The Psychology of Pregnancy and Birthing: Empowering Yourself Through This Critical Period
By Dr. Lara Honos-Webb
Special Issues for Pregnancy
There are predictable themes that emerge for women during pregnancy that are relevant for promoting mental health. The emerging scientific literature on a woman’s psychological adaptation to pregnancy indicate that the stakes are high in terms of maternal and neonatal outcomes lasting through the lifespan of the fetus even through adulthood.
The issues of pregnancy can be divided into two categories:
Pre-existing issues intensified during pregnancy
Relationship with Partner
Relationship with Mother
Body Image
Sexuality
Emotional Lability
Any Traumatic Life Events
Unresolved Grief
2) Psychological challenges related directly to pregnancy
Changing Bad Habits (e.g. quit smoking, drinking alcohol etc.)
Anxiety about Health of the Baby
Coping with Partner’s Reactions or Lack of Understanding
Free-Floating Anger
Changes in Lifestyle, Career
Pre-existing themes/issues intensified during pregnancy
Relationship with partner
Women at high risk for poor psychological adjustment during pregnancy are those with conflicted or unsatisfying marital relationships. While some women may mistakenly believe that starting a family will help smooth over marital problems, pregnancy and its attendant stressors will likely increase marital tensions and highlight existing complaints women have about their spouses.
Any pre-existing stressors or marital conflicts will likely be increased during pregnancy. As a woman begins to imagine her new family and her life as a mother she may realize that existing conflicts will likely be intensified by parenting decisions. If partners cannot agree on how to allocate their finances before children, the complexities will only increase after the addition of a new family member. If partners have conflicting philosophical approaches to life, a pregnant woman may begin to realize that these clashes will be more frequent with a child. As partners begin talking about their ideals of parenting they may realize that their approaches to schooling and child-rearing are as polarized as the issues that created tension prior to pregnancy. Partners may have an early sense of the increased level of polarization as they make complex medical decisions in pregnancy, decorate the nursery or choose names.
In addition to increasing the number of arenas and the complexity of decisions for a couple to make, the stress of pregnancy and the physical and hormonal changes may pose a challenge for couples who had high levels of conflict prior to the pregnancy. The fatigue and increased emotional lability may decrease a woman’s capacity to tolerate conflict. A woman’s increased emotionality may cause a spouse to be increasingly reactive and hostile. The escalating tensions may create a vicious cycle leading to a stand-off between partners leaving the pregnant woman feeling unsupported during her most vulnerable time.
Other predictable physical changes can create more conflict in marital relationships. Hormonal changes may lead a woman to feel less interested in sex. If pre-existing conflicts involved differences in sexual desire then these issues will predictably become even more problematic. Additionally, as women gain weight and go through other changes they may lose confidence in their attractiveness making them less confident in their relationships and less interested in sex. These many changes place a great burden on the partner for sensitivity to these issues and the need for increased support from the husband. If the parents-to-be struggled with issues of attractiveness, sexuality, jealousy and fidelity prior to conception, these arenas will become hotbeds for conflict during the woman’s pregnancy.
In other circumstances it may be that the pregnancy causes a woman to re-evaluate her marriage or her partner through new lenses (Breen, 1975). In some cases, this process of re-evaluation leads to conflicts that did not exist before. For example, a woman whose relationship with her husband is based on a wild lifestyle may have serious doubts about her husband’s drug or alcohol use. Alternatively, a professional woman who realizes she will not work after the birth of her child may begin to re-evaluate her spouse in terms of his role as sole provider for the family. She may begin to doubt his capacities. A woman who leaves her job may also begin to realize that she will be dependent on her husband in ways she previously was not (Hess-Stauthamer, 1985). This change in circumstances may cause her to re-evaluate her husband in terms of her capacity to trust and rely on him to be faithful and reliable throughout the changes and challenges of becoming parents.
Because of these issues you may begin to doubt your own security or question the stability of your marriage. If your marriage had pre-existing conflicts it is predictable that these issues will be magnified.
Relationship with mother
The existing literature points to the central importance of a woman’s relationship with her mother in determining her capacity to adapt successfully to the pregnancy. Studies have reported that women with high levels of unresolved conflict toward their mothers are at risk for health complications during pregnancy (Verny & Kelly, 1981). One study revealed that women who adjusted poorly to pregnancy and motherhood had not examined or dealt with their conflicting feelings toward their own mothers (Breen, 1975).
There are many reasons that a woman’s relationship with her own mother takes on central significance during pregnancy. Psychodynamic theorists point to the strong pull toward identification with and internalizing of the mother as a strategy for making the appropriate developmental transition to motherhood (Breen, 1975). To the extent that a woman has a negative image of her mother it will lead to disturbance in self-image and one’s confidence in one’s capacities to become a mother. Women who are disconnected from their mother will be at risk for an impaired capacity to develop a coherent identity as a mother.
