Determinants of Tokophobia and Preferred Mode of Delivery among Antenatal Mothers – A Hospital Based Cross Sectional Study

 

Jisha Joseph1, Ann Maria S2, Anna Maria James2, Anna Mathai2, Annu Ullas2,

Anu Maria Antony2, Nini Babu3

1Associate Professor and HOD, Department of Obstetrical and Gynecological Nursing,

M.O.S.C College of Nursing, Kolenchery. Kerala, India.

27th Semester BSc Nursing Students, M.O.S.C College of Nursing, Kolenchery. Kerala, India.

3Assistant Professor, Department of Obstetrical and Gynecological Nursing,

M.O.S.C College of Nursing, Kolenchery, Kerala, India.

*Corresponding Author E-mail: sampoornamwebster@yahoo.in

 

ABSTRACT:

Childbirth is a remarkable and deeply personal experience for every woman. A prevalent issue that impacts women's health and well-being throughout pregnancy is fear of childbirth (Tokophobia). This study focused on evaluating the determinants of tokophobia and the preferred mode of delivery among antenatal mothers in third trimester. The research question of this study was, what are the determinants of tokophobia and how do they influence the preferred mode of delivery among antenatal mothers attending the OPD of a selected tertiary care center in Ernakulam district, Kerala? The objectives were to estimate the magnitude of tokophobia and to identify the determinants of tokophobia among antenatal mothers. Also, to analyse the association between tokophobia and the preferred mode of delivery among antenatal mothers. A quantitative cross-sectional analytical design was employed, involving 140 antenatal mothers selected through convenience sampling. Data were collected using the standardized Wijma Delivery Expectancy Questionnaire (WDEQ-10) to assess tokophobia levels and a structured questionnaire to evaluate socio-demographic, obstetric, and psychological determinants, as well as the preferred mode of delivery. The study found that 70.71% of participants experienced low fear, 28.57% moderate fear, and 0.71% high fear, with a median fear score of 18 (IQR: 15.75–21). No significant associations were observed between tokophobia and most socio-demographic, obstetric, or psychological variables, except for a statistically significant association with a previous history of tokophobia (p < 0.05). Additionally, no significant association was found between tokophobia and the preferred mode of delivery, with 97% of participants preferring vaginal delivery. These findings suggested that while tokophobia was prevalent at low to moderate levels, prior experiences of childbirth-related fear significantly influenced its persistence, highlighting the need for targeted psychological interventions. The lack of association with delivery preference contrasts with some prior studies, possibly due to cultural or healthcare system differences. Early identification and management of tokophobia are crucial in improving maternal satisfaction and reducing unnecessary surgical interventions. Insights from this study can guide healthcare providers in offering personalized care plans that enhance maternal satisfaction and reduce unnecessary cesarean sections.

 

KEYWORDS: Tokophobia, Determinants of Tokophobia, Preferred Mode of Delivery, Antenatal Mothers.

 

 

INTRODUCTION:

The birth of a child is a lovely life event that is unique to each mother1. Pregnancy brings a range of physical and psychological changes that help to prepare women for motherhood2. A prevalent issue that impacts women's health and well-being throughout pregnancy, delivery, and the postpartum period is fear of childbirth3. One of the most important physiological conditions in a woman’s life is pregnancy; but, for some women, pregnancy can be a stressful and frightening event that can result in disease-like problems4. Tokophobia, or the intense fear of childbirth, is a psychological condition that affects a significant proportion of pregnant women, influencing their choice of delivery mode5. Tokophobia is defined as a pathological or intense fear of pregnancy and or childbirth, which can lead to significant psychological distress and avoidance of pregnancy altogether6. Both women who have never given birth and those who have had unpleasant birth experiences in the past might be affected by tokophobia7. The third trimester is a crucial period when antenatal mothers finalize their birth plans, making it an optimal stage to assess tokophobia and its impact on delivery mode preferences8. Multiple factors contribute to tokophobia, including psychological distress, previous birth experiences, perceived pain, social support, and exposure to negative birth stories9. There are lot of studies conducted outside India found that the choice of delivery is affected by tokophobia9,3,10. The delivery process may be impacted by the elevated anxiety, which could make it more difficult to form a strong bond with the kid and raise the possibility of trauma during childbirth4. Given the rising trend of elective cesarean and the potential adverse outcomes associated with unnecessary surgical births, it is essential to understand the determinants of tokophobia among pregnant women in their third trimester. Identifying these factors can aid in developing targeted interventions to alleviate childbirth-related anxiety and promote informed decision-making regarding delivery mode.

