Frank Lake's Maternal-Fetal Distress Syndrome:
- An Analysis -

By Stephen M. Maret, Ph.D.
Professor of Psychology
Caldwell University

CHAPTER 3

B. Morphological and Psychological Evidence for Lake's M-FDS

    Fetal Development
      1. Embryonal Development
      2. Fetal Development
      .
      .
      .
        I. Emotion

Whether fetal or neonatal emotion exists in the same or similar manner of adults is impossible to determine due to its subjectivity. Research with both preborn and newborns, however, has shown clear evidence for at least the external behavior normally associated with internal emotion. For instance, crying, of both the intra-uterine and extra-uterine varieties, has been connected to the internal states of pain, anger and rage.

As stated earlier, audible fetal crying is rare because it requires the presence of air in the fetal trachea. However, Ryder,334 after a comprehensive review of the literature from 1800-1941, reported 123 cases by 114 different observers. More recent corroboration has presented three instances when fetal crying occurred in response to rupture of a membrane, manual displacement of the head or the attachment of electrodes for internal monitoring.335 Audible crying has been reported from infants weighing as little as 650 grams 336 and Humphre337 cites instances of 5 aborted fetuses from age 21-22 weeks audibly crying.

It has been argued that fetal crying is not indicative of any emotional state, but is undifferentiated. The same has been asserted with regard to neonatal crying. However, research has shown that crying of preterm and full-term infants is very differentiated, even from each other.338 Utilizing spectrography to produce "cryprints"339 researchers have clearly distinguished various cries as communicating different emotional states,340 including between birth, pain and hunger.341 Spectrographic distinctions have been found in the cries of infants who are had been prenatally and perinatally chronically stressed,342 who have chromosomal aberrations343 hyperbilirubinemia,344 and fetal malnutrition.345

Other studies have also illustrated the range of communicatory cries possible with newborns. Using sonography and audio tape recording before, during and after circumcision, one study346 demonstrated that certain distinctions in "cries" were definitely correlated to degrees of pain as measured by the relative degree of the invasiveness of the surgical procedure. Definite differences in pitch, temporal patterning and harmonic structure were discernable with various degrees of pain.

Another study347 with older infants aged 2-10 months was also able to sonographically distinguish various degrees or pleasure and displeasure. In this study, two month old infants showed emotional expression across the entire continuum of possible affect states, from extreme pleasure to extreme displeasure. Still another study348 demonstrated easily discernible audible sounds of pleasure in child-parent interactions in infants from 2-4 months of age.

Another category of the external indication of internal affect states includes various facial expressions, particularly smiling. The earliest smiles occur during the REM349 stages of sleep,350 perhaps indicating "expressions of private pleasure in dreams."351 what makes REM sleep so significant is the correlation of this stage with dreaming activity. One study352 found that various measurable alterations in specific physiological systems (ie. gross motor movement, raspatory irregularities) was identical for adults as for full-term and premature neonate, leading to the conclusion that even premature infants and fetuses dream.

Whether this activity involves the full visual imagery and the other characteristics of adult dreaming is impossible to determine, but the REMS of neonates and adults is alike in every measurable way. The big difference has to do with the amount of time spent in REM sleep vs non-REM sleep. Those of old age spend less than 1 hour (13% of sleep time) in REM; adolescents 20%; full-term newborns 50%; 36-38 week preemies 58%; 33-35 week preemies 67%; and virtually 100% for 30 week old premature infants. Interesting, this study noted many expressions of emotion on the faces of the various infants during REM sleep: grimaces, smiles, whimpers and even the nuances of affective expression such as perplexity, disdain, skepticism, and amusement.

Smiling has often been observed at birth,353 but until recently it was thought to be a "physiological artifact" (ie. caused by gas).354 However, research has identified neonatal smiling in response to specific tasks and also a wide variation in the frequency of smiling.355

Other facial expressions indicative of affect states have been clearly identified in newborns, including expressions that seem to indicate sadness, fear, disgust, happiness, surprise, anger, interest,356 distress, and shame. Using videotape of neonates in the first week of life, Eisenberg and Marmarou357 revealed of full range of clear-cut expressions of emotion.