If it is true that a woman begins to identify with or internalize her mother image, than a woman with a disturbed mother or negative relationship will be at risk for forging an unhealthy mother identity. It is predictable that if a woman does not have easy access to a healthy mother image to internalize the developmental task of forging such an identity will become complicated thereby creating conflicts and stress.
Women who have unresolved issue of rage and anger towards abusive or neglectful mothers may be at increased risk for depression and anxiety during pregnancy. If pregnancy involves a natural tendency toward internalizing one’s mother image than the anger toward a mother may be directed toward the self leading to psychological disturbance and devaluation of the self.
The absence of a healthy adult relationship with a mother may make it more difficult for the pregnant woman to forge an attachment to the fetus during pregnancy. Recent research has emphasized the importance of mothers developing an attachment with the fetus before its birth in terms of predicting pregnancy, birthing and health outcomes for the baby. Depression during pregnancy may make prenatal attachment more difficult (Kunkel & Doan, 2003). Because the quality of the mother-child relationship in the family of origin serves as a model for the mother-child relationship in the family of procreation, the lack of connection to one’s own mother may put the pregnant woman and her child at risk.
A woman who does not have a positive role model for how to be a good mother may have increased fears about how to transition into the new role over and above the normal developmental demands. The increased fears and anxieties may make the pregnancy more difficult and pose a barrier for a woman to make the role changes and identity transition demanded by becoming a mother.
It is likely that the more outside of awareness these conflicts are, the more the woman will experience physical health complications during her pregnancy. The more a woman is aware of these conflicts, she can identify and work through them to resolution. As a woman contemplates her new life as a mother, she is likely to review her relationship with her own mother, making this an optimal time for the woman to seek support in working through and resolving any unexpressed emotions and conflicts. The resolution of this central relationship can have positive effects for the woman that transcend the immediate outcomes of her pregnancy.
Because the mother-daughter relationship becomes so salient during pregnancy, this is one example of a pre-existing conflict that can benefit by being brought into awareness and resolved. The developmental demands of a pregnant woman to forge a new identity as a mother provide a ripe opportunity for resolving conflicts and issues about your own mother. It may be a critical period for you to become aware of the heightened identification with your own mother during this time and to achieve a psychological separation from your mother. This developmental achievement will promote your general psychological adaptation. Simply by being aware of your need to review your relationship with your mother you can begin the work of healing. You might also consider writing in a journal about how you feel about your mother and how it influences you feelings toward becoming a mother yourself. If you have concerns about your ability to work through this issue on your own, don’t hesitate to contact a psychotherapist or counselor to support you through this process. Below is an activity you can try to get you started.
Finish this sentence:
When I give birth to my child, I give birth to myself as a mother. Sometimes this scares me because my own mother
Body ImageThe predictable and dramatic changes in your body during pregnancy can become a significant source of distress. If you struggled with issues about your body shape or size prior to pregnancy it is probable that these issues will intensify if you do not receive support or some form of intervention. It is on the issue of body image that pregnancy provides the clearest “critical period” in terms of the capacity for the changes to exacerbate existing difficulties or to lead to profound healing.
The difficulties increase because a woman loses control over her hunger and will gain weight. In a culture with a “thin ideal” many women lose self-esteem as they grow larger. However, if you can take on an empowerment perspective you can shift toward a recognition of the wonder and miraculous nature of being capable of creating a human life with your body. This recognition has the potential to lead to a life-long re-evaluation of your body and rejection of the cultural standard to base one’s body esteem on its shape and size.
For women who devalued their body before pregnancy, had obsessive concerns about food and body size, or had clinical eating disorders, pregnancy will present a great challenge. These women are at risk for poor adaptation and may even have difficulty bonding with their child after birth (Verny & Kelly, 1981). Women whose main source of identity and self-esteem before pregnancy were derived from their positive perceptions of their beauty may also struggle as they perceive themselves to be losing control over the main source of their self-esteem.
The threats to body image come not only from the inevitable weight gain but also from other common changes that occur during pregnancy. Women may get stretch marks, can become more clumsy, and swelling can change the appearance of a woman’s features. A woman whose focus on these changes becomes obsessive may be at increased risk for depression and anxiety. Additionally, an intense preoccupation with food intake, weight, skin blemishes and other physical changes can prevent a woman from making the developmental changes that will promote a healthy attachment to her fetus and child and the transition to the role of mother. If a woman’s attention is primarily focused on preventing body changes or ruminating over them, you will need to ask yourself, “What am I not paying attention to?” You may not be paying attention to creating a prenatal bond with your fetus, or planning for the arrival of the baby and beginning the process of negotiating the inevitable life changes.
Take a moment here and answer this question:
If I am spending too much time worrying about my body or my attractiveness, I am not making the internal changes I need to make for the dramatic life changes of becoming a mother. What am I not paying attention to that I need to start thinking about?
