| Introduction
In this article I wish to
explore and describe the possible effects of womblife, birth and early
postnatal life on the mental health of unborn/newborn baby and on the
potential for human development and discuss a few interventions which may
prevent pathology and/or facilitate healing.
If you can, try and imagine yourself as a tiny foetus inside a womb,
bathed in fluid with the only source of nourishment entering your body
through a pipe plugged into your stomach. You have no choice in deciding
what foods you will eat or the kind of air you breathe, and may be flooded
with feelings of terror or anxiety when oxygen levels in this source of
nourishment diminish or fight or flight hormones are transfused.
Or try and imagine that the home you have lived in for nine months
becomes small and tight, squeezing and shoving you through a small angular
tunnel into an alien world, where you are left alone in a square box with
see-through sides. Or imagine that you are preparing for this
tunnel-journey and are suddenly and roughly pulled out of this home and
thrust into a cacophony of voices, clanging instruments, hard surfaces,
beeping machines and glaringly bright lights.
If you can imagine even one of these scenarios you may have a sense of
what it feels like to be a baby in the womb or a baby being born.
Pregnancy and birth are commonly viewed from the perspective of the mother
but few of us are able to empathetically feel or identify with the
experience of a baby in the womb or a baby being born. And if we could,
what would we do to ameliorate the trauma that seems to be inherent in
this journey to life for the baby?
The Evidence of Emotional Trauma to the Fetus
Mother and baby exist in unison and cannot be separated during
pregnancy until after birth and the interactive effects of poor maternal
care or exposure to teratogens have been shown to affect babies severely.
South African research, for instance, documents that babies born to
alcohol dependant mothers present with varying degrees of
foetal-alcohol-syndrome, the most devastating symptom of which is mental
retardation (Cape Times, Fri 7th Mar 04). This clinical syndrome is
currently measurable in terms of physical/intellectual outcome, however
emotional effects of distress on the baby during pregnancy and birth are
more difficult to prove.
Several psychiatrists and psychologists, from the beginning of the
20th century, discovered and proposed that the first nine months of life
in the womb and the birth of the baby are the most important events of
human life. In 1923, Otto Rank wrote “The Trauma of Birth” in which he
examines adult life and culture from a psychological viewpoint and
suggests that birth anxiety is the prime source of adult neuroses and
character disorders.1
Donald Winnicott, a British paediatrician and psychoanalyst, wrote in
the 1960’s how he observed children re-enact what appeared to be their
births, and that their anxiety and emotional problems resolved once they
had been allowed to work through their birth anxiety.2 The late
British theologian and psychiatrist, Frank Lake, who did research into
regressive therapy with patients using LSD, was initially astounded by
what he increasingly understood to be the reliving of birth trauma by his
patients.3
Arthur Janov, an American psychoanalyst and proponent of primal
therapy, a type of regressive psychotherapy, at first refused to believe
that his patients were reliving their birth experiences. He later
suggested the importance of the role of serotonin in mental illness before
it was correlated by neurological research with types of mental illness
and now believes that the ‘most important stage of childrearing occurs
during the nine months of pregnancy.5
Medical professionals may accept that birth is traumatic for the baby
and that there may be residual emotional effects, but may be sceptical
that the nine months of pregnancy are neurologically or emotionally
traumatic for the fetus. Frank Lake, after many years of psychiatric
research, coined the term “Maternal-Fetal-Distress Syndrome”, when he
became aware of the extent of foetal dependency on the mother’s state of
wellbeing. Lake wrote that the first three months after conception “hold
more ups and downs, more ecstasies and devastations than we ever
imagined.4”
A mother’s emotional state and level of stress may determine the
child’s later behavioural and emotional state and may precipitate
neurological changes in foetal brain structure and patterns of
neurotransmission. Lake describes the basic ideas of
Maternal-Foetal-Distress Syndrome as follows:
The catecholamines which convey the messages to do with the emotions
round the mother’s circulation, (gearing all her organs and cells to
feeling joy or sorrow, love or loathing, vitality or exhaustion), pass
through the placental barrier (which to these substances is no barrier)
into the foetal bloodstream via the umbilical vein. In this context the
foetus does its own emotional homework and responds, either passively
accepting the mother’s bad feelings as its own, as if true for itself, or
by being protestingly overwhelmed by them.
