Eight years ago, Anushree* was pregnant with her second child. However, unlike her first pregnancy, she was far from excited. Instead, she found herself at war with her own mind as anxious thoughts she could not control built up inside her. 

“It was in their eyes,” recounts Anushree*. “[My family] didn’t say anything bad to me. But I could tell… it was in their eyes. And once that took root, you know how the mind works.”

It wasn’t like this when Anushree, a dentist by profession, was 25 and carrying her first child. “I was the first to get pregnant in both my parents’ as well as in-laws’ side at the time. It was a very enjoyable time. Everyone was welcoming,” she recounts.

An unplanned second pregnancy came amidst Anushree’s plans to complete her masters and PhD, but she wasn’t immediately deterred. She wanted to have a second child and anticipated her family’s enthusiasm and support. However, with Anushree’s sister-in-law’s wedding approaching, the response was lukewarm at best. 

“I started feeling very anxious because I felt like everyone had too many other priorities,” Anushree tells TNM. 

She was diagnosed with prenatal anxiety — the anxiety experienced during pregnancy that hampers day-to-day activities. 

After this, no matter how much she tried, Anushree could not reign in the feeling that her family was judging her. “There was a lot of self-doubt and blame. How could I have allowed myself to get pregnant when there is a girl who has to be married in the house?”

And maybe if she had felt comfortable sharing her state of mind, she may not have fallen into this spiral of anxiety in the first place, she says. “I tried to quieten my thoughts, be productive, and care for my son in the day; but every night I went to sleep, I was crippled by anxiety.”

Women are often made to believe that they have to choose between their own health and that of their foetus or baby. Between their career and having a family. Between what they want and the expectations of family, the in-laws, the husband. While the birth of a child can be a joyous occasion for the whole family, the woman can feel reduced to a mere vessel. 

Prenatal depression and anxiety can be triggered by physiological factors, but psycho-social factors have been found to play a significant role. Added to that, misconceptions and stigma around mental health, therapy and medication, social expectations, and a lack of research puts women in a difficult position. 

Social pressures and other risk factors

There are a lot of unrealistic ideas about what an ideal expectant mother should look like. For Tanuja*, her family could not fathom why she did not ‘look’ happier upon learning about her pregnancy. “The elders told me things like the baby won’t develop properly if I don’t smile,” Tanuja says. 

“But I just couldn’t find that feeling in myself. I went to bed in tears every night. I fought with everyone for no reason. Everyone was taking care of my food, my physical health… But there wasn’t really anyone to talk to about how I was feeling mentally and emotionally.”

Tanuja, a Benagluru-based communications professional, had discovered she was six weeks pregnant in 2012 in the middle of moving homes and at a critical juncture in her career. She realised that she had prenatal depression after delivery.

“I didn’t self-harm, but I constantly questioned – why did this have to happen to me? Why couldn’t I be a good mother and just smile when people asked me to? It became a big issue later also – the family didn’t like it that I didn’t even smile after I entered the house with the baby after delivery,” she recalls.

Prenatal or antenatal anxiety and depression are fairly common. While there isn’t enough data to determine a broad prevalence rate, there are multiple smaller scale studies that seem to indicate these are not rare.

One 2019 study found that 55.7% of the 380 women surveyed in Bengaluru had prenatal anxiety. Another study which surveyed 202 women in Kerala and Tamil Nadu found that 16.3% of them presented with prenatal depression. A review of 23 studies revealed that prevalence of generalised anxiety disorder and depression in pregnant women in India ranged from 1% to 26% and 1% to 30% respectively. And according to the National Mental Health Survey 2016, 20% of those experiencing depression were pregnant women and new mothers.

However, while postpartum depression is more well known, there isn’t as much awareness or acceptance of prenatal depression and anxiety in society as well as a significant section of the medical fraternity.

But it begs the question - Isn’t it natural for a woman to have mood swings or feelings of worry while she is expecting?

“Prenatal depression and anxiety are different, and much more serious,” explains Dr Shaibya Saldanha, a gynaecologist and co-founder of Enfold India, which works on issues of gender, sexuality and women’s health. “While some worry is normal, if a woman is unable to sleep due to anxious thoughts, it is a matter of concern. If she stops taking care of herself, and her day to day functionality is affected, that is another symptom.”

Dr Shaibya reiterates what plenty of research also establishes – several risk factors for prenatal depression and anxiety are social or familial, such as having an unsupportive family or husband, domestic violence or other forms of abuse, financial strain, history of miscarriage, an unplanned or unwanted pregnancy, and the pressure to have a male child to name a few.

That being said, it is possible to experience prenatal depression and/or anxiety without social or personal triggers. Previous history of mental health issues like depression or anxiety can be a contributing factor in some cases. Dr Ashlesha Bagadia, a psychiatrist specialising in perinatal psychiatry and women’s mental health, adds that physical parameters like anaemia, thyroid dysfunction, diabetes, nutritional deficiencies may also play a role. 

