Importance of Mental Health Care during Pregnancy
Pregnancy is one of the most critical events in a woman's life. Although it is often portrayed as a time of great joy, it is often not the case. It can be very emotional, and many women tend to be more susceptible to antenatal anxiety.
A growing body of literature indicates that depression and anxiety are the most common mental health problems during pregnancy. This is exacerbated if women are exposed to high levels of trauma, leaving them especially vulnerable to mental illness.
1 in 10 women will be experiencing either anxiety or depression at some point, and many will experience both. 1 in 20 men will experience antenatal depression too. 15-20% of women may also carry on to be depressed or anxious in the first year after childbirth.
During pregnancy and the postnatal period, anxiety can refer to worries about changes in appearance, labour, birth, the developing child's health and future parenting. But can include anxiety disorders such as panic disorder, generalised anxiety disorder (GAD), obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD) and tokophobia (extreme fear of childbirth), which can occur on their own or can coexist with depression.
High anxiety and stress levels during pregnancy, if not adequately managed and controlled, may have long-term and sometimes irreparable adverse effects on the mother and baby.
Impact of Anxiety and Stress on the Mother
Anxiety and stress might alternate the duration of pregnancy, cause an impaired attachment to the baby, increase the risk of developing preeclampsia, gestational diabetes, and an emergency caesarean section and could also escalate the probability of suicide and postnatal anxiety or depression.
Impact of Anxiety and Stress on The Baby
The human foetus is actively participating in its own development and constantly collects information for life after birth. This includes chemical signals through the placenta about the mother's mental state. If the mother is stressed, anxious or depressed, that affects how the baby develops after it's born.
High levels of maternal anxiety, in particular, have been associated with specific changes in brain morphology and structure, which have a significant relation with mental disorders, emotional problems, lack of concentration, irritability and restlessness, hyperactivity, higher vulnerability to asthma and allergies, a poor mix of intestinal microbiota, persistent sleep problems and impaired cognitive development later in life.
It may also cause changes in the blood flow, making it difficult to carry oxygen and other essential nutrients to the baby’s developing organs. This may lead to coronary disease in adulthood and a reduction in heart rate variability in children.
New research has even found that maternal psychological well-being during pregnancy can impact a newborn’s telomere length. Shorter telomeres have been associated with multiple chronic diseases, including cancer, type 2 diabetes, and cardiovascular disease later in life.
Depression among both parents during pregnancy was found not only to affect them as individuals but has an impact on pregnancy outcomes such as preterm birth and low birth weight, as well as a long-term effect on the well-being of their newborn child. Even in cases of mild long-term depressive symptoms.
High maternal levels of stress and anxiety can also be sex-specific. Male foetuses tend not to survive under stressful times. In contrast, female foetuses are more adaptable but could be predisposed to developing mood disorders and depressive-like behaviours by age 2. This could be an early point at which the risk for common psychiatric disorders begins to differ in males and females.
What are the current tools for diagnosis?
Regardless of its high incidence and serious complications, pregnancy-specific screening tools for anxiety and depression are practically non-existent in obstetric medicine. Therefore, early identification, diagnosis, and treatment are often compromised.
Fortunately, a recent landmark study by experts at the University of Stirling has now identified several symptoms that are reliable indicators of antenatal anxiety, which will help health professionals improve the identification of severe and problematic anxiety in pregnant women.
Some general factors pregnant women should look for that may increase their risk for an anxiety disorder include:
A previous diagnosis or a family history of anxiety
A previous miscarriage or foetal loss
Pregnancy complications
Financial or marital issues
Fertility struggles
Eating Disorders
Stress at home or work.
Trauma
Side Note: Talk to your GP if you are currently experiencing intense psychological stress while pregnant or have experienced any of these factors. The earlier, the better.
How to cope?
I have written a post on how trauma is passed on and how to mend unresolved emotional issues before trying for a baby.
But if you are currently experiencing psychological stresses while you are pregnant, modification in lifestyle and psychological therapies can help:
Taking a deep breath — Diaphragmatic or deep breathing involves the diaphragm's contraction, the belly's expansion, and the deepening of inhalation and exhalation, which decreases respiration frequency and maximizes the number of blood gases. This type of breathing is an effective intervention for emotional enhancement and causes a reduction in anxiety, depression, and stress. It also reduces breathlessness and hyperventilation in pregnancy and increases lung capacity, which can positively affect the health of the mother and baby.