 

An irrational fear of childbirth can impact the whole pregnancy, make labor more challenging, and contribute to problems in bonding between mother and baby, as well as increase the risk of postpartum depression10. The global prevalence of tokophobia ranged between 3.7 and 43% and a significant heterogeneity was also observed. From 2000 onwards the tokophobia rate was found to be increasing5.

 

In Kerala tokophobia prevalence rate is 21.6% among primigravidae women, which is significantly higher than the national average of 13.2%11. A multi-centre study across South India found that 42% of pregnant women in their third trimester reported moderate to severe stress, with 26.8% specifically demonstrating tokophobia, and 31.7% preferring cesarean deliveries despite absence of medical indications12. Fear of childbirth is a key predictor of the likelihood of undergoing an emergency caesarean section. It can strongly influence a woman's preference for cesarean delivery and significantly affect her psychological well-being, her family, and the overall birthing experience, thereby playing a vital role in decisions about the mode of delivery13. Tokophobia is a pathological fear of pregnancy and can lead to deliberate avoidance of childbirth14. Dr. P. Shah, President of the Federation of Obstetrics and Gynaecology Societies of India, observed that in the last 20 years, caesarean section rates have grown significantly by around 25% in teaching hospitals and over 50% in private hospitals, largely due to various contributing factors, particularly in first-time mothers15. Early identification and management of tokophobia are crucial to improving maternal satisfaction and reducing unnecessary surgical interventions. Insights from this study can guide healthcare providers in offering personalized care plans that enhance maternal satisfaction and reduce unnecessary cesarean sections.

 

MATERIALS AND METHODS:

Data was gathered using two questionnaires. Tool 1, The Wijma Delivery Expectancy Questionnaire (WDEQ) was developed by Dr. Klaus Wijma and his team at Linköping University in Sweden to assess dimensions of fear of childbirth in pregnancy people. Tool 2, Structured questionnaire was prepared to identify socio-demographic data, obstetric history, psychological factors, and preferred mode of delivery of antenatal mother. The tool was developed by the researchers and validated by five experts from the medical and nursing fields.

 

METHODS:

Research Approach:

Quantitative approach

 

Research Design:

Cross sectional analytical design.

 

Variables:

Outcome variables:

Level of tokophobia, determinants of tokophobia and preferred mode of delivery

 

Socio-demographic Variables:

Age, Marital status, Education level, Employment status, Household income level, Religion, Place of residence, Type of family, Support system, Satisfaction with husband support.

 

Setting of the study:

Antenatal OPDs of M.O.S.C Medical Mission Hospital, Kolenchery.

 

Population:

Antenatal mothers in third trimester in Ernakulam District, Kerala.

 

Sample:

140 Antenatal mothers attending OPDs of a selected tertiary care centre in Ernakulam District, Kerala.

 

 

Sampling Technique:

The sampling technique used for present study was convenience sampling technique.

 

Sample Size:

Sample size was estimated using the following equation comparison of two means:

 

Where,

Z (1−α/2)​(Critical Value of Z):1.96

S = SD, 23.5

d = Absolute precision, 4 unit

Estimated Sample Size (n) = 132

140 subjects were included in the study

 

Inclusion criteria:

Antenatal mothers:

·       Who are in their third trimester (29-40 weeks of gestation) irrespective of parity

·       Who attend routine antenatal care at the selected facility

·       Who are able to read and write Malayalam/English

 

Exclusion criteria:

Antenatal mothers:

·       With known psychiatric disorders.

·       With medical or obstetric conditions with absolute indications for cesarean delivery.

 

 

RESULTS:

Section A: Description of subjects according to their demographic variables

Table 1: Frequency and percentage distribution of subjects based on their demographic variables                                              n=140

Sl No

Socio-demographic variables

Frequency (f)

Percentage (%)

1

Age

18-25 yrs

41

29.29%

26-30 yrs

55

39.29%

30-35 yrs

38

27.14%

>35 yrs

6

4.28%

2

Marital Status

Married

138

98.57%

Widowed

2

1.43%

3

Educational level

Below 10th standard

2

1.43%

Above 10th standard

29

20.71%

Undergraduate/Postgraduate

109

77.86%

4

Employment Status

Employed

55

39.29%

Self-employed

7

5.00%

Home maker

70

50.00%

Student

8

5.71%

5

Monthly Household Income

<Rs.50,000/-

113

80.71%

Rs.50,001/- to Rs.75,000/-

18

12.86%

>Rs. 75,000/-

9

6.43%

6

Religion

Christian

44

31.43%

Hindu

38

27.14%

Muslim

58

41.43%

7

Type of family

Nuclear

96

68.57%

 

