Jamie got pregnant immediately. She and her husband were delighted. “We didn’t think anything could go wrong.” Jamie pauses. “It”—the “it” being the possibility of a descent into all-consuming fear—“didn’t even register.”

What did register were the damaging effects of nitrates and the dangers of aspartame. Jamie poured all of her occupational and educational energies into the project of the uber-baby. “I was laser-focused on, like, I wasn’t going to destroy my baby by eating a turkey sandwich! I didn’t even think to worry about anything with me.”

It started somewhere in the second trimester. She began to notice herself engaging in strange behaviors, almost as if they were independent of her. She read an article about women who go in for an exam in late pregnancy only to discover that the baby’s heart is not beating, and then have to deliver the stillborn baby. Stillbirth became the terror at the center of her world. She fixated on her son’s kicks, and he never seemed to kick enough. The doctors would tell her he was fine, but she never believed them. My baby is going to be born strangled, with the cord around its neck, she thought. I’m going to give birth to a dead baby. She lay awake at night thinking this over and over, then running through the conversations she would have with doctors if and when it happened. She wondered how she would react. How she would get over it.

Jamie started going into her OB’s office several times a month, and then several times a week, just to listen to her son’s heartbeat. The office employees got to know her so well that a nurse would let her bypass the typical check-in and go straight to an exam room to listen. No one thought to pull her aside and mention anxiety as a potential problem. Nobody said, “This isn’t normal.” Sometimes they would roll their eyes, telling her, “You’re fine, sweetheart! “You have a healthy baby, a healthy pregnancy.” It was never enough. Eventually, Jamie bought herself a heartbeat monitor on Amazon in order to listen at home whenever she wanted.

At home, she was constantly collapsing in panic. She adhered to all the rules—not a drop of caffeine or a slice of lunchmeat—feeling like that should quell her anxiety. If she could just do everything right. She thought if she just executed her pregnancy meticulously, perfectly, obeyed every command from the medical pantheon and every warning on Google, checked and monitored and devoted her total cognitive capacity to her unborn child, she would be okay. She had a half iced tea/half lemonade from Subway after a doctor told her caffeine intake really didn’t matter, and then she read somewhere on a blog that caffeine was terrible for her baby. She could barely function for days. Her anxiety reinforced itself, solidifying within her. Not a day of her third trimester went by that she did not envision a stillbirth.

Jamie’s pregnancy crept past her due date. The anxiety of those final days was excruciating, and finally she went into the hospital late one night with a concern and they agreed to induce her. They broke her water, gave her an epidural. Unfortunately, it didn’t seem to work: each time she had a contraction, an electric pain flared in her butt and rocketed down her leg to her foot, as if a long bone there was being forcefully broken over and over. They gave her another epidural. It had no effect: the pain ignited with fresh force whenever a contraction kicked up. At one point she screamed,“I’m being electrocuted!”

No one took her seriously. Her baby weighed 9 pounds, 11 ounces, and faced the wrong way, bearing down on her sciatic nerve: the longest and largest nerve in the body, running from the lower back down the legs. This was causing the brutal electric jolts, but no one thought to investigate further. “Everyone thought I was just a snowflake.” Her husband told her at one point to settle down.

The baby would not come out. After twelve hours of labor and incandescent pain, the doctor agreed to give her a C-section. Her baby was born. “The best way I can describe it is: when they took out the baby, they took out my joy. If joy was like a color or a cloud, you would just see it sucked right out of my tummy.”

They handed Jamie her son, and she could not care less. She had no energy or emotion. “I was a zombie; I was completely empty.” After coming from the hospital, she cried constantly. After three or four days of this, she called her gynecologist and said, “Something is seriously wrong with me.” The gynecologist said it just sounded like the baby blues, but prescribed Zoloft. She said they’d only give Jamie thirty days’ worth, and then Jamie would have to meet with a therapist to get more. “What size dose do you want?” the gynecologist asked. “I want all of it,” Jamie said. It took weeks to take effect.

