Obsessive-compulsive disorder (OCD) in women during pregnancy and postpartum is often under-recognised and undertreated, and it can have a significant impact on the health of the mother, the infant, the family, and the mother-baby relationship.

Women with OCD may experience repetitive and forceful, disturbing thoughts centred around the safety and wellbeing of their baby. The mother may experience:

It is typically referred to as either prenatal OCD or postpartum OCD, based simply on whether the symptoms occur during pregnancy or after childbirth. Women who suffered from OCD prior to pregnancy may experience an exacerbation of symptoms.

Why so many mothers stay silent

First and foremost, mothers are often unwilling to disclose their symptoms due to guilt, shame, and fear of judgment by loved ones or healthcare providers. For reasons not fully understood, the perinatal period (from pregnancy to 12 months after childbirth) is a particularly vulnerable time for OCD symptoms to appear, whether as entirely new symptoms or a recurrence of OCD after a period of remission.

Women can also be diagnosed with OCD for the first time during pregnancy and postpartum. Women who have never been diagnosed with OCD can develop OCD symptoms following childbirth. Major depression is the most common co-occurring disorder, and one study found that over 40% of women with postpartum major depression also experienced repetitive, intrusive, unwanted thoughts of harm befalling their infants.

What does perinatal OCD look like?

All new mothers experience anxious thoughts — it's considered normal, and part of adjusting to the new circumstances. Unfortunately, these anxious thoughts can transform into thoughts and images of harming the baby, such as:

Other thoughts involve harm coming to the baby, such as:

These thoughts are, in fact, quite disturbing to any mother — imagine the plight of a mother suffering from OCD, tormented by these thoughts repeatedly, all the time.

These thoughts are generally regarded as "harming infant thoughts," and are experienced by mothers as frightening, shameful, and unacceptable. Women with OCD experience their obsessions as highly distressing and unwanted, and are horrified by them. These obsessions can also present as intense images of injury, death, or thoughts of physical or sexual harm.

Excessive preoccupation with the baby's safety, or complete avoidance, can be a result of these obsessive thoughts. Related compulsions include excessive checking behaviours (frequently checking on a healthy, sleeping infant), over-attachment to the infant, excessive cleaning and washing behaviours, avoidance of the infant, and seeking repeated reassurance about the infant's health and wellbeing. Attachment and bonding between mother and infant may become disrupted, with potential negative effects on infant development.

OCD and the mother-infant bond

Difficult attachment between mother and infant can show up in many different ways. At times, the mother has a hard time being away from her child and may not allow others to care for her child. On the other hand, some women may avoid their infant entirely, or refuse to be alone with their infant, for fear of acting out their obsessions — relying totally on others to care for their child. These behaviours result in impaired mother-infant bonding.

Treatment of perinatal OCD

Like any other period, OCD in the perinatal period is managed with medication and Cognitive Behavioural Therapy (CBT). Serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and benzodiazepines (BZDs) are commonly used to manage OCD symptoms. Other treatments, such as repetitive transcranial magnetic therapy and biofeedback relaxation, are also effective in managing OCD.

Is medication safe?

The decision to take medication while pregnant or breastfeeding can be a difficult one, especially for a woman already grappling with fears of contaminating her child.

First-line medication treatment for OCD involves the use of SSRIs to target OCD symptoms. SSRIs are the most studied medication in pregnancy and lactation, and are considered relatively safe for use in pregnancy and lactation when compared with the risks of untreated anxiety and OCD. Medication will be suggested in case of severe symptoms that are getting in the way of day-to-day functioning.

While SSRIs are thought to be relatively safe, they are not without risks. SSRI use has been linked to preterm delivery and smaller babies, but it is unclear whether this is due to the medication alone or the severity of the underlying anxiety or depressive symptoms. When the results were re-studied after adjusting for confounding factors, the risks with SSRIs were no greater than in the general population.

In up to 30% of infants exposed to SSRIs in the third trimester, there can be a short-term increase in irritability, jitteriness, and lethargy. This is a time-limited condition, and infants go on to show normal development through infancy. A close, collaborative care approach between the treating paediatrician and psychiatrist is recommended.

Other medications used in the treatment of OCD include tricyclic antidepressants, especially clomipramine. Research suggests a mild probability of congenital defects with certain TCAs, but when confounding factors were removed, there was only a very slight increase in the risk of malformations that can be detected through a collaborative care approach.

Using medication during breastfeeding

Very small concentrations of SSRIs are secreted into breast milk, limiting the infant's exposure. There is no evidence of developmental delay in infants exposed to SSRIs through breast milk, and they are considered compatible with breastfeeding. While less is known about the safety of other medications commonly used to treat OCD, this doesn't mean they are unsafe — it means there is less published research on their use in the perinatal period.