The process of imagining a new life with the baby and anticipating parenthood are essential to making a positive transition to motherhood. If the pregnancy is spent in obsessing about food and ruminating about body shape and size the most important developmental work is not being done. This will have significant implications for post-partum adjustment and attachment to the infant. Research has shown that women who do not make fundamental changes in their identities are at greater risk for poor postpartum adjustment. Intense focus on bodily changes may serve as a displacement for the more threatening work of shifting one’s fundamental identity.
The physical changes of pregnancy offer you an opportunity for personal growth and dramatic re-visioning of your relationship with your body. You may come to realize how oppressive the intense focus on body shape and size is once you begin to realize the power and awe of the changes that are happening. If pregnant women can be supported in appreciating their capacity to create, nourish and nurture life with their own bodies, they may be able to make long-lasting changes in their relationship to their bodies. Women can be helped to feel a tremendous sense of power about what their bodies can do. These realizations can change patterns of chronic negative devaluation and a pattern of obsessive focus on size, shape and weight.
SexualityPregnancy often leads to women considering their relationship to their own sexuality. On the most obvious level, pregnancy is evidence that the woman is a sexual being. A pregnant woman is definitely not a virgin. A woman’s relationship with her own sexuality is also brought to the foreground during the process of conception. If her pregnancy was unplanned she may begin to review the history of her sexuality in trying to understand how the pregnancy occurred. If the pregnancy was planned, women often consider their sexuality in determining if they need to make changes in order to conceive.
The process of conceiving may also impact a woman’s sexuality in positive or negative ways. Women who had a long and arduous struggle with fertility may have come to criticize their body or to associate sex with a chore. Women who conceived easily may gain a sense of being empowered by their body and sexuality. Women who find themselves pregnant, have arrived there by their sexual history. This unavoidable fact often propels a review or reconsideration of her sexuality.
Sexuality also becomes an issue during pregnancy because your sexual desire is certain to be impacted by the pregnancy. While hormonal changes affect each woman differently, a common pattern is diminished desire in the first trimester, increased desire in the second trimester and in the third trimester desire is impacted by the physical demands of increasing size and a woman’s confidence with these changes.
Sexuality is another theme for which pregnancy becomes a “critical period” in terms of a woman’s sexual adjustment. If your review of your sexuality reveals a great deal of conflict and discomfort around your sexuality, this review offers you an opportunity to address, resolve and work through these conflicts. In this way, you will be freed from what might have been latent conflicts and an impaired sexuality for the rest of your life. The pregnancy can also empower your sexuality by increasing your awareness of the power of your sexuality in terms of creating life. You might also find that if you stay sexually active throughout your pregnancy that your sexuality is not as tied to your physical size and shape as our cultural values indicate. You may find that the increased intimacy with your partner about the excitement of starting a new family increases your sexual desire. This can be a profound re-learning for women who may have internalized cultural values that a woman is as sexual as she is attractive in terms of cultural definitions of beauty.
A woman’s capacity to embrace her sexuality is also critical during her pregnancy because there is a possibility for lasting impairments. If a woman does not address any sexual conflicts they can remain latent and be exacerbated by the process of conception or the pregnancy. A woman with existing conflicts may intensify her struggles if she had difficulty conceiving or experienced earlier pregnancy loss such as miscarriages. A woman may find the effect of her hormonal changes results in a complete lack of desire. In combination with losing confidence in her attractiveness as she gains weight, a woman may begin to avoid sex altogether. These dynamics may evoke resentment in her partner which may trigger power struggles over sex.
A partner’s reactions to the physical changes in a woman can be healing or can lead to increased trauma. If a partner devalues the woman for the changes during pregnancy, she may feel rejected, angry and internalize the devaluation. The level of struggle and conflict that can arise around sexuality if not addressed and resolved during pregnancy will predictably intensify following the birth of the child. The physical and emotional demands of parenting a newborn are most likely to negatively impact the dynamics. The partner may become increasingly disengaged as a woman’s primary attachment typically transfers temporarily to her newborn.
Because of the vicious cycle that can be created if a woman does not consciously address her sexuality and because of the potential for a woman to embrace her sexuality and recognize her power, the theme of sexuality becomes a critical issue for many women during pregnancy.
Emotional labilityA woman who has pre-existing emotional lability or a clinical mood disorder is at risk for poor adjustment to pregnancy. The combination of actual stressors and hormonal changes that result in increased emotional sensitivity can lead to impairments in relationships, professional functioning or parenting other children. Additionally, the magnitude of the life event of carrying a fetus and preparing for a new family member can create a sensitivity to life and its events which appears to others as excessive.
The predictable stressors of pregnancy that might lead to emotional lability include the many medical tests that are involved in even a healthy pregnancy. A healthy woman who becomes pregnant will find herself involved with medical procedures at a level of intensity she has never experienced before. She will be subjected to frequent tests for herself and her child. She will be asked to consider a range of tests for determining fetal abnormalities. The stress of learning about all the possible things that go wrong with herself and with her baby, in addition to taking the tests and waiting for results creates a stress that may make other life stressors unbearable.
