How to manage worry in pregnancy

Pamela Wiegartz

is a clinical psychologist. She is associate director of ambulatory psychology and chief of the CBT Training Clinic at Brigham and Women’s Hospital in Boston, and on the faculty at Harvard Medical School. She is the author of Ten Simple Solutions to Worry (2006), The Pregnancy and Postpartum Anxiety Workbook (2009) and The Worrier’s Guide to Overcoming Anxious Procrastination (2011), all co-authored with Kevin Gyoerkoe.

Edited by Lucy Foulkes

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Need to know

‘I wish I could just enjoy my pregnancy, but I can’t turn off my brain,’ Paula said at her first therapy session. While she’d been a ‘worrier’ her whole life, it had never interfered like this before. In fact, she used to find her ability to predict and plan for obstacles an asset in her work as an office manager. But five months into her pregnancy, her anxiety was out of control.

Spending her days worrying was taking its toll, leaving her distracted and unfocused. She spent her nights awake, reviewing her to-do list or thinking about things that could go wrong with the baby. Paula created elaborate plans for avoiding imagined future catastrophes, and became exhausted and irritable in the process. This then caused mistakes and oversights, leading to even more worries. All of this was beginning to affect her relationship with her partner, and was understandably interfering with her enjoyment of the pregnancy she’d been so excited to experience.

Anxiety in pregnancy runs the gamut from obsessive intrusive thoughts, to panic attacks, to fear of childbirth. But the generalised anxiety and worry experienced by Paula is one of the most frequent complaints in mothers-to-be. These worries tend to fall into a few broad categories: labour and delivery; the baby’s health or viability; the mother’s own competence as a parent; and the negative impact the baby might have on her life or marriage.

Many mothers-to-be have such worries, falling prey to the ‘what ifs’ of anxiety. In fact, it would be unusual not to feel at least a little nervous about such a big change. For some pregnant women, however, this anxiety becomes highly distressing or interferes with life – it becomes a generalised anxiety disorder (GAD). A person with GAD finds it incredibly hard to control worry, and these thoughts often disrupt sleep and make it hard to relax. Irritability, fatigue and overthinking make it hard to stay present in the moment, and it can seem impossible to concentrate or make decisions.

Up to one in five women meets criteria for GAD or another anxiety disorder during pregnancy or postpartum, and these numbers are higher when it’s a medically difficult or high-risk pregnancy. For some women, anxiety will be an escalation of existing symptoms – as it was with Paula – but, for others, pregnancy will be their first experience of such problematic anxiety.

Whether you have milder levels of worry or a full-blown anxiety disorder such as GAD, cognitive behavioural strategies might be helpful in managing your symptoms. These are practical steps you can take to navigate these worries, which will help you enjoy the more positive aspects of pregnancy. These strategies specifically target the catastrophic thoughts, unpleasant physical sensations and unhelpful behaviours – such as over-preparation and avoidance – that characterise and maintain generalised anxiety.

What to do

Understand worry

What is worry? Although the term gets used a lot, we seldom stop to think about what worry really means. Worry is the cognitive component of anxiety – a chain of thoughts and images about future events whose outcome is uncertain but that we fear will be negative. Worry is characterised by ‘what if’ questions about situations that feel uncontrollable. Perhaps the simplest way to define worry is as catastrophic or negative thinking that is focused on the future. Most of us worry but, for some, their worries can be persistent or severe enough to cause interference in life or significant distress.

At our first session, Paula was shocked to see how quickly her mind travelled from a thought that her baby might be measuring small to the complete devastation of her life and marriage. She described her fears that the baby wasn’t growing and developing correctly, that it might therefore have special needs, that she wouldn’t be able to handle having a child with these difficulties, that she wouldn’t be able to juggle her work and home responsibilities, that she would have a ‘nervous breakdown’, and it would end her marriage.

We can see that Paula is clearly thinking about the future in catastrophic terms – the very definition of problematic worry. You might also notice that her worry moves quickly from one thought to the next. If you worry, this will seem familiar to you: one second you’re having a seemingly benign thought about your pregnancy and before you know it, you’re worrying about how you’ll pay for your child’s college, for example. This 0-to-60 thinking or ‘worry spiral’ is characteristic of generalised anxiety.

