When Marisa Kelley Smith was 12, she watched her adopted brother being born. “It was a traumatic birth with a lot of screaming, and they needed to use the vacuum to get him out,” she says. After that, Smith remembers avoiding holding babies as a teen. She resisted having a serious relationship until her early 20s. And when she was married, Smith, now 32 and living in Utah County, Utah, put off trying to get pregnant until one day her husband asked her what she was waiting for. “I blurted out: I’m afraid of giving birth! That was the first time I’d ever verbalized it,” she says.

If you’re pregnant, it’s natural to have worries about the birth. There are so many unknowns, everyone’s heard horror stories, and the way fellow moms describe the pain—well, let’s just say the epidural was invented for a reason. But some women have tokophobia, a psychological condition involving a paralyzing fear of giving birth.

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Tokophobia characteristics

A 2016 study from the University of Michigan explored the fear of childbirth in a 22-woman focus group. The women in the study expressed fear about complications during birth, something happening to the baby, and the pain associated with delivery. They were also fearful of their clinicians and the maternal care system in general, including decisions being made for them or C-sections being pushed on them (one reason why some women may opt for a homebirth).

These feelings aren’t something to be brushed aside or told you’ll get over. Women who have these fears are more likely to have obstetric complications, the study authors said. One problem the women raised in the study is that appointments are so rushed, they didn’t have time to express their fears—so there was no opportunity for them to be resolved.

“In general, physicians have not readily detected tokophobia because they are not trained to identify it. Fortunately, today there is a greater awareness of perinatal mental health issues, including anxiety and depression,” says Amy Wenzel, PhD, a clinical psychologist and author of Cognitive Behavioral Therapy for Perinatal Distress. “It’s completely normal and very common for women to be nervous about childbirth. Just because you are doesn’t mean you have a phobia. In my research and clinical experience, most people are a bit nervous about childbirth, especially if they haven’t gone though it before,” she says.

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Tokophobia causes and symptoms

What separates a woman from having typical jitters and true tokophobia (which, it’s important to note, Wenzel says, is rare) is how the fear of pregnancy affects the ability to function. Some women may put off family planning because of an internalized fear. Others may go to great lengths to not get pregnant. When pregnant, these women may avoid going to OB appointments, something that can put their and their baby’s health at risk. Or, they may not sleep or have a difficult time meeting work or home obligations, Wenzel says.

Usually, tokophobia is caused by some type of disturbing experience surrounding pregnancy. There are thought to be two types: Primary tokophobia is the result of viewing disturbing images of a birth or witnessing someone else giving birth; a woman with primary tokophobia has never given birth herself. (Primary tokophobia is also sometimes a result of sexual assault or anxiety disorders.) Secondary tokophobia occurs when a woman develops a fear of delivery after going through a traumatic birthing experience herself, although increasingly, experts say, these women may more accurately have post-traumatic stress disorder.

Alexia Leachman, 44, knows this all too well. While many women rejoice after getting a positive on a home pregnancy test, “I felt as if I was kicked in the stomach. The days and weeks that followed, I was wrapped in a cloud of darkness and fear,” she says. Early on in the pregnancy, she discovered she had a miscarriage. “I felt relief. I knew that wasn’t normal,” says Leachman. The following year, then 36 years old, she was pregnant again.

It was then that she did a lot of internal work to figure out exactly what she was afraid of: the pain. Knowing she could have a C-section was comforting, but she eventually learned a technique called hypnobirth, something that would help her stay calm throughout contractions to lessen the pain. By the end of her pregnancy, she says she was one of the most chill pregnant women around.

It wasn’t until later that Leachman realized that her intense anxiety surrounding birth was tokophobia. Leachman runs the UK website Fear Free Childbirth in hopes of sharing her struggles and helping women who want families to overcome the fear standing in their way. Today, she has two girls, ages 8 and 14.

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Tokophobia help and treatment 

Whether you think you have tokophobia or a general fear of birth, you’d be well-served to speak with a professional, whether that’s your OB or a therapist. (And if you feel your OB isn’t giving you the time of day despite your attempts to talk, you may want to consider switching doctors—even within the same practice—depending on how far along you are.)

Wenzel, an expert in cognitive behavioral therapy (or CBT), says that treating any phobia, including tokophobia, is facing—rather than avoiding—fear and anxiety and developing tools to help you tolerate and accept anxiety, risk, and threat. There is a lot of uncertainty associated with birth, says Wenzel. “Negative outcomes do, indeed, occur. Thus, therapists should not try to convince women that everything will be OK, but instead to accept and tolerate the risk that is associated with childbirth,” she says.

Then, there’s exposure, which can really get women over the fear hump. Watching videos of childbirth, talking to other women about their birth stories, or writing your own narrative of how you expect the birth to go are just a few strategies that a therapist might encourage. “One way that exposure works is facilitating habituation, or the emotional and physiological adaptation to anxiety,” says Wenzel. New learning comes when someone realizes that they can tolerate anxiety—and they realize it won’t be as bad as they thought it would be.

Wenzel recalls an especially private patient who was losing sleep over the thought of spreading her legs and exposing her genitalia during childbirth to the doctors, nurses, and even her husband. She eventually concluded that she needed to let it go and roll with it. “She recognized doctors and nurses see this stuff every day, and she was fine,” Wenzel says.

For Smith, who is now looking to have children, what helped her was joining a tokophobia support group on Facebook, finding a female therapist specializing in women’s issues, and learning that with a therapist’s recommendation, she could request an elective C-section. “The idea of birth is still terrifying to me, but it’s doable,” she says. That said, Smith and her husband have been trying on and off for years to get pregnant. With no success–“I wonder if my anxiety has prevented it from happening,” she says–they’re in the process of adoption. But even though she’s got a handle on her fears, one thing is certain: “I will never be in the room for a birth again.”