Care for women: How CBT can help you cope with the fear of birth

Expectant parents often feel anxious or concerned about upcoming contractions, potential pain, and the uncertainty of pregnancy and labor. However, sometimes the feeling may be so overwhelming that it begins to impede on daily life. Fear of birth, or tokophobia, is a treatable mental health condition that is estimated to affect up to 14% of pregnant parents worldwide. 

In cases of intense anxiety, parents-to-be may benefit from cognitive behavioral therapy, or CBT. A mental health provider such as a therapist can be beneficial in helping expectant parents overcome mental health challenges associated with anxiety throughout pregnancy, delivery, and beyond. 

Overview

The fear of birth (FOB), often called tokophobia, is characterized by an extreme fear of pregnancy or childbirth. FOB symptoms include:

• Extreme fear of pregnancy
• Fear of the birth experience, such as contractions or vaginal birth
• Intense fear of stillbirth, birth defects, or maternal death
• Feeling disconnected from partner, loved one, or baby
• Sleep disturbances, panic attacks, and other symptoms of extreme anxiety

While they may not avoid sexual intercourse, those experiencing FOB often use more than one birth control method due to a severe fear of becoming pregnant. Should they become pregnant, they may choose to terminate or undergo a Cesarean section.

Patterns of FOB throughout birth vary, but they may become more pronounced later in pregnancy. In addition, anxiety doesn't necessarily stop after birth, with residual mental distress potentially lingering up to one year postpartum. 

Primary and secondary fear of birth (Tokophobia)

Tokophobia may be divided into primary and secondary fears. 

Primary tokophobia describes the feelings of pregnant parents who have not experienced birth before. Often, this phobia for first-time moms begins in childhood or adolescence. In some cases, primary tokophobia occurs when a person has experienced past trauma or abuse.* In other cases, it may originate from hearing stories of, or witnessing, challenging labor and delivery. 

Secondary tokophobia may arise from a past challenging or traumatic labor or delivery, leaving parents anxious that the complicated, painful, or difficult labor and delivery will repeat itself. Secondary tokophobia may also affect those who have experienced pregnancy termination, infertility treatments, stillbirth, or miscarriage. In some cases, secondary tokophobia may occur in situations where a woman has experienced a healthy pregnancy and childbirth.

*If you are facing or witnessing abuse of any kind, the National Domestic Violence Hotline is available 24/7 for support. Call 1-800-799-SAFE (7233) or text "START" to 88788. You can also use the online chat.

Treatment

Women experiencing pregnancy or childbirth anxiety may benefit from supportive care aimed at helping them cope. These interventions may include:  

• Cognitive behavioral therapy (CBT)
• Eye movement desensitization and reprocessing (EMDR)
• Support groups
• Prenatal classes
• Lifestyle changes

Treatment of FOB through mental health interventions is generally recommended, as FOB is often associated with:

• a decrease in overall well-being
• increased symptoms of anxiety and depression
• obstetric complications
• requests for cesarean births
• traumatic or adverse birth experiences

In addition to addressing strategies for coping when one is feeling anxious about giving birth, healthcare providers may discuss a birth plan, talk about ways to stay in good health leading up to the due date, go over pain relief options, and offer resources for postpartum care. They may also offer further advice to help parents manage life with a new baby and address other pregnancy and pain fears parents may have about delivery or childcare. Thus, the treatment of FOB through therapy may be a crucial part of pre-delivery care. 

Research 

Over the years, several treatment protocols have been developed and evaluated to examine their effects on severe FOB. These studies are often randomized controlled trials (RCT) and compare psychoeducational group sessions designed for individuals with FOB to standard care options. These studies, which are often medically reviewed, examine outcomes such as cesarean birth rates, birth experiences, and depressive symptoms. Correlations in the past have been weak, but there has been a slight decrease in FOB for many clients participating in psychoeducational group sessions.

While standardization of treatment may be limited for FOB, future treatment and interventions may be developed to meet broad needs. Intervention plans may benefit from being adaptable because of the variability between pregnant individuals in symptom presentation, severity, and cause. 

Midwife counseling studies 

In an Australian trial, midwife telephone counseling was compared to standard pre-birth care on two occasions. It was found that both groups had a reduction in FOB symptoms later in pregnancy after the interventions. 

In another study performed in Sweden, pregnant individuals were given counseling by midwives trained in treating FOB. While these clients were satisfied with their care when asked one year after birth, the clients with FOB tended to have less positive birth experiences and higher rates of cesarean deliveries than those who did not report having FOB. While these studies have shown the positive effects of treating FOB in pregnant people, there have yet to be significant findings regarding reducing the fear of birth and improving corresponding birth outcomes.

Cognitive behavioral therapy studies on fear

Cognitive-behavioral therapy (CBT) has shown promise for reducing symptoms of anxiety, depression, and other mental health conditions. Because of the high rates of these symptoms in association with FOB, researchers hypothesize that CBT has the potential to reduce these symptoms in those with FOB and subsequently improve outcomes. 

CBT effectively reduces symptoms of anxiety disorders, even in the presence of additional mental health conditions. Online CBT programs are often broad enough to suit a diverse audience, making them especially suitable for FOB. There can be a wide range of symptom severity and comorbidity among FOB clients, so completing an intervention program aimed at a heterogeneous population could be beneficial. 

