The Tokophobia Severity Scale: What It Measures, and What It Misses
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.
Content note: this piece mentions ending a pregnancy because of fear. There’s support information at the end.
The research at a glance
The scale: the Tokophobia Severity Scale (TSS). Developed by Wootton and colleagues in Australia, published in Clinical Psychologist, 2020. Thirteen questions, first tested with 122 women who had never given birth.
The reanalysis: Martin and colleagues, Journal of Reproductive and Infant Psychology, 2022. Re-ran the statistics from the first study and found the scale works better as three parts than as one.
The latest study: 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 two months after giving birth.
The horse field
I’m allergic to horses. Unless I’m around one, you’d never know. Put me near a horse and I can’t breathe. Within twenty minutes of being near a horse my asthma is so severe that I need medical help. It’s what you might call a severe allergy. I could go my whole life not knowing that.
My tokophobia was a bit like that. It was there my whole life, and I had no idea, until I was in my mid-thirties looking at a pregnancy test and it hit me in the gut. If you’d handed me a questionnaire about fear of birth in my 20s, I wouldn’t have filled it in. It didn’t register that I was scared. I didn’t know. If I had filled it in, I probably would have said that I wasn’t scared.
So when I came across a tokophobia scale built for women who have never been pregnant, I was delighted. Most tokophobia research starts in the maternity unit, with women who are already pregnant. This is exactly the kind of thing women need to help them make sense of how they’re feeling.
I also have questions about it. I build psychometric assessments myself, ones that measure anxiety, fear and phobia, so I read a scale like this with a particular eye.
Thirteen questions, a score out of 39
The Tokophobia Severity Scale asks 13 questions about the past two weeks. Each is answered from 0 (never) to 3 (always), so scores run from 0 to 39. The higher the score, the more severe the fear.
It was written by anxiety specialists, to fit how phobias are defined in the diagnostic manuals, and most of the questions are about worry. For example:
- “I worry that something terrible will happen to my baby during my pregnancy and/or childbirth.”
- “I worry that I will not be able to cope with the pain of pregnancy and/or childbirth.”
- “I have nightmares about being pregnant and/or delivering a child.”
Three parts nobody set out to measure
This is the bit of the story I found most interesting.
The scale’s creators started with 24 questions. They wanted to measure two things: the worry, and the avoidance, meaning the things a woman does (or stops doing) because of her fear. They tested those questions with 122 young women who had never given birth, and the avoidance side didn’t hold together. So they dropped the idea of two parts and kept a single score, and they said in the paper that their questions “may not be tapping the important behavioural aspects” of tokophobia.
Two years later, another research team re-ran the numbers and found the answers fell into three clusters:
- Fear: worry about something terrible happening to you or your baby
- Coping: worry about the pain, the medical procedures and not being in control
- Intrusive thoughts: avoiding the subject, nightmares, and checking whether you’re pregnant
They also warned that the first study was too small to be sure of any of this. The 2026 study, with 1,585 women, found the same three parts held up across four countries and across all three stages: never pregnant, pregnant, and just after birth.
So the three parts came out of the statistics, from how groups of women answered, rather than from a picture of what tokophobia looks like. And the avoidance side, the part that tries to capture what a woman actually does about her fear, has been the weak spot from the very start.
What the latest study found
The 2026 study also suggested cut-offs. A cut-off is the score above which a woman’s fear is considered clinically significant, meaning strong enough to be worth a proper conversation with a professional. Hmmm. Why wouldn’t a woman want to talk to a professional if she was beneath the cut-off?
The cut-off changed with where a woman was in her reproductive life:
- 19 for women who had never been pregnant
- 11 or 12 in pregnancy
- 11 two months after birth
I’d be interested to know how they came to these differences, because on the face of it, it doesn’t make much sense. Why does a woman who’s not pregnant have a higher cut-off? Is she expected to experience more severe symptoms before she’s invited to have a conversation with a professional? We need to be supporting women to help them find support long before pregnancy for this, not moving the goal posts.
In Portugal, 166 women were followed from pregnancy to two months after the birth. Higher scores in pregnancy were linked to choosing an elective caesarean, to experiencing the birth as traumatic, and to more symptoms of depression and anxiety afterwards.
This is not surprising and is reflected in other studies.
What the research can’t tell us
These are links. They don’t show cause. A higher score going alongside a traumatic birth doesn’t mean the fear caused it.
The 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 avoidance questions barely registered. Very few women scored on them in 2026 either, and the intrusive thoughts part was the least reliable of the three. I do wonder whether the women who avoid this subject are also the women who don’t take part in the research.
The groups are small in places. The first study had 122 women, and the links to caesarean, birth trauma and postnatal symptoms come from 166 women in one country.
What the three parts can tell you
For me, the three parts describe how tokophobia shows up. And how it shows up doesn’t necessarily tell you how severe it is.
Take intrusive thoughts. You can have them and never feel a full-body no, or make a decision like ending a pregnancy. Plenty of people have intrusive thoughts and don’t have tokophobia. So having them doesn’t necessarily mean your tokophobia is high.
And coping. What does coping mean, really?
As somebody who builds these kinds of assessments, I’m not sure the scale is telling you that much.