Joint /Extended

44

31.43%

8

Place of Residence

Urban

44

31.43%

Rural

96

68.57%

9

Your support system

Partner

53

37.86%

Family

57

40.71%

Partner and family

24

7.14%

Partner, family and friends

6

4.29%

10

Satisfaction with husband support

Not satisfied

77

55%

Satisfied / Very much satisfied

63

45%

 

Table 1 shows that the majority of participants were aged between 26 to 30 years (39.29%), followed by 18 to 25 years (29.29%) and 30 to 35 years (27.14%) and least subjects (4.28%) were in the age group of above 35 years. Most of the participants were married (98.57%), and only 1.43% were widowed. A large proportion of participants had completed undergraduate or postgraduate education (77.86%). About 20.71% had studied above 10th standard, and 1.43% were educated below the 10th standard. Half of the participants were homemakers (50%), while 39.29% were employed. Self-employed individuals accounted for 5%, and students made up 5.71% of the sample. Majority of the subjects (80.71%) had monthly family income <50,000 Rs and only a number of subjects (6.43%) had family income >75,000 Rs. Participants followed different religions, with Muslims forming the largest group (41.43%), followed by Christians (31.43%) and Hindus (27.14%). In case of type of family, more than half of the participants (68.57%) belonged to nuclear family whereas 31.43% lived in joint or extended families. Strikingly, about 68.57% of subjects were residing in rural areas and the remaining 31.43% were the urban people. Most participants were supported either by family (40.71%) or partner (37.86%). A smaller percentage reported being supported by both partner and family (17.14%), and partner, family, and friends (4.29%). More than half of the participants (55%) expressed that they were not satisfied with the support from their husband. The remaining 45% reported being satisfied or very much satisfied.

 

SECTION B: Description of magnitude of tokophobia among antenatal mothers.

Table 2: Frequency and percentage distribution of subjects according to the magnitude of tokophobia among antenatal mothers.                                                                                n=140

Tokophobia

Frequency (f)

Percentage (%)

Median

(Q1, Q3)

Low fear     

99

70.71%

18(15.75,21)

Moderate fear    

40

28.57%

High fear

1

0.71%

 

The above table depicts that the majority of participants (70.71%) experienced low-level of fear of childbirth, followed by 28.57% with a moderate level of fear, and only 0.71% with a high level of fear. The overall median fear score was 18, with an interquartile range of 15.75 to 21.

 

Figure 1: Pie diagram depicting magnitude of tokophobia among antenatal mothers.

 

The above figure depicts majority of subjects are having low fear (70.71%) of tokophobia.

 

Description of Association between tokophobia and selected socio-demographic, obstetric and psychological variables:

Table 3: Association between tokophobia and selected socio-demographic, obstetric   and psychological variables.                          n=140

Sl. No

Determinants of Tokophobia

Low fear

(n=99)

Moderate to High fear (n=41)

χ²test/

Fisher’s exact test

p value

Socio-demographic variables

1

Age

18-25 yrs

31(31.3%)

10(24.4%)

6.214

0.102

26-30 yrs

43(43.4%)

12(29.3%)

30-35 yrs

22(22.2%)

16(39.0%)

>35 yrs

3(3.1%)

3(7.3%)

2

Marital Status

Married

98(99.0%)

40(97.6%)

Fisher’s exact

0.501

Widowed

1(1.0%)

1 (2.4%)

3

Educational level

Below 10th standard

2(2.0%)

0(0.0%)

Fisher’s exact:0.529

1.00

Above 10th standard

20(20.2%)

9(22.0%)

Undergraduate/ Postgraduate

77(77.8%)

32(78.0%)

4

Employment Status

Employed

38(38.3%)

17(41.5%)

Fisher’s exact:0.747

0.747

Self-employed

5(5.1%     )

2(4.9%)

Home maker

51(51.5%)

19(46.3%)

Student

5(5.1%)

3(7.3%)

5

Monthly Household Income

<Rs. 50,000/-

83(83.8%)

30(73.2%)

 

 