That first month was an experience of breakdown. She was hysterical every day. She was not producing enough milk, but she refused to bottle feed because she’d read something that insisted it would harm the development of her son. He started losing weight, and Jamie went constantly to the pediatrician’s office. A different doctor saw her for each visit, and during each she sobbed. She sobbed when they weighed him. She sobbed when they checked him for jaundice. She sobbed when they took her milk. Her husband or her mother accompanied her for every appointment, because she would not travel alone with the baby; she was terrified to be by herself with him. What if she got in a car accident? What if she had one of those after-pregnancy strokes, what if she was one of the women who have blood clots after cesareans?

Meanwhile, she obsessed over her son’s breathing. Jamie wanted to do everything in her power to prevent his airway from being blocked. She had two vibrating swings, two pack and plays, and an assortment of fluffy infant seats in her living room alone. Her goal was to be able to see the baby facing her no matter where she sat. Still, she would check his belly repeatedly to see if it was moving. She’d be in the middle of a conversation and would walk over and lay a gentle hand on his tummy. “What are you doing?” A friend or family member would ask. They’d help reassure her, but a few minutes later she would go back and check again.

Meanwhile, Jamie was having intrusive thoughts about suicide. She would go online and research how mothers had killed themselves. She’d read and reread the stories. Years later, as she was talking to me, she was still familiar with all of them. The one who went to Dick’s Sporting Goods right before a birthday party and shot herself and her son in her backyard. “I think her husband started a foundation.” The one who stabbed her son and then herself to death. The one who drove off a cliff. She was awed by their bravery. She idolized them. These women found their way out of the relentless degradation of the fear with decisive action; in their minds, they’d saved their children while she was too chicken. She read the stories over and over again, copying the names and pasting them into Google in quotes to make sure she hadn’t missed another from a different news outlet. She circled back to them regularly to see if there were any new comments; she wanted to see if anyone would say, “She could’ve gotten help here.” But no one did.

Jamie developed a plan. If she didn’t feel better in three months, she’d throw herself off of a nearby overpass.

One day when the baby was one or two months old, Jamie was in the car with him and her mother, returning from a shopping trip. The car was stopped in traffic, and her mother was talking on the phone. Jamie kept looking in the backseat to check Killian’s breathing, and she started thinking, open the door and run. Just open the door and run. It was a beautiful, sunny day. Her mom was so happy. There was a little grassy strip dividing their side of the highway from oncoming traffic. It would only take a minute to cross it and run into the rush of cars. Just be brave, Jamie told herself, just do it. Open the door and go. You’re such a pussy! Just do it! She started to count down, three, two, one, go. All she had to do was run across the grass and someone would surely hit her. Three, two, one, go. She couldn’t. Again. Three, two, one, go. Then the car rumbled into motion and they all went home.

* * *

The grooming of mothers as risk managers begins in pregnancy, with a culture of risk aversion so extreme that upon close examination, it starts to look pathological. In an article for The American Journal of Bioethics, OB-GYN Howard Minkoff and bioethicist Mary Faith Marshall explored the implications and the repercussions of this culture and its central tautology: the only acceptable risk is no risk at all. They open their piece with a quote from an editorial in The Lancet on home birth: “Women have the right to choose how and where to give birth, but they do not have the right to put their baby [sic] at risk.” Minkoff and Marshall marvel at the significance of such a claim.

First, they point out that the one major US study that inspired the response in The Lancet places the risk of neonatal death in a home birth at 1 in 1000. For The Lancet editorial’s author, this risk is unacceptable and women who take it “do not have the right,” or rather, should not. Yet like so many claims of risk in pregnancy and childbirth, this one turns out to be not absolute but relative.

