The Fear of a Women in Labor

 

The Fear of a Women in Labor

Don’t be afraid, for I am with you.

    Don’t be discouraged, for I am your God.

I will strengthen you and help you.

    I will hold you up with my victorious right hand. Isaiah 41:10

The fear of childbirth, often referred to as tokophobia, is a significant psychological and obstetrical concern that affects pregnant women worldwide. This fear can range from mild anxiety to severe dread, impacting a woman’s mental health, decision-making regarding delivery methods, and overall childbirth experience.

For many mothers, the anticipation of labor involves uncertainties about pain, complications, and the well-being of both themselves and their baby. In the context of the Philippines, where cultural, socioeconomic, and healthcare disparities shape maternal experiences, fear of labor can influence the increasing rates of cesarean sections (CS).

This comprehensive exploration delves into the causes, manifestations, and consequences of fear of childbirth, followed by a case study examining cesarean cases across regions in the Philippines.

Understanding Fear of Childbirth

Definition and Prevalence

Tokophobia is characterized as an intense fear of pregnancy and/or childbirth, which may lead women to avoid vaginal delivery or even pregnancy altogether. It is categorized into primary tokophobia (fear in women who have never given birth) and secondary tokophobia (fear stemming from previous traumatic birth experiences). 

Globally, fear of childbirth affects 5–40% of pregnant women, with severe cases impacting approximately 7–25% of first-time mothers and 7.7–16.25% of multiparous women. In the Philippines, specific prevalence data on tokophobia is limited, but regional disparities in healthcare access and cultural attitudes toward childbirth suggest varying levels of fear among expectant mothers.

Causes of Fear

The fear of childbirth is multifaceted, arising from a combination of psychological, social, and medical factors:

Pain and Uncertainty: The anticipation of labor pain is a primary driver of fear. Many women worry about their ability to cope with intense pain or the unpredictability of labor.

Previous Traumatic Experiences: Women with histories of complicated deliveries, miscarriages, or stillbirths may develop secondary tokophobia.

Lack of Social Support: Poor emotional or familial support can exacerbate feelings of isolation and anxiety during pregnancy.

Cultural and Societal Influences: In some cultures, childbirth is surrounded by myths or negative narratives, amplifying fear. In the Philippines, traditional beliefs and the stigma around home births may contribute to anxiety.

Medical Concerns: Fear of complications, such as fetal distress or maternal mortality, is heightened in regions with limited access to quality healthcare.

Socioeconomic Factors: Financial concerns, especially in low-income settings, can intensify fear, as mothers worry about affording hospital care or cesarean procedures.

Manifestations and Consequences

Fear of childbirth manifests in various ways, including anxiety, sleep disturbances, and physical symptoms like stomach pain. Psychologically, it can lead to postpartum depression, post-traumatic stress disorder (PTSD), and impaired maternal-infant bonding. One significant consequence is the increased preference for cesarean sections, even when not medically necessary. 

Studies show that 7–18.6% of women with tokophobia request elective cesareans without medical indications, driven by fear of vaginal delivery. This preference can lead to longer recovery times, higher medical costs, and increased risks of complications for both mother and child.

Interventions to Address Fear

Effective management of fear of childbirth requires a multidisciplinary approach:

Educational Interventions: Childbirth preparation workshops and access to accurate information about labor can reduce anxiety.

Psychosocial Support: Counseling, support groups, and empathetic care from healthcare providers can help women process their fears.

Birth Plans: Creating personalized birth plans empowers women and gives them a sense of control.

Antenatal Care (ANC): Regular ANC visits allow healthcare providers to monitor and address fears early, improving maternal confidence.

Mental Health Referrals: In severe cases, referral to psychologists or psychiatrists is essential for managing tokophobia.

Cesarean Cases Across Regions in the Philippines

Background

The Philippines has seen a steady rise in cesarean section rates, surpassing the World Health Organization’s (WHO) recommended threshold of 10–15%. Data from the Philippine National Demographic and Health Survey (PNDHS) and other sources indicate that CS rates have increased over the past two decades, driven by medical, socioeconomic, and psychological factors, including fear of childbirth. 

This case study examines regional variations in CS rates, their association with fear of labor, and contributing factors.

Data and Trends

According to a 2025 study analyzing PNDHS data from 1993 to 2017, CS rates in the Philippines have consistently exceeded 15%, with significant regional disparities.

Key findings include:

National CS Rates: Primary CS rates remained above 20% from 2019 to 2022, peaking at 25.5% in 2021. In 2022, the national CS rate was approximately 10–20%, varying by region and facility type.

Regional Variations:

National Capital Region (NCR): The NCR reported the highest live birth rate (33.5%) and a high CS rate, driven by access to private hospitals and urban socioeconomic factors.