Debates around treatment

Three months after Anushree’s second child was born, she attempted suicide. Though her gynaecologist hadn’t been dismissive about her mental health and prenatal anxiety, a psychiatrist only recommended that she take therapy. 

“They didn’t want to put me on medication due to some concerns about my weight and because they said they didn’t know how it would affect the baby (foetus),” she says.

Anushree was eventually prescribed antidepressants and other medication, but only after the attempt to take her own life. But it wasn’t just her suicide attempt that prompted doctors to finally prescribe medication, she says — it was also because she had stopped breastfeeding her daughter. 

Tanuja decided to forgo medication when she slipped into postpartum depression. She says that because she was breastfeeding, she decided to rely on therapy to deal with her depression, and her family also became supportive post-delivery, which helped. She had concerns about the medication affecting her breast milk, and subsequently, her child. 

Medical experts say that while there are risks associated with psychiatric medication, no medication is without risk. And there is evidence of some pregnancy- and breastfeeding-safe psychiatric medications that can be taken if needed.

“It’s not that all medications are completely safe, but the focus is on the wrong kind of risk and that leads to mothers and families making decisions without being fully informed. This reduces their autonomy in decision making during a crucial time in their life,” Dr Ashlesha says. She adds that all decisions regarding medications should be made depending on the individual, balancing out the risks between the illness and the medications. 

The research on whether it is safe for a pregnant to take psychiatric medication is divided. Some research does suggest that there are some risks to taking some serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs) – commonly used in anti-depressants – to the foetus. The substances cross over the placenta, and can also be in the breast milk. However, there is little consensus, and many studies say that the risks of taking required medication during pregnancy could also be small or even non-existent.

For Sreedevi, a Bengaluru-based software engineer however, medication was a turning point when she was going through postpartum depression. For her, like for Tanuja, it was prenatal depression that had continued into postpartum depression. 

“In some ways, I feel I continued with my pregnancy for my family’s happiness. I don’t remember feeling happy about it until I felt the baby moving around the sixth month,” Sreedevi admits.  

“After I delivered, I knew something was wrong with me. I wanted help, and my psychiatrist also suggested that I take antidepressants. I wanted to get better and trusted my doctor who said that it won’t affect my breastmilk or my child,” Sreedevi says. For three months, Sreedevi took the antidepressant prescribed. Her mental health improved, and she went on breastfeeding for almost two years.     

“As a rule of thumb, if women are already on medication and find out they are pregnant, they should not stop any medications without consulting their doctor. And if they are advised to take medications during pregnancy, they can ask questions about their safety profile till they are satisfied with their requirements,” Dr Ashlesha says.

Apart from these debates, sometimes the women themselves or their partners or families are wary of psychiatric medication, which can result in depriving women of the healthcare they require.

Difficult, unfair choices

Despite the troubling nature of her mental health while pregnant, Anushree was repeatedly told by her family that she should try to overcome her feelings for the sake of her child. And that she would do it by herself — with her willpower.

“When someone has malaria, we don’t tell them, ‘conquer it with your willpower.’ Why is that the case with mental health?” argues Dr Shaibya.

There are also grave risks to ignoring prenatal mental health issues, including depression and anxiety. “Untreated prenatal depression puts the mother at risk of postnatal depression and subsequent depressive episodes in later years. It also impacts her marital relationship and her partner’s mental health,” Dr Ashlesha says.

Untreated depression and anxiety during pregnancy also poses risks to the foetus. “It can lead to neurocognitive impairment in the foetus, developmental delays in infants, more fussy infants and poor emotional regulation in early childhood; and higher risk of anxiety, adjustment difficulties, conduct disorder, ADHD in middle school children. There is a higher risk of depression in adolescent years, and a higher chance of a female child developing perinatal illness herself,” Dr Ashlesha adds. 

While women may be able to manage or overcome prenatal depression and/or anxiety with the right support and healthcare, the scars run deep. The portrait of a ‘good mother’ is embedded in society, and even most mainstream literature and cinema doesn’t portray otherwise. Women whose lives stray from the ideal narrative often find themselves at a loss of support and understanding.

Anushree’s daughter is six now, and her son, nine. And while her doctors have deemed Anushree free of depression and anxiety now, the guilt still creeps up on her. “It still bothers me that I could be a good mother when my son was an infant, but not for my daughter. With her, I had feeding difficulties and when she was around three months old, we had to put her on supplements, ceasing nursing completely. But my son breastfed for over a year,” she shares.

“I know what I was going through was beyond my control,” Anushree adds, referring to the prenatal anxiety turning into postpartum depression after she delivered. “And yet, I still blame myself for depriving my daughter of mother’s milk.”

“What I went through… it was very wounding. I don’t know if I am ever going to be completely out of that headspace. It takes years.”   

*Names changed