Denial of pregnancy – a literature review and discussion of ethical and legal issues

Abstract

SummaryDenial of pregnancy is an important condition that is more common than expected, with an incidence at 20 weeks gestation of approximately 1 in 475. The proportion of cases persisting until delivery is about 1 in 2500, a rate similar to that of eclampsia. Denial of pregnancy poses adverse consequences including psychological distress, unassisted delivery and neonaticide. It is difficult to predict which women will develop denial of pregnancy. There are a number of forms of denial of pregnancy, including psychotic and non-psychotic variants. Denial of pregnancy is a 'red flag' that should trigger referral for psychiatric assessment. A national registry may help to provide more information about this condition and implement appropriate care. This condition poses challenging legal and ethical issues including assessment of maternal capacity, evaluation of maternal (and possibly fetal) best interests and the possibility of detention in hospital.

Evolutionary-rooted models for denial of pregnancy, concealment of pregnancy and pseudocyesis

“…This allows a huge diversity of causative events specific to each woman concerned and explains that risk factors for denial of pregnancy identified in literature are neither necessary nor sufficient conditions (see p. 6 in 'Current understanding of denial of pregnancy'). This also supports that there is no clear-cut typology of a pregnancy denier Jenkins et al (2011);Wessel et al (2007).…”

“…Rather than the pregnancy itself, it is its significance and consequences that are actually denied. Psychotic denial of pregnancy concerns women who tend to be chronically mentally ill and remain psychotic before, throughout and after pregnancy Jenkins et al (2011). This type of denial of pregnancy is usually addressed specifically for that reason and, accordingly, we discard this type.…”

“…The consecutive public health issue has raised the interest of researchers and diverse risk factors for non-psychotic denial of pregnancy were identified, among which: low socio-educational status Dayan and Bernard (2013); Struye et al (2013); lack of social support Dayan and Bernard (2013); the woman's own maternal deprivation Spielvogel and Hohener (1995); acute or chronic psychosocial stressors Brezinka et al (1994); a history of emotional, physical or sexual abuse in childhood Dayan and Bernard (2013); conflicting or repressed sexuality Spielvogel and Hohener (1995);Friedman et al (2007); Bonnet (1993); rejection of the fetus Spielvogel and Hohener (1995); anger toward the baby's father Spielvogel and Hohener (1995); fear of abandonment Friedman et al (2007); memory or anticipation of custody loss Friedman et al (2007);Miller (2003). Denial was also observed in otherwise well-adjusted women that respond to none of these conditions Jenkins et al (2011). It is thus commonly accepted that the heterogeneity of affected women prevents the definition of a clear-cut typology of a pregnancy denier Jenkins et al (2011);Wessel et al (2007).…”

“…It is thus commonly accepted that the heterogeneity of affected women prevents the definition of a clear-cut typology of a pregnancy denier Jenkins et al (2011);Wessel et al (2007). However, beyond the diversity of this list of external risk factors, it must be noted that the hypothesis that a psychological conflict may constitute an underlying cause for denial of pregnancy appears recurrently in research papers for 40 years Jenkins et al (2011); Uddenberg and Nilsson (1975); Sandoz (2016b).…”

“…Nevertheless, the key-point remains the woman's individually subjective appraisal of her own life experience, thus explaining that no overall necessary nor sufficient risk factor can be identified Jenkins et al (2011);Wessel et al (2007). This etiological hypothesis allows also a satisfactory explanation of the particularities of the pervasive and affective subtypes of denial of pregnancy.…”