It can aggressively fight them back, in resolute opposition to sharing
the mother’s sickness. Others become ‘foetal therapists’, trying to
bolster up a debilitated and debilitating mother from their own feelings
of relative strength. Sensitivity to ‘poisonous feelings’ coming from a
rejecting mother is very great ….to be the focus of mother’s love imprints
a confidence that ‘sets you up for life’. (my emphases.6 In
fact, Lake goes so far as to say that the first trimester of pregnancy is
the most critical period for foetal growth and wellbeing.
The Effects of Prenatal Trauma
This tenet is borne out by animal research into the link between
antenatal stress and impaired behavioural adjustment/ emotional reactivity
in offspring, with the effects being carried into adulthood.7
Severe life events occurring in the first three months of pregnancy, such
as the death of a child in the family, show increased incidence of
congenital abnormalities. However, recent research suggests that antenatal
stress and anxiety as early as 18 weeks pregnancy has a programming effect
on the foetus, which lasts at least until middle childhood, and may show
in behavioural problems such as dyslexia, hyperactivity and attention
deficit.8
A mother’s depression during pregnancy is often associated with
interpersonal difficulties leading to poor maternal-infant attachment,
which may have a profound impact on cognitive and emotional child
development.13
What is the significance of pre- and perinatal trauma for the
long-term mental health of an individual or indeed, a whole community for
that matter? Lynda Share, a psychoanalyst, has studied the dreams of her
clients and reconstructed their infant traumas, and notes that very early
foetal trauma seems to induce an overwhelming fear of progress in life.
She posits that two conclusions emerge about infant trauma, namely:
- Memory of infant trauma can be stored indelibly in a primitive
memory system such that it can be accessed through dream analysis and
other psychoanalytic methods at a later point in time.
- Foetal Infant trauma-coming so early in life-also forms memory
schemas through which future development and experience are filtered.
These templates or schemas then become an "organizing principle" for the
entire personality, colouring later ways of living, thinking, and seeing
the world.9
Allesandra Piontelli, an Italian child psychoanalyst,
became interested in prenatal memory when parents brought their
18-month-old to her for his inability to sleep and incessant restlessness.
After observing and commenting that he seemed to be searching for
something he had lost, his parents tearfully recounted that he had been
one of a set of twins and that the twin and died in utero two weeks before
birth.10
Piontelli tells the story of her analysis of a two-year-old psychotic
girl who was born with the umbilical cord wrapped tightly around her neck
and spent most of her early childhood wrapping ropes, strings and curtain
cords around her neck.11
What About Mothers?
These clinical observations have far reaching implications if they are
true and if we are to believe that maternal stress and anxiety is
detrimental to the psychic development of our unborn babies, is this not
just another way of assigning blame to women yet again? British
Psychiatrist Margaret Oates states “it is a utopian fantasy to imagine
there will ever be enough therapists or interventions to treat all anxious
women during pregnancy.12 Let us remember that it was only in
1928 (less than a hundred years ago) that women were granted equal right
to vote in United Kingdom and in many countries women are still not
accorded equal status to men.
Is this research yet another avenue that may be used to control or
victimise women by prescribing how they should be pregnant or give birth?
Although anxiety may well rise during pregnancy, this could be due to
social and environmental factors that women are unable to change, such as
death in the family, poverty, housing problems, unemployment or lack of
partner support. Such factors need to be addressed politically through
mobilised community awareness and action and governmental policy changes
and interventions.
Yet the increased incidence of postnatal depression in mothers who are
anxious or depressed prenatally seems to be prevalent across all
socio-economic levels of society.13
What Can Be Done?
It is my hope that public awareness and knowledge of the varying
degrees of distress and emotional agony that both women and their unborn
babies experience, will lead to the provision of socially supportive and
protective structures for all women.
One such supportive structure, The Thula Sana Project, is a
parent-infant interaction programme in Kayelitsha, Cape Town, and aims to
facilitate the best possible early caregiver-infant relationships and so
improve child developmental outcome. The programme is designed to provide
emotional support and information to new parents, particularly mothers, in
pregnancy and through the early weeks and months of adjustment after
birth. By sensitising the parent to the baby’s individual and unique needs
and communications it tries to increase the parent’s capacity to
understand his or her baby and to make caring for that baby as satisfying
and enjoyable as possible in a way that will best facilitate the baby’s
healthy development.
The programme:
- Focuses on the interaction between the mother/parent/caregiver and
the infant.
