Stress in Pregnancy: How Much Should You Stress About It?

Hi Dr. Aviva: I am so worried about hurting my baby…. I keep reading how bad it is to be stressed in pregnancy – that it could cause my baby to be born premature. But I am under a lot of stress – I have a full-time job, have to help care for my parents, and well – money is tight. What should I do? 

In the past few years, particularly during and since the pandemic, it feels at times that stress has practically become our middle names, while trauma has become a center of focus at the intersection of the mental health and wellness space. Books, podcasts, and social media influencers on trauma have not only skyrocketed in number, but attention, sometimes garnering millions of followers and a lot of airtime. I can barely sit in a cafe these days and not accidentally overhear a conversation in which someone is talking about trauma. Along with this, intergenerational trauma has taken the stage, with an emphasis in the maternal health space on preventing inherited traits and behaviors from being passed onto our children. 

Additionally, in recent years, there has been increasing media attention on research into the impact of stress during pregnancy on the health of the baby. Studies have suggested being exposed to maternal stress in utero is associated with a wide range of risks—from impairments in fetal brain development, to increased rates of illness as infants, to changes in the microbiome in childhood, to higher rates of neurodevelopmental disorders later in life. 

All told, this puts an incredible amount of pressure on parents – but especially mothers – after all, it’s our stress hormones that may directly impact the baby, and as women, we tend to be on the lookout for things we need to do to prevent harm to our unborn children, so when we see headlines about the potential connections between stress or trauma and our babies’ health – naturally, it’s alarming. 

As mothers, we typically feel totally responsible for the physical, emotional, and psychological well-being of our babies and children. For many women, experiencing stress during pregnancy, with the awareness of the possible impacts of stress on their baby, fuels excessive guilt. It also creates absolutely unrealistic expectations for pregnant women to the point that many women believe we are supposed to remain happy, serene, blissful, and grateful throughout our pregnancies, we should ‘glow’ – and if we don’t, we could be causing our babies irrevocable physical, emotional, psychological, or spiritual harm now and long-term. 

“It’s all my fault” is sadly, an all too common, culturally ingrained mother’s lament. And click-bait titles like the 2023 Washington Post “A mother’s stress may change the makeup of her child’s microbiome” don’t help (incidentally, based on a likely flawed and unreliable paper published in Proceedings of the National Academy of Science, only reinforce the many things a pregnant mother might worry about! 

Not only are we facing all the natural stressors of being pregnant, and life – now we’re stressed about being stressed! But before you stress too much about stress during pregnancy, let’s explore the data and get some reality checks in place. 

What is Stress? 

We all know what this feels like. But what is stress, actually? The definition I prefer is “a state of mental or emotional tension resulting from adverse or very demanding circumstances.” I also think it's crucial to differentiate how stress shows up in our lives. Interestingly, there’s something called “eustress” – a form of ‘good stress’ that can create an optimal zone of performance – for example, many people do better on term papers when they’ve procrastinated until the last minute,  because the stress of the imminent deadline and the accompanying flood of a low level of stress hormones, actually increases focus! Similarly, small amounts of stress increase our immune function. 

But not all stress is good stress; Most of it isn’t. Stress that is mild, underlying, or transient is unlikely to be associated with any adverse health problems. But this is in contrast to moderate unremitting or severe chronic stress, or a perceived general lifetime of stress – a near-constant awareness of underlying emotional or psychological overwhelm or even strain which can be due to a host of factors including chronic exposure to financial strain, poverty, racism, genderism, illness, marital tension, or overwhelming life responsibilities,  and to acute stress, which may be caused by a sudden or major life change, loss, or trauma. It is these types of stress – often leading to distress – that are more typically associated with emotional, cognitive, or physical symptoms and even pathologic changes in our physiology.  

These symptoms may be a result of circumstances, as I’ll discuss further, that keep us from taking care of ourselves optimally, or due to the impacts of chronic exposure to the stress hormones adrenaline and cortisol, amongst others, that directly affect our physiology and health. 

How Common Is Stress in Pregnancy?

As common as stress is when we’re not pregnant, stress of many kinds, as well as stress-related mental health conditions, are exceedingly common in pregnancy – and have been on the rise in the past few years, exacerbated by the COVID-19 pandemic. 

What do the numbers tell us? Over 70 percent of pregnant people in the United States report experiencing at least one stressful life event in the year before giving birth. Meta-analyses show that between 18.2 percent and 24.6 percent of women reported elevated anxiety symptoms during pregnancy, with higher symptom severity in the third trimester. And 8–23 percent of infants in the US are estimated to have prenatal exposure to depression. Worldwide, it’s estimated that 10–35 percent of children are exposed to prenatal stress.