Track your own worries

Now that you know what to look for, start paying attention to your own worries. Often, we notice how we feel – tense, nervous, keyed up – but not the thoughts that led us to that feeling. Use a notebook to track your thoughts when you feel anxious (or use one of the thought-tracking apps listed at the end of this Guide). Note the situation and what you were worried about. Be specific and try to capture exactly what was going through your mind. For example, you might have difficulty sleeping when pregnant, worry that you’ll never sleep well again and that, as a result, you won’t be able to function as a parent.

Then take a look at this thought to see if it meets the definition of worry: first, it’s catastrophic or negative thinking; second, it’s about the future. Writing down your worries will not only help you pinpoint the source of your anxiety but will also give you a little distance from these thoughts so you can begin to evaluate them, rather than just accept them as truth.

Determine if your worry is productive

If worry actually helps you to solve a problem, it’s known as productive worry. Productive worry is focused on the present or the very near future, is about a concern that’s specific or likely to occur, and involves definite steps you could take to control or mitigate the problem. For instance, Paula worried that she would eat or drink the wrong thing and harm her baby. This meets the criteria of a productive worry because it’s focused on the present, a specific concern that could occur, and is reasonably within her control. Such worries are best addressed by taking practical action. In this case, Paula was able to ask her obstetrician for a list of the big food ‘no-nos’ during pregnancy, and was able to focus on avoiding these. By limiting her attention to only those foods, she freed herself up to enjoy a range of nutritious and safe options and worried less about her diet in general.

Unfortunately, many worries tend to fall into the unproductive category – such worry is focused on the more distant future, has a low probability of occurring, and/or the outcome is out of your control. Unproductive worry causes distress and anxiety because you can’t just solve the problem that’s troubling you. That doesn’t mean our brains don’t try though! It’s easy to get stuck in a worry loop, spending a lot of time attempting to mentally solve problems that haven’t happened or can’t be solved because you don’t yet have the necessary information. Paula, for example, wasted a lot of time trying to imagine all the possible things that could go wrong when she returned to work after maternity leave, and then tried generating solutions to all these problems. While she thought it would make her feel better to ‘get ahead’ of these things, it actually only worsened her anxiety and kept her stuck in an endless loop of worry.

Challenge unproductive worry

Think of a recent unproductive worry – or choose one from your notebook – and examine it more carefully. Counter your catastrophic thinking by asking yourself these questions and writing down the answers:

Do I know for certain that this will happen?
What evidence do I have to support this prediction? How about evidence against?
What are three other possible outcomes or explanations?
If the worst-case scenario did come true, how might I help myself cope?
What would I tell a friend if they were worried about something similar?

Paula used this strategy to challenge the worry that she would be a bad mother. By stepping back from this thought and asking the questions above, she was able to see that this worry was not a certainty, that even having that concern indicated that she already cared deeply about her child, but that she wasn’t affording herself the same kindness, compassion or benefit of the doubt she would give to a friend.

Change your worry behaviours

Do you ask your friends, family members, or doctors for constant reassurance or check the internet for answers? Do you look in the mirror to check your baby bump frequently or perform kick counts excessively? Do you engage in exacting routines or rituals to prevent fears from coming true, or avoid situations that remind you of your worries? If so, you might be engaging in worry behaviours. These are things people do that seem to help reduce a threat but don’t actually change the outcome or lessen anxiety in the long run. The problem with worry behaviours is that they can sometimes lower anxiety in the moment, but they prevent you from realising that your catastrophic thought very likely won’t be realised, even without doing the worry behaviour – or that, if it does happen, that it’s either not as bad as you thought, or you can handle it. Worry behaviours are different to problem solving, which does reduce the likelihood of the fear occurring in the future.

When you think that something scary or terrible is going to happen, it’s natural for you to want to fix it – but, as you now know, that doesn’t work very well when you’re dealing with unproductive worry because they’re problems that can’t be solved right now. Even when a worry behaviour temporarily calms your worry, it makes your anxiety much worse in the long run. Anyone who has ever Googled a medical symptom, for example, can tell you that the attempt to find reassurance online can sometimes be met with heightened anxiety and even more questions than answers, unless responsible websites are used.