3.550

 

0.169

 

Rs.50,001/- to Rs.75,000/-

12(12.1%)

6(14.6%)

>Rs. 75,000/-

4(4.1%)

5(12.2%)

6

Religion

Christian

27(27.3%)

17(41.5%)

3.182

0.204

Hindu

30(30.3%)

8(19.5%)

Muslim

42(42.4%)

16(39.0%)

7

Type of family

Nuclear

72(72.7%)

24(58.5%)

2.090

 

0.1482

 

Joint /Extended

27(27.3%)

17(41.5%)

8

Place of Residence

Urban

32(32.3%)

12(29.3%)

0.0238

0.8774

Rural

67(67.7%)

29(70.7%)

9

 

Your support system

Partner

38(38.4%)

15(36.6%)

 

Fisher’s exact:1.593

 

0.683

Family

40(40.4%)

17(41.5%)

Partner and family

18(18.2%)

6(14.6%)

Partner, family and friends

3(3.0%)

3(7.3%)

10

Satisfaction with husband support

Not satisfied

51(51.5%)

26(63.4%)

1.2128

 

 

0.2708

 

 

Satisfied / Very much satisfied

48(48.5%)

15(36.6%)

A.    Obstetric Variables

1

No of pregnancies

Primigravida

44(44.4%)

16(39.0%)

0.348

0.555

2 or more (Multigravida)

55(55.6%)

25(61.0%)

2

No of deliveries

Nil

49(49.5%)

18(43.9%)

0.3722

0.8302

1

31(31.3%)

14(34.1%)

2 or more

19(19.2%)

9(22.0%)

3

Previous mode of delivery

VD

46(46.5%)

23(56.1%)

Fisher’s exact

0.634

LSCS

3(3.0%      )

0(0.0%)

Both

1(1.0%)     

0(0.0%)

No previous deliveries

49(49.5%)

18(43.9%)

4

Previous pregnancy complications

Miscarriage

13(13.2%)

5(12.2%)

Fisher’s exact

0.6003

Preterm birth

3(3.0%)

0(0.0%)

Preeclampsia

2(2.0%)

0(0.0%)

Miscarriage & preterm

0(0.0%)

1(2.4%)

Abruptio placenta

1(1.0%)

0(0.0%)

No complications

80(80.8%)

35(85.4%)

5

Planned pregnancy

Yes

77(77.8%)

29(70.7%)

0.783

 

0.376

 

No

22(22.2%)

12(29.3%)

6

History of infertility treatment

Yes

4(4.0%)

3(7.3%)

 

Fisher’s exact

 

0.418

No

95(96.0%)

38(92.7%)

7

Have you heard about painless labor

Yes

75(75.8%)

30(73.2%)

 

0.103

 

 

0.748

 

No

24(24.2%)

11(26.8%)

B.      Psychological Factors

1

History of mental health alterations

Depression

4(4.0%)

5(12.2%)

3.5649

0.1682

Anxiety and PTSD

29(29.3%)

13(31.7%)

No history

66(66.7%)

23(56.1%)

2

History of tokophobia

Yes

29(29.3%)

20(48.8%)

4.021

0.044*

No

70(70.7%)

21(51.2%)

3

History of counselling for tokophobia

Yes

0(0.0%)

0(0.0%)

 

NA

 

 

NA

 

No

99(100%)

41(100%)

4

Family history of mental illness

Yes

1(1%)

1(2.4%)

Fisher’s exact

 

0.501

 

No

98(99%)

40(97.6%)

Level of significance at p value <0.05

 

The above table depicts that there was no significant association between tokophobia and selected demographic and obstetric variables such as age, marital status, educational qualification, work status, family income, religion, place of residence, support system, satisfaction with husband support, type of family, number of pregnancies, number of deliveries, previous mode of delivery, previous pregnancy complications, planned or unplanned pregnancies, history of infertility, knowledge about painless labour, history of mental health alteration, history of tokophobia, history of counselling for tokophobia and family history of mental illness. The result showed that there was a statistically significant association between tokophobia and previous history of tokophobia at p value <0.05.

 

Description of association between tokophobia and the preferred mode of   delivery among antenatal mothers.

 

Figure 2: Pie diagram showing preferred mode of delivery

 

The above figure depicts majority of subjects (97%) choose normal delivery.