The most commonly reported stressors experienced during pregnancy include: moving to a new address, arguing with a partner more than usual, serious illness and hospitalization of a family member, and inability to pay bills. In addition, external stressors such as extreme weather events (eg, hurricanes, tornados, floods) and other global adverse events (eg, the coronavirus disease 2019 pandemic) may contribute to significant acute and chronic stress during pregnancy.

So if you’re pregnant and stressed, first things first: you’re not alone, it’s not just you, and importantly, and I cannot emphasize this enough, it’s not your fault!  

A Challenging Topic to Study

Since we can’t run randomized controlled studies in which we purposefully expose pregnant women to stressful situations and see what happens, the studies on perinatal stress are observational ones, and these can show correlation but not causation. In other words, it can be true and unrelated that a woman experiences stress in pregnancy, her baby has a health issue that may be associated with stress, but that the stress itself didn’t cause the problem. As economist and author Emily Oster explained, one major weakness of much of the research is that it’s hard to tease out whether the effects are due to the stress in utero or due to consequences of the stressful event or the circumstances in which the stress occurs.  

For example, the stress of caring for an aging parent on top of having a day job and a home and family to manage could mean mean that a pregnant woman is not sleeping enough due to worries, is skipping meals as she turns from one caregiving and job related task to another, or is even skipping exercise – or even her prenatal visits – due to lack of available time. Getting laid off may mean that a family no longer has enough money for nourishing food and prenatal vitamins. Is it the stress itself that may impact the mother’s or baby’s health, for example, the accompanying elevation in cortisol? Is it the accompanying impact on time for personal and prenatal care? Or is it a combination of both? 

Major stress is also more common among groups that are disadvantaged or marginalized in other ways. So, for example, the child of a mother experiencing chronic stress from living in poverty may also be affected by other factors that can negatively affect their health, like pollutants or poor nutrition. In addition, women who are extremely stressed during pregnancy often remain so after birth, so it’s difficult to isolate the effects of stress in utero specifically on later child outcomes.

There are almost always many possible confounding variables that are difficult to entirely control for in assessing the impacts of stress on health. 

So What About Stress and Your Baby? 

All of this said, there is some well-designed research that suggests that maternal prenatal stress—at least when it’s severe or chronic—can have an impact on the short-term and long-term health of her baby.

A 2016 study used decades of data on every birth in Sweden to look at the long-term mental health of children born to mothers who had experienced the death of a close family member during their pregnancy. The study was cleverly designed in order to determine if the effects were due to the stress in utero or due to other consequences of the stressful event: they compared the health of the children of mothers who experienced this loss during pregnancy with another group whose mothers had also experienced the death of a family member but shortly after birth. So in both groups, the families had experienced a major stress at a similar time but in only one group had it occurred during gestation. 

They concluded that when the mothers experienced this loss during pregnancy, there was a 12 percent increase in the likelihood their baby had a low birth weight, as well as a 12 percent increase in the risk of prematurity. When these babies became children, they had a 25 percent rise in the likelihood of using an ADHD medication. And when they were adults, they saw 13 and 8 percent increases in the likelihood of taking prescription drugs for anxiety and depression.

It should be noted that these are still fairly modest effects: The increased risk of preterm birth equates to an increase of 1 additional preterm birth for every 250 births. For ADHD prescriptions in childhood, the increase is 1 in 150 children. 

While the study was looking at a unique type of severe stress—the death of a close loved one—the researchers suggested it’s possible that other major life stresses, including financial stresses, could lead to similar impacts. For example, they estimated that in utero exposure to maternal stress from unemployment may lead to a 17.3 percent increase in the likelihood of ever purchasing a drug to treat ADHD in childhood, and 9 and 5.5 percent increases in the likelihood of ever purchasing drugs to treat anxiety and depression in adulthood, respectively. 

We also know that maternal distress that reaches the level of a diagnosable mental health disorder like clinical depression or post-traumatic stress disorder is associated with poorer birth outcomes. For example, one study found that women with depressive symptoms early in pregnancy had almost twice the risk of preterm birth, and the risk increased with increasing severity of depression, suggesting a dose-response effect. 

But severe and/or chronic maternal distress seems to be associated with small increases in the risk of preterm birth, low birth weight, and some behavioral and mental health issues later in life. A 2022 review concludes that maternal stress, depression, and anxiety is associated with an increased risk of child anxiety disorders, attention deficit hyperactivity disorder (ADHD), autism, schizophrenia, behavioral problems, and depression, as well as health conditions like obesity and infectious disease. 

