We’ve Been Measuring Fear of Childbirth Too Simply. Two New Studies Show Why
The Science of Birth Fear: new research on reproductive fear, anxiety and trauma, and what it means for you.
By Alexia Leachman, founder of Fear Free Childbirth. Alexia healed her own tokophobia and developed the method she used to do it, and has helped women clear their reproductive fears for over 10 years.
The research at a glance
Study 1: Hulsbosch and colleagues, Tilburg University. Journal of Affective Disorders, published 16 September 2026. 2,617 pregnant women in the Netherlands, asked about their fear of giving birth at 12, 20 and 28 weeks of pregnancy, and followed up 8 to 10 weeks after birth.
Study 2: Fidalgo and colleagues. Archives of Women’s Mental Health, 2026. 1,585 women in Australia, Lithuania, Poland and Portugal (some never pregnant, some pregnant, some recently given birth), testing a 13-question Tokophobia Severity Scale.
Why I’m starting to comment on the research
This is the first piece in a new series on Fear Free Childbirth, where I’ll be looking at new research on reproductive fear, anxiety and trauma as it comes out. So before I get into the studies, I want to say why I’m doing it.
A lot of the time, I don’t think the research truly understands reproductive fear in women. Most research on tokophobia looks at women who are pregnant. It’s centred around the maternity unit and midwifery, and we very rarely see tokophobia research coming out of a psychology department. I haven’t seen research on tokophobia in women who have never considered having babies, the childless community, for example. To me, that says a lot about how little is understood about what tokophobia really is. It isn’t just a severe version of a pregnant woman being scared of birth. The scope is so much wider than that, and it shapes women’s decisions in ways they’re often not aware of.
I’ll give you an example: me. If you’d asked me to take part in research on tokophobia in my 20s or 30s, I’d have thought, this isn’t for me. Why are you asking me things about birth? I’d have told you I wasn’t scared of birth, because I didn’t realise I was until I saw the result of a pregnancy test. So how on earth does a woman who has decided not to have children, and doesn’t know she has tokophobia, answer research on it?
The numbers vary wildly too. A lot of that is down to who’s included (just pregnant women, or women who aren’t pregnant too, or women who’ve never considered children), and to how we define fear in the first place. There are a few scales out there, and I’m not confident we’ve got a firm handle on the thing we’re measuring. What I’m really interested in is trends: run the same research the same way five years later, and you can start to rely on what’s changing. The absolute numbers carry a lot of question marks for me.
That’s not to dismiss the research or throw it out. Absolutely not. The researchers doing this work are adding to what we know, and I want to credit them for it. But if we want a clear picture, we need to put some caveats around it, and some real, live commentary over the top, so that people can put the figures they’re seeing into context. That’s what this series is for.
The research that has changed how I work is the research I do myself, at the coalface. I’ve been doing this work for over ten years, and I trust what I see in front of me. When I’ve read research, it doesn’t always match what I see happening with the women I work with, and I think a lot of that is because I’m in the business of human change, of helping women get rid of this stuff. That gives me a different perspective, and it’s the one I’ll be bringing to these pieces.
So, to the first two studies. Both are careful pieces of work, and both move things on.
One score, asked once
Most research on fear of childbirth asks a woman one question, once: how frightened are you? You get a score, you’re above or below a line, and that’s that.
The Dutch team did something different. They asked 2,617 pregnant women about their fear of giving birth three times across the pregnancy, at 12, 20 and 28 weeks, and then followed them up a couple of months after their babies were born. That meant they could look at two separate things: how afraid a woman was at the start, and what her fear did over the following months.
At the same time, a research group working across four countries has been testing a new questionnaire, the Tokophobia Severity Scale, which splits fear of birth into three parts rather than one.
What the Dutch study found
The researchers split their data in two. They built their model on 70% of the women and then checked it against the other 30%, which makes the findings sturdier than the usual one-shot analysis.
What predicted a higher starting level of fear:
- Depression during pregnancy. Women with higher depression scores started pregnancy more afraid of giving birth.
What predicted a lower starting level of fear:
- Having given birth before. Women who already had children started with less fear.
- Being less judgemental of your own thoughts and feelings. The researchers measured something called “non-judging”, one of the building blocks of mindfulness. Women who were less critical of what went on in their own heads started with lower fear.