The risk of home birth is double that of hospital birth, which can be made to sound alarming without the qualification that 1 in 1000 remains a very low risk. The risk associated with home birth is also the same as the risk of neonatal death in a rural hospital. Very few OB-GYNS would claim a woman does not have the right to give birth in a rural hospital, yet people who choose to have home births still face stigma and judgment. This in spite of the fact that home births are associated with fewer interventions, C-sections, hemorrhages, and infections, and with lower rates of preterm birth, prematurity, and assisted newborn ventilation. Minkoff and Marshall question the ethics of using alarmist rhetoric to deny women the nuanced and complex choice between home and hospital birth. They claim this ultimately impinges on pregnant women’s bodily and personal autonomy.

Plus, they argue, if we follow the logic that “women do not have the right to put their baby at risk,” then “a laundry list of anodyne activities would be off-limits to pregnant women”: going outside during thunderstorms, driving, riding a bike. It is possible to follow this logic down a narrowing path that leads to a paranoid bunker of counterintuitive and illogical risk prevention, and this is precisely what many pregnant women do.

Philosopher of ethics Rebecca Kukla has written extensively about the bioethics of risk in pregnancy and describes an American cultural tendency to fetishize reproductive risk over other types, demanding a purity and absolutism in this context that would be seen as absurd in everyday life. In a report for The Hastings Center in collaboration with the Obstetrics and Gynecology Risk Research Group–a host of bioethicists, anthropologists, and doctors–Kukla argues that the framing of risk in pregnancy is magical thinking, divorced from evidence-based patient care and arising from deeply rooted, historic obsessions with the purity of the pregnant body. In this purview, a sip of beer is poison; an allergy medication a silent assassin. Even the word we use for substances that may cause reproductive harm—teratogens—is derived from the Ancient Greek root teratos, or “monster.” The overtone here is not so much medical as moral. “Risk in the context of contemporary childbirth,” writes medical anthropologist and midwife Mandie Scamell, “can be seen to operate more as a moral discipline than a scientific calculation of probability.”

Much like the medieval woman struggled for purity by banishing evil, sinful thoughts from her mind lest she imagine her child into a monster, the contemporary mother must banish any and all potential contamination from her body lest she mar the perfection of her unborn child. In this magical thinking, risk acts as a supposedly neutral, medical proxy for the moral, social values of abstinence, penitence, and what sociologist Elizabeth Ettore has termed “reproductive asceticism”: under the whip of societal shame, a woman must get her body, her psyche, her self into a regimen of obedience and denial in preparation for motherhood.

In pregnancy, as in many other contexts in contemporary American life—environmental sustainability, health and wellness—risk is seen as wholly dependent on the individual and his or her personal choice. Just as individuals are asked to, say, take fewer flights or eat less meat, in lieu of corporations being asked to seek alternative energy sources or build fuel-efficient vehicles, pregnant women are asked to control their bodies instead of corporations, government, or social institutions being asked to mitigate the larger factors that put mothers and children at risk. What should be matters of public concern instead become risks managed by obsessive private vigilance. Searching a modern academic library catalogue with the term “pregnancy,” Rebecca Kukla found that 80 percent of subheadings were associated with the toxins an expectant mother must avoid: certain types and quantities of food, alcohol, tobacco, caffeine, and other drugs. Largely ignored in the literature are race, poverty, male violence, and other economic and sociocultural factors that cannot be entirely controlled by the individual pregnant woman and pose far greater risks than a cup of coffee. The responsibility for “making good choices” falls on the pregnant woman, leaving, as Kukla writes, “corporations, fathers, insurers, legislators, and others” off the hook.

Even government acts that seem to claim public responsibility for risk in fact often shift the burden onto the individual pregnant woman. This is on blatant display in California’s Proposition 65, a 1986 law which mandates that businesses post a warning if their buildings or products contain any of 750 listed chemicals known to cause cancer or reproductive harm. Incredibly, the law does not demand that businesses actually test for these chemicals, nor does it ask them to state which ones are present and in what quantities. It simply asks them to post a warning sign, now ubiquitous in California, stating the possibility of reproductive harm. The onus is then on the pregnant woman to make an “informed decision.”