It should be emphasized that not all stress in pregnancy is a problem. In fact, research suggests that children of mothers who are exposed to mild to moderate intermittent distress during pregnancy may actually see benefits in terms of neural development. 

How Stress Impacts the Fetus

We don’t yet understand exactly how stress impacts the growing fetus, but there are various theories. 

Many explanations lead to our inherent stress response, and the resultant elevated level of stress hormones that are produced, especially cortisol, which when chronically elevated, may alter fetal brain development, leading to developmental delays and mental health issues later in life. However, a 2015 review concluded that most studies did not find significant associations between cortisol concentrations and child outcomes. 

Others suggest the stress affects the fetus by affecting the proper functioning of the placenta, which typically protects the fetus from maternal stress hormones. There is also some evidence that stress can cause epigenetic changes (changes that alter gene activity without changing the DNA sequence) in the fetal brain and/or the placenta, potentially obstructing normal functioning and development. Other research suggests that there may be particular “critical periods” during gestation when the developing fetus is especially sensitive to the effects of stress.   

When it comes to the link between stress and preterm birth specifically, there’s a plausible biological explanation: there’s evidence that stress activates cells in the placenta, decidua, and fetal membranes to produce corticotropin-releasing hormone (CRH), which can in turn enhance the production of prostaglandins, the hormone-like compounds that initiate contractions, though studies have not consistently demonstrated a link between maternal stress, CRH concentration, and preterm birth.

As mentioned earlier, it could also be that maternal stress doesn’t impact the fetus directly but rather indirectly by the ways that people tend to cope with stress—often by sleeping less, eating less healthy food, and exercising less. Research shows pregnant women experiencing stress or mental health issues tend to sleep less, sleep worse, exercise less, and experience more exhaustion. They report eating more fatty foods and snacks and getting a lower intake of vitamins. 

And when it comes to the behavioral and emotional issues later in life that have been linked to prenatal stress, it could be that it’s not so much about prenatal stress itself but rather postpartum stress – women who are stressed during pregnancy may be more likely to struggle with mental health challenges after birth, which can negatively impact their parenting style.

Stress at Work

Working outside the home during pregnancy has become much more common. Among American women who had their first child in the early 1960s, just 44 percent worked at all during pregnancy. By the late 2000s, 56 percent worked full time during their first pregnancy. And about 82 percent continued in the workplace until within one month of their first birth.

Research has generally concluded that standard working conditions don’t pose a risk to maternal or child health so women with uncomplicated pregnancies can work until going into labor. And, of course, for many women, their careers are a source of joy and meaning. However, some jobs may increase risk of poor pregnancy outcomes, perhaps through a combination of being physically demanding, mentally stressful, and/or involving long or irregular work schedules. 

In a 2008 Swedish study, women working in manual jobs with low levels of job control and high levels of physical demands tended to have lower birth-weight babies and higher rates of preterm births. A 2019 meta-analysis concluded that working longer than 40-hour shifts was associated with miscarriage, preterm birth, low birth weight, and small-for-gestational age. Women working more than 55.5 hours (versus 40 hours) per week had a 10 percent increase in the odds of preterm birth.

Again, it’s important to keep in mind that, as with much of the research on stress and pregnancy, it’s hard to definitively say it’s the long and/or stressful work conditions that are causing these risks – it could also be that women who work these kind of jobs tend to have other disadvantages that impact their and their baby’s health.  

However, an 2021 survey of women surgeons in the US suggests that work stress might have an impact even among otherwise economically very privileged women. It found that 42 percent of the surgeons had experienced a pregnancy loss, more than twice the rate of the general population. And (compared with female partners of male surgeons) they were more likely to have had a major pregnancy complication (48.3 versus 27.2 percent). The surgeons operating 12 or more hours per week during the last trimester of pregnancy were at higher risk of major pregnancy complications compared with those operating less than 12 hours per week. 

There’s no doubt that most women in the US workforce (and elsewhere) are chronically exposed to a toxic culture of overwork, negative attitudes about women – and pregnancy – in the workplace, lack of paid leave and other support for working mothers/pregnant women, which means that for many women who depend on a paycheck, reducing chronic workplace stress during pregnancy isn’t an option. While there may be reforms in sight, the big ones we really need are still on distant horizons. So it unfortunately becomes yet another ‘to do’ on our daily checklist to find ways to nourish inner resilience and community support as we navigate becoming mothers in environments that don’t truly support us – and worse – may be the source of some of our greatest stress. 