Not only are many of the tests stressful, but many woman experience some sort of pregnancy related complication, and even a woman who has a completely healthy pregnancy may have the experience of a “false positive” result from one or more of the various tests. The advanced technology of ultrasound often leads to false positive detection of possible abnormalities causing intense distress for women until further testing. Throughout much of a typical pregnancy a woman is waiting for the results of one test or another. Particularly combined with normal anxiety about the health of the child and the dramatic physical changes, the level of anxiety can lead to low levels of ability to tolerate the day to day life stressors.
Pregnant woman are often caricatured for their emotional sensitivity. The sight of a pregnant woman weeping at a television commercial, or breaking down in tears at the slightest thoughtless comment represents the cultural depiction of the impact of the hormonal changes on women. On a physiological level alone, the hormonal changes have been thought to contribute to increased levels of depression, anxiety and panic attacks. If you are struggling with emotional sensitivity, you can begin to honor your emotional life by following the activity below.
Activity: The Thirty-Second RuleIf a troubling emotion arises, follow the thirty-second rule: give yourself permission to feel the emotion, but only for thirty seconds. You may be afraid that if you open to your emotions, you will get lost in them and lose control. This fear may be legitimate – sometimes emotions can disrupt your life. Letting yourself experience emotions in thirty-second chunks is a valuable skill that will allow you to honor your feelings without being dominated by them. One of the main benefits of this practice is that it helps you realize that your emotions don’t have to control you – you can control your emotions.
1. When an emotion dominates your attention, set aside thirty seconds to go deeper into it. Breathe into the feeling. See if you can imagine your breath touching the feeling. As you breathe into the feeling, imagine it becoming more intense. Remember, you are only going to do this for thirty seconds, so don’t be afraid of going deeper. Imagine turning up the volume on the emotion, imagine it becoming more and more intense. Feelings are like a wave: they get more intense, they crest, and then they get smaller and go away. With only ten seconds left, imagine your feeling slipping away, just like the wave after it crests. Breathe deeply and let the feeling go.
Many people are surprised to find that, by using this image of a wave, they can let go of a feeling fairly easily.
2. Try to translate the emotion into a form of guidance. For example, if you are angry, you may need to communicate your boundaries or needs more clearly. If you are sad, you may need to find support for your grief. If you are afraid, you may need to determine if what you are afraid of is a likely or unlikely possibility. If it is an unlikely possibility, try to refocus your energy. If it is a likely possibility, begin to seek resources for addressing it.
3. If you find yourself stuck in an emotion, continue to process it either by talking it through with another person or journaling about it. If the emotion reflects difficult life events or tragic losses, spend ten minutes writing about the events and fifteen minutes writing about the remarkable gifts you must have to have survived them.
The Thirty-Second Rule on the Fly
Three steps you can use any time are 1. breathe into the emotion, 2. stay with it for 30 seconds, and 3. find the emotion in your body. Finding the emotion in your body will help you get more of a handle on it, giving you more control. Taking just these three steps can give you control of the emotion – as a result, you will be much less likely to follow an impulse you will later regret.
The Gifts of Emotional SensitivityWhile the emotional changes are often considered to be dysfunctional, these changes might also be thought of as increases in emotional sensitivity rather than as a problem. Women often report increased compassion and caring for others, an increased sense of connection to others. Additionally, the heightened sensitivity might be viewed as an appropriate reaction to the reality of a woman who has a new life growing inside her body. The sensitivity might be thought of as a positive sign of the capacity to protect, nourish and attach to the fetus. In many ways, the process of carrying a human life is one of the world’s greatest mysteries and an intense response to that seems appropriate. Furthermore the responsibilities and risks of carrying a human life in one’s body are very real and increased anxiety and vigilance should be understood as a healthy adaptation to the demands and risks.
Any traumatic life eventsBecause of the physical changes of pregnancy and frequent OB/GYN visits, a history of trauma has the potential to resurface during pregnancy. Of particular relevance is a history of sexual abuse. Currents estimates of sexual abuse in the United States range from 12% to 40% (Weinstein & Verny, 2004). In addition, any history of physical or medical trauma may resurface as a woman’s interaction with the medical system increases in frequency. Because pregnancy increases a woman’s sense of vulnerability a history of being victimized is at risk for emerging. If women were subjected to physical abuse in their family of origin, as they begin to imagine creating their own family it is predictable that such memories from their own childhood will return.
Recent theories on trauma symptoms implicate somatic experiencing in the physical holding of unexpressed trauma as central in creating disturbance. Peter Levine (1997) has described post-traumatic symptoms as “fundamentally, incomplete physiological responses suspended in fear” (p. 34). If trauma reactions are stored in the body, than the physical, hormonal and psychological changes may serve to dislodge trauma-related memories or experiencing. It may be that physical exams or contemplation of one’s new family re-create in different ways the original trauma which has been able to remain hidden for many years.
