When I went to drop off a prescription for Lexapro at Walgreens, the woman behind the counter asked me how far along I was. Twenty-eight weeks, I told her, just starting the third trimester. “You’re going to be so uncomfortable for the next few months, but it’s going to be great,” she said. “I loved my pregnancies. I wish I could feel that way all the time.”
The irony of being assured that I was going to have a great experience with the rest of my pregnancy while I was procuring an antidepressant wasn’t lost on me. I smiled and nodded and made a mental note to myself that I was, in fact, happy for her that her pregnancies went so swimmingly, even though mine had not, and even though the prospect of “feeling that way all the time” struck me as horror-inducing.
I had been diagnosed with antenatal depression, the medical term for depression while pregnant, just a few days before, and it was severe enough that my obstetrician had sent me to the emergency room in hopes that I’d be able to see a psychiatrist on the spot. I’d arrived at her office for my 28-week appointment after three hours of hyperventilating and tears. What in any other case would have felt like a moderate inconvenience with my work schedule had in my mind escalated to a decision that would determine how competent I really was. That creeping horror had become one of the defining feelings of my pregnancy — forget any kind of “glow.”
Over the prior six weeks, breakdowns like this one had become more frequent, and were accompanied by a general malaise. I stopped wanting to eat, I stopped gaining weight, I stopped talking to my friends and family, it took everything I had to make doctor appointments and keep them, and every step I took was like moving through molasses. I was even having symptoms of postpartum psychosis — graphic, sudden, vivid visions of harm being done to me or the baby by strangers or by accident, in addition to suicidal thoughts — just, you know, three months early.
This isn’t a source of shame for me. I’ve been receiving mental health care since I was twelve, mainly for high-level anxiety and, as an adult for post-traumatic stress disorder. The fact that I struggled during pregnancy wasn’t a shock: I had a hunch that I might have a hard time based on the fact that hormonal birth control always threw me for an emotional loop.
But it’s not easy for everyone who becomes depressed while they’re pregnant to talk about it. While searching for stories that looked and felt like mine, I soon found out why. I had heard similar sentiments in various comment sections, but Andrew Solomon’s 2015 article on the challenges of antenatal depression for the New York Times became a breeding ground for highly polarized reactions. Commenters with something negative to say fell into two categories: people with a sort of “eugenics-lite” argument who said women who have depression shouldn’t procreate, or commenters who denied that depression while pregnant was a problem that actually existed.
“My advice to women such as Mary in this story is not to reproduce,” said one commenter, mentioning that a cousin had made that decision and “feels sad, but I agree with her.” Another wrote: “Some of the women described appeared to be seriously mentally ill. That does not appear to be a good qualification for motherhood!” Another suggested that if you have a condition that could be worsened by pregnancy and medications for which carry an unknown risk to the fetus, “You would… maybe adopt a child?”
Such judgments aren’t just the province of anonymous internet commenters. In Origins, journalist Annie Murphy Paul describes her experience of observing a depressed, pregnant participant in a research study:
I have every reason to feel empathetic, but to my chagrin I find that I feel repelled. Her drawn face is jarring above the lush curve of her belly, and the deadness of her affect seems painfully at odds with the life moving inside her. For the first time, I begin to understand why the notion of depression during pregnancy arouses such discomfort.
My first impulse is to call the commenters’ and Paul’s reactions plain old sexism, but they seems less a judgment on women per se and more an example of our culture’s extraordinary anxiety over the risks around pregnancy in general. It’s another form of the phenomenon I’ve encountered during my own pregnancy, of people telling me what I should or shouldn’t do — eat deli meat, drink alcohol or coffee, have sex, pursue a vegetarian diet, take Zofran. But in this case it’s either that, because I had risk factors for mental health issues and developed antenatal depression, I shouldn’t have gotten pregnant at all, or that I shouldn’t worry about, put a name to, or even try to address how very, very, very bad I feel.
Sociologist Barbara Katz Rothman describes pregnancy as the “pregnant canary” in the “coal mine of medicalisation,” meaning that it was one of the first aspects of health to not just be professionalized, but framed in the context of a risk so great that it merited constant medical surveillance. And, strikingly, one of the factors that led to the medicalization of pregnancy after centuries of cooperative care from midwives and doulas was the eugenics movement.
Sociologists Helga Hallgrimsdottir and Bryan Benner explain in their 2014 article "Knowledge is Power," that the rise of obstetrics and first-wave feminism’s embrace of science to help women “achieve their womanly potential” in the US and Canada was tied to nativist movements. These groups were concerned with creating ideal citizens, in this case through ideal health, which in families was the responsibility of women. So, by the early 20th century, pregnancy became an issue of morality: “The pregnant woman’s conduct was exclusively governed by invoking distinctly moral directives aimed against avoiding possible – and avoidable – dangers,” write Hallgrimsdottir and Benner. This included manuals by authors of varying expertise, such as Roger Norman’s 1914 The Wife’s Handbook, which told women that they could be “fit candidates for matrimony” while being unfit, medically, for motherhood. Women were warned to exercise caution when selecting mates in order to avoid risks to the future of the human race. By the 1960s, avoidance of danger and risk had become the dominant narrative of medical care in and after pregnancy.
