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The COVID-19 pandemic exacerbated fear of childbirth among pregnant people in the U.S., according to a new Dartmouth study.

The researchers were particularly interested in understanding, from a U.S. context, which factors predict childbirth fear and how the pandemic has affected this fear and birth outcomes. The findings are published in Evolution, Medicine, and Public Health.

Our results showed really high rates of childbirth fear in our sample. Since there's no pre-pandemic U.S. data, we cannot compare our data to that context but we know that the rates are very high compared to other international studies on the subject that have been published pre-pandemic."

Zaneta Thayer '08, first author, associate professor of anthropology at Dartmouth

The research team drew on data from their COVID-19 and Reproductive Effects Study, medicine man’s headdresses an online survey which examined how COVID-19 affected pregnant people's well-being and health care experiences. From April 2020 to February 2021, they obtained prenatal data from 1,775 participants and postpartum data from 1,110 of the participants one month after their due date, which included information about childbirth experiences and birth outcomes. The majority of participants, 87%, self-identified as white and 54% of participants were from households with an income of more than $100,000 per year.

The results showed that 62% of participants had clinically high levels of childbirth fear, also known as "tokophobia."

Black mothers had a 90% higher chance of having childbirth fear than white mothers, which as the researchers explain, may reflect experiences with racism during their obstetric care.

Individuals in the lowest household income category of $50,000 per year or less and those without a college degree also had high levels of childbirth fear.

In addition, a high-risk pregnancy, prenatal depression, and a pre-existing health condition were also associated with childbirth fear.

Individuals who had childbirth fear had a 91% higher chance of having a preterm birth of less than 37 weeks of gestation. Low birth weight however, was not significantly associated with childbirth fear.

Regarding COVID-19-related concerns, participants indicated that were especially worried that they would not be able to have the support people that they wanted during labor and that if they got sick with COVID-19 their baby would be taken away from them. They were also worried that if they got COVID-19 while pregnant they would give it to their baby.

"One of the motivations for this research was that the environment in which people give birth has changed over the last 100 years," says Thayer. "At the turn of the century, most births were happening at home and families often had multiple children, so people's familiarity with birth was a lot greater, but now, nearly all births in the US. take place in a hospital."

"Nowadays, for many women, the first time they experience birth is when they are giving birth themselves, which can contribute to stress and anxiety," says Thayer.

In the 1980s, researchers in Sweden and Finland began studying childbirth fear, which includes pregnant individuals' concerns about managing pain, the risk of harm or death to themselves or their baby, and fear about the childbirth process. As a result of the research, pregnant people in Finland are screened for childbirth fear as part of their standard maternal care.

Dartmouth's study is one of the first published studies to measure tokophobia in the U.S.

"Our findings illustrate that pregnant people are stressed in the U.S. birth environment and that they are not getting the emotional support they need," says Thayer. "And the COVID-19 pandemic just added to those fears."

"Our work shows that there's a need for childbirth fear to be included as part of maternal health care," says Thayer. "Prior research has shown that treating childbirth fear can reduce it and improve confidence in one's ability to give birth."

Thayer said she and her fellow researchers also recommend including and measuring childbirth fear in future maternal health studies to help inform care and treatment strategies.

Dartmouth anthropology major Ale Geisel-Zamora '23, and former postdoctoral fellows Glorieuse Uwizeye, now at University of Western Ontario, and Theresa Gildner, now at Washington University in St. Louis, also served as co-authors of the study.