Pregnancy and Childbirth

Pregnancy is often regarded with excitement, but no matter how eagerly a child's birth is anticipated, stress and other forms of emotional distress are still likely to occur during the challenging period of pregnancy. Pregnancy issues may be mild or serious, but they can affect the health of the mother or child, put strain on a romantic partnership, and lead to life changes, both predicted and unpredictable.

When concerns that arise during pregnancy or after birth cause distress or otherwise affect one's mental health, the support of a therapist or other mental health professional may be helpful. 

• Challenges Associated with Pregnancy and Birth
• Pregnancy and Mental Health Concerns
• Impact of Birth on Emotional Health
• Therapy for Pregnancy and Birthing Concerns
• Reducing Stress in Pregnancy
• Pregnancy Loss
• Case Examples

Challenges Associated with Pregnancy and Birth

Though pregnancy can be challenging for both parents, in many cases the pregnant woman experiences the greatest amount of strain. A single mother may experience even higher levels of emotional distress, as single mothers may often lack help and support. Pregnancy proceeds smoothly for many women, but even an "easy" pregnancy may be accompanied by some mental or physical concerns, and many mothers-to-be experience stress or anxiety regarding the health of their child, the impending birth, or the variety of complications that can occur with pregnancy. These worries may be mild or severe, but the stress they can cause may lead some women to experience increased physical or mental strain, depression, or poor physical health, all of which may lead to increased risk in childbirth. 

Pregnancy can put strain on a partnership, especially when a pregnancy was unplanned and partners have different goals. When one partner desires children and the other does not, for example, differing views about the outcome of the pregnancy may affect the relationship significantly. Even when both partners wish to have a child, being unprepared for the child's arrival financially or in other ways may still be a cause for concern. When a couple has unaddressed or unsolved relationship issues, their partnership may be further tested by the varied challenges of childrearing. If one or both partners is ambivalent to the idea of parenthood, having a baby may have a negative impact on the relationship, especially when other strains or stressors are present. Discussing any issues or parenting disagreements before pregnancy or before the child arrives may help a couple to become stronger, both as partners and as parents. 

Financial issues can also be a source of distress during pregnancy. Recent figures show that the combined cost of pregnancy-related services and childbirth in the United States averaged $32,000 for a vaginal birth and $50,000 for a cesarean birth (birth by C-section). These rates are the highest in the world. Because of the high cost attached to childbirth, many women who become pregnant may find themselves experiencing stress or anxiety as a result of impending medical bills. While some insurers may cover a significant portion of childbirth costs, other insurers may pay little to nothing, leaving families responsible for extensive and unexpected medical bills that frequently include charges for unused items or unnecessary services. 

The physical challenges that often accompany pregnancy can also be difficult for many women to cope with. Morning sickness, aches and pains, fatigue, insomnia, and indigestion are just a few of the concerns that a pregnant woman may face. Women who contract illnesses while pregnant can be more severely affected by symptoms and may have a greater risk of complications, the most severe of which are birth defects or fetal death. In order to prevent certain birth defects and foodborne illnesses, a physican will typically recommend certain dietary restrictions to women who are pregnant, such as the avoidance of alcohol and raw or unpasteurized foods. Beyond these restrictions, some women may find it difficult to eat a variety of foods, due to morning sickness or other pregnancy-related stomach concerns. 

Some women may have the opportunity to choose their own doctor or midwife, but many women are not able to do so and find themselves with an overburdened or distant health care provider or one who is difficult to connect with. This can make necessary doctor visits another source of distress, and some women may avoid essential care as a result. A therapist or counselor may be able to help women in this situation connect with a different doctor or clinic, if possible, and may also be able to help those in this situation explore other possible solutions. 

Pregnancy and Mental Health Concerns

While pregnancy often elicits many positive emotions, it can also cause a woman to experience negative thoughts and feelings. During pregnancy, past family issues, insecurities, relationship difficulties, and financial issues can become real and immediate concerns. A woman who is expecting may find herself experiencing mood swings, fear, anxiety, forgetfulness, or body image issues. Women who experienced depression or anxiety before becoming pregnant may be more likely to experience mental health concerns during pregnancy. When mental health conditions do occur during pregnancy or postpartum, a woman's doctor will generally be able to provide referrals to mental health professionals as well as immediate health care and support. 

Because some psychotropic medications can have harmful effects on developing fetuses, women who are taking these medications and discover they are pregnant or intend to become pregnant are advised to contact their doctor and mental health care provider. In some cases, another medication is prescribed, and in others, a woman may receive an alternative form of treatment for the duration of the pregnancy, such as therapy only. This may not be effective for all individuals, but a therapist's help and support can help each woman find the right option for her. Some mothers who have mental health concerns may become anxious when considering the possibility of passing their illness on to their child, but information and resources obtained from a health care professional may be helpful at addressing their concerns. 

