Anxiety in pregnancy and after birth: what mothers rarely talk about

Three in the morning. The baby is finally asleep, and so is her partner. She, however, is standing by the cot, watching to see whether the little chest really is rising. It rises. She goes back to bed, closes her eyes — and two minutes later gets up again, because she isn’t quite sure. In the morning she will tell visitors she is “a bit tired”. Nobody will ask any further, and she won’t say that she got up eleven times in the night.

People talk about low mood after birth more than they did ten years ago. Far less about anxiety. Perhaps because from the outside it looks like conscientiousness: a mother who checks everything, reads everything and lets nobody near without disinfected hands is, in the eyes of those around her, above all “a very good mum”. What is going on inside her stays hidden — often from herself as well, because she assumes this is simply how everyone feels with a newborn at home for the first time.

In this post I will write about anxiety in pregnancy and after birth: what it looks like, why it appears precisely now, what intrusive thoughts about harming the baby are and why they don’t mean you are dangerous, how fathers experience it, and where you can turn for help in Slovenia.

It isn’t only postnatal depression

When people hear “mental distress after birth”, depression is usually the first thing that comes to mind. I have already written about it in Postnatal depression: when you “should” be happy and you are not, so I won’t repeat it here. Anxiety is its sister, but it wears a different face. Depression often means emptiness, numbness, a sense that you don’t care. Anxiety is almost the opposite: you care too much, you are constantly on alert, you can’t stop.

And it isn’t rare. In 2017 the Canadian researcher Cindy-Lee Dennis and her colleagues brought together more than a hundred studies from different countries in a meta-analysis. Between 18 and 25 per cent of women had raised anxiety symptoms during pregnancy, depending on the trimester, and around 15 per cent in the first months after birth. When they counted only diagnosed anxiety disorders, the figures were lower, but still comparable with postnatal depression. Put simply: in the gynaecologist’s waiting room or at an antenatal class there are almost always a few women going through exactly this — and each of them thinks she is the only one.

Anxiety and depression also often intertwine. A woman who lives in a state of constant readiness for months will sooner or later be exhausted, and exhaustion can turn into despair. That is why it is worth taking anxiety seriously while it is still “just worry”. In the knowledge base this broader idea is described under postnatal distress.

What anxiety looks like in this period

In pregnancy, anxiety often gets stuck on a single question: is the baby all right? Every scan is both a relief and a new reason to worry, because there are several more weeks of uncertainty before the next one. Some women count kicks, others avoid reading about pregnancy because every story frightens them, still others read forums at night until they find the worst possible outcome.

After birth the worry shifts to the newborn: is he breathing, has he fed enough, is this rash something serious, will someone pass on an infection? The body often joins in — a pounding heart, a tight chest, tension in the shoulders, a restless stomach. One of the most typical and most cruel forms is not being able to sleep even when the baby sleeps. Everyone tells you to sleep when the baby sleeps. You lie there and listen.

Anxiety shows in behaviour too. Checking, searching online, logging every feed and every nappy without the paediatrician having asked for it. Or the opposite: avoidance — you don’t bath the baby on your own, you don’t take him out, you don’t hand him to anyone, because “nobody knows how to do it properly”.

Intrusive thoughts about harming the baby

Now I am going to write something that mothers (and fathers) almost never say out loud. Many new parents have sudden, unwanted thoughts or images of something terrible happening to the baby — dropping him down the stairs, him drowning in the bath — and also thoughts of doing something to him themselves. The flashes are brief, horrifying and completely alien to everything the person wants.

Research, including the work of Nichole Fairbrother and Sheila Woody, shows that such thoughts are very common among new parents: the great majority have thoughts of accidental harm, and quite a large share have thoughts of deliberate harm — in people who pose no danger to their child whatsoever. Psychologically, this is a side effect of heightened vigilance. A brain tuned after birth to scanning for danger also offers up the worst possible image. I have written more about why this happens in Intrusive thoughts: why you have thoughts that frighten you, and there is a short explanation in the knowledge base under intrusive thoughts.

