CONCEALED PREGNANCY AND NEWBORN ABANDONMENT: a contemporpary 21st century issue Part 1

CONCEALED PREGNANCY AND NEWBORN ABANDONMENT

Sylvia Murphy Tighe Doctoral Midwifery student

Professor Joan Lalor

and Health Research Board

Associate Professor of

Research Fellow,

Midwifery, Trinity

Concealed pregnancy and newborn abandonment: a contemporary 21st century issue Part 1 Trinity College Dublin

College Dublin

This two-part series explores the phenomenon of concealed pregnancy and the association with newborn abandonment, with reference to recent cases of public interest. In Part 1 we focus on defining concealed pregnancy as a complex process which involves hiding a pregnancy, that can lead to tragic consequences such as maternal or neonatal morbidity or mortality (Murphy Tighe and Lalor 2016; Chen et al 2007). The psychosocial issues involved will also be presented (Murphy Tighe and Lalor 2016).

BACKGROUND Concealed pregnancy is defined as a complex and life-altering experience, where a woman is aware of her pregnancy and copes by keeping it secret and hidden. Behaviours such as avoidance, staying away, using a daytime (cover) story and secrecy are key characteristics. A paralysing fear is central to the process and levels of fear and avoidance can be observed (Murphy Tighe and Lalor 2016). The psychological processes involved are poorly understood and there is much ambiguity around the definitions used. The antecedents of concealed pregnancy (See Table 1) are awareness of pregnancy, fear (of others or for others), comparison of personal situation to societal norms and expectations, context: relationships, financial, culture or religiosity, and the perception of lack of support or mechanism to mother her infant (Murphy Tighe and Lalor 2016). Prevalence rates of concealed pregnancy (See Table 2) are difficult to establish with accuracy because of

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the nature of the phenomenon, with few studies involving large sample sizes.

THE KEEPING IT SECRET STUDY (KISS) Our research, the Keeping it Secret Study (KISS) into concealed pregnancy, involved exploring the nature and impact of the experience for women. We interviewed 30 women, on up to three occasions, who were concealing a pregnancy or had done so in the past. Pregnancy outcomes varied in the extreme, from mothering the infant to fostering/adoption, neonatal death and neonaticide.

DEFINITION The literature usually refers to denied pregnancy (Hatters Friedman et al (2007); Conlon 2006; Wessel et al 2007). Confusion around definitions has been problematic and has hindered service developments to meet the needs of women (Murphy Tighe and Lalor 2016). We have generated a new definition for

CONCEALED PREGNANCY AND NEWBORN ABANDONMENT

Table 1 Antecedents, attributes and consequences of concealed pregnancy Antecedents

Attributes

Consequences

• Aware of pregnancy

(Internally or externally

Woman

• Fear (of others or for others)

mediated)

• Maternal death

• Compares own situation to

• Secrecy

• Self harm/suicide

societal norms and

• Hiding

• Mothering /termination of pregnancy:

expectations

• Daytime story (cover story)

• Context – relationship/finances/

• Staying away • Avoidance

forced or voluntary • Recurrence Infant • Neonatal death

culture/religiosity • Perceives a lack of support or

• Abandonment/neonaticide

mechanism to mother her

• Fostering/adoption

infant

• Parented Society • Increased child surveillance • Anonymous birthing

(Murphy Tighe and Lalor 2016)

• Baby hatches

Table 2 Prevalence rates of concealed pregnancy Place of study

Prevalence rate

Ireland (rural)

1 in 146 (20 weeks gest)

Methodology IPA and quantitative retrospective case control study (Thynne 2006; Thynne et al 2012)

Ireland (rural)

1 in 403 (20 weeks gest)

Case study (Conlon 2006)

Ireland (urban)

1 in 625 (20 weeks gest)

Case study (Conlon 2006)

1 in 2,500 (until birth) Germany

1 in 475 (until birth)

Case study (Wessel et al 2002)

USA

1 in 516 (20 weeks gest)

Exploratory retrospective medical record

1 in 2,500 (until birth)

review (Hatters Friedman et al 2007)

1 in 2,500

Retrospective population based study

Wales

over 11 yrs (Nirmal et al 2006)

concealed pregnancy and hope it will help midwives better understand the process of concealed pregnancy: Concealed pregnancy is a complex, multidimensional and temporal process where a woman is aware of her pregnancy and copes by keeping it secret and hidden. Behaviours such as avoidance, hiding, using a daytime story, staying away and secrecy are key characteristics. Fear (of others or for others) is central to the process and an interaction with another antecedent; for example: context/culture or a perceived lack of support to mother her infant leads to concealing a pregnancy. It is a difficult and traumatic experience for the woman. Variations in the duration of concealed pregnancy exist and recurrence may feature in this process (Murphy Tighe and Lalor 2016).