However, as Kukla argues in an incisive article for Health, Risk, & Society, this is impossible when the signs offer neither quantitative nor qualitative information. The pregnant woman is left only with the warning and the possibility of reproductive harm, and her choice—as in so many other areas, from the most minor decisions to the most powerful ones—is reduced to a simple yes or no. This dichotomy is not only reductionist, it is frequently nonsensical. A woman can avoid any and all objects and institutions with Prop 65 warnings without ever knowing whether or not she is actually preventing any harm, and without knowing whether having used those objects or entered those buildings might have actually conferred benefits greater than any risk of harm. One of the buildings with a Prop 65 warning is the prenatal clinic run by the University of California at San Francisco. Should women avoid this clinic because of the sign, therefore foregoing prenatal care or seeking it elsewhere at a clinic of lesser renown? Is this a smart calculation of risk or a bizarre, unnecessary tradeoff? This is risk as maddening labyrinth.

These omnipresent Prop 65 warnings, Kukla writes, “entrench an implicit and impossible ideal of zero risk”; they suggest that a woman can and should avoid any and all possible danger, even though this is physically impossible. But just as no one is measuring the actual chemicals in the buildings and objects that might contain them, no one is studying how creating an obsession with the total eradication of risk might carry its own significant risks to both the mother and her child.

Insisting on zero risk to the fetus may actually cause harm to the mother. In another article by the Obstetrics and Gynecology Risk Research Group, the authors cite the examples of doctors who refuse to take diagnostic X-rays of sick pregnant women despite significant scientific evidence that shows no effect on the fetus from a single X-ray, and doctors or insurance companies who won’t allow a vaginal birth after cesarean (VBAC) because of a .00046 percent risk of uterine rupture. In the latter case, the risk is the same as that of a woman giving birth vaginally for the first time, but slightly higher than that of a typical second birth. This reasoning alone is the impetus for the decision. Woman’s values and experiences are ignored. The pursuit here actually becomes neurotic and absurd, looking much like mental illness. In this light, a woman’s desire to hide all her knives, to refuse to let her child touch animals, to never allow a single food additive into her child’s body, starts to look not crazy but reasonable. If any risk at all is too much, no caution is too extreme. A risk becomes synonymous with inevitable disaster, blurring any and all context. A friend of mine attended a class at a local hospital called “Dogs and Babies,” thinking it’d give her useful pointers. Instead, the class was composed of a sequence of horror stories. It began with the instructor asking people what kind of dogs they had. One man raised his hand and offered, “Husky,” and the instructor said, “Number one killer of kids.”

Another woman, pregnant with her third child, mentioned to an OB at her practice that she’d like her four-year-old daughter to be present at the birth. The OB, she told me, closed the door and harangued her for more than a half an hour about the insanity of this decision. “This is a medical procedure,” the OB said, as if my friend were a child imagining fairy tales and not a mother who’d already given birth twice, to a nine and a ten-pound baby. “You could go into cardiac arrest on the operating table. Do you want your daughter to see that?” The woman made a list of all of the risks the OB had tried to scare her with: tearing, hemorrhaging, her daughter being traumatized by witnessing “blood and fluids,” her daughter being traumatized by seeing her mother naked, her daughter reporting the experience to all of her friends at school and traumatizing other children, her daughter seeing the baby covered in vernix and fluid and being disgusted and unable to bond with the baby.

My friend sent this in a formal letter of complaint to the hospital. The risk of a woman going into cardiac arrest during labor is less than .001 percent. The risk of severe postpartum hemorrhage is approximately one percent. The four-year-old daughter witnessing birth, witnessing her baby brother’s first breaths in the world, may have been one of the whole family’s most powerful shared memories, but the OB did not seem to care about this. My friend, passionate about women’s rights and about making women’s lives visible, cares deeply about sharing with her daughter the epic significance and struggle of birth, but the OB did not seem to care about this. She cared about the remote possibilities of disaster that she blew up to larger-than-life dimensions. She cared about zero risk.