Levine (1997) has described trauma as primarily physiological, embedded in one’s nervous system. He writes that “the incomplete responses now frozen in our nervous systems are like indestructible time bombs, primed to go off when aroused by force” (p. 62). The changes of pregnancy may represent a “force” that arouses the physiological time bombs described by Levine. A woman’s nervous system may be pushed past its capacity to tolerate and contain daily stressors, hormonal changes and specific stressors of pregnancy such that dormant trauma is no longer frozen or protected by the nervous system.
One of the necessary components for symptoms of trauma is experiencing an event that causes a person to feel helpless or out-of-control. Pregnancy has the potential to recapitulate these feelings of helplessness as the mood and bodily changes take over and the woman feels herself to be increasingly out of control. The parallels between feeling out of control over the pregnancy and the feeling of helplessness of previous trauma can also lead to heightened awareness and increased intrusion of memories from prior trauma.
The re-emergence of traumatic memories offers the pregnant woman specific challenges but also an opportunity to address and resolve these issues. The challenge is that having to cope with past history of trauma while negotiating the intense demands of even a healthy pregnancy can tap out a woman’s coping skills leading to a serious disturbance. However, even such a disturbance can provide an opportunity if a woman seeks counseling to help her work through and resolve the trauma. If pregnancy does lead to a woman gaining access to a previously suppressed trauma, it gives her the opportunity to heal herself for the rest of her life from the trauma that had hitherto been latent. Much of the research on trauma points to the chronic life-draining effects of unrecognized trauma on the quality of a person’s life.
The symptoms of traumatic life experiences that have not been fully integrated include numbness, rage, difficulty sleeping, somatic symptoms and chronic anxious arousal. These symptoms can exist without a person having any sense of the underlying trauma. The effort to keep such awareness out of memory can be in itself severely disabling as individuals resort to drugs and alcohol or avoiding any reminders of the trauma to prevent having to cope with the trauma. By facing the trauma itself that may be brought to awareness during pregnancy, a woman may heal herself from the life-long challenge of avoiding and suppressing awareness of the experience. If you find yourself facing previous traumas, it is essential that you seek help from a trained professional to work through these issues.
It is in relation to the possibility of having to confront prior trauma that pregnancy can be viewed as a “critical period.” If a woman fails to successfully identify and cope with emerging trauma she can find herself stuck in a vicious cycle of increasing depression and anxiety and a breakdown of coping skills. Alternatively, she can increase awareness of, confront and resolve previous trauma preparing her for the challenges of pregnancy and motherhood even more healthy than she was prior to her pregnancy.
Unresolved griefOne of the central tasks for a woman during pregnancy is to begin to imagine and create the new family of procreation that will result following the birth. If it is a first child, the woman begins to imagine the new role of mother and her husband in the new role of father. She needs to begin thinking about how she and her husband will relate differently and how they will raise their child. If it is not a first pregnancy, the woman begins to imagine the new family dynamics that will result from the addition of a new family member. As a woman begins to imagine the structure and interactions of her own family, she inevitably will begin to think of her own family of origin.
Pregnant women will begin to think about what features of their family of origin they want to change and what they hope to re-create. For women who find there is much they want to change or avoid, they may find themselves confronted with feelings and emotions of an earlier troubled family life. As women begin to imagine the ideal family life they hope to create, they may be overwhelmed by a sense of many needs of their own that never were met in their family. This may result in a need to grieve their unmet needs and broken ideals in their own family.
The process of grieving your losses are necessary to help you heal from previous wounds so you can be free to create the family you want. It is difficult for a person to meet the needs of others that they have never recognized in themselves. By allowing your grief over the realization of the failings of your own family, you can gain a poignant awareness of how you did not get your deepest needs met. This awareness will prepare you to meet the needs of your own children.
Pregnant women who had a significant loss in their family of origin and who never fully grieved the loss will also be confronted with a significant challenge (Breen, 1975). Pregnancy in its evocation of the circle of life often causes losses of family members to return to vivid reality. For pregnant women who lost a parent before the birth of a child, they will likely have to re-enter into the grief or work through unprocessed grief. Because the imagination of the new family involves thinking of who the grandparents will be and what role they will play, the loss can not only return but can seem like an entirely new loss since the woman realizes she is losing a grandparent for her child.
The best way for a woman to increase her capacity to create the family she imagines is to enter fully into the grieving process that may emerge and to honor it fully. A woman who is at risk for poor adaptation or re-creating the very family dynamics she hoped to avoid is one who does not begin the process of imagining and planning for the family of procreation she hopes to create.