What does “severe” actually mean?
When tokophobia is severe, one of the ways it can show up is that you reorganise your whole life around it, especially your relationships and your career. It’s almost like it blanks out the whole topic of pregnancy and birth, and you might not even realise it’s happening. That’s when it’s really severe. And I don’t think we’re ever going to capture that by asking about symptoms. It’s the avoidance side again, the part that fell away in the very first study.
So what does severe mean? Is it that you’d choose a termination, and if you wouldn’t, your tokophobia counts as mild? Is it that you can’t sleep at night? That you spend your days crying and avoiding any conversation about it?
I’m not saying I have the answer. But we need to have that conversation, and agree what we mean by severe tokophobia.
One fear, or a whole stack
The scale also doesn’t explore the different shapes tokophobia takes, and I think that’s what’s missing.
Say your fear has a narrow focus: the pain of birth. You’re fine with being pregnant or your body changing. There’s just this one thing. That’s a very different phobia profile, which affects your life in a very different way.
The questions ask about “pregnancy and/or childbirth”, and I’d split those out. Fearing the pregnancy but not the birth is a very different thing from fearing the pregnancy and the birth and the motherhood that follows. That’s a long stretch of time, and it can carry a lot of dread. If it’s only the birth, some women might think, I can get through it. It’s a day, maybe two. I can do it. Pregnancy is nine months, and that can feel very different emotionally.
With so many shapes and profiles, one severity score is a very simplistic view.
The allergy you didn’t know you had
Back to the horse field. In my book Betrayed By Your Biology, I use that allergy idea to describe reproductive anxiety disorder (RAD): a very sensitive system, with tokophobia as the main allergy, one you might not know you have until life puts you in the field. RAD is a framework I developed, not a formal clinical diagnosis. But it’s why a scale that looks only at fear of pregnancy and birth misses the bigger picture for me.
Why I built my own assessments
A lot of women don’t know whether they have tokophobia. They might suspect, but they don’t know. Asking her about her intrusive thoughts won’t tell her.
I’ve built two assessments, and they do different jobs.
The Tokophobia Test is free. When I built it, I looked at how tokophobia shows up in women’s lives: how to tell if you have it. It’s 15 questions, takes about five minutes, and gives one of four levels (mild, moderate, strong or severe), because the level helps work out what kind of support will help. With mild tokophobia, you can probably tackle it yourself with DIY resources, like the ones I have available. As it gets stronger, you might need one-to-one support including trauma support. You can take the test here.
The Birth Readiness Profile is something else entirely. It’s an in-depth psychometric assessment, built specifically around reproductive fear and anxiety. It’s 56 questions across 14 areas, from your body and your sense of safety to control, trust, the mothering you grew up with and the shift into motherhood, and it’s for women whether or not they’re pregnant. It maps the shape of your fear: where it sits, what’s feeding it, and where to start. That’s the part a single severity score can’t show. It’s a paid assessment, run by our partner site Fearless Birthing. You can find out more about the Birth Readiness Profile here.
These are both starting points for understanding what’s going on.
What needs to change
If you think you might have tokophobia: notice which part frightens you. The pregnancy, the birth, the motherhood after it, or all of them? And notice whether you’ve been quietly organising your life around it. That can tell you more than how often the thoughts come.
If you’re a midwife, doctor or health visitor: treat a severity score as one reading. Ask which part she’s frightened of, and how much of her life has been shaped by it.
For researchers: it’s fantastic to see a scale built with women who’ve never been pregnant. Next, I’d love to see work on what “severe” really means, on the avoidance side the scale has struggled to capture, and on reaching the women who don’t know they have it.
The bottom line
The Tokophobia Severity Scale is a real step forward. It was built for women who have never been pregnant, and it’s now been tested across four countries. But its three parts describe how tokophobia shows up, and that doesn’t always tell you how severe it is. We need a shared understanding of what severe tokophobia means, and I’d love this to be the start of that conversation.
If you’d like to understand your own fear, 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.
If this has brought something up for you, you’re not alone. Talking to your GP, midwife or health visitor is a good first step, and our tokophobia hub has more on what tokophobia is and what helps. If you’ve ended a pregnancy because of fear, When Fear Takes Over: The Abortions We Don’t Talk About was written for you.
Sources
- Wootton BM, et al. The development and initial validation of the Tokophobia Severity Scale. Clinical Psychologist. 2020;24(3). doi:10.1111/cp.12220
- Martin CR, Jones C, Huang C, Jomeen J, Boubert L, Marshall CA. The Tokophobia Severity Scale (TSS): measurement model, power and sample size considerations. Journal of Reproductive and Infant Psychology. 2022;40(6). doi:10.1080/02646838.2021.1931070
- 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
- We’ve Got Tokophobia All Wrong, and It’s Hurting Women
- We’ve Been Measuring Fear of Childbirth Too Simply. Two New Studies Show Why
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.
- The Tokophobia Severity Scale: What It Measures, and What It Misses - 1st October 2026
- We’ve Been Measuring Fear of Childbirth Too Simply. Two New Studies Show Why - 24th September 2026
- IVF Anxiety: What It Actually Takes To Get To This Place - 24th September 2026