Best Beginnings Episode 21: Dr. Fiona Challacombe on the anxiety that arrives with the baby

The thought that goes unspoken

There is a question that new parents sometimes cannot bring themselves to say out loud. It arrives at odd moments, unbidden: during a nappy change, in the car on the way to a routine appointment, in the small hours when the house is quiet. It has nothing to do with feeding or sleep or the hundred other worries that come with a new baby. It is darker than that. And for most of the forty years that clinical research has been paying attention to parental mental health, the people experiencing it were met with responses ranging from confusion to alarm.

Dr. Fiona Challacombe, Associate Professor of Clinical Psychology at the University of Oxford and the UK's foremost expert on anxiety and OCD in pregnancy and new parenthood, has spent two decades working out why. Her answer is at once specific and sweeping: for decades, we have been looking at the wrong condition.

The forty years spent looking at the wrong thing

The conversation around perinatal mental health has, for most of its existence, been a conversation about depression. Postnatal depression has had the campaigns, the headlines, the public profile. It has been the framing for almost everything.

What a landmark review published in the Annual Review of Clinical Psychology found is that anxiety disorders and related conditions are actually more common in the perinatal period than depression, affecting one in five pregnant and postpartum people. The research is relatively recent. The epidemiological evidence, Challacombe notes, has only been clear for a short while. The field has been catching up with a reality that many parents could have described long before the studies confirmed it.

The consequences of this lag are not trivial. They show up in clinical training, in the questions practitioners do and do not think to ask, and in the referral pathways that exist or do not. They show up most acutely in the handling of what is, clinically speaking, one of the most important presentations in perinatal mental health: intrusive thoughts.

The thought that is not a danger

Up to 17% of parents may meet clinical criteria for perinatal OCD at some point during pregnancy or the postnatal period. That figure comes from research Challacombe has been involved in, and it is striking. So is what happens when clinicians encounter a parent disclosing intrusive thoughts about harm without the framework to understand what they are looking at.

"There have been inappropriate social services involvement," Challacombe says, "when some follow-up questions might have really helped that person understand, and helped the clinician understand, that it really was OCD."

This is not a rare edge case. It is a recurring pattern, and its consequences are severe. A parent with perinatal OCD referred into a child protection system because a clinician misread intrusive thoughts as evidence of danger finds themselves in an environment that reinforces their worst fears rather than dismantling them. The experience of OCD is precisely that the thought feels like a signal of something terrible. The last thing that person needs is a system that appears to confirm it.

What Challacombe is clear about, from two decades of clinical work, is that parents with OCD are not a danger to their children. They are, if anything, extraordinary in their vigilance. "They are doing everything they can to move away from those thoughts, to suppress them, to kind of stay safe," she explains. "They are horrified by the fact that the thoughts are in their mind."

What the research shows about the bond

One of the most important findings from Challacombe's research is also one of the most reassuring. When her team studied parent-infant attachment in families where a parent had OCD, there was no statistically significant difference compared to families without OCD. The affective bond, the underlying love and connection between parent and child, was intact.

This matters for how clinicians frame treatment, and for how parents understand their own experience. The observational work did show something more nuanced: in high-anxiety contexts, difficulties can intermittently affect interactions. A parent with contamination concerns changing a nappy outside, away from familiar routines and a sense of safety, will find it harder. But the relationship is not damaged. The foundation is there.

The most effective treatment, Challacombe argues, addresses both the parent's own difficulties and the impact on parenting together, rather than treating the mental health condition in isolation and hoping the rest follows.

What good treatment looks like

The good news, and Challacombe is direct about this, is that effective treatments exist. Cognitive behavioural therapy with exposure and response prevention has a strong evidence base for OCD. SSRIs are available for those who prefer or need them. Perinatal-tailored CBT, adapted to the specific context of pregnancy and new parenthood, is what Challacombe and her colleagues are working to make more widely available.

The message she returns to, the one she wants practitioners to carry into their interactions, is simple: this is an understandable and treatable problem. Normalising that for parents is not a small act. For someone sitting with thoughts they believe make them monstrous, hearing that the experience makes sense and that it responds to treatment can be the thing that allows them to seek help.

There is also a growing body of work on intergenerational transmission: on what happens to children when an anxious parent is not supported. Challacombe ran an intervention, a light-touch group programme for parents with anxiety focused on breaking that cycle, that was the only research project she has ever run that was oversubscribed. Parents did not come because they wanted help for themselves. They came for their children.

The gap between need and access

The community infrastructure for perinatal mental health has been transformed over the last decade, largely because of advocacy from people with lived experience. The Maternal Mental Health Alliance, which brought together 140 organisations to make the economic case for investment, established that untreated perinatal mental health conditions cost society 8.1 billion pounds a year. It has produced real change: mother and baby units where there were almost none, community mental health services where there were gaps.

But the architecture still has significant gaps. Health visiting, as Challacombe notes, has been decimated. Structural inequalities mean that younger parents, those in more deprived areas, those from racialised communities and those dealing with multiple co-occurring challenges are the most likely to fall through. Loneliness and isolation, she says, are independent risk factors for perinatal mental health difficulties, and they are things we could do something about.

The model she points to is a familiar one: integrated services, under one roof, where mental health is not a separate destination with a stigma attached but part of the conversation from the beginning. Sure Start understood this. The challenge is building it again, with the evidence that now exists to make the case.

In the meantime, there is a community. Self-referral to talking therapies is available. Specialist services are there, and skilled at helping people find the right support. And the people who had the hardest experiences of this system, and came back to help change it, are still there too.

That, for Challacombe, is the source of her greatest hope.