are heard and not judged.  Acknowledge the fear and share with them psychoprophylaxis!

What is psychoprophylaxis?  Based on a method of preparing women for childbirth with education, psychological and physical conditioning and breathing, psychoprophylaxis soon became synonymous with Lamaze, after Dr. Fernand Lamaze brought the Russian style of childbirth preparation to the West in the mid 1950s.  Quite simply, psychoprophylaxsis (psycho means mind and prophylaxsis means prevention) gives expectant mothers the educational and practical techniques to understand the careful hormonal orchestration of birth and be empowered to use simple techniques to produce effects that are not only healthy for both mother and baby but truly define self-efficacy for birth and the postpartum period.

As Barbara Hotelling so brilliantly put it: 
We once lost touch with a caring model of birth, and we are fortunate to have that knowledge and the availability of that model again. Childbirth education must evolve from the technological curriculum to a physiologic study of how well women's bodies are created, not for being delivered, but for giving birth.

With physiologic birth as our guide, we can reduce or eliminate tocophobia.


Bergstrom M. et al.  Fear of childbirth in expectant fathers, subsequent childbirth experience and impact of antenatal education: subanalysis of results from a RCT.  Acta Obstetricia et Gynecologia Scandinavica 2013 Apr 16.

Harris, R., Ayers S. What makes labour and birth traumatic? A survey of intrapartum 'Hotspots'. Psychology and Health 2012; 27(10): 1166-77.

Hotelling, B. Considerations when using videos in Lamaze Classes.  Journal of Perinatal Education 2012 Summer; 21(3): 189-92.

Hotelling, B.  From Psychoprophylactic to Orgasmic Birth.  Journal of Perinatal Education 2009 Fall; 18(4): 45-48.

Ip, W et al. An educational intervention to improve women's ability to cope with childbirth.  Journal of Clinical Nursing 2009 Aug; 18(15): 2125-35.

McGrath, K. The Courage to Birth.  Journal of Perinatal Education 2012 Spring; 21(2): 72-79.

Rouhe H. et al. Obstetric outcome after intervention for severe fear of childbirth in nulliparous women, a randomized trial.  British Journal of Obstetrics and Gynecology.  2013 Jan; 120(1): 75-84. 

Saisto T., Halmesm√§ki E. Fear of childbirth: A neglected dilemmaActa Obstetricia et Gynecologica Scandinavica, 2003 82(3), 201–208 

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