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Sally Dear Healy, Ph.D. by Sally Dear-Healey, Ph.D., PPNE, CCE (BWI), CD (BWI), TICP Research shows that “both psychosocial stress and pregnancy-specific stresses can have marked effects on pregnancy, maternal health, and human development across the lifespan.”  Moreover, both animal and human studies suggest that activation of what is referred to as the “maternal stress response” and resulting changes in endocrine and inflammatory activity can span generations.  This is considered an epigenetic influence (Coussons-Read, 2013).[1]  Additionally, fear of childbirth can increase the number of unnecessary cesarean births, especially those which are elective (Aksoy et al., 2014).[2] Perhaps even more concerning is the fact that moms with clinical anxiety are at increased risk for postpartum depression and postpartum anxiety. It is not unusual, nor is it always unhealthy, to fear something we have no experience with or know little to nothing about.  In fact, Carleton (2016)[3] argues that “fear of the unknown may be a, or possibly the, fundamental fear.” While the term xenophobia is often correlated with fear and hatred of strangers, it also is correlated with the fear of anything that is strange or foreign.  For many women, and men, birth, and especially birth in a hospital is a ‘strange and foreign’ land for which there is no travel guidebook, and often no designated and/or reliable guide.  Moreover, the “us” and “them” aspects of xenophobia clearly play out as beliefs and prejudices develop around certain birth practices, including but not limited to place of birth, type of care provider, the mode of birth, and beliefs and behaviors around early infant care. These beliefs can be embodied by women, their partners, as well as their care givers and differences are often a source of anxiety, stress, or fear- which can be counterintuitive in pregnancy and birth. Tokophobia, a term first identified by Dr. Kristina Hofberg in 2000, is defined as “A pathological fear of pregnancy (which) can lead to avoidance of childbirth.  It can be classified as primary or secondary.  Primary is morbid fear of childbirth in a woman, who has no previous experience of pregnancy.  Secondary is morbid fear of childbirth developing after a traumatic obstetric event in a previous pregnancy” (Bhatia and Jhanjee, 2012).[4]  Fear and anxiety are inextricably linked, and both can produce a stress response in both the mother and her baby.  Let’s unpack what this means for birthing women today. Many women today fear pregnancy or birth, or both.  An article in the Journal of Perinatal Education suggests that one of the reasons women today are so fearful of birth has to do with its negative portrayal in the mainstream media.  The author provides examples of how these influences, as well as the way hospital births today are “managed” with technology and ‘fear-based’ attitudes can single-handedly convince most women that their bodies are incapable of birthing without major medical intervention and that they would be crazy not to want all the technology they can get their hands on.”[5]   In other words, their fears are often generated by what they have seen, heard, or experienced.  They may also be generational in the sense that they are “old” memories of the experiences of our mothers and grandmothers.[6 ]  The fear itself may be conscious or unconscious.  Either way, as we have already acknowledged, fear not only impacts the woman/mother, it impacts the yet-to-be-born and newborn infant. While some stress is normal and considered to be healthy, and most people return to balance after a stressful experience, constant or chronic stress and the inability to regulate can have both short- and long-term negative impacts, sometimes referred to as fetal programming.[7]  For example, among other things, constant stress alters the body’s stress management system, causing it to overreact and trigger an inflammatory response.  According to Ann Borders, MD, MPH, MSc, “There are some data to show that higher chronic stressors in women and poorer coping skills to deal with those stressors may be associated with lower birth weight and with delivering earlier.”  She adds that “Chronic stress may also contribute to subtle differences in brain development that might lead to behavioral issues as the baby grows.”[8] Additional research by Myatt (2006) shows that “Untreated, significant, and ongoing antenatal anxiety exposes the fetus to excess glucocorticoids, which may influence the fetus’s susceptibility to enduring neuroendocrine changes.”[9] This is especially troubling as research by Bhatia and Jhanjee (2012) shows that between 20% and 78% of pregnant women report fears associated with pregnancy and childbirth. While screening for fear, anxiety, and stress – as well as depression – should be incorporated into every woman’s prenatal care, or as those in the field of prenatal and perinatal psychology suggest even prior to conception, obstetricians don’t regularly, or adequately screen for them.  This may be because it is assumed that pregnant women must be happy or because women feel ashamed to bring it up.[10]  And, while treatments such as Cognitive Behavioral Therapy (CBT) or psychopharmacology can be very effective for the treatment of anxiety disorders, we can also effectively argue that practices such as conscious conception, pregnancy, and birth – as well as having a positive mental attitude – can have a positive influence.[11]  Additional benefits can be realized through relaxed breathing, progressive muscle relaxation, meditation, and changing over from less healthy thinking patterns to healthier ones that focus on strengths-building and positive states of mind.  In turn, mothers and babies can have a more positive and less fearful and anxious experience of pregnancy and birth, which sets the stage for bonding, attachment, and greater physical and emotional health for mothers and babies. [1] Coussons-Read, M.E. (2013). Effects of prenatal stress on pregnancy and human development: mechanisms and pathways. Obstetric Medicine. 6(2): 52-57. [2] Aksoy, M, Aksoy, A., Dostbil, A., Celik, M. and Ince I. (2014). The relationship between fear of childbirth and women’s knowledge about painless childbirth. Obstetrics and Gynecology International. 274303. doi: 10.1155/2014/274303. [3] Carleton, R.N. (2016). Into the unknown: A review and synthesis of contemporary models involving uncertainty. Review. Journal of Anxiety Disorders.  Vol. 39: 30-43. [4] Bhatia, M. S. & Jhanjee, A. (2012). Tokophobia: A dread of pregnancy.  Industrial Psychiatry Journal. Jul-Dec; 21(2):158-159. [5] Lothian, J.A. and Grauer, A. (2003). “Reality” Birth: Marketing Fear to Childbearing Women.  The Journal of Perinatal Education. 12(2): 6-8. [6] Those who have given birth at home often experience a model of birth that has been shown to reduce the incidence of birth injury, trauma, and medical interventions which in turn decreases the fear and subsequent stress response(s). [7] “Fetal programming occurs when the normal pattern of fetal development is disrupted by an abnormal stimulus or ‘insult’ applied at a critical point in in utero development.  This then leads to an effect, which manifests itself in adult life” ( [8] [9] Myatt, L. Placental adaptive responses and fetal programming.  The Journal of Physiology. Vol. 572: 25-30. [10] Rope, K. (2019). How to Cope with Anxiety and Depression During Pregnancy. [11] It should be acknowledged that in some cases women need to take medication, however it is currently unclear whether and to what extent these medications impact the infant while still in the womb and during breastfeeding.  In addition, “Information of mixed quality in lay media, stigma, and fear may lead women to decline effective pharmacological treatment, take less than the recommended dose; or stop treatment prematurely, which may lead to discontinuation symptoms, relapse of underlying anxiety, and even suicidal ideation” (See Einarson, A. and Selby, P. (2001). Abrupt discontinuation of psychotropic drugs during pregnancy: Fear of teratogenic risk and impact of counseling. Journal of Psychiatry and Neuroscience. Vol. 26: 44-48 and Gawley, L. and Bowne, A. (2011). Stigma  and attitudes towards antenatal depression and antidepressant use during pregnancy in healthcare students. Advances in Health Science Education. 16(5): 669-679).