A British Soldier in Afghanistan is reported as delivering a baby ‘on the front line’ without knowing she was pregnant – how is this possible? The latest psychiatric research reveals the answer.
Raj Persaud and Nicholas Morris
Pregnancy, particularly late pregnancy when a mother is close to giving birth, would seem an utterly obvious condition. Yet Obstetricians repeatedly encounter women who even deliver at full term, without being at all aware they were pregnant.
Many of these predicaments end joyously, with a woman who initially complained to doctors of baffling tummy pain, finding themselves astonished, but eventually pleased mothers. Yet doctors know that the story doesn’t end there, what happens to that baby afterwards can be of grave medical concern.
There is a possible and controversial association between so called ‘denial of pregnancy’ and killing of such newborns. Women who deny pregnancy obviously don’t get the right antenatal care and this is hazardous. But is there also a strong link in some cases with neonaticide (homicide within the ﬁrst 24 hours of life)? This serious problem is being actively researched at the moment.
Some women who deny pregnancy might be much more likely than the general population to kill their newborns, sometimes through neglect, and these can be found in the lavatory, garbage disposal, or a hasty grave.
Klaus Beier, Reinhard Wille and Jens Wessel from the University Clinic Charite´, Berlin and Sexual-Medical Department, University Clinic, Kiel, Germany have surveyed research on pregnancy denial, and found that reports of the phenomenon are in fact increasing recently.
German data suggests one case of denied pregnancy occurs in 475 deliveries for women who were not aware of being pregnant, and did not receive a diagnosis of pregnancy during the first 20 weeks of the pregnancy. Women who do not realize they are pregnant until going into actual labour occurs 1 in 2455 deliveries.
Wessel lead a team whose survey of all births in Berlin over one year, published in the academic journal ‘Acta Obstetricia et Gynecologica Scandinavica’, found such totally unexpected deliveries of a viable fetus, without any previous knowledge at all of being pregnant, occurs roughly 300 times a year in a country the size of Germany. According to their calculations, in the study titled ‘Frequency of denial of pregnancy: results and epidemiological significance of a 1-year prospective study in Berlin‘, this means denial of pregnancy occurs three times more often than triplets.
Wessel and colleagues point out that besides denial of pregnancy, there is concealment of pregnancy; the woman actually knows she is pregnant, but hides it from those around her. Possibly fear of disgrace, or worry her partner will leave, may be factors. Very immature younger women who are victims of an unplanned pregnancy may try to ‘forget’ they are pregnant, perhaps hoping it will go away.
In their study of ‘pregnancy deniers’ entitled, ‘Denial of pregnancy as a reproductive dysfunction: A proposal for international classification systems’ Beier, Wille and Wessel found 38% had actually visited the doctor during their pregnancy, but the physician, remarkably, didn’t spot the pregnancy. The researchers explain this surprising finding as not in fact that unusual, and explained by a fair degree of obstetrical ignorance being common in non-gynecologists.
An interesting psychological theory they propose is that an unconscious dynamic sometimes develops between a mother in strong denial and her doctor, so they both end up colluding in the denial. This common process is known as ‘projective identification’ and a sympathetic doctor-patient relationship is vulnerable to the physician embracing the denial projected on to them by the patient.
Another peculiar phenomenon which contributes to pregnancy denial is the continuation of regular menstruation during a pregnancy, which was the case in 46% of Beier, Wille and Wessel’s sample of pregnancy deniers. In the study published in the ‘Journal of Psychosomatic Research’, the authors declare doctors still don’t have a medical explanation for this frequently described mystery. Sometimes in older women no periods is confused or rationalised as the start of menopause.
The authors conclude that women who fail to grasp they are pregnant before delivery are commonly suspected of deception or psychosis, yet this and other research finds the overwhelming majority have a normal lQ, little or no obvious psychiatric disorder, and only around 5% appear to suffer psychotic illnesses like schizophrenia.
Beier, Wille and Wessel point out that before we jump to the conclusion these women are stupid or insane, denial of physical illness is very common. Indeed it is almost normal following a life-changing diagnosis such as cancer or severe heart disease. Such denial frequently leads to not following medical advice and this is even a norm in many serious physical illnesses.
There are many different kinds and levels of psychological ‘denial’. One form is ‘affective denial’ and means while intellectually aware of the pregnancy, a woman demonstrates little emotional reaction. For women with severe addictions for example, if unable to give up their dependency, emotional denial defends against guilt from harming their foetus through substance abuse. Psychotic denial of pregnancy might be particularly likely in those with a previous history of psychosis, combined with prior loss of custody of other children, as a result of their severe mental illness.
Natacha Vellut, Jon Cook and Anne Tursz from the Centre de Recherche Médecine, Sciences, Santé, Santé mentale et Société, Paris, have just published a study examining what proportion of neonaticides are made up of women who deny their pregnancy. In 3 regions of France over a 5-year period there were 32 cases of neonaticide of which possibly 3 pregnancies were undiscovered until delivery. The authors wonder whether denial of pregnancy has been over-rated by doctors before as an underlying factor in eventual neonaticide.
The study entitled ‘Analysis of the relationship between neonaticide and denial of pregnancy using data from judicial ﬁles’, argues pregnancy deniers may disconnect pregnancy from childbirth. While aware of being pregnant from time to time, none of these mothers seemed to foresee or get ready for delivery.
Just published in the academic journal ‘Child Abuse and Neglect’, perhaps the most disturbing finding of the study, is that it revealed neonaticide to be at least 5.4 times more frequent in France than officially recorded in mortality statistics.
The authors also point out that as 25% of cases related to discovery of the corpse of a newborn whose family was never identified, this raises the possibility of a much higher unknown number of bodies never discovered.
If so, denial or concealment of pregnancy, might also be much more common that officially realised.