WHY IS CONCEALED PREGNANCY A SERIOUS CONCERN TODAY? The Confidential Enquiry into Maternal Deaths (Lewis 2007) and serious case reviews of infant deaths in the UK have identified concealed pregnancy as an area of concern, as the risks to maternal and neonatal wellbeing are significant. Concealed pregnancy is a traumatic experience and women experience considerable distress during and after the event (Murphy Tighe and Lalor 2016). Little or no antenatal care may lead to serious pregnancy-related and childbirth complications (Ali and Paddick 2009; Wessel et al 2007; Nirmal et al 2006) and even unassisted childbirth may occur (See Table 3). It has been identified that concealed pregnancy

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CONCEALED PREGNANCY AND NEWBORN ABANDONMENT

Table 3 Maternal and neonatal risks associated with concealed pregnancy Risks of concealed pregnancy for the woman

Risks of concealed pregnancy for the infant

Inadequate or absence of antenatal care

No opportunity to detect fetal anomalies amenable to

Hard to detect EDD; unprepared for birth

treatment

Previous concealed pregnancy

Risk of prematurity, low birth weight, small for

Precipitous or unassisted birth

gestational age

Maternal death (Lovett case)

Birth injuries

Immense psychological distress, isolation, feeling

Admission to NICU

judged, sense of stigma, shame

Abandonment (Baby Maria cited in Murphy Tighe and

Poor obstetric outcomes: increased risk of breech

Lalor 2015) Neonaticide (Kerry Babies case cited in

presentations; pregnancy and childbirth

Murphy Tighe and Lalor 2016; Conlon 2006)

complications

Higher perinatal mortality than comparsion groups

Poor adaptation postpartum

Infants often raised by grandmothers or given up for adoption Effect on maternal-infant attachment unknown

(Chen et al 2007; Conlon 2006; Murphy Tighe and Lalor 2015; Murphy Tighe and Lalor 2016; Thynne 2006; Thynne et al 2012; Wessel et al 2007)

is closely associated with newborn abandonment (Drescher-Burke et al 2004; University of Nottingham 2012) and neonaticide (Riley 2005; Putkonen et al 2007; Amon et al 2012); therefore a focus on accessible and supportive services for women and children is necessary (Murphy Tighe and Lalor 2016). Abandonment and neonaticide are still recorded in countries where termination of pregnancy services are available and in liberal pluralist societies. Women in our study described the extreme

The therapeutic relationship at the heart of midwifery care is critical when working with a woman who is experiencing a concealed pregnancy measures they went to to hide their pregnancy, such as wearing restrictive clothing, isolating themselves from family and friends and even moving away, citing opportunities elsewhere. Serious case reviews into child deaths in the UK have found that concealed pregnancy has been a precursor, in some cases (Murphy Tighe and Lalor 2016). Scant attention has been paid to concealed pregnancy, its impact on the developmental trajectory of infants and mothers and on maternal-infant attachment (Murphy Tighe and Lalor 2015), and warrants urgent attention.

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WHO CONCEALS A PREGNANCY? The notion that only teenagers conceal their pregnancies is a fallacy. In reality concealed pregnancy crosses many boundaries, and women who conceal their pregnancy are not a homogenous group (Wessel at al 2002). Unfortunately concealed pregnancy continues to have the same negative consequences in terms of maternal and neonatal outcomes today as it had 50 years ago. As pregnancy outside of marriage is now generally accepted, societal opprobrium has moved from condemning the pregnancy to condemnation of the woman who conceals her pregnancy, as concealment is often viewed as an abnormal response to a crisis pregnancy. Although women who experience a concealed pregnancy report it as a distressing time where they often had no support, it is still the case that some authors approach this event as being related to a pathological disorder, such as psychosis or mental ill health (Jenkins et al 2011; Sandoz 2011; Kenner and Nicholson 2015). The potential exists for women who conceal a pregnancy to become pathologised, stereotyped and demonised (Murphy Tighe and Lalor 2015); rather than women being supported with a crisis pregnancy they wish to keep secret, it may be assumed that they have a mental health problem. The literature has not substantiated the association between concealed pregnancy and mental illness as a causative factor. We have found that mental distress and suicidal thoughts are a consequence of concealed pregnancy (Murphy Tighe

CONCEALED PREGNANCY AND NEWBORN ABANDONMENT

and Lalor 2016). Some women may have had traumatic experiences in their earlier lives and some may have had no access to support or health care.

CONCLUSION Concealed pregnancy is a public health issue of significance and a precursor to newborn abandonment. Contemporary society imposes expectations on pregnant women, which discourages the expression of ambivalent or conflicted feelings. The silence and lack of discussion around conflicted feelings about a crisis pregnancy is problematic (Murphy Tighe and Lalor 2016). Midwives may meet women who are concealing their pregnancy in advanced gestation (late booking) or during labour. It is essential that midwives are non-judgemental, caring and can build trust through empathic listening. Through sensitive enquiry and listening to women, it may enable them to reveal deep feelings about their lives and the pregnancy, and careful questioning about the support available to a woman may reveal a hidden narrative. Women may feel compelled to mother their infants; therefore the availability of nondirective crisis pregnancy counselling is necessary to ensure that informed decisions are made. The therapeutic relationship at the heart of midwifery care is critical when working with a woman who is experiencing a concealed pregnancy. Midwifery care that builds trust may enable a woman to reveal the pregnancy, feel in control of her life and can empower her to make decisions regarding guardianship of her child. In Part 2 of this article we will focus on the consequences of concealed pregnancy, by reviewing a specific case study and suggestions for midwifery practice development. tpm

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