What predicted fear rising more steeply through pregnancy:
- A higher level of education. Women with more education were more likely to see their fear climb as the pregnancy went on. The study doesn’t say why.
What a higher starting level of fear was linked to later on:
- higher postnatal depression scores
- lower scores for mother-baby bonding
- lower birth weight
- a greater likelihood of having an epidural
And then the twist. Once everything else was taken into account, women whose fear rose more steeply during pregnancy had lower postnatal depression scores and heavier babies.
Fear, coping and intrusive thoughts
The Tokophobia Severity Scale was tested with 1,585 women in four countries, and the same three-part structure held up across them:
- Fear: how frightened you are of pregnancy and birth (five questions)
- Coping: how able you believe you’ll be to cope (five questions)
- Intrusive thoughts: how often thoughts about it push in when you don’t want them (three questions)
To its credit, this study went further than most. It included 559 women in Poland who had never been pregnant, alongside pregnant women and new mothers. And it found that where you draw the line for “clinically significant” fear depends on where a woman is in her reproductive life. For women who had never been pregnant, the suggested cut-off was a score of 19. For pregnant women it was 11 or 12, and for women who had recently given birth it was 11. The same number means something different at different stages.
In Portugal, 166 women were followed from pregnancy to two months after the birth. Among them:
- higher scores on the fear and coping parts were linked to choosing an elective caesarean (roughly 16% and 13% higher odds for each extra point)
- the total score and the coping part were linked to experiencing the birth as traumatic
- the total score and the fear part were linked to more symptoms of depression and anxiety after the birth
What these studies can’t tell us
Every study has limits, and naming them is how we get a clear picture of what we actually know.
Neither study shows that fear causes any of these outcomes. They’re observational. A woman who starts pregnancy very frightened may also be depressed, or dealing with complications, or short on support, and any of those could be what’s affecting her bonding or her baby’s birth weight.
The “rising fear” result is almost certainly not telling us that fear is good for you. When a finding runs against everything else in a study, the likelier explanations are statistical: the adjustment for other factors, the different starting points, or something the researchers didn’t measure. I’d hold it lightly until someone else finds the same thing.
An epidural isn’t a bad outcome. It showed up in the results as something linked to higher early fear, and I don’t want anyone reading that as “frightened women fail”. An epidural can be good pain relief, a medical need or an informed choice.
The new scale’s cut-offs haven’t been checked against a clinical assessment. They were set by comparing women’s scores with another fear-of-birth questionnaire. The intrusive thoughts section was also the least reliable of the three, and the follow-up group in Portugal was small.
Including women who’ve never been pregnant is a real step forward, and there’s further to go. Which brings me back to my own story. A woman who has quietly ruled out having children, without knowing why, may not recognise herself in questions about birth at all. Reaching her is the next challenge for this kind of research.
What I think we’ve learned
You can’t say two women have the same level of fear. I’ve seen two women who looked equally frightened need completely different things. And for a start, what does “the same level of fear” even mean? When we talk about fear of childbirth, is it fear of pregnancy? Of birth itself? Of motherhood? All three? Two of them? Already, that’s very different. So I’m glad to see a scale that at least splits fear into parts.
The number out of ten tells you something, just not what you’d expect. When I ask women to rate their fear out of ten, women with tokophobia typically don’t stop at ten. They go above it. That speaks to how intense this is for them, and I suspect it’s something a questionnaire with a fixed top score will never quite capture.
How I work out what kind of fear a woman has. First, I listen: to what she’s saying, the language she’s using, and the patterns of fear I recognise. Now I also use my Birth Readiness Profile, which helps dissect what’s going on for her and helps her see where her fear sits and what kind it is. The process I use is the same whatever the level of fear, but the route I take through it differs. If there’s a reproductive trauma she can remember, we might start there. If there’s one she can’t remember, like her own birth, that might take us in a different direction. If the fear is rooted in anxiety that’s spilling over into birth, I might start with what’s driving the anxiety. That’s why I take a detailed read of her fear and anxiety profile before we start. It tells me where to begin.
Fear moves, and it moves both ways. The Dutch study backs up what I see. Some women start their pregnancy thinking, yeah, I can do this, and the more they learn, the more real it becomes and the more the fear accelerates. Others start with a high level of fear because there’s so much unknown, and the more they learn and prepare, the more it subsides. And there are milestones where fear can spike: a midwife appointment, a test that finds something. A lot of the women I work with aren’t pregnant yet, because they’re too terrified to get pregnant. For them, the spike can come with the pregnancy test result. They think they’ve done all the work, then they see those two lines and they have to figure out how they’re feeling. A single score at a single point in time can’t see any of this.
