Suffering in Silence: Postpartum Anxiety in the Wake of COVID-19

Postpartum anxiety and the COVID-19 pandemic

While postpartum mood disorders have quietly tormented mothers and their families throughout history, the onset of the COVID-19 pandemic has only amplified the experience of mothers who wrestle with anxiety and depression, often in silence. Mothers are experiencing a 43% increase in maternal anxiety and depression during the COVID-19 pandemic (Davenport, Meyer, Meah, Strynadka, & Khurana, 2020). Health fears, increased isolation, couple stress, and contextual stressors, such as economic security precipitated by COVID-19, contribute to these elevated rates of maternal anxiety and depression (Lebel, MacKinnon, Bagshawe, Tomfohr-Madsen, & Giesbrecht 2020). Postpartum women who are suffering from anxiety experience pervasive worry, disabling fear, excessive self-sacrifice, and hypervigilance (Das, 2020). Mothers are more likely to experience social isolation and less likely to access social and familial support and childcare during the COVID-19 pandemic. Due to transitions to telehealth, decreased in-person visits, and overall provider burnout, postpartum mood disorders may not be as easily assessed and diagnosed during the pandemic. Minority, immigrant, and low-income mothers are at increased risk for developing postpartum anxiety, while limited access to postnatal healthcare and mental health and financial barriers to treatment are exacerbated during COVID-19.

Postpartum mood disorders

Approximately 3,791,712 births occurred in the United States in 2018 (The Centers for Disease Control and Prevention, 2020). More than 50% of new mothers are affected by a range of mood disorders including baby blues, depression, anxiety or psychosis after childbirth (Knops, 1993). Mood disorders refer to psychopathology that interferes with functioning as a result of unbalanced emotional states. Depression and anxiety are the most common postpartum mood disorders, presenting at 21% (Wisner et al., 2013). Postpartum mood disorders may present either days or months after childbirth; if such disorders are untreated, they may persist up to four years post-birth (Woolhouse, Gartland, Mensah, & Brown, 2015). Women are more likely to develop mood disorders such as anxiety in the first year postpartum than at any other period of their lives (Vesga-Lopez et al., 2008).

The distinction and prevalence of postpartum anxiety

Up to 20% of women experience postpartum anxiety disorders (Wenzel, Haugen, & Goyette, 2005). Generalized anxiety disorder and social anxiety disorder are the most common types of anxiety disorders that mothers experience during the postpartum period (Wenzel et al., 2005). It is important to note that such statistics refer only to diagnoseddisorders. Thus, an increased percentage of women do not meet the threshold for clinical diagnosis, yet still experience distressing symptoms potentially requiring clinical attention. Postpartum mental health issues have been predominately fixated on depressive disorders, even though a multitude of studies indicate that anxiety is highly prevalent and perhaps even more prevalent than depression (Matthey, Barnett, Howie, & Kavanagh, 2003).Postpartum anxiety symptoms and disorders are easily overlooked when screening for postpartum mood disorders; prevalent anxiety disorders remain unnoticed and untreated. Furthermore, approximately half of mothers diagnosed with postpartum mood disorders do not receive treatment (Cox, Sowa, Meltzer-Brody, & Gaynes, 2016).

Women are more likely to develop mood disorders such as anxiety in the first year postpartum than at any other period of their lives.

Maternal postpartum anxiety

Postpartum mood disorders have deleterious effects on the experience of motherhood and maternal behavior. Specifically, postpartum anxiety symptoms erode maternal confidence and diminish self-regard and perceptions of competence (Reck, Noe, Gerstenlauer, & Stehle, 2012). Anxious mothers experiencing such distress exhibit less maternal receptivity to infant signals, and express fewer positive emotions through posture, facial expression, and tone of voice (Stein et al., 2012). Postpartum mood disorders impact structural changes in regions of the brain that are critical for parental behavioral functioning (Kim et al., 2010). A lack of synchronous interactions between mother and infant register less activation in subcortical brain regions involved in parenting behavior, the expression of empathy, and the regulation of emotion (Swain, Lorberbaum, Kose, & Strathearn, 2007). Mothers not only exhibit distress through maternal behavior, but also through cognitive appraisal and internalization of emotion. Anxious mothers’ brains show the most activity in regions associated with emotion and fear, rather than regions associated with reward and pleasure as exhibited in synchronous mothers (Kim et al., 2015). Marriage and family therapists (MFTs) must attend to a mother’s mood regulation, compassion for self, and attachment behaviors.

How are partners/spouses and children affected?

While the majority of postpartum anxiety research focuses on mothers and children, it is clear that partners and spouses are also significantly affected by the contagion of anxiety during the postnatal period. One in 10 partners of anxious postpartum mothers is also likely to suffer from anxiety (Matthey et al., 2003). The most common mental disorder in partners’ postpartum is an adjustment disorder with anxiety symptoms (Wynter, Rowe, & Fisher, 2013). Partners describe excessive stress, emotional exhaustion, irritability, as well as role strain and a pervasive sense of inadequacy (Hill, Gomez, & Clegg, 2020) during the first postnatal year. MFTs need to be aware that partners often feel alienated from mother-infant bonding, experience excessive adjustment stress, and are at risk for both anxiety and depression (Kim et al., 2015). Systemic therapists are uniquely positioned to support partners taking an active role in the baby’s care, reinforcing the partner’s sense of competence, and normalizing the partner’s adjustment struggles. Similar to mothers, partners also benefit from social support and should be encouraged to access support outside the family unit, either from extended family members, friends, or support groups.

Children may experience a multitude of detrimental short-term and long-term effects as a result of maternal disengagement and insensitive parenting, which are behaviors common among anxious mothers. The undeniable link between postpartum mood disorders and parenting behavior has been established (Reck, 2018). Studies suggest that postpartum anxiety impacts children’s internalizing and externalizing behavior problems. Some studies suggest that maternal anxiety impacts a child’s long-term internalizing difficulties twice as likely as children of mothers with postnatal depression (Behrendt, Wade, Bayet, Nelson, & Enlow, 2019). The impact of postpartum anxiety is witnessed in children’s behaviors across the lifespan or development from infancy to preschool (Behrendt et al., 2019) and beyond into teenage years (Karevold, Røysamb, Ystrom, & Mathiesen, 2009). Prevention and early intervention is critical. Thus, MFTs should facilitate and support attachment bonding between parent(s) and their infant children during therapy sessions.   

How does postpartum anxiety affect couple relationships?

Partners act as a buffer against postpartum anxiety, while also being vulnerable to it. Given the critical role that partners play in the development of postpartum anxiety, their role in treatment is equally important. MFTs should be aware that relationship quality and adjustment is strongly associated with both paternal and maternal postpartum anxiety symptoms (Odinka et al., 2020). Anxiety functions bi-directionally for couples in the postpartum period. A perceived lack of support is one of the main stressors that impacts couple satisfaction during the postpartum period, while also negatively affecting couple functioning and intimacy (Bener, Gerber, & Sheikh, 2012). MFTs can de-pathologize relational difficulties during the postpartum period, and facilitate supportive dyadic coping skills, such as encouragement, practical assistance, and emotional support. MFTs should also assess for sexual struggles, which often plague couples during the postnatal period (Faisal-Cury, Menezes, d’Oliveira, Schraiber, & Lopes, 2013). MFTs should assess both physical and emotional aspects of the postpartum recovery process, while normalizing sexual difficulties and validating reactions to the postpartum adjustment period. MFTs can collaborate with couples to help them facilitate expressions of intimacy in ways that feel comfortable to both partners. Interventions addressing couple functioning and facilitating co-regulation, mutual support, and mutual empathy will strengthen the couple relationship and reduce anxiety during the postnatal period.

Given the critical role that partners play in the development of postpartum anxiety, their role in treatment is equally important.

Clinical implications

Since postpartum mood disorders affect the entire interlocking network of family relationships, a collaborative approach to treatment that facilitates a mother’s healing is the most effective way to proceed (Letourneau et al., 2012). MFTs are well positioned to treat families during the transition to early parenthood. It is imperative that MFTs regularly screen for both depression and anxiety in mothers and their partners during the postpartum period. Including anxiety-specific scales, such as the Postpartum Specific Anxiety Scale (PSAS; Fallon, Halford, Bennett, & Harrold, 2016), can be complimentary to the more typically used Edinburgh Postnatal Depression Scale (EPDS; Cox, Chapman, Murray, & Jones, 1996). While respecting a mother’s needs and sense of agency in therapy, MFTs should encourage the inclusion of partners and children in therapy and observe dyadic behavioral interactions (e.g., between mother-child, mother-partner, and partner-child) that may inform assessment and intervention. MFTs should assess parenting expectations, hopes, and fears, gender roles, and contextual factors with cultural humility. MFTs should normalize and de-stigmatize the challenges that many new parents experience during the postpartum period. While parents may feel increasingly self-critical as a defense against feelings of anger, grief, and despair, MFTs should offer a “holding space” for such feelings. Furthermore, MFTs can help offer restorative attachment experiences through the therapeutic alliance with parents. Parents also often feel isolated in their postpartum struggles, therefore therapists should encourage connections to extended family, friend networks, and social support organizations. MFTs can facilitate healthy attachment practices between all family members to decrease anxiety symptoms, increase their co-regulation skills, and increase sense of self-efficacy. Channeling the parents’ ultimate hopes and desires for family connection can activate their sense of agency. Families possesses the inner resources to reach their fullest potential during the fragile, critical postpartum period, and systemic therapists are well-positioned to facilitate the process of welcoming a baby into the family system.