Original article
Denial of pregnancy as a reproductive dysfunction: A proposal for international classification systems

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Abstract

Objective

To propose a new Diagnostic and Statistical Manual (DSM) and International Classification of Diseases (ICD) category concerning reproductive dysfunctions not caused by organic disorder.

Methods

Forensic (n=93) and obstetrical cases (n=78) of denied and concealed pregnancies are compared and discussed.

Results

Denied pregnancies occur with a ratio of 1:475 births. An overwhelming phenomenological agreement is demonstrated between obstetrical and forensic cases. The findings were similar for denial and concealment of pregnancy, probably representing two different types of reproductive dysfunction that can be classified psychosocially together under the heading “negated pregnancy”.

Conclusions

Analogous to the phenomenology of “sexual dysfunctions”, “reproductive dysfunctions” could be distinguished by the extraordinariness of both reproductive experience and behavior (as part of human sexuality) and psycho-physiological changes, which characterize the reproductive course of events and cause obvious suffering and interpersonal complications. It is therefore suggested to include these entities as categories in their own right under the appropriate existing headings in DSM and ICD.

Introduction

The chapter “Sexual and Gender Identity Disorders” in Diagnostic and Statistical Manual (DSM-IV) places human sexuality disorders at the center of attention and suggests a classification of sexual dysfunctions, of gender identity disorders, and paraphilias. On the one hand, what is striking about these clinical pictures is that comorbidity seldom occurs in combination with psychiatric illness and that sexual dysfunctions are usually separate entities with different etiologies. On the other hand, this means that dysfunctions of reproductive parts within human sexuality have not been included. This is also true for the International Classification of Diseases (ICD), which is even more remarkable given that reproductive dysfunctions occur frequently. Nevertheless, they are for the most part serious dysfunctions of reproductive experiences and behaviors that can be dangerous for both mother and child. This is especially true for denied pregnancies. Denial of pregnancy is a woman's subjective lack of awareness of being pregnant. In contrast, concealment of pregnancy is where the woman does know about her existing pregnant state, usually at a very early stage. However, she attempts to conceal this at all costs—no one else should know. This paper proposes a new term, “negated” pregnancy, as the main category for both denied and concealed pregnancy subtypes.

In recent years, reports on denied pregnancies have increased in number. Most, however, describe only one or a small number of cases [1], [2], [3], [4]. Very few studies describe larger numbers of women [5], [6], with a maximum of 27 [7] or 28 patients [8] at a single obstetrical hospital. However, these case series lack epidemiological relevance. In 2002, the first population-based frequency ratios were published [9], revealing one case of denied pregnancy in 475 deliveries (95% confidence interval 370–625) for women who were not aware of being pregnant and did not receive a diagnosis of pregnancy during the first 20 weeks or more of gestation. For those women who did not realize that they were pregnant until they went into labor, a ratio of 1 in 2455 (95% confidence interval 1429–5000) was determined. Interestingly, the general ratio of 1:475 is comparable to frequency calculations of nonepidemiological studies with greater patient numbers, which indicates a similar frequency of denial of pregnancy across different socio-demographic regions. In light of these statistics, the accepted view that denied pregnancies are rare and exotic events is no longer valid. At approx. 1 in 280 pregnancies, the incidence of HELLP syndrome is slightly more frequent than the overall pregnancy denial. The incidence of eclampsia at approx. 1 in 2500 pregnancies in Europe corresponds to the incidence of pregnancies denied until birth, which are, in other terms, about three times more frequent than triplets [9], [10].

In addition to the primary clinical-obstetrically relevant form, it is necessary to point out the secondary, less frequently occurring group, for which forensic relevance of nonperceived pregnancies exists. In extreme cases, this results in both the death of the child (most often through neglect after birth; see Ref. [11]) and criminal prosecution of the mother. Empirical data considering a larger number of cases now also exist for this situation [12], [13]. According to these numbers, neonaticide is generally seen as a rare event (the estimated number of unknown cases is not clear), and it is usually not associated with maternal psychiatric symptoms. Rather, it is the result of extreme final paths of (psychological) coping with pregnancy—in the sense of a continually and completely negated (denied or concealed) pregnancy. This assertion, however, can only be validated within the comparative sphere of a clinical and forensic sample, which will be presented by the following data.

Section snippets

Method

The following section describes the methods of two studies with different sample groups: (1) an obstetrical sample, (2) a forensic sample.

Obstetrical sample

A total of 94 women matching the criteria were recruited during the 1-year prospective clinical study. Sixty-six women (including the only case of neonaticide) were identified as having a denied pregnancy, and 12 women were noted to have a concealed pregnancy. Sixteen women with totally different reasons not related to denial or concealment of pregnancy were excluded.

Comparison between the mothers with “denied” pregnancy and those with “concealed” pregnancy, based on the variables listed in

Discussion

Denied and concealed pregnancies undoubtedly threaten the mother (due to lack of preparation for birth) and the child (in extreme cases, death may occur due to neglect after birth). The data from the clinical sample not only demonstrate the frequency of the phenomenon, one denied pregnancy out of 475 births, but also reveal a close connection to the women in the forensic sample whose giving birth resulted in death of the child. This similarity between the two groups in terms of the variables in

Acknowledgment

The clinical study was financed by the German Research Foundation (Deutsche Forschungsgemeinschaft) in the form of a habilitation grant (We 1706/1-3). Gratitude is expressed for this.

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