- Is delivered through a therapeutic counselling approach that allows
space for the mother to share and explore her own personal struggles.
- Demonstrates to the mother the individual, communicative and
interpersonal characteristics and capacities of the baby.
- Provides a space for the counsellor and mother, together, to think
about the infant’s individual communications and needs.
- Provides information and useful strategies for managing common
difficulties.
- Provides a model of positive, responsive and sensitive parenting.
The programme is delivered by trained and supervised family
support workers from the community through a series of 19 home visits (4
antenatal and 15 postnatal) starting as early in the pregnancy as possible
and terminating at six months after birth.
Another project, The Perinatal Mental Health Project at the Liesbeeck
Midwife Obstetric Unit, Mowbray Maternity Hospital, Cape Town was started
by Dr Simone Honikman in 2002. The aim of the project is to offer a
woman-centred efficient mental health service to the women who attend the
clinic. Women are screened for anxiety and depression during the pregnancy
with informed consent and are referred to a psychologist or social worker
for counselling if desired. Midwives are trained to use and score the
screening tools, the Edinburgh Postnatal Depression Scale and A Risk
Factor Questionnaire, which the women complete.
Sometimes all women need is someone to talk to, someone who will
understand and listen. This is particularly relevant in cases of
miscarriage, where a family member has died during the pregnancy, with
marital or relationship difficulties and where a woman has suffered from
depression previously, although there are many factors which may lead to
emotional distress.14 This process of screening, referral and
counselling helps staff and counsellors to support pregnant women who
suffer emotional or interpersonal stress and refer women to appropriate
services for further assistance with life problems or emotional
difficulties.
Conclusion
These projects are not based on a utopian ideal, but have been
developed in response to the needs of women and their unborn offspring. We
may not be able to change the world in a lifetime, but we can make a
difference to those women around us, our neighbours, sisters, colleagues,
staff, and patients by really caring and putting compassion into
practice.
__________________________
References:
1Rank, Otto. (1952). The Trauma of Birth. New York:
Richard Brunner.
2Winnicott, D. (1958) In Collected Papers: Through
Paediatrics to Psychoanalysis. New York: Basic Books, pp174-193.
3Winnicott, D. (1949), Birth memories, birth trauma, and
anxiety. In: Through Paediatrics to psychoanalysis. New York: Basic
Books, 1958, pp. 174-193.
4Lake, Frank. (1966). Clinical Theology: A Theological
and Psychiatric Basis to Clinical Pastoral Care. London: Darton,
Longman and Todd.
5Lake, F. (1981). Tight Corners in Pastoral
Counselling. London: Dartman, Longman and Todd.
6Janov, A. (2000). The Biology of Love. Prometheus
Books: New York.
7Lake, F. (1978) In a Report from the Research Department
and Theological Issues in Mental Health in India. Nottingham: Clinical
Theology Association, Lingdale.
8Weinstock in O’Connor, T. (2002). British Journal of
Psychiatry 180:389-391.
9O’Connor, Thomas G., Heron, J., Golding, J., Glover, V.,
and the ALSPAC Study Team. (2003) Maternal antenatal anxiety and
behavioural/emotional problems in children: a test of a programming
hypothesis. Journal of Child Psychology and Psychiatry 44:7 pp
1025-1036.
10Share, L. (1994). If Someone Speaks, It Gets Lighter:
Dreams and the Reconstruction of Infant Trauma. Hillsdale, N. J.: The
Analytic Press.
11Piontelli, A. From Fetus to Child: An Observational and
Psychoanalytic Study. London: Tavistock/Routledge, 1992, p 18.
12Piontelli, A. “ Prenatal Life and Birth as Reflected in
the Analysis of a 2 Year Old Psychotic Girl.” International Review of
Psycho-Analysis. 15(1998):73-81
13Oates, M.R. (2002) Adverse Effects of Maternal Anxiety on Children:
causal effect or developmental continuum? The British Journal of
Psychiatry (2002) 180: 478-479.
14Nonacs R. and Cohen L.S. (2002). Depression during
Pregnancy: Diagnosis and Treatment Options. Journal of Clinical
Psychiatry 2002:63 (suppl 7) p 25
15Dr Simone Honikman : Personal Communication 2004. The
Liesbeeck Midwife Obstetric Unit, Mowbray Maternity Hospital, Cape
Town.
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