You can begin to pay attention if you are doing this work of preparation. If you are not, you might jumpstart the process by asking the following questions:
1. What parts of my family that I grew up in, do I want my own child to feel?
2. What parts of my family that I grew up in, do I want to spare my own child?
3. The most important thing I want to give to my own child is:
4. The most important thing I want to spare my own child is:
A woman who is not imagining the family she will create may be avoiding it because of the pain of re-visiting her own family of origin dynamics. Women may avoid the central task of creating their ideal family by focusing excessively on other things. They may not be able to think beyond the distress of bodily changes, or fear of the impending birth process. If you need help with this process, seek out a therapist or friend to give you support.
Create Your Own CultureThe process of planning for your ideal family can be very empowering. While the culture conveys messages that tend to devalue the roles of motherhood, a woman who enters fully into this process realizes the extent of her power to create her own family, in short to create her own small culture. As she realizes the impact her family of origin had on her, she begins to see how wide-ranging and powerful her own capacity to plan for and create her own family is.
Psychological challenges related directly to pregnancyNecessity of changing existing habits
One challenge and potentially unrecognized stressor for pregnant woman is the necessity to change habits that are toxic to the fetus. Women who are pregnant are told by medical professionals that any drug use, alcohol use and cigarette smoking should be given up during pregnancy. Medical advice differs on caffeine, but in general women are advised to give up or significantly reduce caffeine consumption. Changes in diet can be required which pose a challenge for women. For women who are very thin, the need to gain weight may seem like a constant struggle. Some women who are substantially overweight are told to gain weight, but not too much weight. The pressure from medical professionals, family and friends to make these changes can be a constant source of stress for pregnant women.
The stresses caused by changing these habits can be threefold: the stress of changing any behavior, the emotions or psychological states that emerge that were masked by the use of the substance and the guilt and self-recrimination that emerge when a woman fails to abstain altogether or has occasional “slips.” The more dependent a woman is on any of the habits that need to be changed the more intense the struggle. Individuals who are not pregnant often have to go through intensive behavioral interventions to change unwanted habits and pregnant women are no exception. However, often pregnant women are expected to be able to just drop any and all bad habits without intervention. Medical professionals often advise women of the recommended behavioral changes without providing referrals to get the necessary help. The stress of stopping a bad habit is recognized in the general population, but pregnant women are often not offered the necessary support for coping with this salient stressor.
One of the primary unrecognized stressors for pregnant women relates to those who have successfully given up a bad habit during the pregnancy and have to cope with the emotions or psychological states that the substance served to mask. Studies suggest that up to 50% of individuals who smoke cigarettes also have depression. The nicotine in cigarettes may serve as an attempt to self-medicate the depression. When pregnant women stop smoking they are likely to experience increased depression just by dint of withdrawing from nicotine. Caffeine is also a stimulant and can serve the same function of masking depression or as a coping strategy for keeping up with a fast paced life. Similarly, alcohol and other drugs may be used to moderate anxiety levels and abstaining from alcohol may take away a woman’s central coping strategy. Thus, women may be left with intense anxiety and little resources for coping.
Thus women who abstain from using substances they habitually used are in “double jeopardy.” They have intensified experience of what was masked by the drug and they may have used the drug in place of other coping strategies so they are without internal skills for managing emerging emotions. For example, a person with a stressful and overscheduled life may have used a lot of caffeine to manage the many demands and may have used alcohol to cope with the stress. When these habits are given up, her life may seem completely unmanageable and she may not have developed any stress management skills.
The demands to change bad habits can also take a psychological toll on women who fail at abstinence. Women may feel intense guilt and constant self-recrimination at their inability to quit altogether or their occasional slips. Women may begin to internalize a negative image of themselves as a mother and see their indulgence in their habit as a sign that they are an uncaring mother. They may not have been given the information that any person – pregnant or otherwise – who sets out to change a habit needs support and often behavioral interventions. To the extent that they internalize a negative image of their new role as mother they may have difficulty in forming a prenatal attachment to their fetus. It is possible that these effect could last after the birth.
Anxiety about health of babyAn intense and unremitting source of anxiety for a pregnant woman is her concerns about the health of her baby. This section will review the sources of anxiety of a woman who has a healthy child. The anxiety of a miscarriage or coping with a pregnancy of a child that will have birth defects is a significant stressor in itself and is a separate topic (see Sherr, 1995 for a comprehensive review of the psychological impact of medical complications).
It is not uncommon for women to be told before conception or in their earliest appointments that 20% of pregnancies end in miscarriage. For many women this grim statistic casts a pall over the entire first trimester. Many women are told by medical professionals not to tell family and friends about the pregnancy until the second trimester because the risk is so high of miscarriage. This intensifies the stress of a woman who lives in anxiety of losing her fetus and also is told not to reach out for the social support that might be one source of comfort.
Shortly after the first trimester, most medical protocols for pregnant women involve extensive testing and education about possible genetic defects and other possible abnormalities. Women may be taking tests or waiting for test results throughout much of the second trimester. In addition, it is not statistically uncommon for women with healthy babies to have false positives on one or more of the screening tests leading to intense distress. In addition to birth defects, women receive counseling on the signs and symptoms of complications in pregnancy.
