Stephania Vu had a vision of what it would be like to give birth to her first child. She grew up in a large, close-knit Vietnamese family. Last year, as she was preparing for her son to be born, she imagined “a rotating door of family members who would be in and out helping me,” she explains.
Then, on March 13, 2020, New York City announced that all schools, including the one where Vu worked in Queens, would temporarily close to stop the spread of the coronavirus. Two weeks later, Vu’s pregnancy took a turn for the worst: She was diagnosed with preeclampsia, which forced her to go into labor at 36 weeks. Vu had a C-section and her baby was born at only four pounds, one ounce. He was immediately taken to the NICU.
“I never got to physically touch Neil because I was always in PPE,” she tells me. “When I went to the NICU unit, I would go and nurse him and that was, like, as much skin-to-skin that we had. I didn’t kiss him because I was masked. I didn’t touch him because I was wearing gloves.”
After ten days, Vu was able to take her newborn home, but the complications didn’t stop there. At that point, no one knew how COVID-19 was transmitted, if it was even safe to go outside — people regularly sanitized their groceries and delivery boxes. Fearful, Vu and her husband stayed inside (Neil didn’t go outside until he was 3 months old).
Meanwhile, Neil seemed to cry nonstop. And Vu, who had expected to be surrounded by friends and family, felt completely alone. “The days were so, so, so, so long and lonely,” Vu recalls. “For me, it was not feeling as much of a connection with Neil at the beginning.” Vu would take extra long showers just to escape and to drown out the baby’s cries.
She would also swing between bouts of extreme anger and sadness, crying even over small things. “We had ordered Indian food one night and it didn’t get there on time and I just started crying,” she says.
Vu started to resent her new life. She felt “a lot of anger, a lot of rage,” she tells me. “Just really not having any support,” after coming from such a caring family, “was really devastating.”
There’s reams of data on how much rates of mental-health conditions have sky-rocketed during the pandemic. But these numbers are even higher among pregnant and postpartum people, who have experienced increased levels of PTSD, depression, and anxiety compared to the general population, according to a study from the Harvard T.H. Chan School of Public Health. Another study from Canada conducted between April and May 2020 showed a spike in anxiety among participants, from 29 percent pre-pandemic to 72 percent.
Now that we’re nearly two years into the pandemic, when schools and daycares have reopened, and much of the country is vaccinated, you might think that these rates of depression and anxiety would have decreased since those dark days of lockdown. But this isn’t necessarily what clinicians are seeing.
“It’s a maternal mental-health crisis,” says Paige Bellenbaum, the founding director of the Motherhood Center in New York City, which specializes in treating postpartum depression and anxiety. “I don’t think we’re anywhere near the finish line,” she says. “We’ve tripled our business since the pandemic began, and we cannot keep up with the need.”
When most people think of postpartum depression, they think of a woman having obsessive thoughts of harming herself or her baby (known as postpartum psychosis). But PMAD (which stands for perinatal mood and anxiety disorders) encompasses a wide range of symptoms, including: fits of crying, anger, and sadness; feeling numb; being unable to sleep; feeling anxious; OCD behaviors; and extreme mood swings. This can make it harder to recognize from normal post-baby stress.
After giving birth to her daughter Cosette in February, Samantha Coggins was having difficulty breastfeeding. She had an undersupply of milk, and in addition to feeding her baby every two to three hours, she also had to pump eight to ten times a day to stimulate her milk. Her nipples soon became chapped and bleeding.
“It was a nightmare for me, and my mental health took such a hit,” recalls Coggins. “I was crying every night.”
The pandemic meant that she couldn’t get her friend, who was a doula, to come and help her troubleshoot her breastfeeding issue. Telehealth appointments didn’t help, either. “I was trying to learn to breastfeed with, like, lactation consultants over the phone,” Coggins explains. “And that was not working. And Cozy wasn’t gaining weight.”
She felt like a failure. After a month, she stopped breastfeeding, but the crying and extreme mood swings didn’t stop. Normal, everyday struggles would cause arguments between her and her husband where she felt like “he didn’t support me and he was trying to control me.” She had regular breakdowns: “I would be on the floor crying for 30 minutes at a time, and really feeling unable to problem solve and figure out how to move forward,” she says. “When you have an infant, that’s a real problem, because their diapers don’t wait for that. Their needs can’t really wait for you to freak out.”
It’s unknown what exactly triggers PMAD. One explanation is the extreme hormone fluctuations that happen throughout pregnancy and after delivery, according to Kayla Mullin, a licensed counselor who specializes in postpartum depression and anxiety: “You get pregnant, there’s a hormone adjustment. You deliver, there’s a hormone adjustment. Your milk comes in, that’s a hormone adjustment. If you continue to breastfeed, that’s a hormone adjustment. If you stop breastfeeding and dry up your supply, that’s a hormone adjustment.” Mullin runs her own practice at Montani Mental Health in Morgantown, West Virginia, where Coggins is a patient.
Women who have a history of anxiety and depression also have a higher risk of developing PMAD. According to Dr. Karestan Koenen, a professor of psychiatric epidemiology who co-authored the Harvard study, other risk-factors can include everything from having a high-risk pregnancy or a traumatic delivery, to struggling to breastfeed. Then there’s also life stressors, including “financial stressors … or life disruptions.”
So what happens when you mix extreme hormone fluctuations with a global pandemic? One thing that’s made pregnant people more prone to PMAD is having their birth plan disrupted. I spoke with moms who had to wear masks while they were delivering. Once they entered the hospital with their partners, they were not allowed to leave. They couldn’t have visitors in the hospital.
