When Dartmouth College anthropologist Zanetta Thayer asks students in an evolution class what words come to mind when they think of childbirth, almost all of them are negative: pain, screams, blood, fear.
Then I asked if any of the female students had ever seen a woman give birth. Most of them have not.
Curious about how cultural attitudes and expectations affect the physical experience and outcome of childbirth, Dr. Thayer began a study to assess the prevalence of tokophobia, the medical term for a pathological fear of childbirth.
Although tokophobia has been well studied in Scandinavia, and some do screen and treat pregnant women for it, very little research has been done in the United States. Dr. Thayer’s online survey of nearly 1,800 American women found that in the early days of the pandemic, tokophobia probably affected the majority of American women: 62 percent of pregnant respondents reported high levels of fear and anxiety about childbirth.
the The results were published last month in the journal Evolution, medicine and public health.
Other scientists who study childbirth said fear levels in the United States are higher than those reported in Europe and Australia, which are less than 20 percent. However, they noted that birth conditions in the United States are different and that the circumstances of the pandemic may have exacerbated concerns.
There is a certain level of anxiety about childbirth globally. It may be an adaptive behavior favored by evolution that prompts women to seek help and emotional support during labor, said Karen Rosenberg, a professor of anthropology at the University of Delaware.
said Wenda Trevathan, a senior research fellow at the School for Advanced Research in Santa Fe, New Mexico, an anthropology think-tank.
Severe phobias may be maladaptive, however, causing some women to have unnecessary caesarean sections or to refrain from becoming pregnant.
The new study has limits. Antenatal and postnatal data were collected during the first 10 months of the pandemic, when the healthcare system was under severe strain. The sample was not nationally representative, and consisted of a disproportionate proportion of high-income and high-income white women.
Half of the women have never given birth, and more than a third have had high-risk pregnancies.
More than 80 percent of women said that because of the pandemic, they were worried that they wouldn’t have the support person they wanted in the hospital during labour, that their baby might be transferred if they were diagnosed with COVID or that they might infect their babies if they contract the virus.
Black mothers, who face nearly three times the risk of dying from pregnancy-related complications, were twice as likely to have an intense fear of childbirth as white mothers.
“Black women are more likely to have complications or die during childbirth,” one pregnant woman said in her response, adding that her fears had heightened because she wasn’t sure she would have a loved one or a lawyer hospitalized with her because of COVID. “Who will speak for me?”
The study found that women with tokophobia were twice as likely to give birth prematurely or deliver a baby before 37 weeks of gestation. Premature babies are more likely to have health problems and are at higher risk of disability and death, and they often spend time in neonatal intensive care.
The association did not prove a causal relationship between fear and preterm labor. But the risk of premature birth among women with high levels of fear and anxiety remained high even after adjusting for other factors, such as caesarean sections.
The study also found links between fear and higher rates of postpartum depression and the use of formula to supplement breastfeeding. It did not find a relationship between tokophobia and a higher rate of caesarean sections or low birth weight in newborns.
Fear of childbirth may be an “underappreciated contributor to health inequalities,” said Dr. Thayer.
“It is likely that individuals who fear unfair treatment and discrimination in birthing settings will have a greater fear of childbirth, which may increase complications during the perinatal period,” she said.
In the United States, black women experience more premature births than any other race or ethnic group. The rate is about 50 percent higher than for white women. About 14 percent of black infants are born premature, compared to just over 9 percent of white and Hispanic infants.
Previous studies have linked premature birth to psychosocial stress, Dr. Thayer said, but this study is the first to find an association with tokophobia.
It found that fear of childbirth was higher among all socially disadvantaged women, including women with lower incomes and women with less education. Unmarried women, those receiving care from an obstetrician and those who had their first child were more likely to be afraid.
Dr. Thayer found that women with high-risk pregnancies who had prenatal depression were more likely to have a fear of childbirth.