There are a lot of breathing exercises out there, but my favourite is the Cardiac Coherence - 365 technique that you can start doing straight away: 3 times a day, six breaths per minute for 5 minutes.
Talk Therapy— Connecting to others face to face can be the best way to handle emotional issues and minimize the need to withdraw and isolate oneself. Friends and family members can help with this. Still, for a more structured therapy, it can be beneficial to join a support group or seek an experienced prenatal Counsellor or Psychotherapist.
Research has found that talk therapy may be a preventive intervention strategy for daily life stresses and perinatal mental health care in all mothers-to-be and should be delivered early in pregnancy.
There are three primary forms of talking therapies that have been used in the treatment of mild anxiety and depression in pregnancy: cognitive-behavioural therapy interventions, interpersonal therapy, and mindfulness interventions. Out of the three, cognitive-behavioural interventions have the strongest evidence-based for preventing and treating mild perinatal anxiety and depression.
Getting the right amount of sleep - Sleep and mental health are closely connected. Sleep deprivation affects the psychological state, and those with mental health problems such as anxiety or depression are more likely to have insomnia or other sleeping problems. Lack of sleep could trigger and worsen the symptoms of anxiety disorders and prevent recovery.
Research has found that, in general, 4% of pregnant women have insomnia in the first trimester of pregnancy, which increases to 46% in the second trimester and 64% in the third trimester. This figure is ten times higher if women had insomnia before pregnancy.
And due to the dynamic relationship between sleep and immunity, pregnant women with anxiety are more likely to suffer from disturbed sleep and experience immune system disruption, leading to adverse pregnancy outcomes, including growth restriction and preterm growth.
On the other hand, long periods of undisturbed sleep in pregnancy (more than 9 hours), especially when sleeping on the back, are associated with late stillbirth (after 28 weeks gestation).
Sleep is a modifiable behaviour. Therefore, it is essential to implement it as a priority and practice good sleep hygiene!
Create a calming evening ritual without distractions 1 hour before bedtime
Block out blue light from screens which can cause preterm labour
Get 8 to 9 hours of sleep every night
Take a short midday nap to boost energy levels, improve mood and lower blood pressure.
Sleep on your side and not on your back, especially in the third trimester
Wake up at the same time every day, including at weekends.
Calming the mind – Making time for Complementary and Alternative therapies (CAM) such as regular meditation, yoga, acupuncture, music therapy, or a massage have been shown to help alleviate anxious feelings and are practised and encouraged in several clinical settings during pregnancy.
Light – Sunlight or Light therapy (in which individuals are exposed to artificial daylight, administered for a prescribed amount of time and, in some cases, at a specific time of day) helps relieve depressive symptoms.
In addition, researchers are increasingly linking vitamin D deficiency (usually obtained from natural sunlight) to mood disorders. The importance of vitamin D sufficiency should not be underestimated in expectant mothers. Studies have highlighted how vitamin D might improve perinatal mood and musculoskeletal systems and can even affect pregnancy outcomes and the social development of children in their early years.
If your due date is in the darker months of the year, you may have a greater risk of developing postpartum depression once the baby is born.
Get frequent exposure to daylight (or devices such as light boxes that provide light therapy) throughout your pregnancy.
If weather and safety permit, daily walks can be the most effective in improving mood and increasing vitamin D exposure.
Moving the body – Exercise for depression in the general population is an active area of research, with a growing number of clinical studies reporting a positive benefit of exercise promoting calmness and raising levels of anti-stress neurotransmitters like dopamine, serotonin and noradrenergic activity in the Central Nervous System.
Mothers-to-be that are suffering from symptoms of depression are more likely to sit down for long periods. Movement improves the mood of previously inactive pregnant women and helps reduce their fatigue levels.
Exercise also has positive effects on gestational diabetes. Given that gestational diabetes doubles the risk of perinatal depression, brisk walking, low-impact aerobics, yoga, stretching, and even weight training could be particularly important given its potential to address both illnesses simultaneously. Regular practice of exercise during pregnancy can also protect women against pregnancy-related insomnia.
Anti-Anxiety Diet – A balanced whole-food Mediterranean diet rich in whole grains, pulses, seeds, beans, vegetables, fruits, protein, and healthy fats has been shown to benefit mental and physical health.