At the end of the day, women must weigh the pros and cons for themselves, and discuss their options with their psychiatrist or physician. Perinatal OCD is a significant obstacle to maternal bonding and infant development, and in some cases, using medication to help restore that bond may outweigh the risks of the medication itself. Other therapies, such as repetitive transcranial magnetic therapy and biofeedback relaxation, are considered safe augmenting treatments.

Deep TMS for OCD

Deep Transcranial Magnetic Stimulation (Deep TMS) can help OCD by changing the activity of brain circuits involved in obsessive thoughts, error signals, anxiety, and compulsive urges. It is different from regular TMS because the coil is designed to stimulate deeper and broader areas of the brain.

How Deep TMS works for OCD

1. It targets the OCD circuit. One important target is the medial prefrontal cortex (mPFC) and anterior cingulate cortex (ACC). OCD is associated with dysfunction in these circuits, which are responsible for "just right" responses.

2. Magnetic pulses change brain activity. The Deep TMS coil delivers repeated magnetic pulses through the skull, producing small electrical currents in the brain that can modify the activity of the targeted neural networks.

3. It may reduce the "alarm" that drives compulsions. In simple terms, OCD can make the brain's error/threat alarm go off unnecessarily. Deep TMS aims to normalise activity in the relevant circuit, so intrusive thoughts may produce less anxiety and urgency, making it easier to resist compulsions.

4. It can reduce OCD severity.

What improvement might feel like

If you respond to treatment, you may notice:

Deep TMS doesn't necessarily make intrusive thoughts disappear completely. The goal is often to make them less powerful and easier to ignore — ideally allowing you to use ERP or CBT more effectively.

Will Deep TMS change my normal thoughts?

Usually, no. Deep TMS for OCD is not intended to change your normal personality, values, memories, or ordinary way of thinking. It is intended to reduce the brain-circuit activity associated with OCD symptoms. The FDA-cleared OCD indication specifically targets OCD circuits, rather than trying to alter a person's overall personality.

How Exposure and Response Prevention (ERP) helps with OCD

Exposure and Response Prevention (ERP) is one of the most effective psychological treatments for OCD. It helps people gradually face the situations, thoughts, or feelings that trigger their OCD, while learning not to perform compulsions or rituals.

OCD often follows a cycle: trigger → obsessive thought → anxiety or distress → compulsion → temporary relief → a stronger OCD cycle. ERP works by breaking this cycle.

1. Exposure. During exposure, you gradually and safely face the situations, thoughts, or sensations that trigger OCD anxiety. For example, someone with contamination OCD may gradually touch something they consider unclean; someone with checking OCD may practise leaving home without repeatedly checking the door. Exposure is carefully planned and increased at a manageable pace, usually with guidance from an experienced OCD therapist.

2. Response prevention. After facing the trigger, the person practises not performing the usual compulsion — for example, "I feel like I need to wash my hands again, but I will allow the anxiety to be there without washing," or "I am uncertain whether I locked the door, but I will resist checking again." Over time, the brain learns that anxiety and uncertainty can be tolerated without performing a ritual.

What does ERP teach the brain?

With repeated practice, ERP can help you learn:

Does ERP make intrusive thoughts disappear?

Not necessarily — the goal of ERP is not to eliminate every unwanted thought. Instead, ERP helps change your response to those thoughts. A thought that once felt urgent or frightening may gradually become less important, and easier to let pass without performing a compulsion. Before ERP, a thought might feel like: "What if something bad happens? I need to check again." With ERP practice, it becomes closer to: "This thought is due to my OCD — it's a false alarm, there's no need to check again."

OCD compulsions are not always visible. Some people repeatedly analyse, mentally review, seek reassurance, compare feelings, or try to cancel unwanted thoughts in their mind — ERP can address these mental rituals as well as physical compulsions.

ERP is usually introduced gradually and personalised to the individual's OCD symptoms. Working with a therapist who has specific experience treating OCD can help make exposure exercises appropriate, structured, and manageable.

The goal of ERP is not to change who you are. It is to help you regain control from OCD, so that your thoughts and actions are guided more by your values than by compulsions.

If intrusive thoughts about your baby are keeping you up at night, you are not alone, and you are not a danger to your child. Perinatal OCD is treatable. Reach out to a perinatal mental health specialist to talk through what you're experiencing. For a broader look at emotional wellbeing through pregnancy, see Pregnancy and Your Mental Health: What to Expect, and When to Ask for Help, or read about Depression During Pregnancy and After Birth.

Dr. Swetha Reddy. S

Dr. Swetha Reddy. S

MBBS · DNB (Psychiatry) · Consulting Psychiatrist, Co-founder & Director at Synapse Mind Clinics. Read full bio →