Dannielle Bahri had done everything she could to prepare for having her first child. She registered for CPR classes. She signed up for a breastfeeding course. She took careful note of the advice and warnings her healthcare providers gave her.
But, despite her diligence, she felt anything but calm when she finally brought her daughter home. She had recently learned about sudden infant death syndrome, and the condition consumed her thoughts. She found herself staying up all night to watch her daughter breathe and taking her temperature obsessively, worried she would overheat and die suddenly. Even nine months later, she would stand over her crib at least three times a night to check she was breathing.
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It isn鈥檛 uncommon for parents to feel anxious for the first few months. After all, bringing a newborn home presents a huge change in their lives. But Bahri felt her fear was out of control. As she watched her husband get over their shared worries, she wondered why hers weren鈥檛 going away.
Like most parents, Bahri, who lives in Canada, had been warned about postnatal (or postpartum) depression, but no one had told her about postnatal anxiety. Masked by the focus on depression and the assumption that these are normal worries every parent faces, this hidden condition has a huge impact on parents and their children. But as more and more people speak out about their experiences of crushing anxiety after becoming parents, and it rises up the medical agenda, researchers are beginning to figure out the causes and explore the best treatments.
By some estimates, postnatal anxiety affects . Some researchers think that its , while others attribute this to increased reporting of the condition, perhaps partly because more celebrities are going public with their experiences. said she broke a tooth when she started grinding her teeth in her sleep due to anxiety after having her first child, while actor described not being able to go into a grocery store because of an overwhelming sense of panic.
Postnatal depression
It isn鈥檛 just mothers who are affected. Much as with postnatal depression, fathers are at risk: . Partners and can also have the condition.
Most people are aware of the symptoms of postnatal depression: sadness that continues unabated, crying, a lack of joy. 鈥淭he symptoms of postpartum depression are a departure from what people expect when someone has a baby, which is for it to be a happy time,鈥� says , the Canada research chair in perinatal mental health.
Postnatal anxiety, by contrast, may not be immediately visible in new parents because it is normal to have a few worries after having a baby. But for some people, that worry can become all-consuming, persisting beyond the first few months. Some, like Bahri, stay awake all night. Some become intensely fearful about leaving their baby with another person, even their partner or parents. Others start avoiding certain activities or rarely leave the house for fear of something happening to their baby or themselves.
For Kelley Hassanpour, a diagnosis didn鈥檛 come until she registered her son for day care when he was 13 months old. She stopped sleeping and started having trouble breathing because she worried her son wouldn鈥檛 receive the same care she had been providing. 鈥淚 just didn鈥檛 recognise it, and I think as a first-time mom, it was really hard to tell the difference between what鈥檚 normal worry and what was not normal worry,鈥� she says.
The effects of postnatal anxiety reach far beyond parental well-being. 鈥淚t鈥檚 tragic when it gets missed because people can suffer a great deal and it can interfere with the mother-infant bond,鈥� says Van Lieshout. This impaired emotional connection can , especially in the first year of life. In extreme cases, it can result in . Postnatal anxiety can also affect , further adding to her distress.
Pregnancy hormones
All this goes to show that postnatal anxiety is an insidious condition, the causes of which will probably take some serious untangling. Thankfully, as awareness of it grows, we are starting to do just that. Most research to date has focused on women with postnatal depression, but given there is an overlap with anxiety 鈥� about 75 per cent of women who experience postnatal depression also experience anxiety 鈥� many believe the results can apply to both.
Some of the first studies of the causes of postnatal depression looked at pregnancy hormones. During pregnancy, the hormones oestrogen and progesterone rise to prepare the body for growing and delivering a baby. Within 48 hours of birth, however, they quickly decline. The assumption was that these changing levels were somehow responsible for postnatal depression.
To investigate, , now at Tel Aviv University in Israel, and his colleagues artificially replicated these changing levels of progesterone and oestrogen in 16 women, half with a history of postnatal depression. For eight weeks, the volunteers were given the same increasing doses of the two hormones, before they were withdrawn without either the researcher or volunteer knowing. Of the eight women with a history of postnatal depression, . None of the other eight did.
鈥淭he best way to think about it is that every person who gives birth goes through this huge drop in oestrogen and progesterone after giving birth, but not every person develops postpartum depression or anxiety,鈥� says at Weill Cornell Medical College in New York. 鈥淪o, it has to be something about people鈥檚 vulnerability to the shift rather than about the level itself, because otherwise everybody would develop it.鈥�
Stress hormones
While researchers try to get a grip on what is behind this difference in vulnerability, other potential causes are being investigated. One of these is our stress response. The stress hormone cortisol also increases during pregnancy and has been linked with postnatal depression. However, most studies show no association between the absolute levels of cortisol and the condition, says at the University of California, Irvine.
Instead, as with oestrogen and progesterone, it is thought that the body鈥檚 reaction to the hormone is what affects the response. 鈥淭he hormone in and of itself doesn鈥檛 do anything,鈥� says Yim. 鈥淚t needs to bind on a receptor somewhere in the body, and then that creates some change, or an organ reacts, or some other process starts happening.鈥� Essentially, two people with the same levels of hormones could experience different reactions, depending on the sensitivity of their receptors, she says.
Why these differences exist isn鈥檛 yet known. That is partly because the funding hasn鈥檛 always been available to do the lab studies needed, says at the Tufts University School of Medicine in Massachusetts. She is working with her team to tease out an answer in relation to stress. Their focus is on the role of the hypothalamic-pituitary-adrenal (HPA) axis, a physiological system that regulates how a person perceives stress and how their body reacts to that stress. During pregnancy, the stress-induced activation of the HPA axis is suppressed. 鈥淚t鈥檚 thought that this is a protective mechanism to prevent stress levels of hormones from adversely impacting the fetus,鈥� she says.
