Digital intervention for tokophobia: a randomized controlled trial of internet-based cognitive behavioral therapy on fear of childbirth and self-efficacy among Egyptian pregnant women

Background Tokophobia affects up to 14% of pregnant women globally and is linked to high cesarean rates,
particularly in Egypt. This study evaluated the efficacy of a culturally adapted Internet-based Cognitive Behavioral
Therapy program on fear of childbirth and maternal self-efficacy among Egyptian pregnant women.
Methods A randomized controlled trial was conducted in Damanhur City, Egypt, involving 96 pregnant women with
moderate to severe tokophobia. Participants were randomly assigned to an intervention group (n = 48) receiving a
six-week program via WhatsApp or a control group (n = 48) receiving routine antenatal care. The intervention included
cognitive restructuring, exposure therapy, relaxation techniques, and psychoeducation grounded in Bandura’s Self-
Efficacy Theory. Outcomes were assessed using the Childbirth Attitude Questionnaire and Childbirth Self-Efficacy
Inventory at baseline and post-intervention.
Results Post-intervention, the intervention group demonstrated a significant reduction in fear of childbirth scores
(mean decrease: 14.32 ± 5.55; p < 0.001) and an increase in maternal self-efficacy (mean increase: 38.3 ± 35.7; p < 0.001).
Large effect sizes were observed for both fear reduction (η²=0.876) and self-efficacy enhancement (η²=0.600). The
control group showed no significant changes.
Conclusion The culturally adapted Internet-based Cognitive Behavioral Therapy program significantly reduced
tokophobia and enhanced maternal self-efficacy, supporting its integration into perinatal care. These findings align
with Bandura’s Self-Efficacy Theory and suggest the potential of digital interventions in improving psychological
outcomes, especially in resource-limited settings.
Implications for practice
Integrating the program into routine antenatal care could provide accessible, cost-effective support for women experiencing tokophobia, potentially reducing unnecessary cesarean sections and informing health policy regarding the effectiveness of the ICBT program. Future research should assess long-term outcomes and generalizability in diverse populations.
Trial Registration
The study was registered on ClinicalTrials.gov under the identifier (NCT06640608) on October 15, 2024