The key point is this: a thought that horrifies you is not an intention. The very fact that it frightens you shows that it runs against who you are. The problem isn’t the thought, but what you do with it. If you take it as proof that you are a bad mother, you start avoiding it: you stop bathing the baby, you hide the knives, you don’t want to be left alone with him. And every act of avoidance tells the brain that the danger is real — so the thought returns more often.

Many women tell nobody about these thoughts because they fear their baby would be “taken away”. Professionals who work with new parents know these thoughts well and can tell anxious intrusive thoughts apart from the rare serious conditions I write about a little further down. If you tell your doctor or health visitor, you won’t hear judgement. More often you will hear: “That is very common.”

Why now

Pregnancy and the first months after birth are a time when almost everything changes at once: the body, hormones, sleep, the daily rhythm, the relationship with your partner, the relationship with your own parents and your picture of yourself. Any one of these changes would be enough to put the nervous system on alert. Together they are a heavy load.

Sleep matters a great deal. Lack of sleep heightens reactivity to threat and weakens your ability to calm down — I wrote about this in Sleep and emotion: why everything hurts more after a bad night. For new parents, though, it turns into a loop: anxiety won’t let you sleep, and sleeplessness makes the anxiety stronger.

History matters too. Women who had anxiety before, who have been through a miscarriage, difficulty conceiving or a traumatic birth, are more vulnerable. And from relational family therapy, in which I am training, I know something else: when you become a parent, your own experience of childhood wakes up in you. How you were cared for, how you were soothed, whether anyone was with you when you were scared. If worry was the main language of love in your family, you will almost certainly start speaking it yourself. There is more about this layer in Parenthood as a transition: who am I now that I am a mother or a father?

And finally: the social picture. A mother is expected to be happy, to know what to do and for everything to come “naturally”. When it doesn’t, guilt joins the anxiety. I wrote about why the most devoted mothers feel it most strongly in Mother’s guilt.

Fathers too

When we talk about anxiety after birth, we almost always talk about mothers. Yet fathers who become parents also experience anxiety more often than men at other times of life. A review published in 2016 by the Australian researcher Liana Leach and her colleagues showed that anxiety disorders in fathers around the time of a child’s birth are common and often overlooked.

In fathers, anxiety is often less visible. It more often shows as irritability, retreating into work, constant worry about money and safety, excessive control or physical symptoms, and less often as fear put into words. At the same time, fathers are rarely asked how they are at postnatal check-ups. The health visitor comes to see the mother and baby, and the father is often at work.

For a couple this matters, because the two partners’ anxieties can feed each other. If both are on alert, neither can be the one who calms the other.

How anxiety lives in a couple

Anxiety after birth isn’t only an inner experience. It quickly becomes an arrangement between partners — often an unspoken one. One takes on the role of the person who worries, the other the role of the person who “doesn’t worry enough”. The first grows ever more tired and lonely, the second ever more pushed aside. A conversation at half past midnight might sound like this (a composite, not a real person):

“You’ve put him on his tummy again.”
“Just for a minute, while I was changing him. I was watching him the whole time.”
“The whole time, yes. And what if you’d looked at your phone?”
“You don’t even trust me to hold him.”
Silence. “I don’t trust anyone. Not even myself. That’s the problem.”
“Why didn’t you tell me before?”
“Because I thought I was the only one who was this mad.”

Something important happens in this short exchange. As long as they were arguing about who holds the baby properly, they were opponents. When she said she doesn’t even trust herself, the conversation became about anxiety — and anxiety is something they can face together. A partner who knows it is anxiety defends himself less and helps more. A mother who names her worry submits to it less.

It also helps if the partners split the nights so that each of them has at least one longer block of sleep, and if the other takes over part of the care without being supervised all the time. For an anxious mother this is often hard, but the very experience that the baby spends a few hours with someone else and is perfectly fine is one of the best remedies for anxiety.

It is worth knowing that a partner’s help can’t be endless reassurance. If the mother asks ten times a day whether the baby is all right and the partner answers “yes” ten times, the anxiety will settle for a moment but will be fed in the long run. I will write more about how loved ones can help without keeping anxiety going in How to help someone you love with anxiety — without burning out.