Maguire and her colleagues wondered whether this suppression could go awry in postnatal depression. They turned to mice to investigate the neurons in the hypothalamus that govern the activity of the HPA axis, specifically a protein called KCC2 that sits on the outside of neurons and helps move potassium and chloride ions in and out of the cells. They found that pregnant mice engineered to have no KCC2 protein in neurons that govern the activity of the HPA axis and reduced maternal behaviours after giving birth.
鈥淲hat we鈥檝e been able to understand [in the lab] is that the inability to suppress the stress response during pregnancy increases vulnerability to mood disorders,鈥� says Maguire. 鈥淚 think there鈥檚 a combination of biological and environmental factors that can contribute.鈥�
As we learn more about the causes of depression and anxiety in general, researchers are looking at whether these can also apply postnatally. One growing area of research is the link between , as well as the link between , a helper T-cell that regulates inflammation. There is plenty of evidence that this , but it is difficult to draw conclusions for anxiety, largely because much less research has been done.
That trend is starting to change. In 2022, Hao Ying at Tongji University in Shanghai, China, and colleagues assessed 226 women for signs of both conditions six weeks after giving birth while also testing their blood for helper T-cells and the signalling molecules they secrete, called cytokines. They found that levels of Th17 and one cytokine it secretes, called IL-17A, were , and that levels of both were higher in women who had symptoms of postnatal anxiety than in those who didn鈥檛 have symptoms.
We still don鈥檛 know why these cells seem to have this effect, but IL-17A is known to have a pro-inflammatory effect and cytokines can enter the brain. The team suggests that higher levels of Th17 cells and IL-17A could lead to inflammation in the brain, which may contribute to the development of postnatal anxiety.
While research into the biological causes of postnatal anxiety is still in its early days, we know more about why some people are at a higher risk of developing the condition. One factor is having had generalised anxiety disorder before, says Van Lieshout. 鈥淎 significant proportion of people who develop some postpartum anxiety or pregnancy anxiety have had anxiety in their life.鈥� Bahri says she has had periods of anxiety in the past, but she had seen a therapist and wasn鈥檛 feeling anxious when she became pregnant.
Sleep disruption
Situational changes can also make people vulnerable. at the University of Maryland says that medical complications, such as gestational diabetes, can increase someone鈥檚 risk of developing postnatal anxiety. Van Lieshout says a history of pregnancy loss, an unplanned or unwanted pregnancy, a history of intimate partner violence or even major life changes like moving house can affect someone鈥檚 vulnerability to the condition.
These 鈥減sychosocial鈥� factors are thought to explain why and fathers can be affected. 鈥淭here鈥檚 been very little done biologically on fathers,鈥� says Osborne. 鈥淚t鈥檚 all about psychosocial factors and sleep disruption and some of the same psychosocial things that affect moms.鈥� The few studies that have been done look at testosterone levels, with one showing that .
Ultimately, postnatal anxiety is a function of biological, psychological and social factors, says Osborne. 鈥淚 don鈥檛 think we鈥檙e ever going to get to the point where we say 鈥榯his is the one cause鈥�, but I think we will make substantial progress beyond where we are now in pinpointing those biological causes,鈥� she says. 鈥淏ut they鈥檙e always going to interact with psychosocial causes.鈥�
Cognitive behaviour therapy
When it comes to treatments, there is a much better idea of what works for postnatal anxiety. 鈥淲e have very, very strong evidence that talk therapy, in particular cognitive behaviour therapy, is very effective,鈥� says at the University of British Columbia in Canada. She believes that publicly funding such therapy could make a huge difference to new parents. 鈥淭here鈥檚 a strong preference among perinatal people for talk therapy and, at present, that鈥檚 really hard to access,鈥� she says.
Medications such as antidepressants can also be helpful, but Fairbrother says that many women are hesitant to take them. Often, this is due to fears that they will harm the baby, as these drugs are excreted in breast milk, although at . Hassanpour eventually started taking Zoloft (sertraline) for her anxiety, but she also sought out a therapist. 鈥淚 personally think the therapy was a huge part of it. It just helped to normalise [the anxiety] and I was much 鈥� like 100 per cent 鈥� better,鈥� she says.
In addition to medication and therapy, physical activity can be helpful for those able to exercise. A study released last November showed that three or four aerobic exercise sessions a week, each lasting 35 to 45 minutes, could , so it may also be helpful with postnatal anxiety. Cuddling your newborn is also thought to be beneficial, as it releases oxytocin, a hormone that has been shown to . And asking for 鈥� and accepting 鈥� assistance for everyday tasks may also help. Hassanpour says that she 鈥渟truggled deeply to ask for help and felt I needed to do everything myself. That in and of itself affected many things as I was exhausted and overwhelmed.鈥�
Screening guidelines
Slowly, anxiety is making it onto the postnatal agenda. Last June, the American College of Obstetricians and Gynecologists that recommend screening for both depression and anxiety during and after pregnancy. In the UK, the National Institute for Health and Care Excellence recommends that women be during their first appointment while pregnant and soon after giving birth.
Latorre is happy to see that postnatal anxiety is being talked about more frequently. Sadness and anxiety are normal emotions, just like happiness and joy, so it is important that we don鈥檛 pathologise them, she warns. 鈥淏ut we don鈥檛 want to miss them either when they become problematic.鈥�
鈥淣obody mentioned that postpartum anxiety can be a thing. I just think it鈥檚 not as mentionable as postpartum depression because people think it鈥檚 not as bad,鈥� says Bahri. 鈥淏ut it鈥檚 not true. Anxiety can take over your life.鈥�
