Becoming a parent is a very important transition in life. Even if you really wanted to welcome a baby in your life, you’re quickly faced with many unknowns. You’ll face questions, concerns that sometimes come without answers. We lose control of many things, each day we learn to function with different symptoms throughout gestation, then with our children. It requires continual adaptation, shuffling our daily life during each stage.

Based on current literature, a high degree of anxiety is experienced during the perinatal period, twice as much as usual. This is even higher for women. 1 person in 4 will have symptoms associated with anxiety during this period. The signs are more frequent and intense for people who are already experiencing anxiety.

Becoming parents, not always easy!

You might say to me that it’s normal to experience anxiety in the period surrounding the arrival of a baby, in the face of this great unknown. Well, yes! Of course. How can you distinguish if the anxiety that you’re experiencing is normal or excessive? This is another thing you should consider.

In this article, we will look at the definition of anxiety, anxiety in men and women, the different forms of anxiety, potential consequences and the support services that are available to help you.

Definition of Anxiety

Anxiety has no clear definition in a perinatal context.

The term “anxiety” is often used to group a series of phenomena like fear, stress, worries, concerns, panic, and anguish.

When a parent talks about their anxiety and what they’re feeling, they often talk about these aspects generally to describe the discomfort they’re experiencing. Many mothers and fathers report feeling stress or anxiety at different levels starting in the first trimester of pregnancy or following childbirth. Many anxiety triggers are set off in this period of life. It can be a situation, for example, a parent that is worried about their child’s potentially declining health, or a parent that is worried because they will have lower available income after the child’s arrival. It can also be a feared situation, such as the fear of illness in yourself or your child, the fear of future financial problems, the fear of problems in the couple, etc. It can also be uncertainty itself, the fact of not knowing or being able to control everything.

Other people talk in terms of worries or concerns: “I’m really concerned about my health,” “I’m scared of the delivery,” “I’m scared of dying.”

Others will feel a general dread that something negative and unknown will happen, like for example that the baby won’t get enough oxygen.

Finally, others describe their anxiety in terms of physical and somatic problems like tension, apprehension, a feeling of always being on alert and having anxiety attacks.

Generally, anxiety is a “state” characterised by the dreading of a negative situation/consequence involving a real or anticipated danger.

This state of anxiety can be observed based on four main levels:

• Emotional, meaning feeling anxious, internally agitated, irritable, with anger as a secondary emotion
• Physiological, like muscle tension, heart palpitations, shortness of breath, chest pains
• Cognitive, which refers more to thoughts, such as worries, obsessions, the fear of dying or losing control
• Behavioural, where we avoid places or situations because of the fear of feeling bad, overprotecting the child, controlling their environment

Pregnancy follow-up means repeated contact with a health care provider and they can help identify signs of mental distress (SOGC, October 2024).

Worries and Levels of Anxiety

Worrying, which frequently occurs during the perinatal period, can be defined as a train of thoughts difficult to control accompanied by negative emotions. We talk about a train of thought because one worry rarely occurs on its own. It usually leads to other worries that vary a lot depending on situations. For example, worrying that you aren’t eating the right things for the baby during pregnancy.

As the perinatal period involved many changes, new roles, different things to learn and new challenges to face, a necessary period of adaptation occurs for most parents during which many stressful things can happen. In this sense, it’s true that during the perinatal period mothers and fathers will develop excessive anxiety or anxiety disorders for the first time. When anxiety was already an issue in the past, this is more frequent, with the anxiety symptoms increasing during the perinatal period.

It’s useful for a future or a new parent if they can distinguish between their worries, stress and the physiological symptoms of anxiety. They can better identify what they’re experiencing, better understand their reactions and as such work on the situation. For example, we can offer strategies to face worries, others for managing the anxiety emotion, others to work on behavioural reactions such as avoidance and reassurance, which trouble the way the person functions. Other techniques can also be used to work on vulnerability factors the person may have.

The Levels of Anxiety

How do I know if my anxiety is excessive?

Great question! No set criteria for the quantity of anxiety exist, what is seen as reasonable or excessive, or types of anxiety that are better or worse than others. It’s all about how the person experiences the anxiety in its intensity. It’s a very subjective notion which belongs to the individual. Each person is unique, each life lesson learned over time and their age impacts the way they react and deal with new situations, difficulties, the unexpected and problems that need to be solved.

A woman can be uncomfortable with the fact that she doesn’t know how the delivery will be. A father can be uncomfortable not understanding why their baby is crying.

A first criterion to distinguish what is “more excessive” anxiety is the disruptions that the anxiety causes on the person’s way of functioning.

A dad can worry about their skills and be scared of doing something bad to their baby. However, if their anxiety means that they let their partner take on most baby responsibilities because they’re afraid of erring, it disrupts the way the father normally functions with their offspring.

In the same way, we can expect a mother will be worried the first time she leaves her baby to go out with friends or their spouse. She will call the babysitter to check how things are going to be reassured. However, if her going out causes physical discomfort due to her anxiety, and she has to go home to calm down and care for her baby, this is much more than merely being worried.

According to some research, 60% of parents indicate that they’re worried more after the arrival of their child, and about 25% say their worries negatively impact how they function. One parent in four has a higher level of anxiety during this period, which is rather high.

The notion of disruption or interference in quality of life is essential to consider. Close ones, friends, parents, the spouse can help reflect on the space that anxiety takes at a personal level, but also on the relationship dynamics, the couple and family.

A second criterion is distress the parent can feel due to their anxiety. Signs of distress can be sadness, depression, dark thoughts, a feeling of vulnerability, isolation or the impression that they lack support.

If one or both of these elements is present, either the disruption of the way they function or distress, the parent possibly has more excessive anxiety, what they could categorise as “less normal.” However, the anxious person shouldn’t always be asking themselves if their anxiety is normal, if it’s justified. It’s more the distress they feel that will help the anxious person become aware of their problem and then get help.

Indicators of Perinatal Anxiety: GAD, Panic Attacks, OCD

When a parent recognises that their anxiety alters their daily way of functioning, we can identify one or several possible anxiety disorders, each with their characteristics. Here I would like to talk about Generalised Anxiety Disorders (GAD) such as panic attacks, obsessions and compulsions, phobias, and post-traumatic stress disorder stemming from childbirth.

Anxiety disorders have a common characteristic — “the presence of excessive fear or concern relating to a more or less specific situation or thing.” It can be something in the present or the future. What distinguishes anxiety disorders are the “reason” for the fear, what the person dreads, and all the indicators or symptoms of anxiety that accompanies it. I want to present the different anxiety disorders with their best-known characteristics.

Generalised Anxiety Disorder (GAD)

Main Indicators:

• Excessive anxiety and worry about several areas of life or activities;
• The worries occur most of the time over several months and are uncontrollable;
• Worries are accompanied by somatic symptoms such as difficulties concentrating, memory loss, fatigue, sleep difficulties, and agitation.

In other words, if a mother or father has the impression that they worry more than 50% of the time about several things, they might have Generalised Anxiety Disorder (GAD). It can be worrying about minor daily life things, or more important issues such as finances, the health of children, their physical or psychological condition, or the future. A small thing can lead them to worry. Each parent has things they worry more about.

Work by different researchers has shown that GAD is the most extensive anxiety disorder during the perinatal period. It affects almost 9% of mothers, and rates are a bit lower for fathers, but based on some studies can be similar. So nearly 1 in 10 people may face this problem. Since the main GAD symptom is worrying and it’s less apparent to those around the person, it’s the anxiety disorder that is most difficult to identify. Researchers have evaluated mothers multiple times during pregnancy and after giving birth, and they have shown that GAD tends to be stable or chronic and that few mothers have their symptoms disappear on their own naturally. Recent research on fathers shows that the perinatal period, which can last from 2 to 12 months, is the period when they’re most at risk for developing excessive worries. Finally, GAD during the perinatal period is one of the disorders that increase the risk of postpartum depression occurring.

Panic Disorders With/Without Agoraphobia

Main Indicators:

• The presence of recurring panic attacks, with some occurring unexpectedly
• Excessive fear of having another panic attack

Panic attacks are the very intense and fast rise in anxiety, with symptoms such as increased heart palpitations, difficulties breathing, transpiration, hot flashes and shaking. These symptoms are often accompanied by the fear of becoming crazy, fainting, dying or having a heart attack. Panic attacks can be associated with severe avoidance behaviours, such as avoiding locations where the person fears feeling uncomfortable and having a panic attack. This is called panic disorder with agoraphobia, the fear of being outside the home or in a public place.

