In almost all other phobic situations than childbirth phobia, the phobic person is able to avoid a great part of what she fears. However, the pregnant woman with severe CA is constantly “trapped” until the child is born [31]. In phobic situations, the idea of being trapped without the ability to flee is an indispensible trigger for intense anxiety. Moreover, the progressing pregnancy brings her closer to the feared, unavoidable situation. Women with childbirth phobia can experience their status as mental torture when they have to endure a seemingly endless time in constant horror for what will come [32]. On the other hand, this same phenomenon is favorable for the woman’s motivation to take part in treatment of her phobic CA, as she has minimal chances to postpone the final confrontation with the phobic situation.

During pregnancy, many women with severe CA can only imagine the approaching delivery as an upcoming disaster and have the same PTSD symptoms as those who already have experienced a trauma in reality [30]. In case of CA, one could speak of a “Pre-TSD” [33].

Unfortunately, we found that the delivery experience for most women will turn out as expected [3, 8, 34]. The pregnancy confronts the woman with massive bodily changes that influence her physical functioning. Simultaneously, such changes can be appraised as real symptoms of abnormal physical phenomena. Anxious persons have a tendency to be observant of their body functions, which makes the anxious pregnant woman more vulnerable to alarms from all physical changes. Thus, whereas most pregnant women see their physical changes as belonging to pregnancy, in women with severe CA, these changes instead easily add to their suspicion that their body functions are abnormal (a false alarm).

Pregnancy has been called “a healthy illness,” which in many countries is underpinned by societal service, such as regular obstetric controls to confirm that the woman and her fetus are all right. A woman with CA may interpret these controls as indications that pregnancy and delivery are combined with serious risks for complications. Extended consultations as means of alleviating anxiety rarely work [35], which is further exemplified in illness anxiety (Box 1.1).

In all other forms of phobias, the phobic person only needs to care for herself, while a pregnant woman, suffering from CA, is forced to think both of her own and the fetus’ well-being. This means that the potential origin of her anxiety is widened extensively.

In many societies the advent of a new child is socially highly appreciated, and an observed pregnancy is freely favored. Therefore, it is not easy for a woman with CA to get approval for her problems, and when expressed, she often feels minimized. She may also feel an enormous social pressure, as she has to fulfill one of the most appreciated societal tasks and on top of that “feel happy.”

During delivery the woman with severe CA is finally trapped in the situation she has feared for a long time, and all ways to flee are blocked. Then valuable matters are at stake. She has the task to contribute, maximizing the options of delivering a healthy child, even if this means physical and mental suffering for her personally. In the end, she is often locked up within some square meters, and while enduring pain, she has to yield to prerequisite performances while her efforts are closely observed. In extreme cases it is about life and death for both herself and her child.

Giving birth is for all women a strenuous effort, physically and psychologically. An important point is that during this process, most women experience moments with a more or less altered state of awareness. The woman has to endure extreme levels of physical stress and pain, which she probably otherwise never experiences in her life, that influence her awareness. Moreover, many women breathe quickly when they have contractions, thus hyperventilate, which also affects their state of consciousness.

Therefore, during labor and delivery there are several elements that stimulate a temporary change in awareness; some women can even welcome this as a way to cope with extreme pain.

Such states are normal in daily life, like during daydreaming, when extremely tired, when fasting, having slept too little or too long, or when influenced by fever or a medicine or another external agent, which by no means is pathologic in a psychiatric sense. The decisive factor for how she experiences this phenomenon emotionally is her cognitive labeling of what happens. Therefore, helping the woman to interpret the process correctly is meaningful. However, during this process, and especially in critical moments when the child’s or her own health is in danger, much of the staff’s attention is concentrated on the woman’s and the child’s physical conditions, even if that is at the expense of their attentiveness toward the mother’s mental state. In any case, even when she receives correct information, in connection with labor and delivery, the stress can become so intense that she dissociates in a pestiferous sense, e.g., when it is part of extreme anxiety like during a panic attack. See DSM-5 for the description of the symptoms of a panic attack [26].

