When Amy Redfern was pregnant with her first baby, now a healthy 3 1/2-year-old girl, she wasn't at all nervous about giving birth.
Her daughter, who was positioned sideways in Redfern's uterus, needed to be delivered via a planned cesarean section that she described as peaceful. "I used a lot of stress reduction techniques that I know from meditation and yoga," said Redfern, a freelance creative consultant and yoga instructor. "We really had a great experience."
But during her second pregnancy, Redfern, who was 39 weeks along when she spoke to The Huffington Post, was "really, deeply afraid." At 39 years old, Redfern is considered "old" in the pregnancy world, she joked ("They like to scare you more when you're older, but then tell you not to be afraid."). She was also trying for a vaginal birth after her C-section -- a procedure that carries a slight risk of uterine rupture, and that would require a 90-minute drive from her Maine home to the only area hospital that would perform it.
"At one point, it seemed like everywhere I looked, there were articles about mothers dying in childbirth," she said. "I kept thinking, is this a premonition? Intuition? Just irrational fear? I couldn't figure it out." Regardless of the cause, she has spent much of her pregnancy trying to manage daily moments of panic about dying and leaving her husband to raise the pair's two children on his own.
NORMAL ANXIETY OR SOMETHING MORE?
Childbirth is an enormous physical and emotional event, and it is not without risk. About 650 women die each year in the United States as a result of pregnancy or delivery complications, according to the Centers for Disease Control. Though many women approach birth with little apprehension, others admit to at least some degree of fear: A 2013 poll of 900 women in Britain found that 35 percent said their greatest anxiety before starting a family was the act of giving birth.
But for a smaller percentage of women, fear plays a more defining role. Estimates suggest that 13 percent of women postpone pregnancy, or avoid it altogether, a condition known as "tokophobia" -- a pathological fear of pregnancy and giving birth, first introduced into medical literature in 2000. And for women like Redfern, who become pregnant despite their anxiety, or who become overwhelmed by it only after they conceive, help and empathy are often in short supply. What generally is expected to be a happy time, can become one of dread and self-reproach.
"I was grateful to be having this baby and having a healthy pregnancy," Redfern said. "But I felt ashamed of the feelings I was having."
Tokophobia, which is not currently included in the Diagnostic and Statistical Manual -- often considered the bible of modern psychiatry -- is generally broken into two categories. Primary tokophobia refers to women whose fears predate their pregnancies, and the range of potential concerns is broad -- the actual pain, the increasingly high odds of medical interventions and surgery, or simply the unknown. Others experience tokophobia only after a previous traumatic delivery experience, explained Dr. Shari Lusskin, a clinical professor of psychiatry in the Department of Obstetrics, Gynecology and Reproductive Science at Mount Sinai Medical Center in New York.
"Some have faced a life-threatening trauma, which can certainly induce post-traumatic stress disorder," she said. "Other women may not have had a trauma that was potentially life threatening, but who felt traumatized by the experience of being a patient in some way or another."
For Stephanie Jones, a 25-year-old mother of two from North Carolina who had a C-section after 13 hours of labor with her first child, it was a fear of reliving the pain. Something went wrong with her anesthesia and she felt much of the cutting and tugging on the left side of her body. "They would not stop despite the fact that I was screaming," she said. “They put me straight to sleep after delivering my daughter and I didn't actually 'meet' her until she was over 4 hours old." With her second C-section, Jones cried uncontrollably from the second the doctors and nurses began prepping her for surgery, until she was in recovery.
Whatever the cause, research suggests women's angst can become a kind of self-fulfilling prophecy. A 2012 study from Sweden found that women who feared birth were more likely to ask for, and to have, a C-section. They also reported their pain as more intense than women who were unafraid -- even with widespread use of pain medication. A Norwegian study found labor lasts roughly one hour and a half longer in women who are scared of childbirth than it does for those who are not. Another study published in the journal BMJ Open found that "fear of childbirth appeared to increase the prevalence of postpartum depression by about three-fold in women without a history of depression and five-fold in women with known depressive disease."
Yet despite the range of ways in which fear can affect birth and the postpartum period, some women find little sympathy from their health care providers. "The first time I brought it up, she was so dismissive," said Redfern, whose OB-GYN's response what something like, 'You've brought this up with your therapist, right?'" Redfern was so taken aback she didn't admit to not having a therapist -- nor did she feel comfortable asking for a referral.
Victoria Spina, a 36-year-old stay-at-home mom, felt similarly dismissed. She was elated when she became pregnant with twins -- until she bought a book about expecting multiples, which made her panic about miscarriages, preterm birth or birth defects. "I had family telling me … 'It's just your hormones, it's just your hormones!'" she said. "But when you're freaking out, having someone tell you, 'it's just your hormones' doesn't help."
WHAT TO DO ABOUT THE FEAR
Yet there are approaches that can make a difference. "Cognitive behavioral therapy can be very effective at reducing the anxiety," said Lusskin. "Some women who have tokophobia -- or even if it doesn't quite move to that level of severity -- will also have underlying anxiety disorders or mood disorders that need to be addressed. Some will need medication during pregnancy, in addition to therapy."
Another approach that can be helpful is hypnobirthing -- a birth preparation technique gaining popularity. Exact methods differ, but it aims to arm women and their partners with mindfulness tools, such as positive visualizations, which they can focus on throughout delivery.
"The theory is that when patients have fear of labor and the pain of labor, it increases endorphins, which increases the pain receptors," explained Dr. Rebecca Starck, an OB-GYN at the Cleveland Clinic's Hillcrest Hospital, which has been offering hypnobirthing classes since last fall. "It's very hard to prove cause and effect, because each patient is different and each labor is different. But there really is no downside to going into labor with positive visualizations ready."
Christina Levine, a 31-year-old mother from North Carolina, was incredibly nervous about childbirth. Then she discovered hypnobirthing, which she found only because the birth center where she intended to deliver required parents to take a birthing class and it fit with her schedule. A self-described planner who struggled with not knowing what birth would feel like, or how her body would perform, Levine said it provided a surprising sense of purpose and control in the months leading up to her due date.
"It really did help keep me focused on the positive," she said. During labor, she listened to hypnobirthing CDs filled with guided meditations and imagery exercises. Levine said they helped her surrender to the pain -- to a point. "I was really glad to have something to listen to and focus on, but there was a moment when I called the lady [on the CD] a liar and turned it off!" Levine laughed.
For Redfern, things began to improve when she finally acknowledged her fears to a more receptive OB-GYN with her practice. She told her husband, her sister and a few close friends about her fear of dying during childbirth, and found that saying it aloud almost instantly released some of the shame. Still, with three months to go, she felt she needed more tools to fight her anxiety. She stopped reading anything related to maternal health and began studying hypnobirthing. In lieu of a baby shower, she asked her female friends and family to attend what she dubbed a "baby blessing" where guests brought her poems, or a prayer or blessing of support.
"I've been able to get myself mentally, emotionally and spiritually into a place where I feel more relaxed," said Redfern, adding that one week before her due date, she was feeling optimistic.
At a friend's suggestion, she developed a mantra, which she continues to use whenever she feels afraid -- say, while folding onesies or trying to fall asleep at night.
"We are safe," Redfern whispers to herself and her unborn baby. "We are safe."