Online CBT also has the added benefit of being completed at home in a self-paced manner, which increases reach for populations with time, financial, and transportation constraints. Because those later in pregnancy may experience more discomfort when moving from place to place, the ability to participate in the intervention at home can offer value. 

Common fear studies

When developing an intervention, researchers often look to understand the most common themes for those experiencing anxiety. For some, it is the fear of labor pain and not receiving adequate pain relief; for others, it is the fear of harming their baby inadvertently. In a study published in BMC Pregnancy and childbirth, ten pregnant individuals experiencing FOB and thirteen midwives who supported them were interviewed to identify common fears.

While fear of birth is not necessarily limited to these themes, understanding common experiences might inform the development of internet-based interventions to best cater to those experiencing these symptoms and concerns.

Has current research shown CBT is effective in treating fears about birth?

To further evaluate internet-based cognitive behavioral therapy for individuals with FOB, a study was conducted to examine the efficacy of a guided internet-based self-help program compared to standard prenatal care. In this randomized controlled trial, levels of FOB during later pregnancy and one year after birth were evaluated.

The RCT was designed with the Uppsala University Psychosocial Care Program (U-Care) for this study. The U-CARE Pregnancy trial was an RCT that compared guided internet-based cognitive behavioral therapy (ICBT) with standard antenatal care for pregnant individuals experiencing FOB. 

In this study, pregnant clients were screened during their 17–20-week ultrasound for symptoms of FOB. They were then given a number 1-100 on the Fear of Birth Scale to identify the severity of their FOB. Those who received a score over 60 could be included in the study if they did not meet exclusion criteria, such as adverse pregnancy findings or lack of reach to technology for follow-up information. Participants were then given a brief questionnaire to gauge their symptoms before the intervention.

ICBT intervention design

The goal of the intervention in the study was to improve care for those experiencing FOB. Pregnant women in the intervention were guided on coping with complex thoughts and emotions and observing and understanding their FOB. It was designed to be broad and flexible to meet various needs and ensure the intervention was applied to each participant.

The program was given to participants through an internet platform using a double-verification login. The participants were also randomized to have one of two licensed clinical psychologists involved in the intervention. They could frequently message their therapist through a texting app on their mobile phones. In the program's second half, the psychologists would call participants to help with adherence and motivation within the intervention.

The ICBT intervention was divided into modules, one of which was completed each week. Each module had one to three homework assignments per week. The modules were as follows:

• Introduction and motivation enhancement

• Program introduction

• Understanding fear and anxiety

• Motivation and behavior change

• Emotion

• The function of emotion

• Physiological, cognitive, and behavioral aspects of emotion

• Behavior

• Learned and emotion-driven behavior

• Avoidance and negative reinforcement

• Cognition

• Automatic appraisals and catastrophizing

• Viewing cognitions as merely cognitions

• Mindfulness and acceptance

• Nonjudgmental present-moment awareness

• Acceptance of pregnancy and childbirth

• Exposure

• The purpose of exposure-based intervention

• Different forms of exposure

• Planning and implementation of exposure-based interventions

• Generalization and maintenance

• Progress and acquired skills

• Being your therapist: working with maintenance

• Post-partum follow-up

• Childbirth in retrospect

• Generalizing acquired skills to other areas of life

Primary outcomes 

Information was collated through questionnaires completed independently by the clients in the trial. The questionnaires were conducted at the ultrasound screening at 17-20 weeks, online at gestational weeks 20-25, online at gestational weeks 30 and 36, and one year post-partum.

In this study, researchers found that fear of birthing decreased over time in both the ICBT intervention group and the group that received standard care (standard care involved two to four counseling sessions by midwives or obstetricians). The ICBT group had a slightly more significant decrease in FOB. Significant differences between the groups were also found one year post-partum, where the ICBT group had a much higher reduction in FOB.

One potential reason for the lack of a significant difference between the groups may be that the control group (the group that received the standard care) had counseling sessions with midwives and practitioners. Many pregnant parents in the US may not receive counseling from midwives. The study may have benefited from having a control group that did not partake in any therapy.

These results may indicate the value of implementing consistent counseling and contact between healthcare workers and expectant parents to improve care for pregnant individuals and decrease anxiety. Future studies can include multiple levels of control groups with different types of standard care to evaluate the efficacy of internet-based or in-person forms of cognitive therapy for pregnant people.

Counseling

Although fear of birth can be common, symptoms and origins of symptoms often vary between individuals, making it difficult for healthcare providers to have standardized diagnostic and treatment methods. It has been associated with symptoms of anxiety and depression, adverse birth outcomes, increased cesarean deliveries, and feelings of distress up to one year after birth. Because of the high association rates with adverse mental and physical outcomes, receiving treatment can be valuable. 

Internet-based CBT has shown potential in treating anxiety and depression, commonly associated with fear of birth. Internet-based treatments can also offer benefits to expectant parents, such as reduced financial and transportation requirements and a self-paced curriculum. In addition, clients can choose between phone, video, and live chat sessions with a licensed therapist educated on birth and postpartum care. 

If you're wondering whether internet-based CBT can help you manage symptoms of mental health concerns, consider reaching out to licensed therapists through a platform like BetterHelp. BetterHelp is an online therapy platform that provides tools, support, and therapy sessions tailored to clients, with over 30,000 independent therapists, counselors, and social workers available to match with.