Example: A mother bathing her baby and suddenly has a panic attack can eventually avoid giving baths. Many new parents note having panic attacks in cars, stores or places at home.

Characteristics: Panic disorders significantly impact new parents’ quality of life, because avoidance of situations tends to increase. The symptoms are discomforting, so the parents try to avoid them. The intense, sudden and unexpected aspects of panic attacks mean that they’re often associated with significant questions about one’s mental health. Normally, the parent doesn’t understand what is happening and wonders if they’re slowly becoming crazy. Because the symptoms they feel are very physical, the father and mother might wonder if cardiac or other physical illnesses might be present. They can even question their ability to care for the child, which leads to more distress because they don’t want to remain alone. Over time, panic attacks tend to diminish during pregnancy and increase around the sixth month postpartum.

Obsessions and Compulsions (Obsessive-Compulsive Disorder [OCD])

Main indicators: Obsessions are mainly characterised by recurring disturbing thoughts, often in the form of images. The main obsessions in the perinatal period involve:

• Thoughts of infection;
• Thoughts of accidentally hurting the baby;
• Visions of accidents;
• Unacceptable sexual thoughts.

These thoughts occur mostly in the form of mental images.

The second characteristic is the presence of automatic compulsions. These can include repeated behaviours in response to obsessions or rigid personal rules. These compulsions try to reduce distress and discomfort caused by obsessions or prevent danger from occurring. This can frequently be checking to see if the door is locked to ensure that a stranger doesn’t intrude, protecting the baby. They can also be mental compulsions, like continually repeating a phrase or number.

The mother or father can’t stop the compulsions given their discomfort and distress. This can lead to avoidance, being extremely controlling and excessive verification, among other things. Even if this disorder is more widespread than we think, a parent scared of being judged means they won’t talk about it and hide their obsessive-compulsive disorder behaviours as much as possible (2% in the perinatal period).

It’s important to note no loss of contact with reality occurs, like hearing voices, seeing imaginary things (psychotic thoughts or psychosis). Obsessive-compulsive disorder is always associated with distress.

Signs of Anxiety: Phobias and Post-Traumatic Stress

Phobias Related to the Perinatal Period

Many specific intense fears can arise during the perinatal period. Two phobias occur frequently and can significantly interfere with how you function.

The first is the fear of giving birth, also called tokophobia. In short, the fear of giving birth can involve many fears, such as pain, complications and death, either for you or the baby. It can also include the fear of losing control during delivery or that childbirth will be traumatic. To a certain degree, the fear of giving birth is felt by the majority of women. Once again, to be considered an anxiety disorder, it has to interfere with the way the mother functions. The pregnant woman recognises that her fear is excessive. Finally, her fear is actually associated with avoidance. I already dealt with this subject in an educational entry, and you can read, “Do you know about the fear of giving birth? It’s called tokophobia.”(in french).

The second phobia experienced during the perinatal period is the fear of vomiting. 

In fact, the fear of vomiting is a rather common phobia in children and adults. During pregnancy, nausea can reactivate this fear in some mothers, who then become fearful of the pregnancy, delivery, and even the postnatal period given frequent regurgitation and vomiting in newborns. Then other worries follow, such as fear of not being able to care for the baby or burdening the family. Like for fear of giving birth, the fear of vomiting can negatively affect the mother’s preparation during pregnancy. She will try to avoid situations that might make her want to vomit. After giving birth, the new mother will tend to over-verify the health of the child and exercise over-control to avoid either the baby or a member of the family becoming ill.

Post-traumatic Stress Disorder after Childbirth

As the name indicates, post-traumatic stress disorder associated with childbirth is identified when the father or mother has anxiety symptoms following birth that is judged to be traumatic, scary or threatening.

Main Signs: In other words, post-traumatic stress disorder can occur when the parent shows anxiety symptoms following childbirth that is judged to be traumatic, scary and threatening. They saw the childbirth experience as a threat, a danger to their life or their baby’s or partner’s life. It can occur by merely having witnessed a threat to the baby and/or partner. The person feels powerless to act.

Once the childbirth is over, the parent states that they repeatedly relive the traumatic experience:

• Repetitive involuntary memories or thoughts that cause distress
• In flashbacks where they feel as if they’re reliving a traumatic situation
• In repeated dreams of the event that produce a feeling of distress
• When seeing something that makes them think of childbirth (hospital gown, umbilical cord, specific people).

Similar to the previous anxiety disorders, the parent can show signs of increased irritability, anger, hypervigilance and jumpiness. This can lead to avoidance or efforts to avoid memories or things that remind them of the experience, such as the location, certain people, or conversations about childbirth.

Social Anxiety Disorder or Social Phobia

This is probably the least studied anxiety disorder during the perinatal period.

Main Signs: Excessive and persistent fear of social situations or a fear of being negatively judged. The parent feels anxiety almost every time they’re with people that could judge them. The parent recognises that their fear is excessive. They generally avoid social situations or experiences them with much distress.

For 2–6% of mothers, body changes, new parent roles and spending a lot of time with the child can make them feel like don’t have exciting things to say and/or can look bad to others. She will often compare herself to others and even doubt how she’s caring for the baby, which will lead her to isolate herself even more. By doing so, this increases her distress.

Possible Effects of Anxiety Disorders

Anxiety or an anxiety disorder doesn’t often occur alone. So a father or mother may have two or three problems already listed or frequent such as:

1. Depression
2. Insomnia

For example, a parent with post-traumatic stress disorder stemming from childbirth can, at the same time, develop excessive worries. This can create reactions to life uncertainties that can in their mind potentially be dangerous. Being in an underlying emotional state of anxiety, with avoidance, reassurance or control behaviours that it causes, can lead to fatigue, exhaustion over the long term and create a demoralised or depressed state.

1. Perinatal Depression 

For both men and women during the period they become parents, this occurs more than we think. Again, being in an emotional state of anxiety, causing avoidance, reassurance or control behaviours, creates fatigue, exhaustion and lead to a demoralised state. I recently produced a video about perinatal depression (in french) with a psychologist specialising in this field. I also wrote an educational entry about postpartum depression. I suggest you consult both.

2. Insomnia

Frequently the physical tension associated with anxiety and anxious thoughts (worries, obsessions, fears) affect sleep. Insomnia can be difficulties falling asleep or waking up frequently or too early in the morning. These problems feed into the parent’s anxiety by lowering their energy and making them vulnerable to its symptoms.

Finally, we have seen that anxiety has physical effects. Many physical effects can stem from anxiety. This is what often gets parents to consult their doctor. They will talk more about their physical pain (chest for example), tension, sleep or concentration problems or depressive symptoms. If anxiety isn’t searched for properly, it often goes unnoticed.

Impacts of Perinatal Anxiety

here can be many impacts on people who live with daily anxiety problems.

The first series of consequences stem from the behaviours that the person adopts to try and manage their anxiety. This person tries, for good or for bad, to diminish or prevent the occurrence of their discomfort. These repeated efforts to prevent their reactions lead to different impacts during their daily life, such as:

1. 1. Avoidance (behavioural or thought)
   2. Reassurance
   3. Behaviour that increases the feeling of security (excessive verification, over-control and overprotection)
   4. Other possible consequences

1. Avoidance

When the parent feels anxious and anguish, first, they can adopt two types of avoidance: 1) in their behaviour or 2) in their thoughts (cognitive).

• Behavioural avoidance: is the most evident. It consists of avoiding what causes fear. We have seen some examples, such as delegating tasks for the child, avoiding places because of a fear of feeling bad.
• Cognitive avoidance: refers to everything the parent can do to avoid thinking about what makes them anxious. It can be trying to think about something else, repeat things that make them feel safe or feel good.

2. Reassurance

Reassurance behaviour aims a lowering discomfort and trying to convince ones’ self that what they dread won’t happen. It can be constant demands for reassurance from the spouse, repeated medical visits. Often anxious parents think about strategies to not bother the people around them, which means that their needs for reassurance go unnoticed. For example, asking the other parent to go check if an object was left in the baby’s room, indirectly asking them to check if the baby’s okay.

3. Behaviour That Increases the Feeling of Security

Finally, behaviours can be developed that increase the feeling of security, adopted as a reaction to anxiety. Three very frequent ones occur – excessive verification, over-control and overprotection, which we can group together.

Excessive verification: Often done to ensure that everything is fine to reduce their anxiety. For example, constantly check for signs of health problems in themselves or the baby, even after having already had them checked. Spend a lot of time repeatedly checking the daycare bag, or regularly checking up on the babysitter.

Over-control and overprotection: both refer to behaviour adopted to control the environment, protect the child and lower their anxiety. For example, leave little space for others for the care of the baby. Prevent older children from doing activities so that nothing can happen to them.

These behaviours are the result of anxiety. They have important impacts on the parent’s quality of life. They can lower the anxiety over the short term, but it will always return. This increases fatigue and affects their relationships with others. For example, a dad can feel excluded from their children and each spouse can feel alone, separated from the other.

What’s unfortunate about over-control and overprotection is that often the dreaded consequences never occur, which will reinforce the person’s controlling behaviour. They think that they were right to be protective and controlling.

4. Other possible consequences of anxiety

High and persistent anxiety for a pregnant woman can affect their intra-uterine blood circulation and impact the baby’s growth and birth weight, and even lead to premature birth.  

Regarding attachment, we can say that anxiety can impact the development of the parent-child relationship. The effects of anxiety can also affect the couple’s relationship and lead to lower spousal satisfaction. Many parents avoid talking about certain subjects or doing activities to avoid triggering anxiety reactions that might occur in their partner.

Over-control and overprotection behaviours can have a medium—and long-term impact on the development of the child themselves, both for motor skill and social development. Preventing the baby from doing things or doing things for them will harm their autonomy and develop insecurity in the baby at the psychological level.

The consequences aren’t always evident. You need to pay particular attention to the comments of those around you, family and friends, to understand what is happening. Be more conscious of your reactions, what they provoke, the effects they have on your life, and how you can deal with these feelings over time. For me, this is the first step to exploring possible solutions.  

We can learn to understand our anxiety and better manage it gradually over time and, in the end, experience less distress.

Predisposing Factors for Perinatal Anxiety

Indeed, personal factors can predispose the development of anxiety during pregnancy or after childbirth.

1. Biological, hormonal, physical and psychological changes
2. Difficult life experiences and events
3. Previous personal history of anxiety or emotional difficulties

1. Biological, hormonal, physical and psychological changes

Research has shown contradictory results about the effects of certain hormones on anxiety. It suggests that some women are highly sensitive to sudden changes in hormones, which will bring on more negative emotions.

Physically, women experience an increase in their heart rate. Also, as the uterus grows, it pushes on the diaphragm, which leads to shorter breath and difficulty breathing. Women that are sensitive to these symptoms can erroneously label them as danger signs or signs that their emotional state is becoming worse, which leads to anxiety (increased psychological vulnerability).

On a psychological level, there’s more anxiety about their new identity, their developing social role and their often idealized parenthood. Social networks are a major source of stress for new and future parents. Redefining their priorities and needs, reorganizing their married life, feeling the pressure to be happy – these are just a few of the issues parents have raised in investigations on the subject, to better understand their experiences.

2. Certain difficult life experiences or events

Certain traumatic events, like sexual abuse, perinatal loss or miscarriages can also predispose anxiety.

3. Previous personal history of anxiety or emotional difficulties

Most studies conclude that a previous personal history of anxiety or emotional difficulties is a recurring risk factor for the development of perinatal anxiety.

This supports the idea that previous psychological vulnerabilities can be reactivated during this period of life. This doesn’t necessarily mean that anxiety disorders were present in the past. Some developed vulnerabilities can affect how you react, think or manage your emotions.

During the perinatal period, we sometimes see people that tend to think that nothing works, that something negative will always happen. Generally, they can even have a very negative attitude about possible complications or problems, pessimistic thoughts. In other words, during life, some people develop a lower level of tolerance for uncertainty. Because the perinatal period is full of uncertainty, new things, changes and unexpected events, the parent is less able to tolerate these uncertainties, which will make them worry more, and they can become obsessed with specific issues. All this can reactivate vulnerabilities or expose them in this period full of challenges to overcome.