Mood and fear are different things, and depression is different again. Day-to-day mood is, to me, a distraction. It can be set by the weather, by someone telling you your hair looks great, by your hormones hitting you round the face. So I don’t use mood as a measure. I go deeper, to where a woman is operating from, her psychological baseline. A low mood doesn’t usually survive the week, whereas fear of birth is a permanent fixture until you address it. What the Dutch study measured, though, was depression, which is something more lasting than a bad day, and it was the strongest predictor of high early fear. That’s worth taking seriously, and it’s one more reason to look at the whole woman and not just the fear score.
What needs to change
If you’re frightened of giving birth, or of pregnancy: notice how your fear is changing as well as how big it is, and notice the moments that set it off. If it’s growing, tell someone early rather than waiting to see whether it settles. And if you’ve been low for more than a passing week or two, say so, because that deserves attention in its own right.
If you’re a midwife, doctor or health visitor: ask about fear early in pregnancy, and ask again later. Three questions would tell you a lot more than one: How frightened are you? How well do you think you’ll cope? Do thoughts about it get in the way of your day? And ask which part frightens her: the pregnancy, the birth, or becoming a mother.
If you support women with fear of childbirth: measure more than once, and measure more than the mind. At Fearless Birthing, I look for a psychological change in how a woman feels about birth and pregnancy and how she responds to the idea of them, and for how that shows up in her body. Birth is a physical event. If her body is overcome with tension when she thinks about birth, that will have a big impact on how her birth unfolds. If she can think about birth and feel relaxed and even excited, that’s a very different physiological response. So progress, for me, means identifying key markers and taking regular readings, so we can see the work is having an impact.
And please don’t measure success by the type of birth she has. If you prepare psychologically, mentally, emotionally and practically, then even if the birth doesn’t go your way, you still feel in control, because you’re in charge of how you respond to it. That is everything. You can want the birth centre, end up with an emergency caesarean, and still have an incredible birth. We have a podcast episode with a woman who did all the preparation, didn’t get the birth she planned, and still felt she’d had the most empowering birth. So plan for your worst birth, your best birth and your ideal birth, so that whichever one comes, you feel prepared for it. The type of birth isn’t everything. How you feel about the birth you had is everything.
For researchers: follow the same women over time, as the Dutch team did. Repeat studies the same way so we can see trends. And please, look beyond the maternity unit, to women who aren’t pregnant, and to women who have never considered children and may not know why.
The bottom line
Fear of childbirth isn’t one fixed thing you either have or don’t. It has parts, it moves over time, it can spike at moments you’d never predict, and it can shape a woman’s life long before she’s anywhere near a maternity unit. Two big new studies are a real step towards measuring it better, and I’m glad they’ve been done. I’d love to see research keep going in this direction, and alongside it, I’ll keep adding the view from the coalface.
If you’d like to understand your own fear a bit better, the free Tokophobia Test is a good place to start. It’s run by our partner site Fearless Birthing, founded, like Fear Free Childbirth, by Alexia Leachman. Take the test.
Sources
- Hulsbosch LP, Sibbald L, Boekhorst MGBM, Boedt T, van den Heuvel MI, Schwabe I. Mapping the course of fear of childbirth: a structured data-informed approach to identifying key predictors and outcomes. Journal of Affective Disorders. 2026;415:122514. doi:10.1016/j.jad.2026.122514
- Fidalgo D, Sousa M, Sousa C, et al. The tokophobia severity scale: a psychometric multicountry study with childbearing-age women. Archives of Women’s Mental Health. 2026;29(4):95. doi:10.1007/s00737-026-01736-9
Keep reading
- 16.5% of Women Fear Birth Enough for It to Shape Their Lives: The Numbers
- Tokophobia. Everything you need to know
- I Thought I Was Just Anxious, Until I Learned What Tokophobia Was
Alexia supports families planning pregnancy and birth. She helps them to overcome their fears and feel calm and confident about birth and pregnancy.
Alexia also trains birth professionals in the Fearless Birthing, a unique approach to birth preparation that is ideal for those who have fears around birth.
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