Pregnancy has never been so anxiety-ridden as in the time of coronavirus. A patient recently told me, “My No. 1 priority is keeping my baby safe and healthy — but the thought of telling my in-laws that they can’t see their granddaughter makes me feel nauseated.” Apprehension about the future is a normal part of pregnancy, but with COVID-19 completely reshaping family life, new moms in particular are faced with unprecedented uncertainty and difficult decisions.
As a board-certified perinatal psychiatrist, I take care of women who are struggling with the transition to motherhood, some of whom suffer from pregnancy-related mental health conditions like postpartum depression and anxiety. While typically about 15% of women will experience a perinatal mood or anxiety disorder, a new pre-print, not yet peer-reviewed study is showing much higher levels of psychological distress for pregnant women during the pandemic, including increased levels of depressive and anxiety symptoms. Through my clinical work and the online community I co-founded for pregnant and postpartum women during the pandemic, I’m seeing an increase in a particular type of stress: women worrying about whether it’s OK to set boundaries with family in the postpartum period.
My answer is a resounding yes. In general, children who contract COVID-19 seem to show a milder form of illness. However, there have been reports of a subset of children becoming very sick, and the small amount of data that we do have suggests kids under the age of 1 are at higher risk for more severe illness.. Taking this into account, along with newborns’ immature immune systems, and that a fever in a newborn may require an emergency room visit and invasive testing (thus risking exposure to COVID), pediatricians are recommending that postpartum women limit social contact after bringing their babies home.
Pregnant people have dealt with restrictive labor and delivery policies as they have come up, but after they return home, there are fewer guidelines in place and anxiety tends to ramp up. Saying no is always hard, but it’s especially difficult when it comes to grandparents, siblings, or in-laws who are expecting to spend time with a cute new baby.
In some cases, families will need to invite grandparents or other helpers for childcare needs. This can be done with appropriate social distancing precautions in place. My concern is for mothers who are feeling pressure to entertain a parade of visitors, not helpers, as this not only poses a safety risk for everyone but also increases mom’s feeling of being out of control.
I’ve written previously about the importance of saying no and drawing boundaries as a parent — when mothers don’t make choices with their needs in mind, they are at risk of falling into martyr mode. In a global pandemic, it’s even more important that they prioritize their own well-being — another pre-print, not yet peer-reviewed study shows one-third of moms with children under the age of 18 months reporting signs of clinically relevant depression or anxiety. Setting limits and voicing your choices gives a sense of agency. It’s a way to exert control in a chaotic and scary world, and now more than ever, it’s critical for moms to focus on taking care of themselves and their families. While setting boundaries is not a substitute for professional treatment of a perinatal mood or anxiety disorder, it can be a coping strategy to modify your external environment and to manage stress levels. Here are some strategies for handling these difficult conversations and tips for how to feel more confident when setting boundaries.
Start early. If you can, set these boundaries before your baby arrives. Relatives will go through their own stages of grief when you set limits. It may take them a few weeks or even months to get to acceptance, so it’s best to be clear about your wishes postpartum well in advance.
You have choices. For most of my life, I accommodated other people’s wants and needs. In working with my own psychotherapist, I finally understood that I’m the only one who knows what works for me. Boundaries are a line in the sand. You can only draw your line; you can’t take responsibility for other people’s feelings. Even if those people are your loved ones. I now remind my patients that there are always three options to any request: yes, no, or negotiate. In this case, negotiation could look like grandparents arriving only after quarantining themselves or family members dropping new baby gifts outside the house.
Remind yourself why you need these boundaries. Whenever I need to have a difficult conversation or deliver bad news, connecting with the reason why I’m doing so helps me face the unpleasant task. Perhaps here, your values are safety or security for your family. Write your why on a piece of paper, and carry it with you to remind yourself why setting boundaries right now is important.
Don’t go to the hardware store for milk. We all have people in our lives who, no matter what, love to criticize. When you’re setting new boundaries it can be tempting to look for permission from friends or family members. If you’re expecting a demanding coworker or codependent sister to make you feel better about your limit-setting, you’re looking for permission in the wrong place. Surround yourself with others who respect your boundaries and celebrate your capacity to draw them.
Just because you feel guilty does not mean you are doing something wrong. If you struggle with people-pleasing, you will feel guilty when setting these limits.
Be clear and concise. When making these communications, provide a clear and concise rationale, and state your decision. Don’t ask for permission. Don’t over-explain. You want to be clear this is not a decision that is up for discussion. Especially if you have family members who historically have not respected boundaries, you will want to make sure this message is short and sweet.
If it feels too difficult to communicate the message over the phone, it’s OK to use email or to lean on your partner if you have one. If you find yourself backtracking when speaking in real time to a family member or loved one, consider delivering the message via email. You have time to carefully craft the message you want. You also don’t run the risk of conceding your limits out of anxiety or guilt. With email, there is no expectation of an immediate response. If a family member insists on rehashing, a simple “this is not up for discussion” will suffice. If you’re dealing with demanding in-laws, it can be helpful to use your partner as a gatekeeper as well.
Guilt doesn’t need to be your compass. When I work with women on setting boundaries and saying no, the most common pushback I get is “but I’ll feel so bad.” And this is 100% true. But guilt is just a feeling that you feel. It’s not a moral compass. Just because you feel guilty does not mean you are doing something wrong. If you struggle with people-pleasing, you will feel guilty when setting these limits. Setting boundaries is like building a new muscle. It hurts in the beginning, but as the muscle grows stronger it becomes easier over time.
It’s even more important for women who are at higher risk for perinatal mood and anxiety disorders, including those with a previous history of mental health conditions, women of color who have higher rates of maternal mental health issues and lower access to treatment, and women who have experienced traumatic births or have babies with medical issues to be setting firm boundaries right now. Yet women suffering from perinatal mood and anxiety disorders may have a more difficult drawing these limits with family or loved ones. If you find yourself struggling to make these decisions, consider seeking professional help; Postpartum Support International is a good place to start.
While the postpartum period looks very different right now than it did a few months ago, my hope is that women remember the locus of control exists inside each of us. The internal strength you build during this pandemic will stay with you for the rest of your life.
If you or someone you know is experiencing depression or anxiety during pregnancy, or in the postpartum period, contact the Postpartum Health Alliance warmline at 1-888-724-7240 or Postpartum Support International at 1-800-944-4773. If you are thinking of harming yourself or your baby, get help right away by calling the National Suicide Prevention Lifeline at 1-800-273-8255 or dialing 911. For more resources, you can visit Postpartum Support International.
Lebel, C., MacKinnon, A., Bagshawe, M., Tomfohr-Madsen, L., Giesbrecht, G. (2020) Elevated depression and anxiety among pregnant individuals during the COVID-19 pandemic. PsyArXiv PrePrint, https://psyarxiv.com/gdhkt/
Cruz, A., Zeichner, S. (2020) COVID-19 in Children: Initial Characterization of the Pediatric Disease. Pediatrics, DOI:10.1542/peds.2020-0834
Cameron, E., Joyce, K., Delaquis, C., Reynolds, K., Protudjer, J., Roos, L. (2020) Maternal Psychological Distress & Mental Health Service Use during the COVID-19 Pandemic. PsyArXiv PrePrint, https://psyarxiv.com/a53zb/