Of course, another big factor is extreme social isolation, and not having the support of friends and family — which is especially important in the early days of motherhood when sleep is scarce and the needs of an infant can be overwhelming. A friend or family member coming over to help or bring food could allow new parents to get some much needed rest, or even time to shower. And moms usually gather with other moms, to air their questions and concerns, and to find a sense of community — that was also impossible to do during a pandemic.
Then there’s the uncertainty about the pandemic itself: “Could your baby get COVID? Could I give COVID to the baby? Is breastfeeding safe? All that is just adding to any anxieties women might have, especially if it’s their first kid,” says Koenen.
For Liz, who requested we only use her first name, those thoughts were constant after she gave birth to her son, Jackson, this past May.
“I had been worried about COVID and all of that while being pregnant. And then suddenly, you’re in charge of this tiny human. I had to look out for this baby who has no immune system,” Liz told me.
Liz was scared to take Jack outside. She and her husband, Josh, live in Texas, where regulations around masking and vaccinations are unfortunately lax. “I was just so worried. But if he’s home, he’s with me and he’s safe,” Liz says.
As Jack grew, so did Liz’s anxiety. Soon, she wasn’t sleeping. Granted, most new parents don’t sleep. But Liz would stay awake even when Jack wasn’t. “I was waking up every two to three hours, going to check on him, making sure he was okay. And then I couldn’t go back to sleep,” she explains. “I couldn’t turn my brain off the moment it was on: What if I die? What if Josh dies? What if Jack died? That was constant.”
It got to a point where Liz was nervous letting Jack be in a separate room, even when her husband was with him. “I didn’t want anyone to be with Jack except for me,” she says.
Though we’re not as isolated as we were in those pre-vaccine days, postpartum anxiety and depression don’t seem to be letting up. As Bellenbaum points out, children under 5 still can’t get vaccinated. Then there’s the Delta variant, and now Omicron, which have made it seem like there’s no end in sight to the pandemic. “That anxiety that was always there about, you know, being protective of one’s pregnancy, protective of the gestating fetus, protective of the infant — that has gone up exponentially.”
Early in the summer, Coggins traveled with Cosette on a plane to visit her best friend. Afterwards, she was wracked by guilt when news emerged about the Delta variant. “My therapist was like, ‘You did the best you could with the information at the time. You needed to see your friend,’” recalls Coggins, who didn’t see her friends in person for months after Cosette was born. “It was stuff we’re getting robbed of, as pandemic parents.”
Then there’s the fact that only about 35 percent of pregnant people are fully vaccinated, according to CDC data, pointing to concerns about the vaccine itself. “Vaccination rates in pregnant people remain low,” says Dr. Archana Basu, another co-author of the Harvard study and a psychologist at Mass General. “So in terms of thinking about their worries, the level of distress that they’re experiencing, and its implications for mental health — I would say it’s still pretty salient.”
Some of those who spoke to me for this story said they felt nervous about leaving their child in a day care, or worried about finding a nanny who is vaccinated.
And because hospitals are still under COVID-19 safety protocols, birth plans are still being disrupted. For instance, moms that have babies in the NICU are still unable to have skin-to-skin contact with their infants. Mullin has seen more moms with NICU babies being referred to her practice with mental-health concerns. “It definitely, in my anecdotal experience, raises the risk factors” of PMAD, says Mullin.
Meanwhile, parents with more grown babies are coming to her with new anxieties, like, “Do we require people to test before they see the baby for the holidays?” she says. “They come to therapy and they’re like, ‘Am I crazy for being like this?’” And here, Mullin answers honestly: “I don’t know.”
These days, it’s normal for new mothers to be screened for postpartum depression and given a pamphlet with signs to watch out for. Those who spoke for this story said that this current practice is woefully insufficient.
While newborns usually get weekly checkups, women are told they can follow up with their OB/GYN six weeks after giving birth. It sends the message, even unconsciously, that the health of the mother is not as important as the baby’s.
And many people, even medical professionals, will dismiss PMAD as “the baby blues.” This was what happened to Liz when she reported her anxiety to her OBGYN: “I kind of got written off at first as like, ‘Oh, it’s new-mom worries.’” It wasn’t until months later, when Liz was still feeling anxious and not sleeping, that her doctor finally prescribed Zoloft.
Liz has started seeing a therapist and feels a lot better on her medication. She is finally able to sleep. “I don’t feel like it’s me and Jack versus the world.”
Basu and Koenen are helping launch a pilot program for Mass General that will incorporate mental-health screenings in the routine care that pregnant people receive. The program will also include screenings during routine pediatric visits, so as the baby is getting a checkup, so will mom — without having to make an extra appointment. Major hospitals around the country are starting to incorporate those screenings into routine pediatric checkups.
But that doesn’t necessarily mean it’s accessible to everyone. Multiple experts recommended Postpartum Support International, a website that hosts a helpline, online support groups, and a directory of free or low-cost mental health-care providers. And while PMAD is treatable, it’s largely on mothers to advocate for their own well-being.
“You basically have to trust yourself,” says Koenen. “Because if you think something’s wrong, even if other people are saying, ‘Oh no, don’t worry about it’ — you’ve got to be persistent.”
Though the pandemic has been “crushing,” Coggins is trying to see the bigger picture, and remind herself that this difficult time is temporary.
“Something cool about babies is that they are a living testament to how there’s a season for everything,” she says, playing with Cosette on the floor of her house while talking to me. “In the same ways that babies outgrow clothes and start making new sounds — we will outgrow this pandemic.”