The Impact of Stress on Pregnant Mothers’ Health

Speaking of mother’s health…

We’ve talked about the impact of stress on your baby during pregnancy, which so many women put as their top concern. But what about the impact of stress on you and your pregnancy health? 

Pregnancy, because of the intense demands it places on our bodies, along with the incredibly profound emotional and social changes we go through in becoming mothers, has sometimes been referred to as ‘a natural stress test.’ The extra demands may bump up against our vulnerabilities to cardiovascular disease, diabetes, depression, and other conditions. 

Some research does show a correlation between chronically elevated stress levels in pregnancy and various adverse outcomes, such as increased risk for gestational hypertension, preeclampsia, and gestational diabetes. One study reported that chronic hypertension, in combination with high stress before or during pregnancy, was associated with a dramatically increased risk of preeclampsia. Not all studies have come to the same conclusions; several have not found a correlation between psychosocial stress and development of gestational hypertension or preeclampsia later in pregnancy.

While we’ve now spoken about stress and physical health, it’s important to address maternal mental health. In the past few years there’s been not just growing awareness – but growing incidence of – maternal mental health challenges during pregnancy and postpartum, anxiety and depression topping the list. The mental health of pregnant women is of paramount concern, as conditions such as anxiety and depression can be exacerbated by stress, leading to a higher incidence of postpartum depression and anxiety. So awareness of our own levels of stress – and honest communication with our healthcare providers about it – may help us to prevent or more quickly detect levels of stress that could more significantly impact our mental well being now or down the road. 

Various studies have found high levels of stress of different kinds during pregnancy correlate with a higher risk of postpartum depression. A few studies suggest that stress related to the pregnant woman’s relationship is especially linked to postpartum depression, underscoring the importance of supportive healthy relationships during pregnancy. Meanwhile, a recent study that looked at the effect of the COVID-19 pandemic found that women with high levels of pandemic-related perceived stress during pregnancy had higher rates of postpartum anxiety symptoms.

Again, however, this begs the same question: How much stress? For how long? And is it the stress itself, or is it the circumstances causing the stress, the impact of stress on our ability to care for ourselves optimally, or some combination of all of these factors?

We do know that chronic, relentless, insidious or overt stress can lead to substantial allostatic load, including during pregnancy. Allostatic load is the cumulative burden of chronic stress and life events that may impact our health mediated primarily by cortisol and adrenaline through the Hypothalamic Pituitary Adrenal (HPA) Axis. Allostatic load creates “wear and tear” on your body – in fact cortisol, the primary chemical behind the stress response, is nicknamed the wear and tear hormone. All of this can lead to us getting sick. Physically. Mentally. And on top of that, high allostatic load is associated with worse health outcomes. 

How You Can Reduce Prenatal Stress

Talking about the impact of stress on pregnancy feels – well – stressful and burdensome. The last thing I want to do is add more stress or worry for you to be anxious about. And the other last thing I want to tell you to do is ‘just relax’ because that never really helps, either!  

But, as trite as it sounds, the truth is that stressing about stress doesn’t help at all —it usually just makes it worse. Awareness about stress can help us begin to take ownership of what we can change to bring us more ease and peace. 

The reality is we all experience stress from time to time if not daily. Few of us can fully eliminate stress from our lives, none of us can prevent the unknown from happening while we’re pregnant, and many many pregnant women – and this may be the case for you, too – live with chronic stressors like racism that have an insidious impact and about which you can do little to change systemically. And as if mothers didn’t already have enough to worry about, this is really just not a fair burden.

It’s also why, however, in addition to eating well, exercising, and doing the other things we do to be optimally healthy when we’re pregnant – it’s important to add checking in with ourselves about our stress levels regularly to our self-care list in pregnancy – and beyond. It helps us to take stock of what we can shift and change, how to proactively and self-protectively cope with what we can’t change, and when we need help managing stress levels that just feel too much to bear on our own. 

Here are important steps you can take to manage the stress in your life that you do have control over and importantly, to build stress resilience, including for those things you can’t immediately change:   