Societal expectations of pregnant women and new mothers may lead many women to experience anxiety or stress. Well-meaning individuals—family, friends, or even strangers—may criticize the practices, diet, and weight gain (or lack thereof) of pregnant women and may often offer unsolicited opinions or advice. Some women may experience irritation, anger, or frustration as a result, but others may come to doubt their own ability to be good mothers. Soon-to-be parents may turn to parenting books or other sources of advice and become overwhelmed by conflicting opinions on the best or safest options for delivery. 

Symptoms of mental health concerns are the most common complication of childbirth. According to research:

• Between 15 and 20% of women experience clinically significant anxiety or depression after childbirth.
• Two thirds of mothers diagnosed with severe postpartum depression began experiencing changes in mood during pregnancy.
• Sixty percent of mothers with moderate postpartum depression had pregnancy complications such as gestational diabetes.
• Stress experienced during pregnancy, especially posttraumatic stress (PTSD) has been linked to premature birth, low birth weight, and risky behavior (such as drinking or smoking) during pregnancy. 
• Many women experience "baby blues," or a period of low mood and tearfulness, for a week or two following childbirth. These feelings generally resolve with the support of one's partner or family. When they do not resolve or include hopelessness, negative thoughts about oneself or one's baby, or a loss of appetite, a more serious condition may be indicated.
• Postpartum psychosis is rare but serious: The condition is characterized by delusions, rapid mood swings, paranoia, and hallucinations and carries a 5% rate of suicide and a 4% rate of infanticide. Symptoms generally appear suddenly, within two weeks after giving birth. 

Impact of Birth on Emotional Health

It can sometimes be difficult for parents, especially new parents, to become accustomed after the birth of a child. A difficult birth can leave both parents emotionally and physically fatigued, and it can be difficult and stressful for parents to adapt to new roles and responsibilities. Some partners of women who have just given birth may wish to offer support but provide either too little or too much, thus straining a partnership that may already be challenged by the new baby. Both the mother and her partner may experience fatigue or have trouble sleeping, due to the demands of a newborn, and this lack of sleep may lead to a lowered immune system, increased irritability, and stress. While it is often possible for a couple to communicate their issues and work through them together without outside help, often professional support is beneficial to this process. 

Some women who have just given birth may find it difficult to accept that certain aspects of pregnancy and delivery did not happen as expected. A mother who carefully designed a birthing plan but was unable to use it due to medical complications may experience regret that the birth did not go the way it was planned. Women who have a difficult recovery may feel frustrated by their inability to do things for themselves or find it difficult to cope with pain and fatigue. Some women who are unable to breastfeed may experience feelings of failure or frustration and become stressed or experience symptoms of depression as a result. 

When a child cannot be carried to term, is stillborn, or is discovered to have a fatal or life-threatening birth defect, this can cause significant grief that, if untreated, may lead to mental health concerns such as depression. Telling family and friends about the death of an infant instead of announcing the birth may be an exceedingly difficult task that can have a lasting impact on parents, especially the woman who carried the child. Therapy can help address and treat feelings of grief. 

Therapy for Pregnancy and Birthing Concerns

Pregnancy, childbirth, and childrearing can all be difficult, even when everything proceeds without significant upset. Parents who have a strong bond and the support of others may still face unavoidable health or financial challenges, among others, which can significantly strain a partnership. The support of family and friends is considered by many to be an essential aspect of the well-being of new parents, especially new mothers. 

Therapy can help expectant mothers, women who are facing postpartum concerns, and the partners of these women to address the various issues that pregnancy and childbirth are likely to cause. Women who experienced mental health issues before pregnancy may fear that the added challenge of motherhood will exacerbate their conditions or cause further concerns to develop, but the support of a therapist or counselor throughout their pregnancy may help them feel more at ease. Women who experience postpartum depression or psychosis may find that that therapeutic treatment, combined with medication when necessary, has a beneficial effect. 

The type of therapy used will generally vary based on the concerns a woman is experiencing. Some women find the stress of motherhood and new responsibilities to be difficult to handle, and voicing their concerns in a support group to others in the same situation may be helpful to them. Those experiencing depression or anxiety may seek individual therapy. Couples therapy can also be helpful when a couple finds that a new baby has placed added challenges and stresses on their relationship. In therapy, couples can voice concerns or areas of disagreement and resolve any issues in their partnership. 

Parents or single mothers who lack assistance and support may also be able to seek resources and find help developing a support network in therapy. In any case, a therapist will be able to offer resources and help for those experiencing difficulty. 

