Tokophobia support - am I right to be concerned?

"More needs to be done to help women who have a morbid dread of childbirth...", says expert.

I am trying very, very hard not to be cynical about this call for midwives to recognize tokophobia as a legitimate issue affecting as many as 10% of women. Firstly, why has it taken so long and why have so many educated health professionals never even heard of it? But secondly - and more importantly, - why the concern NOW?

Could it be that this call is a direct response to the November 2011 NICE Caesarean section guideline update, which recommended that all women who request a caesarean should ultimately be offered one (once informed of the risks and benefits), and which specifically cited tokophobia as a reason some women might prefer surgery? And note, NICE says that tokophobic women should be 'offered' counseling, but not that it should be a requirement prior to offering a c-section.

Here are some of the reasons for my concern:

1) Expert Zara Chamberlain is quoted as saying, "This could result in the women deciding to have an abortion or to seek an elective C section", as though these two options are an equally terrible consequence. I know of three cases where abortion was sought by tokophobic women, and in all three, had their cesarean maternal request been granted, they would have happily taken that option – and a live baby - but surgery was refused.

2) Zara talks about "a robust birth plan" for tokophobic women, as though they can somehow be guaranteed a more predictable trial of labor than anyone else – but they can't, and this is one of their legitimate fears. Women and babies CAN die or suffer injuries during the birth process, and this is why tokophobia is not wholly irrational.

3) Zara concludes, "Other women have an elective Caesarian section - which is also a very scary option". This demonstrates to me that even this midwife counselor, who is trying to educate midwives, may not have fully understood that for many tokophobic women, the very opposite is true. They do not perceive planned surgery as particularly "scary" at all, and in fact, once surgery is scheduled, their anxiety is vastly reduced (even though fears such as premature labor or their doctor being unavailable on the day may remain).

4) The "offer" of counseling to vulnerable and scared women can too often mean a thinly veiled attempt to pressure or convince them into having a trial of labor; labor risks are completely downplayed and cesarean risks are overemphasized. And this is more to do with an ideological desire to reduce cesarean rates and increase 'normal' births than anything else.

Norway study

For evidence, just look at this article today on a recent Norwegian study, which begins, "Group therapy can help women avoid risky and costly cesarean sections":

Lead study author Dr. Hanna Rouhe, from the Helsinki University Centralö Hospital, is quoted as saying (about tokophobia), "Symptoms of the intense fear included panic that affected daily life, nightmares about delivery and a strong desire for a C-section."

"A number of initiatives aim to reduce the first cesarean section by waiting longer to induce labor and by allowing longer delivery times before C-sections are offered, she noted. But… I am not aware of initiatives surrounding childbirth fear - maybe there should be."

With all this in mind, I'm left wondering whether some midwives are developing a new concern for tokophobic women with purely altruistic intentions, or actually because these women - with their "strong desire" for a cesarean now supported by national clinical guidance - are a danger to the RCM (and others)’s ideological goal of reducing cesarean rates.

After all, 6-10% tokophobia is a very big number when you're trying to hit low CS targets...