Here are some nutrients that I recommend during periods of perinatal stress or anxiety in food and supplementation :
Folate (Folic acid) and Choline- can lower a baby’s vulnerability to stress-related illnesses and the influence of prenatal maternal infections such as colds and influenza on its brain development.
Magnesium- may help a mum feel calmer and optimize her vitamin D status. In addition, Magnesium Sulfate during labour has been shown to reduce maternal fever. This condition can lead to newborn complications, including difficulty breathing, seizures, cerebral palsy and a disease known as “floppy baby syndrome”.
Fermented foods & Probiotics —contain beneficial bacteria that may positively impact mood and brain health.
Fatty Fish & Omega3’s - Fishes such as salmon, sardines, trout, herring or anchovies are high in omega. Omega-3 is a fatty acid with a strong relationship with cognitive function and mental health. Current recommendations suggest eating at least two servings of fatty fish a week. Studies have also found that omega-3 supplementation reduces anxiety levels and incidences of diagnosable postpartum depression.
Turmeric- is a renowned spice whose active ingredient is called curcumin. Curcumin may help lower anxiety by reducing inflammation and oxidative stress that often increase in people experiencing mood disorders.
Dark Chocolate- is a rich source of magnesium and polyphenols, especially flavonoids and has a high tryptophan content, which the body uses to turn into mood-enhancing neurotransmitters, such as serotonin, in the brain. Research has found that eating around 30 grams of Chocolate daily during pregnancy may benefit foetal growth and development and have babies who show less fear, smile and laugh more often at six months of age. When choosing dark Chocolate, one should aim for 70% or more.
Nuts - such as brazil nuts, are high in selenium and can help improve mood by reducing inflammation. Others, like almonds, are an excellent source of vitamin E. Vitamin E deficiency has been linked to mood disorders.
Final thoughts
While many women are understandably cautious about taking medications during pregnancy, antenatal anxiety is not benign. In more severe cases, your primary caregiver might prescribe medication. Although, the potential effects of a drug on birth defects and long-term child development should be considered and assessed.
Refer to this post for more on the impact of antidepressants during pregnancy.
+References
Brandlistuen, R.E., Ystrom, E., Eberhard-Gran, M., Nulman, I., Koren, G., and Nordeng, H. (2015). Behavioural effects of fetal antidepressant exposure in a Norwegian cohort of discordant siblings. International Journal of Epidemiology 44, 1397–1407.
Cronin, R.S., Li, M., Thompson, J.M.D., Gordon, A., Raynes-Greenow, C.H., Heazell, A.E.P., Stacey, T., Culling, V.M., Bowring, V., Anderson, N.H., et al. (2019). An Individual Participant Data Meta-analysis of Maternal Going-to-Sleep Position, Interactions with Fetal Vulnerability, and the Risk of Late Stillbirth. EClinicalMedicine 10, 49–57.
Darling, A.L., Rayman, M.P., Steer, C.D., Golding, J., Lanham-New, S.A., and Bath, S.C. (2017). Association between maternal Vitamin D status in pregnancy and neurodevelopmental outcomes in childhood: Results from the Avon Longitudinal Study of Parents and Children (ALSPAC). British Journal of Nutrition 117, 1682–1692.
Gaston, A., and Prapavessis, H. (2013). Tired, moody and pregnant? Exercise may be the answer. Psychology and Health 28, 1353–1369.
Glover, V. (2014). Maternal depression, anxiety and stress during pregnancy and child outcome; What needs to be done. Best Practice and Research: Clinical Obstetrics and Gynaecology28, 25–35.
Goyal, D., Gay, C., Torres, R., and Lee, K. (2018). Shortening day length: a potential risk factor for perinatal depression. Journal of Behavioral Medicine 41, 690–702.
Graham, A.M., Rasmussen, J.M., Entringer, S., Ben Ward, E., Rudolph, M.D., Gilmore, J.H., Styner, M., Wadhwa, P.D., Fair, D.A., and Buss, C. (2019). Maternal Cortisol Concentrations During Pregnancy and Sex-Specific Associations With Neonatal Amygdala Connectivity and Emerging Internalizing Behaviors. Biological Psychiatry 85, 172–181.
Heazell, A.E.P., Li, M., Budd, J., Thompson, J.M.D., Stacey, T., Cronin, R.S., Martin, B., Roberts, D., Mitchell, E.A., and McCowan, L.M.E. (2018). Association between maternal sleep practices and late stillbirth – findings from a stillbirth case-control study. BJOG: An International Journal of Obstetrics and Gynaecology 125, 254–262.
