Pregnancy Denial: When the baby is a big surprise

The morning newspaper had a report of another tragedy. A woman accused of murdering her newborn baby. The baby was found wrapped in a garbage bag after she presented to a health clinic in her Boston neighborhood. Was this a horrific murder or a case of pregnancy denial resulting in the ruination of two lives?

All obstetricians and emergency room physicians will be able to relate stories of women who come in to the hospital with "abdominal pain" and wind up delivering full term babies much to their and their families shock. "I didn’t know I/she was pregnant." How can a woman not know she is pregnant? Denial of pregnancy is more common than most people think.

There is little research on the phenomenon of pregnancy denial. One study in Berlin (Germany) quantifying the prevalence of pregnancy denial, found that pregnancy denial occurred in about 1 in 475 pregnancies. About half of all denied pregnancies were found during labor. (E.g. mother presents with abdominal pain). Many of the women who didn’t know they were pregnant had noted physical changes (weight changes or lack of menses) but they did not associate these changes with pregnancy. The results of the study seem comparable to what I personally have observed working as an obstetrician in several hospitals in different geographic areas.

Rationalizing physical changes of pregnancy is perhaps not as difficult as one would think. These self rationalizations can include: my period is just a little late; spotting assumed with relief to be a normal period; no period because of "stress;" periods are always irregular; gaining weight because of eating too much; not exercising enough or wearing baggier clothes to disguise an expanding abdomen. Denial of pregnancy symptoms can extend to parents who don’t want to believe what should be obvious about their daughters. But why would women deny to themselves that they are pregnant?

Denial is a psychiatric defense mechanism to protect against something that our minds cannot accept. Denial of pregnancy is easier than accepting the reality of pregnancy and having a child. Denial can occur when the mind is overwhelmed with the responsibilities and adjustments that have to be made with a pregnancy. Women in denial about pregnancy may be uncertain about wanting to be a mother and be unable to see themselves as a mother. Pregnancy and motherhood can be in such conflict with the idea of what she sees herself as being or doing that it is not accepted as a reality.

Other women may recognize they are pregnant but are too afraid to seek medical care or confide in their friends or relatives. They may fear a parent’s or boyfriend’s reaction, they may fear they will be pressured into abortion, they may be hiding a rape or incest, they may fear "shattering their upstanding image" or losing a relationship.

Many women who deny pregnancy will seek medical care when they experience the pain of labor. However there are instances where the mother delivers the baby in isolation and the baby is killed or neglected such that death occurs. Is this homicide or the result of a complicated psychiatric and medical illness? It is interesting to note that of 21 developed countries the United States is the only one that considers this scenario a homicide but has the fourth highest rate of neonatocide. Other countries have legislation that recognizes this behavior as a distinct entity requiring psychiatric treatment and probation rather than incarceration.

There have been legislative attempts in some states to develop infant "drop-off" laws, laws that permit a baby to be left at a safe location (e.g. emergency room or police station) without fear of prosecution for child abandonment laws. This has its proponents and opponents and is clearly not ideal but if such legislation would prevent the death of any infant it should be considered.

Project Cuddle (www.projectcuddle.org, 1-888-6-cuddle) is a national organization based in California that can provide help to women and girls who are keeping their pregnancy a secret and also provide information for people who suspect a friend or relative is pregnant but in denial.