Consider limiting these worry behaviours or replacing them with another activity. You could try a breathing or mindfulness exercise (see below), or taking a break for some self-care activities, such as going for a walk, scheduling a prenatal massage or reaching out to friends for some support. In the short run, you might feel anxious giving up these worry habits but, over time, eliminating these behaviours will pay off with lower anxiety and fewer worries.

Relax your body

Heart palpitations, shortness of breath, nausea and dizziness can all be part of a normal pregnancy. As your uterus expands and pushes up against your diaphragm, it crowds your lungs and limits the amount of air you can take in. Your respiratory system is adapting to carry oxygen to the placenta, and hormone changes are causing you to breathe more frequently. Together these developments can result in shallow and quick breathing, or hyperventilation, and the focus on these physical symptoms can trigger anxiety.

Hyperventilation – breathing too quickly – is not always sudden and dramatic, the way we see it portrayed on TV or in films. It’s often more subtle and chronic, the result of breathing shallowly through the chest, but it can still trigger the same cascade of anxiety symptoms. When we’re more relaxed, breathing happens in a slow and rhythmic way with the stomach gently expanding and contracting. To encourage this, you can practise a type of deep breathing called diaphragmatic breathing:

sit in a comfortable position and turn your attention toward your breathing;
place one hand on your chest and the other on your abdomen, right above your belly button;
try to move the location of your breathing from your chest to your abdomen, keeping your chest still while your stomach expands and contracts with each breath;
count each inhale and, when you exhale, think the word ‘calm’ or ‘relax’;
continue this practice for 3-5 minutes, while focusing on the feelings of relaxation this exercise creates.

Remember that you can’t eliminate risk

Perhaps you’ve tried the solutions presented above and they’ve helped. But you might still find yourself looking for a guarantee that these awful worries won’t actually come true. Unfortunately, this isn’t possible. Life is filled with uncertainty and we cope with this on a small scale nearly every minute of the day. Think about it: each morning when you have breakfast, you face the risk of choking to death on your toast – but you eat. When you enter the bathroom, there is no guarantee that you won’t slip and hit your head – but you shower anyway. Guarantees don’t exist in life and we tolerate uncertainty all the time. And yet it’s often hard to accept uncertainty in the areas that we worry about.

For some people, uncertainty feels the same as a negative outcome. They use worry, and worry behaviours, as a (faulty) means of warding off uncertainty and risk. How can I be prepared for every potential problem if I don’t consider all the possible outcomes? The short answer is: you can’t be prepared for everything. It’s impossible to consider every possibility and exhausting to try. And, paradoxically, the more you try to push these uncertainties away, the more frequent and intense anxiety becomes. Since uncertainty is a part of life that’s impossible to avoid, the goal is not to eliminate it but instead to acknowledge it, accept it, and learn to co-exist with it. Try the strategies below to help reduce distress and the struggle for control, and focus on your ability to cope and live life even with uncertainty.

1. When unproductive worry strikes, refuse to answer the ‘what ifs’ and instead use these coping statements to acknowledge, rather than squash, uncertainty:

I may never know for sure.
Maybe it will, maybe it won’t.
I can’t predict the future.
I’ll cope with things as they happen.
Risk is part of living.

2. If you find yourself getting caught up in your thoughts or anxiety, try a mindful grounding exercise to bring you back from imagined future catastrophes and into the present moment:

Pause for a moment and become aware of your feet on the floor.
Look around and notice three things you can see.
Listen carefully and notice three things you can hear.
List three things you can feel or touch right now.

While you might find the idea scary, by disengaging from attempts to achieve the impossible outcome of total certainty, you’ll be taking an important step toward refocusing your energy on things that matter right now.