 

Table 4: Association between tokophobia and preferred mode of delivery.                                                                                         n=140

Sl No

Preferred mode of delivery

Low fear(n=99)

Moderate to High fear (n=41)

χ²test/Fisher’s exact test

pvalue

1

Cesarean

3(3.00%)

0(0%)

Fisher’s exact test

0.556

2

Normal delivery

96(97%)

41(100%)

Level of significance at p value<0.05

 

The above table depicts that there was no significant association between tokophobia and preferred mode of delivery.

 

DISCUSSION:

The present study was intended to assess the determinants of tokophobia and preferred mode of delivery among antenatal mothers. The findings of the present study have been discussing in relation to the observation made by other studies which the investigator had reviewed.

 

Section A: Major study finding related to magnitude of tokophobia among antenatal mothers.  The present study revealed majority of the subjects (70.71%) had low fear about child birth whereas (28.57%) had moderate fear and (0.71%) had high fear of child birth. These findings are consistent with the results reported by Demšar et al. (2017), who found that75%of pregnant women had low to moderate fear, and 25% had high or very high fear16.

 

Section B: Major study findings related to determinants of tokophobia among antenatal mother. The present study revealed tokophobia was significantly associated with a previous history of tokophobia (p<0.05), suggesting that past experiences of fear related to childbirth may predispose women to similar psychological responses in subsequent pregnancies. Interestingly, no statistically significant associations were observed between tokophobia and a wide range of other demographic and obstetric factors,  and psychological variables such as age, marital status, educational level, employment status, income level, religion, place of residence, support system, satisfaction with husband support, type of family, number of pregnancies, number of deliveries, previous mode of deliveries, previous pregnancy complications, planned or unplanned pregnancies, history of infertility, knowledge of painless method of childbirth, history of mental health conditions, previous psychological support or counselling for fear of childbirth and family history of mental health disorders. These results stand in contrast to the findings of Matinnia et al. (2016), who identified multiple predictors of childbirth fear among Iranian primigravidae. In their study, factors such as lower educational level, unplanned pregnancy, and lack of support were significantly associated with higher fear of childbirth. The discrepancy may be attributed to cultural differences, sample composition, or variations in healthcare access and antenatal support system17.

 

Section C:

Major study findings related to association between tokophobia and preferred mode of delivery among antenatal mothers in the present study, there was no statistically significant association between tokophobia and the preferred mode of delivery, indicating that fear of childbirth did not necessarily translate into a request for cesarean section among participants. A similar study conducted on preferences and factors determining preferences for mode of delivery among primigravidae mothers at antenatal OPD of AIIMS Bhopal, a medical research institution of national importance, located at Saket Nagar of Bhopal, Madhya Pradesh, India revealed that majority of the participants (98.4%) preferred vaginal delivery over elective cesarean section as a mode of delivery. The significant factor influencing preferences was speedy recovery after delivery18.

 

CONCLUSION:

Tokophobia, a significant psychological concern, is comprehensively explored in this study, revealing its magnitude, determinants, and influence on delivery preferences among third-trimester antenatal mothers. The findings revealed that the majority of participants (70.71%) experienced low levels of fear of childbirth, followed by 28.57% with moderate fear, and a minimal proportion (0.71%) with high fear, indicating that severe tokophobia is relatively uncommon among the antenatal mothers. A significant association was identified between tokophobia and a previous history of tokophobia (p<0.05), underscoring the persistent nature childbirth-related fear across pregnancies. However, no significant associations were found between tokophobia and other socio-demographic, obstetric, psychological variables, and the preferred mode of delivery. The study also revealed that most of the subjects (97%) preferred normal vaginal delivery. These results highlighted the importance of recognizing past experiences of tokophobia as a key risk factor and suggested the need for targeted screening and psychological support during antenatal care to mitigate fear. The lack of association between tokophobia and delivery preference contrasts with some existing literature, potentially reflecting cultural or healthcare system influences specific to the study setting. These findings contribute to the growing body of knowledge on tokophobia and emphasize the necessity for tailored interventions to enhance maternal psychological well-being and informed decision-making regarding childbirth. Future research should explore longitudinal designs and broader populations to further elucidate the dynamics of tokophobia and its impact on maternal health outcomes.

 

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Received on 08.12.2025         Revised on 06.01.2026

Accepted on 31.01.2026         Published on 25.02.2026

Available online from February 28, 2026

A and V Pub Int. J. of Nursing and Med. Res. 2026; 5(1):27-33.

DOI: 10.52711/ijnmr.2026.07

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