Such overly cautious language has since extended to risks to the fetus, despite the fact that it can be difficult to determine what puts a fetus at risk. “No one can weigh unknown risks and benefits,” as bioethicists Rebecca Kukla and Katherine Wayne note, because pregnant women cannot be included as research study participants on the basis of potential risk to fetuses, which puts us all in a double-bind. As a result, doctors, family members, and strangers feel free to instruct pregnant folks to abstain from practically everything. And apparently that abstention can include getting pregnant to begin with if you have depression or are taking medication to treat said depression if you’re pregnant.
When I was not yet pregnant, but honest with loved ones about how I assumed pregnancy probably wouldn’t suit me, they told me that I’d change my mind once I was pregnant. During my first trimester, when I was laid out with hyperemesis gravidarum, an especially severe type of morning sickness, friends who were uncomfortable with my distress constantly told me, “It’ll all be worth it in the end!” or “You’ll feel so much better in your second trimester!”
When I was in the ER, the two social workers on shift told me that my depression was “just hormones” and that everyone goes through it, a popular but incorrect understanding of the biological processes at work. To clarify: It is hormones, but fluctuations in hormone levels are known to affect mood by interacting with neurotransmitters. By the end of pregnancy, levels of the reproductive hormone progesterone are 10-12 times higher than it is at the height of your menstrual cycle, which, according to a 2001 study in the Journal of Clinical Endocrinology & Metabolism, may affect some pregnant people’s mood more severely than others’.
If you’re either depressed already or, as in my case, you’re sensitive to hormonal changes, that can mean certain destruction of your emotional well-being. Saying that anything is “just hormones” is a tremendous underestimation of how complex the endocrine system is and just how much of your body it affects.
Even the pharmacy tech at Walgreens performed a similar version of denial, inasmuch as she wanted to reassure and guarantee me that pregnancy was going to be great. Everyone’s strongest impulse has been to convince me, and perhaps themselves, that I will have an overall positive experience with pregnancy, even in the face of ongoing evidence to the contrary. Rothman notes that “weighing the risks” of our experiences and actions in pregnancy also means weighing the risk of other people’s responses. Perhaps the people who deny that my depression is happening and tell me it will be a positive experience are trying to protect me from other people’s judgments, or the way they assume I will judge myself, or maybe even the way they would be inclined to judge me if they actually acknowledged that my account of my experience was truthful and accurate.
But this, too, is related to medicalization. Authority on the pregnant person’s experience has been removed from the pregnant person and placed externally, first in the hands of doctors, but also in the hands of the medically untrained onlookers. This is where denial becomes dangerous, because hearing over and over that I should endure this feeling, it’ll get better, it’s just hormones, it’s normal, I’ll be fine — it means that I postponed treatment until the pain was too intense to tolerate.
For me, that was relatively early. And thankfully so: The best indicator for postpartum depression is antenatal depression. It’s one thing to be pregnant and untreated, but entirely another to be a child’s primary caregiver and untreated. Some medications that are prescribed for depression can take up to six weeks to kick in. I got a head start by getting treatment three months before my son arrived. By the time he’s here, I’ll be able to take care of both of us.
I’m a good self-advocate when it comes to my medical care, and I was able to get effective treatment in a timely manner. But that isn’t the case for everyone. Kukla notes that “social marginalization can create the appearance of incompetence.” And an article from the British Journal of Psychiatry discusses experiences of psychiatric professionals not trusting their patients, and stigma surrounding mental illness is well-documented. Self-advocacy in an environment like this is difficult. I have to imagine that if you’re depressed and unpracticed with self-advocacy, you feel the resulting judgment and self-doubt all the more heavily, all of which has to have a chilling effect on a pregnant patient’s willingness to speak up and get the help they need.
I ultimately do agree that pregnancy is risky, but I think it’s risky in the same way leaving my apartment, driving a car, eating food, or engaging in interpersonal relationships are risky. One of the big takeaways I have from getting treatment for anxiety and trauma is that if I can’t tolerate a normal-sized risk, I’ll be too scared to do anything, and that in turn carries its own risk. It’s hard for me to believe that the physiological process by which the continuance of our species is ensured is so dangerous that I just shouldn’t be pregnant at all. And, I’ll point out, a 2002 study published in the British Medical Journal showed that cultures that view pregnancy and childbirth as normal physiological processes (rather than abnormal dangers meriting high surveillance and risk avoidance) tend to have more medically ideal birth outcomes.
If I had the chance to go back and tell myself what pregnancy has been like, it also wouldn’t have deterred me, because I wanted to go through this experience and see for myself what it was like. Baffling over why a depressed person would choose to get pregnant when it carries a risk of creating or worsening their depression doesn’t take into account the desire to live a full life for one's self.
Finally, it bears pointing out that the intolerance of risk in pregnancy, this paranoia over outcomes for children, implies that birth defects, chronic conditions, hereditary conditions, and mental illness necessarily represent failure and obstruction to the child’s future. I was born with a hole-in-heart birth defect and, clearly, a propensity for mental illness. This hasn’t made my life less worthwhile or satisfying or full. A less than perfect life is still worth living. I wouldn’t deny it to myself, and I wouldn’t deny it to my son. ●
Rebecca Vipond-Brink is a journalist based in Chicago.