The women doctors, anthropologists, and bioethicists of the Obstetrics and Gynecology Risk Research group point out, “It is the physician’s obligation not to eliminate risk, but to help patients weigh risk, benefit, and potential harm, informed by best scientific evidence and guided by a patient-centered ethic.” But this obligation, otherwise in evidence in patient-doctor relationships–as doctors try to help patients decide whether or not to go on certain medications, for example or whether or not to undergo certain procedures–vanishes in the context of pregnancy.

A pattern can be seen that governs almost all of women’s choices in the context of reproduction: a minimal risk, which can be made almost nonexistent with the right precautions, is exaggerated and applied equally to all women and all babies, with the explanation that women will not be able to mete out any differences in risk by themselves and so must be counseled to avoid a situation entirely. Meanwhile, this extreme interpretation of risk can actually damage mothers and babies in subtler, more insidious ways, not so easily measured by science, or which science is not particularly interested in measuring.

* * *

By the date Jamie had set for her own suicide, the Zoloft her doctor prescribed had kicked in just enough to knock the constant crying down a notch. It weakened the depression and the suicidal thoughts to the point where she could move past them, thought they remained present. It did very little for her anxiety, which persisted mostly unchecked and which no one seemed particularly concerned about. The first therapist Jamie saw diagnosed her with postpartum depression, postpartum OCD, postpartum anxiety, and post-traumatic stress syndrome, and told her that the fact she had a plan and an exact date for killing herself meant she had “good coping skills.” This therapist was confident. “It’ll pass!” she said. Jamie found a different therapist, whose treatment consisted mostly of asking Jamie to try and wait for ten minutes instead of three between breathing checks, which Jamie failed to do and found pointless and baffling. In most of the sessions with this therapist, Jamie bawled. Finally, a few months in, she asked if the therapist saw a lot of women like her, and if she would get better.

The therapist was cool. “Some women,” she replied, “just don’t like being moms.”

This therapist might as well have carved out Jamie’s heart and tossed it into an incinerator. Jamie left and never looked back. She has never gotten the doubt sown by that comment out of her head.

Jamie had wanted to be a mom. She had chosen to get pregnant. She had waited until later in life, when she had the resources, the stability, the time and desire. She’d selected her moment, the right moment. She had done everything right, damn it. Jamie had plenty of mom friends and knew what being a mom entailed: the sleep, the exhaustion, the frustration, the financial and emotional stress. She did not hate motherhood: she hated being so scared all the time. She knew something chemical, hormonal, and biological was at work, yet she struggled to lift the recrimination of some women just don’t like being moms. She had sought help, and what she got instead was a deep wound that scarred into life-long guilt.

Over time, her depression abated. If she felt it flaring back up, she would see her psychiatrist, who’d alter her medication. Sometimes, late at night, rocking her son, she would fantasize again about killing herself. She’d lean back, close her eyes, and mentally blow her head off, for hours. She told me, “I had thoughts like that even on a high dose of Zoloft, even when I looked like I was functioning.” On the day of her son’s first birthday, she went on a binge researching all the moms who’d killed themselves over the years.

Still, she could separate out the depression from the anxiety and to some extent, she could deal with the depression better: feel it coming on, halt it, distance herself from it. The anxiety was more pervasive and evasive. The drugs were supposed to help it too, but they never did. It never went away, but no doctor seemed concerned about it. So Jaime learned to live inside of the perpetual question, is this normal?

*

Excerpted from Ordinary Insanity: Fear and the Silent Crisis of Motherhood in America by Sarah Menkedick, published by Pantheon Books, an imprint of the Knopf Doubleday Publishing Group, a division of Penguin Random House LLC. Copyright © 2020 by Sarah Menkedick.