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New Moms, You Need to Hear This

The majority of postpartum women experience unwanted, intrusive thoughts.

Key points

  • It is common for new moms to experience unwanted, intrusive thoughts of infant harm during postpartum.
  • Rather than reflecting psychiatric illness, these can occur in all mothers.
  • It is essential to differentiate between distressing, ego-dystonic intrusive thoughts and the much more rare disturbance of postpartum psychosis.

As a new mother, I can remember experiencing repeated intrusive images of pushing my child’s stroller into the street, something I found truly horrifying, causing me to grip the stroller handle until my fingers were white. Like many postpartum moms with these anxious thoughts, I kept them to myself, afraid my obstetrician could see any mention of such terrible worries as a sign of an inability to properly care for my beloved child.

A Key Study for New Mothers and Their Health Care Providers

A recent publication from Fairbrother and colleagues pointed out how common these types of thoughts are in the postpartum period and that in the great majority of cases, and certainly when the thoughts are so highly distressing to the mother, the risk to the infant is not increased. Instead, these women often begin compulsive protective behavior, such as repeatedly checking on their infants to ensure they are safe and healthy.

The findings in this new study update the clinical practice of any provider treating women during pregnancy and postpartum. Conducted via two questionnaires and interviews during the postpartum, 388 women participated in this prospective sample to assess whether unwanted, intrusive thoughts (UIT) during the postpartum were associated with an increased risk of maternal aggression toward their infants.

This work is so important because of the high prevalence of these types of thoughts in the general postpartum population. In fact, a 2017 comprehensive review suggested that a significant majority of women, as high as 91 percent of new mothers, report unwanted, intrusive thoughts (UIT) of illness or accidental injury, and as many as half report UIT of intentionally harming their child. Importantly, UIT occurs in high numbers in women with no diagnosable mental illness and has been suggested to provide an adaptive (if unpleasant) biological function for new parents as they seek to protect their vulnerable offspring.

How Do We Know When We Should Worry?

It is no surprise that providers must take any possible risk to the infant seriously. However, as many clinicians treating women with anxiety and OCD have understood for years, UIT is ego-dystonic, meaning inconsistent with the woman’s beliefs, wishes, and values, and therefore experienced as abhorrent and highly distressing, has a very low likelihood of leading to infant harm.

This stands in contrast to our understanding of postpartum psychosis, a rare but severe childbirth complication, when delusional thoughts of infant harm may occur and be ego-syntonic, i.e., aligned with their (delusional) beliefs or wishes. These thoughts, then, are often not experienced by the mother as distressing.

For example, a woman with postpartum anxiety who experiences highly disturbing intrusive images of dropping her child down the stairs, causing her to avoid the stairway, and even asking others to carry her child to the upstairs bedroom, is very different from a new mother. The latter is suffering from psychotic delusions that the world is evil and she must protect her infant through tragic actions.

To help differentiate between the significantly more common UITs in postpartum women and the rare postpartum delusional thoughts of psychosis, clinicians can also screen for impaired reality testing, hallucinations, or disoriented behavior, all symptoms of the severe and life-threatening complications of postpartum psychosis, which warrants emergency intervention.

Findings From the Fairbrother et al. Study

In this recent study published in the highly-regarded Journal of Clinical Psychiatry, 44 percent of these postpartum women experienced some type of unwanted, intrusive thought in the first nine-months postpartum. The findings from this sample of the general population suggest that many women, even those without psychiatric illness, experience these distressing thoughts.

The baseline prevalence of maternal-infant abuse suggested by a recent meta-analysis is 4.5 percent. In this study, the prevalence of reported maternal physical aggression toward the infant was 2.9 percent. Notably, although not statistically significant, more women who denied UIT reported aggression toward their infant (6 (3.1 percent)) than those who endorsed UIT (4 (2.6 percent)).

Most importantly, the 44 percent of postpartum women who reported UIT during 9-months postpartum were at no greater risk of aggression toward their infants than those who didn’t have these intrusive thoughts of infant harm. Additionally, women experiencing postpartum obsessive-compulsive disorder (OCD) with frequent UIT were at no greater risk of infant harm than their peers without OCD. These findings replicate and reinforce earlier work by this study’s authors.

What message can we take from this data?

The reassuring findings in this study reflect the opinions expressed by experts in OCD and anxiety. They report that the ego-dystonic, unwanted, intrusive thoughts experienced by their patients during the postpartum period are not, in fact, a sign of danger for the child.

Though further investigation is warranted to rule out more dangerous symptoms, swift removal of the child or referral to emergency services for ego-dystonic UIT can actually harm the mother, creating shame, distress, and further isolation. As the authors state, rather than pathological, these thoughts reflect a “normal, albeit unpleasant and likely distressing, postpartum experience.”

This data can certainly be added to other key work in this area, but more importantly, how can we use this information to help our new mothers?

Key Takeaways

  1. Women and their partners must be informed of the frequency of these types of thoughts. They need to understand and expect these experiences as a common part of the postpartum period, rather than interpreting them as shameful or a sign of poor preparation for motherhood. This will facilitate their likelihood of seeking support and information to allow treatment, if needed, rather than unnecessary suffering, avoidance of their infant, or emergence of depression and increased isolation.
  2. Providers who care for women during pregnancy and postpartum, whether obstetricians, nurses, psychiatrists, or other mental health staff, must be aware that these thoughts can occur frequently. However, if they are ego-dystonic and distressing to the mother, they are not likely to place the infant at risk.
  3. Mothers, partners, and providers should all be aware of the rare but dangerous symptoms that can lead to infant risks, such as postpartum psychosis with ego-syntonic, often delusional thoughts of harm to themselves or their child, possibly alongside disorientation, impaired reality testing, or hallucinations. Treatment needs to be swift and aggressive in these cases.
  4. A network of other new mothers can be a lifeline for women who experience these thoughts but are too afraid or ashamed to discuss them. Encouragement of participation in high-quality groups or online support networks, as well as other access to ongoing peer support, should be a part of every postpartum hospital discharge discussion.
  5. Let’s all work together to share this information with new and potential parents in our lives and our medical or psychotherapy practices. We must increase awareness of these experiences and help mothers recognize and understand these types of thoughts. Together, we can help to decrease so much suffering.

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Brok E, Lok P, Oosterbaan D, et al. Infant-related intrusive thoughts of harm in the postpartum period: A critical review. J Clin Psychiatry 2017.78(8):e913-e923.

Fairbrother N, Collardeau F, Woody SR, et al. Postpartum thoughts of infant-related harm and obsessive-compulsive disorder: relation to maternal physical aggression toward the infant. J Clin Psychiatry. 2022;83(2):21m14006.

Fairbrother N, Woody SR. New mothers’ thoughts of harm related to the newborn. Arch Women Ment Health. 2008;11(3):221-229.

Russell EJ, Fawcett JM, Mazmanian D. Risk of obsessive-compulsive disorder in pregnant and postpartum women: a meta-analysis. J Clin Psychiatry. 2013;74(4):377-385.

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