Dissociation can be summarized in simple words as when the woman experiences either or both:

Although dissociation is seen as a way to escape from extreme stress and anxiety, reality testing is intact, and thus dissociation can at the same time in itself be very frightening, as absolutely any control is lost, and the woman can think that she has become crazy. Postpartum, such an experience can become a part of a childbirth-linked posttraumatic stress disorder (PTSD). Therefore, it is recommended to notice dissociation during delivery as possibly harmful when it goes together with severe anxiety, and/or postpartum is seen by the woman as (part of) a traumatic experience.

Severe CA does not automatically disappear after the delivery and becomes most alive when a woman considers a new pregnancy. Nor does a psychologically perfect accomplished delivery, following a traumatic delivery that gave postpartum phobic CA, “treat” the phobic CA. The intensity of a phobic anxiety, also of severe CA, varies with the distance to the phobic stimulus. Thus, an untreated phobic CA re-intensifies when a woman considers a new pregnancy or is pregnant again.

Some studies show that severe CA is associated with obstetric complications such as prolonged labor, instrumental vaginal deliveries, and cesarean sections [10, 43, 44], although this is not found in all studies [4, 6].

As we have argued [45], very little is known about possible links between the level of fear women experience and the physiological functioning during the process of labor and delivery. As the endocrine system is essential for the well functioning of the different steps in the delivery process, we measured CA and stress hormones hourly during the process of labor and delivery, but could not find a systematic correlation between the two variables [34].

However, women’s CA may influence deliveries in another way, i.e., by the reaction to her fear by obstetric health providers. Already in the 1980s [46] and three decades later [34], we found that during delivery, a staff’s standard response to CA is offering pain relief, which may conceal the problem of fear. Throughout the last decade, CA is regarded as the main reason for the increasing number of cesarean sections (CS) on maternal request [47–49].

In Western countries, severe CA has caused a significant increase of CS without medical reasons [50, 51]. This trend is not without concern, since CS implies higher short- and long-term risks for both mother and infant as compared to vaginal delivery [52–56].

In many delicate situations, where obstetric caregivers are confronted with a pregnant woman panicking when only thinking of a vaginal delivery, an elective CS seems to be an easy way out. As it implies the greatest possible reinforcement for these women’s urges to escape delivery, most also will wish to end a following pregnancy by means of a CS [5, 49].

Sometimes, in acute situations, CS may be an emergency solution also for psychological reasons, but for handling a woman’s severe anxiety, this is an insufficient treatment. Moreover, pregnant women with severe CA, who get a CS on maternal request but do not have a treatment for their CA, run a risk to have a negative experience of their delivery anyway [46]. Therefore, such actions have to be completed with proper care for the woman’s CA, which will be discussed later.

After delivery, severe CA more often is found in women having had complications such as an instrumental vaginal delivery, emergency CS, or fetal compromise [6, 7, 10, 33, 57].

CA during labor and delivery is a risk factor for postpartum PTSD [30, 33, 58, 59]: Extreme fear (panic) can be so overwhelming that women experience the delivery as a trauma. Then, anxiety-vulnerable women may develop postpartum PTSD [60].

For many women, pregnancy, labor, and delivery are a challenge, and for some women the endeavors carry a price by affecting their mental condition with a risk for postpartum psychiatric problems [37] and difficulties in a healthy mother-child bonding [46]. It has been found that for a notable number of women with panic disorder, their panic started during pregnancy or soon after delivery [61].

Although it earlier has been hard to show how anxiety during gestation is related to delivery outcome and the condition of the child, the study results of Andersson et al. [62] revealed no differences in neonatal outcome between women with antenatal depressive disorders and/or anxiety disorders and healthy subjects. The authors conclude that neonatal outcome did not deteriorate despite the women’s impaired mental health during pregnancy.

It is unclear if and how CA directly influences the biologic process of labor and delivery. According to recent reviews, it becomes increasingly evident that at least there might be a relation between anxiety during pregnancy and preterm birth [63, 64].

