In our focus on “post” partum, we might be forgetting the “pre”

Abigail Murray, Psy.D

Consider the following thoughts: “I bumped into that door. What if I meant to bump the door? Did I mean to bump the door? I could have hurt my belly. What if I was trying to hurt my belly?”

No, the person who experiences this line of thinking is not psychotic …. just pregnant. Delusions are defined as “thoughts or beliefs that are unlikely to be true.” We know that when someone is in a psychotic state, their ability to reality-test, or to check thoughts and beliefs against the world around them, can become non-existent. Although pregnant women are not in a psychotic state in the traditional sense, there can be something akin to this. Rather than thinking “I just bumped into the car door by accident,” the fact that you grazed the door can become “proof” you “meant” to bump baby (when of course, you did not). At the base of these disturbing thoughts is fear and worry about how baby is doing and how anything you do may impact baby. More confusing is the fact that most of the time, no one can give you any real assurance. While you have regular check-ups, even the most advanced medical care cannot offer you any guarantees. In this way it is more like psychosis than not – there is no easy way to “argue” against these thoughts. More frighteningly, most birthing people keep these thoughts to themselves, suffering in silence. While there may be cases of true psychosis, these thoughts are more commonly symptoms of anxiety, a particular type seen in the prepartum (and postpartum) periods. Intrusive thoughts like those above are *also* associated with a form of Obsessive Compulsive Disorder and can present during and after pregnancy even in people who have never experienced anxiety, OCD, or depression.

As in psychosis and OCD, there is a through line around making sense of experiences. In psychosis, typically, one experiences such trauma that a distorted reality is necessary to help the brain cope. In OCD, beliefs in rituals allow one to feel in control of things which cannot be controlled. Similarly, pregnancy and postpartum are periods of major transition and loss of control. It has been documentedthat approximately 60 % of mothers** experience postpartum anxiety and/or depression. Despite this, it is only in recent years that the postpartum experience has entered the conversation. Postpartum Depression earned its own clinical designation in the DSM (Diagnostic and Statistical Manual of Mental Disorders) in 1994. Depression screenings are now a regular part of the early visits to the pediatrician, there is education around symptoms of postpartum anxiety and depression, and many mothers are starting to share their postpartum narratives more openly. While these changes are just the beginning of adopting a holistic lens for understanding the transition into parenthood, we may be ignoring an important part of the puzzle – the prenatal period.

Before baby is even born, mothers are faced with quite the task. Conception in and of itself can traverse a path of trauma, from struggles with infertility to processing early pregnancy losses. Once baby is conceived, certain anxieties may dissipate (Can I get pregnant? Will I get pregnant?) while others take hold (Is baby growing ok? Am I doing the right things to support baby?). There are waiting periods between appointments and many questions without answers, all of which occurs often before the news has been shared. This leaves mothers and partners floating (and sometimes drowning) in these unknowns. There is a hypervigilance that develops around bodily sensations as these become one way to try and “know” the unknown. Dissonance is a constant presence – for many mothers, pregnancy brings a slew of conflicted feelings to the surface. Joy at conception, terror about pregnancy and birth, fears around being a parent and identity change, sadness at idea of losing aspects of “old” self. None of these are mutually exclusive and often the biggest confusion comes from feeling all of these things at once. Many of these complicated feelings are accompanied by guilt and shame, particularly if the path to pregnancy was fraught.

Doctors’ appointments, particularly during the Pandemic, are often short and can feel rushed. There is little focus on mothers’ anxieties *during* pregnancy, often more on screening for preexisting anxiety as a way of preparing to watch anxiety in postpartum. This can lead to missing present and new anxieties or worse, disregarding current worries as part of a “pre-existing condition.” Mothers are given contradicting messages throughout this time. “Make sure you are still getting exercise and eating a healthy balanced diet” contrasts with “It is normal you feel nauseous and are exhausted.” “Be sure to keep your anxiety levels low” can be delivered following “Your progesterone levels aren’t rising as quickly as we’d like so we will need to keep monitoring.” Genetic testing, typically performed at around 10 weeks, opens the door to fears about chromosomal abnormalities, yet the results of such profound tests can be left in an expecting mother’s voicemail.

It is believed in fact that somewhere between 14 and 23 percent of pregnant women experience depression; that number ratchets up to approximately 70% when you include episodic symptoms of anxiety and depression. Given this, we need a more honest middle ground – a space for mothers to exist within the contradictions. This means understanding that it is okay to be both excited for a baby *and* sad about a loss of identity; that it is okay to not feel joyful while pregnant, too.

Rather than just leaving mothers to manage anxiety on their own with vague statements about “self-care,” we need to normalize and validate. So what can you do if you are pregnant or are looking to become pregnant?

1. Ask yourself how you are feeling (often); you can even begin this practice before conception

* this can take the form of journaling, meditation, even a two minute practice before you get out of bed or on your commute

2. Consider beginning therapy; if therapy is not an option financially know that there are many therapy-adjacent options for support (support groups, community meet-ups, virtual groups)

3. Look for a doctor who leaves time for asking questions and is well-versed on mental health aspects of pregnancy; pay attention to how you feel before, during, and after appointments – these are good indicators of how safe you feel with your practitioner

4. Share scary or “weird” thoughts with your friends/family/partner when you can; identify these thoughts as anxiety talking so you can “talk back” to them when possible

               * for example, “Oh hey anxiety, I see you are back to talk to me today”

5. Monitor any changes in these thoughts, using them as cues to increase self-care; if they become too distressing or overwhelming, or if you have any thoughts of harming yourself, seek treatment immediately

By becoming more aware of what is *normal* we can learn to sit with these uncomfortable thoughts, together. This can provide expecting mothers and fathers with a much-needed anchor in the sea of unknowns.

** For the purposes of this article, the term “mother” will be used to as an inclusive one to signify “birthing person”