Region VIII (Eastern Visayas): Over 98.9% of women received ANC from skilled providers, correlating with higher CS rates due to better healthcare access.

Bangsamoro Autonomous Region in Muslim Mindanao (BARMM): BARMM had the lowest ANC coverage (47.5%) and postnatal care (44.5%), contributing to lower CS rates but higher maternal and neonatal risks.

Cordillera Administrative Region (CAR): 

89.1% of women received ANC, but CS rates were moderate due to geographic barriers and reliance on public facilities.

Demographic Factors:

• Older women (35–49 years) had higher CS rates (26.9%) compared to younger women (20–34 years: 18.3%; <20 years: 14.6%).

• Women with higher education, income, and urban residence were more likely to opt for CS, often in private hospitals.

• Indications for CS: The top indications included dysfunctional labor, fetal distress, and malpresentation, but maternal request due to fear was noted in urban settings.

Fear of Childbirth and CS Preference

Fear of childbirth significantly influences CS rates in the Philippines, particularly in urban areas with access to private facilities. Women cite fear of labor pain, complications, and loss of control as reasons for preferring cesareans. 

In a 2009 study across Southeast Asian countries, including the Philippines, maternal request for CS without medical indication was noted in some tertiary hospitals, though less common than in Indonesia.

The “No Home Birth” policy, implemented in 2008 to reduce maternal and neonatal mortality, has inadvertently increased hospital-based CS rates, as women fear penalties or complications associated with home births. In rural regions like BARMM, fear of hospital-based delivery due to cost or cultural unfamiliarity may suppress CS rates, but it also limits access to safe delivery options.

Regional Case Examples

Metro Manila (NCR): A 32-year-old primiparous woman in Quezon City opted for an elective CS at St. Luke’s Medical Center due to intense fear of labor pain and a history of anxiety. Despite no medical indications, her decision was supported by her obstetrician, reflecting urban trends where maternal request drives CS rates. The procedure cost approximately ₱137,000, partially covered by PhilHealth.

Nueva Vizcaya (Region II): A 24-year-old multiparous woman, Mylene, underwent an emergency CS due to fetal distress. Her fear of hospital delivery during the COVID-19 pandemic was compounded by financial strain from renting an apartment near the hospital. This case highlights how fear and socioeconomic barriers intersect in rural areas.

BARMM: A 28-year-old woman in a remote village avoided hospital delivery due to fear of medical interventions and cultural preference for traditional birth attendants. Her home birth resulted in complications, underscoring the impact of limited healthcare access and fear-driven decisions.

Contributing Factors to CS Rates

Healthcare Access: Regions with higher ANC coverage (e.g., Region VIII, NCR) have higher CS rates due to better access to skilled providers and facilities.

Socioeconomic Disparities: Wealthier women in urban areas are more likely to choose CS, while rural women face barriers to accessing any hospital care.

Policy Impacts: The “No Home Birth” policy has increased hospital deliveries but also CS rates, as women fear penalties or complications from home births.

Cultural Factors: In urban settings, CS is sometimes perceived as a “modern” or safer option, while rural communities may distrust medical interventions.

Fear of Childbirth: Fear of pain, complications, or loss of control drives maternal requests for CS, particularly in private hospitals.

Interventions and Recommendations

To address the interplay of fear and rising CS rates in the Philippines:

• Enhance ANC Services: Increase ANC coverage in regions like BARMM to build trust and reduce fear through education and support.

• Promote Trial of Labor After Cesarean (TOLAC): Encourage TOLAC to reduce repeat CS rates, addressing fears through counseling.

• Psychological Support: Implement routine screening for tokophobia during ANC and provide counseling or support groups.

• Policy Reforms: Re-evaluate the “No Home Birth” policy to balance maternal autonomy with safety, ensuring affordable access to hospital care.

• Public-Private Collaboration: Address disparities in CS rates between public and private facilities by improving public hospital infrastructure and staffing.

Conclusion

Fear of childbirth is a complex issue that significantly influences maternal health outcomes and delivery preferences, including the rising cesarean section rates in the Philippines. 

While urban regions like NCR show high CS rates driven by maternal fear and access to private care, rural areas like BARMM face challenges from limited healthcare access and cultural fears of medical interventions.

Addressing this requires a holistic approach, combining psychological support, equitable healthcare access, and policy reforms to empower mothers and ensure safe, informed childbirth experiences.

Citations

Philippine Statistics Authority, 2023.

NPR, 2020.

BMC Pregnancy and Childbirth, 2025.

Philippine Journal of Obstetrics and Gynecology, 2024. SciELO Brazil, 2023. 

St. Luke’s Medical Center, 2021. 

Philippine Journal of Obstetrics and Gynecology, 2020. NCBI, 2009. 

ScienceDirect, 2024. NCBI, 2023.

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