Grief counseling, typically recommended after the loss of a child, can help parents come to terms with their loss, cope with their grief, and prepare to try again, should they wish to do so.  

Reducing Stress in Pregnancy

Stress reduction is considered to be one important way an expectant mother can achieve better health and prevent certain complications. The causes of stress during pregnancy are often varied. A woman may become stressed as her body begins to change, as she experiences the effects of pregnancy-related hormones, or as a result of anxiety or fears about pregnancy and childbirth. Individuals who experience negative or catastrophic life events during pregnancy or who have chronic stress, PTSD, or other mental health concerns may also experience greater levels of stress during pregnancy. 

A health care professional will likely advise a woman experiencing stress to cut back on stressful activities, stay healthy and fit by eating nutritious foods and keeping as active as possible, maintain a support network and keep in contact with friends and family, seek and accept help when needed, participate in childbirth education classes, and take up relaxation techniques such as prenatal yoga or meditation. Professional help from a therapist or counselor may also be recommended. 

Pregnancy Loss

Stillbirth and miscarriage are two pregnancy complications that lead to fetal death. Miscarriage is pregnancy loss occurring within the first 20 weeks of pregnancy, while a stillbirth occurs after 20 weeks. About 1 in every 160 pregnancies will end in stillbirth, and between 10% and 25% of all clinically recognized pregnancies will end in miscarriage. Up to 50% of all pregnancies end in miscarriage, but a number of these occur before the pregnancy is recognized. 

Miscarriage and its causes are often misunderstood and stigmatized. In most cases, the cause of a miscarriage cannot be determined. Some possible causes include chromosomal abnormalities, hormonal concerns, improper egg implantation, maternal age, and exposure to toxic substances. Stillbirth is somewhat more understood than miscarriage. Its causes, which include placental problems, birth defects, restricted fetal growth, and bacterial infections, among others, can more often be determined.   

Pregnancy loss can lead to complex emotions, such as grief, shame, guilt, and isolation. Some of those who have experienced pregnancy loss believe they could have prevented it, but this is not often the case. Because pregnancy is not yet apparent in many of those who have a miscarriage, many feel isolated following this loss. Experts say acknowledging the pain and loss, and having it acknowledged by others, can help reduce these feelings and allow the processes of grieving and healing to take place.

Case Examples

• Therapy to help resolve uncertainty regarding unplanned pregnancy: Tonia, 27, enters therapy with symptoms of stress and depression. She has recently discovered that she is pregnant and is unsure of what to do. The father has no interest in helping her raise the child, and she tells the therapist that she does not want to give the baby up for adoption or have an abortion. But because she is unmarried, single, and does not have many resources, she thinks one of those choices may be best and is distressed as a result. Tonia tells the therapist that has been unable to sleep well or focus on her work, as she constantly cycles through her options in her head and dreads having to make a choice. The therapist helps Tonia list all of the options available to her and visualize the best and worst outcomes for each option. Together they address Tonia’s values and goals for the future. Tonia reveals that she has not yet told her parents, although they have a fairly close relationship and she visits them often. The therapist encourages her to do so, and Tonia returns for her next session with the news that her parents want her to return home and raise the child with their help. Tonia has mixed feelings about this, as she did not want to become dependent on her parents again, but she tells the therapist that it is the best option for her.
• Relationship difficulties after difficult birth: Alejandro, 32, and Desiree, 28, enter couples therapy shortly after the birth of their first child. Desiree expresses anger and frustration with Alejandro, who she says does not help out around the house enough, spends time with his friends instead of helping with the baby, and "is not supportive." Alejandro protests her claims, saying that he does whatever he can to help her and offers to do more, but that she snaps at him for not doing things correctly and tells him to just "go out" and leave her alone. He tells the therapist that Desiree had a difficult birth and that she expresses discontent with her inability to exercise and move easily and that she is disgusted with her post-pregnancy figure, although he thinks she is "more beautiful than ever." Desiree states that she feels unattractive and that she knows Alejandro does not want to be intimate with her. He disagrees, saying that he only wanted to give her time to recover after the birth. The therapist encourages them to communicate their feelings to each other. Through discussion, he discovers that Desiree is still distressed that her doctor insisted on a C-section when she wanted to give birth manually and that she fears having a scar and being unable to regain her pre-pregnancy body. Desiree admits that she experiences feelings of anger and frustration with Alejandro, who experienced no bodily changes or pain, although she recognizes that it is not his fault. Alejandro apologizes for being unable to entirely understand what Desiree is going through, and the two begin to be better able to communicate their feelings and understand each other. They continue in therapy for a few more sessions, exploring ways that they can better support each other and strengthen their marriage. 

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