Key points – How to manage worry in pregnancy

Anxiety and worry are common when having a baby: one in five women meets criteria for an anxiety disorder during pregnancy and postpartum. For women who experience medically difficult or high-risk pregnancies, these numbers can be even higher.
Worries are catastrophic or negative thoughts about the future. Productive worries are solution-focused and can be helpful to address current problems. Unproductive worries are about events that aren’t happening in the near future, have a low probability of occurring, and/or are out of your control.
Using cognitive behavioural techniques, you can counter unproductive worries by identifying them and challenging their veracity. A thought isn’t true simply because it crossed your mind, so try to stop accepting worries as gospel. To put anxious thoughts in perspective, take a step back to evaluate their accuracy.
Worry behaviours can make anxiety worse in the long term. These are behaviours that feel like they’re helping to reduce a threat but don’t ultimately lessen the likelihood of anxiety. Try replacing these behaviours with more beneficial activities that focus on self-care, social support or relaxation.
The physical changes that accompany pregnancy can lead to unpleasant bodily sensations that can mimic or trigger the body’s anxiety response. By using relaxation strategies, such as diaphragmatic breathing, you can counter these effects and lower stress and anxiety.
Some uncertainty is unavoidable during pregnancy, and fighting against this fact only escalates anxiety – in fact, the harder we push uncertainties away, the more anxious we feel. Getting away from trying to answer unanswerable questions or solve unsolvable problems can allow you to redirect your attention to the present moment and to experience your pregnancy in a different way.

Learn more

Researchers are still trying to understand why anxiety during pregnancy is so common. Anxiety is a built-in body system to protect us from threat, and it’s possible that the dramatic increase in responsibility for a vulnerable infant during pregnancy, coupled with the relative lack of control over outcomes, could be the trigger for anxiety systems to be switched on.

But the question is why only some women’s pregnancies trigger highly problematic levels of anxiety, while others seem to sail through with little or no anxiety. Hormones (including oestrogen and progesterone) might seem like the obvious culprit, but all pregnant women experience the hormonal fluctuations of pregnancy, and not all of them develop anxiety problems in response. One possibility is that there are individual differences in women’s genes and neurochemistry that affect how biologically sensitive they are to this hormonal flux. Hormones have many effects on multiple processes in the brain; untangling the ways in which this affects anxiety, and why some women are more vulnerable to these changes, is a vitally important project for future research.

There will also be important external factors. For example, all mothers will experience a sense of responsibility for preventing their baby from harm, but some of them might be particularly sensitive to messages about potential threat that come from the endless (and often conflicting) information available in the outside world. Pregnancy websites, blogs, podcasts and books, while often well-intended, can leave women feeling like danger is everywhere. This perfect storm of hormonal sensitivity, overestimation of risk and responsibility, and the stress that accompanies any role transition can lead to the experience of anxiety during pregnancy.

If you try the strategies in this Guide and still find that anxiety is a significant problem for you, it might benefit you to seek additional help from a therapist trained in cognitive behavioural therapy (CBT) and experienced in supporting people with anxiety disorders. If your anxiety is less severe, you might find that there are many things, such as those suggested here, you can try yourself. Experiment with what works for you: if a tool isn’t helpful, then modify it to fit your needs and preferences or focus on a different tool.

Trust yourself that you can solve problems if they happen. If you can break the cycle of anxiety by learning what worry is, and what is and isn’t helpful for you, then you can get back to enjoying the special moments of pregnancy as and when they arise.

Links & books

The book The Pregnancy and Postpartum Anxiety Workbook: Practical Skills to Help You Overcome Anxiety, Worry, Panic Attacks, Obsessions, and Compulsions (2009), which I wrote with the clinical psychologist Kevin Gyoerkoe, contains a series of simple exercises and worksheets to help you manage anxiety.

Another book, Worry Less, Live More: The Mindful Way through Anxiety Workbook (2016) by the psychologists Susan M Orsillo and Lizabeth Roemer, offers step-by-step exercises that build self-knowledge and self-compassion using mindfulness techniques.

The Headspace app is a great paid option for mindfulness exercises, and a free trial is available before subscribing.

Another app you could try is the CBT Thought Diary, which is a free app available to record and challenge your anxious thoughts. There is also a paid Pro version that offers some additional features.

A more comprehensive paid app is the CBT Companion, where you can learn and practise CBT techniques. It includes video lessons and meditation exercises to address anxiety.

Visit the website of the US-based organisation Postpartum Support International for information and resources on anxiety during pregnancy and postpartum.