For example, a parent can have very high demands, perfectionist, for themselves and for others around them, or is someone who is never wrong (dysfunctional perfectionism). This parent will likely never be satisfied with their efforts. They have overly high and unacceptable standards for themselves and others. Consequently, their thoughts and behaviours regarding anxiety will be more present.

If the parent looks at life through a filter of intolerance of uncertainty, perfectionism or sensitivity to anxiety, they will strongly react to the stages and the stresses during the perinatal period. Once activated, these vulnerabilities can continue and become more and more automatic, which helps sustain the anxiety.

Perinatal Anxiety in Men and Women

First, we should say that few studies have directly compared fathers and mothers regarding anxiety during the perinatal period. Work completed on this topic focuses mostly on the experience of future or new mothers. However, research is currently underway to explore possible anxiety experienced by men on their way to becoming fathers. Unsurprisingly, we can say that to date, men express their anxiety less than women, which can explain, in part, why anxiety rates are higher in women.

Men can experience anxiety which can lead to distress like in women, but they’re less inclined to ask for and receive help. There seems to be a difference in the way worries and anxiety are managed by a father and mother. Fathers are quicker to look for solutions, problem-solving when they’re worried about something compared to mothers. Consequently, the solutions they find are sometimes temporary or superficial, which relieves them over the short-term but tends to sustain their anxiety over the medium- and long-term.

Also, what is interesting is that if the mother is fine physically and psychologically, able to manage her daily life in the couple and family, the father’s anxiety rate will be lower. If the mother is doing fine, the father has a better chance of doing fine.

Important Resources and Support for Anxiety

Early detection is undoubtedly a decisive factor in providing the best possible help to those experiencing a mental health problem during the perinatal period (SOGC, October 2024). The health guidelines aim to raise awareness among future and new parents of the fact that mental health problems in the perinatal period go far beyond postnatal depression. The sooner a diagnosis is made, the sooner the person can be helped appropriately, and the better the outcome for the family.

Each person is unique and has ways to deal with their vulnerabilities. You also have to take care of yourself to be able to care for your child, partner, friends and family.

Unfortunately, we have to admit that there’s a big gap between knowledge and concrete action in the healthcare network’s offer of services to better support future and new parents who are experiencing (SOGC, October 2024)

How can I get support?

• Get personalised support for the transition to becoming parents, for example. This can help people handle this specific period.
• Get help at home after the baby’s arrival. You need to feel supported, helped, surrounded by friends and family. You need to feel comfortable and supported during this stage filled with new things.
• Write a daily journal to keep your observations. This can help recognise unpleasant emotions and understand when they appear. You will have hints and power over what you can quickly do instead of letting the impacts worsen over time.
• Help is available in CIUSSS, private services, community services, professional orders that can refer you to professionals in your region. Research teams in universities can often provide free or low-cost services.
• You can consult professionals (doctors, psychiatrists, psychologists) who will provide you with a full evaluation and an action plan and therapy to deal with underlying factors, not just the symptoms.
  

For example, it could be a cognitive-behavioural approach, where the changes they will suggest will significantly improve people’s lives.

There’s no magical cure to heal all life’s pains, but actions taken can mean that life can be better and easier on a day-to-day basis for yourself and with your family and in society.

It’s important to remember that the way you react to anxiety during different stages of life is for the most part already learned. Ways of dealing with vulnerabilities, such as intolerance and uncertainty, are also already learned. On the other hand, we can learn to lower our anxiety, or at least better tolerate uncertainty. You can do it!

We will experience uncertainty, question ourselves and even have anxiety during this period when we become parents. However, this in no way makes you bad parents!

Marie Fortier
The Baby Expert

References :

• SOGC: journal des obstétriciens et gynécologues du Canada, vol 46, issue 10, octobre 2024.
• SOGC: journal des obstétriciens et gynécologues du Canada, Directive Clinique No 454.
• SOGC : Journal, volume 46, issue 10, octobre 2024 : Simon N. Vigod Md Msc, Benicio N. Frey, Md Phd.

Updated article : December, 2024.