;As mentioned in the previous section, all of these anxieties will be increased by the requirement for abstinence from many different substances. Women who are imperfect or failing altogether in their abstinence are likely to have increased anxieties over the health of the baby. The “common wisdom” and medical advice on substances to be avoided is enormous and contradictory. Women may live in fear of eating certain cheeses, the chemicals in hair dyes, the fumes in nail polish, environmental pollutants, over the counter medications and sugar substitutes among many other risks. It may seem that anywhere a woman turns is a threat to the health of her baby. The anxiety of trying to figure out what really is a threat and what is not and trying to avoid every toxin can become overwhelming.
Taken together, these many sources of concern about the health of one’s baby suggest that high levels of anxiety may be a normal reaction to the demands of pregnancy. A certain level of vigilance is important to protect the fetus and change in behavior is often well-advised. For women with high levels of anxiety related to the health of the baby, a focus on coping skills might be more appropriate that a focus on diagnosing and pathologizing high levels of anxiety. Medical professionals can be quick to prescribe medications for women who report anxiety without appreciating the day-to-day experiences that caution a woman at every turn about the risks to her fetus.
Coping with partner’s lack of understanding of internal changesA common stressor to the marital relationship caused by pregnancy is the partner’s reactions or lack of reactions to the changes of pregnancy. As women’s lives are seemingly turned upside down emotionally and physically, their partner’s lives essentially stay the same. Many women report that not only do they have to cope with changes, they have to deal with their anger and sense of being alone in the changes if the partner cannot empathize at a deep level.
This complaint may be more common during the first trimester when a woman is not yet showing physical changes but symptoms may be the worst. Women may feel impaired by their level of fatigue and nausea. Spouses may not be able to provide the emotional support or be willing to make necessary changes in demands, roles and scheduling to accommodate the symptom severity. Spouses may be insensitive at the change in diet, a woman’s unwillingness to cook and other changes around food caused by nausea. Women may have the additional burden of coping with an insensitive husband and their anger toward him. Women who are pregnant for a second or subsequent time may also find that husbands are even less sensitive to the internal changes because they expect the woman to have figured it out the second or third time around.
Throughout the course of the pregnancy, many symptoms women experience as distressing may not be validated by their spouses. Husbands may not be sensitive to a woman’s distress over the changes in her body. One threat to a woman’s stability is if a man exacerbates a woman’s concerns by rejecting her implicitly or directly with negative comments for predictable changes in the pregnancy. In these cases, it is as if her worst fears are coming true and she may have to cope with increasing doubts about the stability of her marriage.
As a woman becomes more emotionally vulnerable her needs for support and understanding from her husband increase. Because many of the changes are internal, her husband may not be able to meet these increasing needs. At times, the developmental changes in men during their wives’ pregnancy may make a husband less available to be emotionally supportive of his wife. Many men respond to the imminent birth of a child by focusing on the financial demands and planning for ways to increase their earning power. This may lead men to devote more time and energy to their work, to new ventures or to planning for providing for a growing family. These dynamics may be intensified if the woman is planning on leaving or cutting down her employment.
This pattern where men become more committed or preoccupied with work and women become more emotionally needy and vulnerable can lead to increased marital conflict, creating another stressor. When this dynamic is not identified women are at risk for being pathologized for what appears to be increasing emotional instability. If a woman can become aware of her needs and articulate the failure of her spouse to meet her needs she can begin to work toward finding ways of getting these needs met.
Processing anger at cultural devaluation of pregnancyMuch of the emotional instability that women report during pregnancy can be shown to be an understandable reaction to internal changes and responses from the environment to these changes. A significant but perhaps less conscious source of anger and depression in pregnancy is the realization of the cultural devaluation of pregnancy, childbirth and motherhood (Hess-Stauthamer, 1985). This source of anger is probably least conscious in the sense that women are likely to have internalized the devaluation and therefore not be able to articulate the reasons for their anger clearly.
The most readily identifiable place for experiencing this devaluation is in the medical setting. Women may be surprised at the approach to pregnancy as a disability or medical condition to be managed through testing and intervention. Women may be attuned to their sense of the miracle and responsibility of generating a new life while they feel they are being reduced to a medical condition. Natural birthing approaches and providers such as midwives may be more attuned to woman’s sense of the sacred nature of her “condition.”
However, women may begin to feel a sense that the culture as a whole devalues and does not recognize the significance of pregnancy. There are few cultural reflections and expressions of the value, beauty and power of pregnancy in art forms or other venues. Women have to look far and wide to see statues, paintings or cultural depictions of the state they find themselves in. We have campaigns to raise awareness and increase sensitivity about cultural plurality but we hear little or nothing about the struggles of pregnancy in the media.