We have classified CA in its extreme form as a specific phobia. Among the mental problems, specific phobia is probably the most widespread with a lifetime prevalence of 11 % [65] and of all anxiety disorders, probably the best understood [66] and best treatable [29, 67, 68]. In general, persons with phobias hardly seek help for their problems, possibly because they can find ways to avoid the object they fear. It is also probable that phobia, and even more so subclinical fear, is so common that sufferers get used to its existence and find strategies to live with it and confine themselves to living with their phobia. Nevertheless specific phobia can have serious consequences, especially in its severe form and when the phobic stimulus cannot be avoided.

These general aspects also count for women with childbirth phobia who turn up in obstetric care when pregnant. However, here the phobic patient often expresses her anxiety by means of worries about her physical condition and all the bodily dangers and suffering that might occur during labor and delivery. These, in interaction with the caregivers’ reactions, develop a kind of obstetrification of CA, where the patient seems to demand from caregivers measures to ensure her and her fetus’ health, and caregivers try to answer the woman’s anxiety with (inappropriate/insufficient) obstetric measures.

In addition, this interaction comes with the woman’s way of expressing her need for help by rephrasing her anxiety as fear of pain [36, 46]. It is well known that help-seeking patients try to formulate their questions in such a way that they think the care system will understand and for which the system is able to offer remedies [35]. Concentration on pain can be a manner for an anxious woman to win approval for her apprehension and helplessness, as pain is a topic that is often discussed before and during labor. For both the woman with CA and her caregiver, pain is a rewarding topic. The woman can formulate a clear question about a topic that fits the frame of reference of the caregiver, not the least being that obstetrics in Western countries nowadays can offer advanced pain relief, and thus the staff can feel reassured that the woman’s request has been adequately met. Interestingly, severe pain almost always reflexively generates an acute panic-like reaction that can be sedated by means of pain relief. Thus, during the delivery, psychologically and pain-generated panic easily can be mixed up. Accordingly, in various studies we have found that during childbirth women with severe CA get significantly more pain relief than others [34, 46].

In obstetric care, practically all service is concentrated on the physical condition of the mother and the fetus. Even childbirth-preparing classes focus on these aspects. Generally spoken, this is logical and adequate. Midwives and obstetricians are educated to attend to the care of the pregnant woman and her fetus, with responsibility for the gestational aspects of the well-being of the woman and her child. As the physical condition of the woman is the main goal for obstetrics, CA may easily be marginalized. When midwives and obstetricians are preoccupied with the woman’s physical condition, her CA is easily overlooked, as “a certain amount of CA is normal and should be tolerated,” thereby minimizing the communication about fear when a woman signals CA.

But also the reverse can be the case. For a pregnant woman, statistically speaking, there are risks for real dangers for her own and the child’s well-being, and therefore she may think that her fears are appropriate, and she will focus on medical assistance. A caregiver’s rewording of such worries into a discussion about the woman’s anxiety can easily be experienced as a playdown of her concerns. There is a real risk for a conflict between the patient expressing her beliefs and the caregivers’ more accurate estimation of these threats. In that case it will be difficult to motivate the patient for psychological treatment. Moreover, to center upon her mental state would also mean a confrontation with the discomfort she wants to reduce and preferably manages by means of avoidance.

Consequently, proper discussions of the patient’s CA easily go astray in concord between staff and patient. When a patient expresses her worry, caregivers use to literally concentrate on the content of the patient’s questions, answering with comforting reassurance, which often may be helpful for subclinical fear, but is no effective remedy for clinical anxiety. There is plenty of experience with patients who somatisize, that frequent medical consultations met with reassurances or even physical tests can make the patient even more eager to come back for new consultations, as these actions only give temporary relief [35].

At least in Western countries, women trust obstetric staff and expect to get all the service they need in connection with their pregnancy and delivery. Staff, doing their best to reassure the woman, promotes this impression. And therefore this idea is nurtured in harmony. This is particularly suitable for those women who want to avoid getting in touch with their CA until the last minute, telling themselves that “it’s going to work out.” An additional aspect is the belief that childbirth anxiety only exists during pregnancy and automatically vanishes after delivery, only she endures until she has given birth. At the end of gestation, these women can find themselves in a situation where their CA finally erupts in full swing, while time for psychological treatment has run out. The risk for a traumatic delivery is then impending, with negative consequences for the woman’s postpartum mental health.