Hinkle, S.N., Buck Louis, G.M., Rawal, S., Zhu, Y., Albert, P.S., and Zhang, C. (2016). A longitudinal study of depression and gestational diabetes in pregnancy and the postpartum period. Diabetologia 59, 2594–2602.
Lassale, C., Batty, G.D., Baghdadli, A., Jacka, F., Sánchez-Villegas, A., Kivimäki, M., and Akbaraly, T. (2019). Healthy dietary indices and risk of depressive outcomes: a systematic review and meta-analysis of observational studies. Molecular Psychiatry 24, 965–986.
Liu, C., Cnattingius, S., Bergström, M., Östberg, V., and Hjern, A. (2016). Prenatal parental depression and preterm birth: a national cohort study. BJOG: An International Journal of Obstetrics and Gynaecology 123, 1973–1982.
Liu, X., Agerbo, E., Ingstrup, K.G., Musliner, K., Meltzer-Brody, S., Bergink, V., and Munk-Olsen, T. (2017). Antidepressant use during pregnancy and psychiatric disorders in offspring: Danish nationwide register-based cohort study. BMJ (Online) 358.
Ma, X., Yue, Z.Q., Gong, Z.Q., Zhang, H., Duan, N.Y., Shi, Y.T., Wei, G.X., and Li, Y.F. (2017). The effect of diaphragmatic breathing on attention, negative affect and stress in healthy adults. Frontiers in Psychology 8.
Monk, C., Feng, T., Lee, S., Krupska, I., Champagne, F. A., & Tycko, B. (2016). Distress during pregnancy: Epigenetic regulation of placenta glucocorticoid-related genes and fetal neurobehavior.American Journal of Psychiatry, 173(7), 705–713.
Okun, M.L., Luther, J.F., Wisniewski, S.R., and Wisner, K.L. (2013). Disturbed sleep and inflammatory cytokines in depressed and nondepressed pregnant women: An exploratory analysis of pregnancy outcomes. Psychosomatic Medicine75, 670–681.
Pietikäinen, J.T., Kiviruusu, O., Kylliäinen, A., Pölkki, P., Saarenpää-Heikkilä, O., Paunio, T., and Paavonen, E.J. (2020). Maternal and paternal depressive symptoms and children’s emotional problems at the age of 2 and 5 years: a longitudinal study. Journal of Child Psychology and Psychiatry and Allied Disciplines 61, 195–204.
Román-Gálvez, R.M., Amezcua-Prieto, C., Salcedo-Bellido, I., Martínez-Galiano, J.M., Khan, K.S., and Bueno-Cavanillas, A. (2018). Factors associated with insomnia in pregnancy: A prospective Cohort Study. European Journal of Obstetrics and Gynecology and Reproductive Biology 221, 70–75.
Sinesi, A., Maxwell, M., O’Carroll, R., and Cheyne, H. (2019). Anxiety scales used in pregnancy: systematic review. BJPsych Open 5.
Stone, P.R., Burgess, W., McIntyre, J., Gunn, A.J., Lear, C.A., Bennet, L., Mitchell, E.A., and Thompson, J.M.D. (2017). An investigation of fetal behavioural states during maternal sleep in healthy late gestation pregnancy: an observational study. Journal of Physiology 595, 7441–7450.
Verner G, Epel E, Lahti-Pulkkinen M, Kajantie E, Buss C, Lin J, Blackburn E, Räikkönen K, Wadhwa PD, Entringer S. Maternal Psychological Resilience During Pregnancy and Newborn Telomere Length: A Prospective Study. Am J Psychiatry. 2021 Feb 1;178(2):183-192.
Winterfeld, U., Merlob, P., Baud, D., Rousson, V., Panchaud, A., Rothuizen, L.E., Bernard, N., Vial, T., Yates, L.M., Pistelli, A., et al. (2016). Pregnancy outcome following maternal exposure to pregabalin may call for concern. Neurology 86, 2251–2257.
DR NAUF ALBENDAR
My name is Dr Nauf AlBendar and I am the founder of The Womb Effect. As a medical scientist with a BSc in Molecular Genetics and Genomics, an MSc in Nutrition & Food Science and a PHD in clinical medicine, I have developed a deep appreciation and understanding for the developmental origins of health and disease.