• Learn to recognize the symptoms of stress, including those that are not always obvious. Stress shows up in many ways – the most obvious is ‘feeling stressed out.’ But hidden symptoms of stress are also important to be aware of and may include: irritability, anxiety, depression, poor sleep, changes in appetite (more or less), weight gain or weight loss, cravings for sugar, alcohol, cigarettes, etc, headaches, stomach aches, digestive problems, fatigue, low sex drive, and more. 
• Develop tools for reducing and managing stress in your life: substantial numbers of good quality studies reinforce the value and effectiveness of simple practices that you can easily make a part of your daily life including meditation (an app like Insight Timer can easily get you started), yoga (which you can do at home with any number of free streaming classes or paid subscriptions), journaling (listen to my podcast or read my article on The Worry Journal for a practice you can start today), time in nature, warm showers, and dancing it out, and listening to music are just a few examples. 
• When you’re stressed it’s often the hardest time to focus on self-care, but do your best to prioritize sleep, regular exercise, and a balanced diet. This will not only help you to be more stress-resilient, but may be an important way to buffer the potentially harmful impacts of chronic cortisol exposure on your well-being. 
• If you’re experiencing a chronically stressful situation, try your best to carve out moments of relaxation and calm. In this way, you can try to convert chronic stress to intermittent stress, which is healthier for both you and your baby. 
• Connect with other mothers: not only will this help you to realize you’re not alone in your worries, but social connections increase levels of hormones like oxytocin and DHEA that mitigate stress and help us to feel more courage and confidence. 
• Ask for help from loved ones. One 2021 study surveyed mothers on both their stress levels and their levels of social support during pregnancy. They found that those who reported both high stress and low social support were at increased risk of having babies who were temperamentally unpredictable, while prenatal stress by itself had no impact on the infants’ overall temperament. “Support of others,” the researchers concluded, “can reduce the impact of prenatal stress.”
• Seek out mental health care. Even if you can’t eliminate the source of your stress, support from a mental health professional may help you better manage it. Yet in one study, over 70 percent of women did not self-disclose symptoms of anxiety and depression because they regarded their feelings as a natural part of pregnancy. Consequently, only 15 percent received treatment, like psychotherapy. 
• Remember that even if stress during pregnancy does impact your baby, its effects can likely be alleviated by sensitive, responsive parenting after birth. In one 2022 study, children who had been exposed to elevated maternal distress during pregnancy did not display negative outcomes – decreased cognitive functioning and higher negative emotionality – if they received high-quality caregiving from their mother after birth. Other research suggests secure attachment with their mother protects children from the negative impacts of maternal mental health issues during pregnancy.

What Practitioners Can Do

• Screen for maternal mental health issues throughout pregnancy. Since 2015, the American College of Obstetricians and Gynecologists has recommended that clinicians screen patients at least once during the perinatal period for depression and anxiety symptoms, using validated tools like the Edinburgh Postnatal Depression Screen and the Perinatal Anxiety Screening Scale. In the last several years, the Perceived Prenatal Maternal Stress Scale was developed to aid in the early detection of stress among pregnant women and timely intervention by health care professionals. 
• Decrease stigma and talk about maternal mental health. Because of the stigma around mental health challenges and the cultural expectation that women feel happy during pregnancy, it can be difficult for women to bring up how much they are struggling. It’s important for health care providers to be proactive about asking about stress and mental health during pregnancy. One study found the main reason that women disclosed their symptoms of anxiety or depression during pregnancy was because their midwife asked about their mental health, whereas the main reason they didn’t disclose was because their midwife didn’t ask them. Unfortunately, many providers, including midwives, obstetricians, pediatricians, and family medicine practitioners report feeling like they don’t have the knowledge and skills to do so. 
• Offer early, evidence-based treatment. A few evidence-based programs for pregnant women with mental health issues exist. One that has been tested in a few randomized trials is the Mindfulness-based Childbirth and Parenting (MBCP) program, which is adapted from Mindfulness-based Stress Reduction. 
• Avoid inducing more stress in pregnant women. As a 2022 article notes, when communicating with pregnant women about these risks, it’s important to emphasize that “pregnant women are not responsible for negative outcomes of their unborn child due to their own stress or mental disorder.” 

As a society, we absolutely need to reduce the amount of stress pregnant women experience. We need social reforms on every level – from food and housing and job security, to access to trauma-informed, compassionate, respectful, caring care during pregnancy, birth, and postpartum, to paid leave in pregnancy and beyond, determined by our personal needs, health needs, and later, readiness to return to work, should we need to or so choose. Life is also really complex – sometimes we do need to change jobs, homes, cities during a pregnancy, we may experience a loss in our lives, or, as we saw with the pandemic, larger crises over which we have zero control may arise. 

What we also learned from the pandemic, and what I’ve seen in pregnant women and mothers is that we are incredibly strong and capable and resilient and so are our children. We are all doing our best with what life hands to us – so taking the blame off of ourselves, off of each other, and giving ourselves more credit for all the things, within our control, whether it’s taking that prenatal vitamin, getting that extra protein, going to that yoga class (even if it’s on line), and staying connected to other mothers in your life – all of which help support and protect our babies’ health – is a great place to start.

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