Exercise: ten minutes for an anxious thought

You can do this exercise today, even with the baby in your arms. It won’t get rid of the anxiety, but it can help you not to follow the thought automatically.

1. Notice and name it. When a worry or an image appears, say to yourself: “This is an anxious thought.” Not “the baby is in danger”, but “my brain is offering me danger again”.
2. Check your body. Where do you feel it — in your chest, throat, stomach? Put your hand there and take three slow breaths, with the out-breath longer than the in-breath.
3. Ask yourself whether this is a warning or an alarm. A warning brings concrete information (the baby has a temperature, I need to ring the paediatrician). An alarm repeats itself without any new information.
4. With an alarm, deliberately don’t check. If you checked on the baby five minutes ago, don’t check again. Wait ten minutes and watch how the anxiety rises and falls on its own.
5. Be kind to yourself. Say what you would say to a friend: “This is hard because you care so much.” There is more on this under self-compassion.

At first the fourth step will feel almost impossible. That’s all right. Every time you manage a few minutes without checking, your nervous system learns that it can survive uncertainty.

Where this explanation doesn’t apply

In this post I stress that worries and intrusive thoughts are common and don’t signal danger. That holds true for the great majority of people. But there are situations in which it would be wrong to put everything down to anxiety.

Some worries are justified. If the baby isn’t feeding, is unresponsive, has a fever or is struggling to breathe, that isn’t anxiety but a reason to ring the paediatrician or the out-of-hours service. Anxiety differs from justified concern mainly in that it keeps coming back despite reassuring answers.

Postpartum psychosis is a rare but urgent condition. It usually appears in the first weeks after birth: confusion, several nights with almost no sleep, unusual beliefs that seem strange to others, hearing or seeing things that aren’t there. In psychosis, thoughts of harm don’t feel alien and horrifying — they seem to make sense. This isn’t something to address with therapy or an exercise; it calls for ringing 112 straight away or going to A&E.

Thoughts of suicide are not part of “ordinary” anxiety. If you are having them, tell your doctor or call the crisis line Klic v duševni stiski on 01 520 99 00 in Slovenia (every day from 7 pm to 7 am) or the Samaritan helpline on 116 123 in Slovenia (every day, 24 hours).

And finally: anxiety isn’t always purely psychological. Some physical conditions, such as thyroid problems, which are not unusual after birth, can cause similar symptoms. That is why talking to a doctor is always a sensible first step before you put everything down to nerves.

Where to find help in Slovenia

The hardest step is often the first sentence. You don’t need a diagnosis or to know what it’s called. It is enough to say: “I’m frightened all the time and I can’t calm down.”

The health visitor (patronažna sestra) visits you at home after birth and is often the first professional to see how you really are. Tell her. Your gynaecologist sees you during pregnancy and at the postnatal check-up — there too you can mention how you feel, not only how your body is healing. Your GP can refer you to a psychiatrist or clinical psychologist. With moderate or severe anxiety, medication can also help; which medicines are suitable in pregnancy and while breastfeeding is decided together with a doctor, never on your own.

Psychotherapy is a space where you can explore your fears without hurry — on your own or together with your partner. With postnatal anxiety it often makes sense to include both of you, because anxiety lives in the relationship and not just in one head.

If you were in therapy before pregnancy, it is worth going back before the anxiety takes hold. If you weren’t, the time around a baby’s birth is a good moment to start — not because something is wrong with you, but because this is one of the biggest reshapings of a life, and you don’t have to carry it alone.

What to remember

• Anxiety in pregnancy and after birth is at least as common as postnatal depression, yet far less talked about.
• It shows as constant worry, physical restlessness, sleeplessness even when the baby sleeps, and checking or avoidance.
• Intrusive thoughts about harming the baby are common in new parents and don’t mean you are dangerous — a thought that horrifies you is not an intention.
• Fathers experience anxiety too, often hidden behind irritability or a retreat into work.
• The first step is one sentence to your health visitor, gynaecologist or GP. With confusion, unusual beliefs or thoughts of suicide, ring 112.