Women may also experience this devaluation in work settings. Women are often applauded for proceeding as if they were not pregnant and not complaining about their many symptoms. Different work settings no doubt differ in their support for and ability to tolerate pregnancy related accommodations and complaints. While legally, employment setting are required to provide accommodations, women’s experiences will differ on the sense of support they receive and the underlying attitude toward providing such accommodations. Many women may feel there are implicit risks and subtle forms of discouragement for women to request and accept any form of accommodation for their pregnancy.
While the stressor of cultural devaluation may be the most pervasive it may also be the most unrecognized source of distress for pregnant women. In the absence of any awareness-raising movement regarding the support pregnant women need, they may internalize the devaluation. It can help to be aware of any negative messages you receive and to challenge them – at least to yourself. An additional benefit of identifying sources of cultural devaluation is that it can reveal women’s emotional intensity as understandable reactions to real events and prevent further pathologization and invalidation of pregnant women.
Here are some writing activities to raise your awareness:
What bothers me most about the way I’m treated since my pregnancy is:
Even though people at work don’t support me, I know that I need
Even though my husband doesn’t understand the miracle of my experience, I feel that
Preparation for changes in professional role
One of the most significant stressors for women during pregnancy is to prepare for changes in their professional roles and careers (Blechman. & Brownell, 1998). For women who anticipate making no changes other than a medical leave for the birth, they must still come to terms with juggling schedules to accommodate the end of their free time. They recognize that while they might not have to give up their careers something will have to go. Often it is self-care or recreational activities that women expect to give up. The more realistic a woman is, the more she will realize the challenges in balancing both a career and motherhood. A woman who plans to return to work with little interruption must also plan for childcare arrangements and other details during her pregnancy.
For women who plan to leave their work and become a stay at home mother, the developmental transition during pregnancy may be intense. A woman will have to come to terms with leaving a significant part of her identity in addition to the pragmatic concerns of planning for the loss in financial income. In addition to her shifting professional identity, she will likely re-evaluate her marital relationship. The transition to becoming financially dependent on her spouse will likely change that relationship in significant ways. This change will also unearth deep-seated issues about security, trust and dependency. Women may begin to re-process family of origin issues if the feeling of becoming financially dependent on their spouse recapitulates their feelings of being dependent on their parents as they were growing up. In this way, the decision of a woman to leave a professional role can evoke many layers of developmental issues to be negotiated (Hess-Stauthamer, 1985).
Women who are ambivalent about how to balance professional roles with motherhood also experience identity confusion and distress about making this difficult decision. Women in high powered positions may agonize over the seeming impossibility of integrating motherhood into their lives. Women who strongly desire to create a child-centered family but are strongly identified with their professional roles may have difficulty coming to terms with compromising one of their values.
The necessity of wrestling with the difficult decisions about how to manage one’s professional and family commitments often leads to existential questioning about one’s deepest values and the meaning of life. This essential quest for meaning during this developmental phase often interacts complexly with pragmatic concerns for financial stability and security. Women may feel they want to stay at home with their child but know that financial realities do not permit such an arrangement. Others may want to continue their professional lives uninterrupted but feel guilty about their ambitions. Women may struggle with the logistics of finding child care arrangements. Women may dread the change in life-style that a loss of income will entail.
many cases, pregnancy entails a thorough review of one’s personal and professional choices and a substantial disruption of current lifestyles. You will need a great deal of support during this time of re-visioning your livfe. Whether the existential struggle results in a complete overhaul of one’s existing life or minor changes, you will need validation of the intense struggle and the complexity of the life choices you are making. One of the greatest things you can do to find this support is to join a local mother’s group. There are also many on-line forums for mothers. During your pregnancy, you should spend one half hour a week researching local resources for new mothers and arranging to join one or more groups.
SummaryGiven the review of the psychological and social stressors entailed in pregnancy, and the high stakes for mother and child, it is remarkable that little attention is paid in society to identifying and providing the necessary support to women during this critical period. The review of the developmental demands of pregnancy and its interaction with pre-existing psychological issues suggests that moderate levels of anxiety and mood instability during pregnancy are totally normal. In this way, the anxiety and mood lability would be considered appropriate reactions to the developmental demands of pregnancy.
There is some evidence that the expression of anxiety during pregnancy is associated with more positive adaptation to motherhood because it provides the woman with the opportunity to identify and work through fears and emerge healthier (Breen, 1975). Other studies have suggested that unconscious or hidden anxiety can lead to increased psychosomatic symptoms (Hess-Stauthamer, 1985). Unexpressed fears require constant vigilance to keep out of awareness and thus repression itself can become a stressor. From a pragmatic perspective, by identifying fears, women can plan for strategies for coping with events that might occur thereby facilitating more effective adaptation in the event of complications (Sullivan & Cameron Foster, 1989). By reading through the themes in this special report that cause anxiety, you can begin to let them out into the open and seek support for them. Below are some questions to ask yourself:
After reading this special report, the topic that makes me the most anxious is:
What I really need to help me cope with this anxiety is:
I take my needs seriously. 3 things I can do to start to meet my own needs are:
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