Another study358 examined neonatal affect states as perceived by their parents. Ninety-five percent reported seeing joy and interest, 78% saw anger, 68% surprise, 65% distress, 40% sadness, 40% disgust, and 35% fear in their babies during the first week of life. The introduction of new information resulting in the quick appropriate change of affect suggests the dependence of emotion upon cognitive beliefs and cognitive processes.359

Key to any verification of Lake's M-FDS360 as a possible paradigm must be the explanation of how the maternal-fetal affect flow functions. Lake noted early on that the reaction to early emotional stress tended to set up a pattern of similar reacting that is life-long.

Persons who early on reacted "hysterically" tended to react hysterically as adults. Persons who adopted the typical "depressive" defense patterns early on, tended to utilize them as adults.

How does the emotional life of the mother effect the developing fetus? Lake's understanding is essentially that of Mott's, who conceptualized a bi-directional flow of blood from mother to fetus as mediated by the placenta through the umbilical cord, which gives rise to various physical "feeIings"361 that are the basis for subsequent psychological "feelings". Lake picked up on Mott's term "umbilical affect" to designate this exchange, defining it as the "feeling state of the fetus as brought about by blood reaching him through the umbilical vein."362

As both Lake and Mott define this exchange, the umbilical vein not only conveys nutritive resources and as such could be experienced as a "life-giving flow, bringing renewal and restoration" but could also "be the bearer of an aggressive thrust of bad feelings into the foetus if the mother herself was distressed and 'feeling bad."' If the mother felt emotionally unsupported, then "this feeling of deficiency, lack of recognition and the failure of looked-for support, would be just as specifically felt by the fetus. It became distressed by the failure of its immediate environment to provide the expected acceptance and sustenance, not so much at the level of metabolic input . . . but to nourish the earliest beginnings of the person in relationship."363

Certainly the biological morphology for this exchange exists very early on, from about the fifth week after fertilization until birth. With the development of the placenta and umbilical cord, the embryo/fetus exchanges C02, water, urea, hormones and waste products for oxygen, water electrolytes, protein and lipid carbohydrates, vitamins, antibodies and other nutrients. But the morphological structures which allow this "natural" exchange to occur also allow for the passage through the placental barrier of various teratogens,365 namely drugs366 and almost all viruses. Much research has been done on the deleterious effects of various teratogens and other prenatal "conditions", including hyperthermia,367 malnutrition,368 alcohol,369 phencyclidine (PCP),370 heroin,371 cocaine,372 codeine,373 methadone,374 amphetamines ,375 antidepressants and sedatives,376 caffeine,377 smoking,378 barbiturates,379 marijuana,380 khat,381 thalidomide, phenobarbital,382 diethystilbestrol (DES),383 lead,384 rubella,385 infIuenza,386 diabetes,387 tuberculosis, syphilis, hepatitis, chicken pox, lead,388 and radiation.389

The idea that the pregnant mother's emotional state during pregnancy might have a positive or deleterious effect on the developing baby within here is certainly not new390 In an early study from 1941, Sontag391 found that pregnant women who were anxious, angry and/or afraid tended to have babies with higher heart rates, digestive problems, lower birth weight, and hyperactive. Numerous studies392 since have confirmed these findings, reinforcing Sontag's original results. For instance, emotionally disturbed women tend to have infants who are irritable,393 poor sleepers,394 prone to gastrointestinal difficulties,395 have higher activity rates,396. cry more,397 are perceived by their parents as having a difficult temperament,398 and score lower on mental and motor skills tests.399 Several studies have connected anxiety400 and/or various psychiatric diagnoses401In pregnant women with a much higher incidence of various birth complications.

Another study402 examined 37 children with severe emotional/behavioral disorders vs. 119 children with severe emotional handicaps vs. 211 "normal" children. Using 26 items from the MPS (Maternal-Perinatal Scale),403 this study found that the item with the highest correlation as a predictive factor of post-natal emotional and behavioral disorders was cigarette smoking followed closely by matemal stress throughout pregnancy.404 This study reinforced other studies that have connected maternal stress with general behavior problems,405 attention deficit disorder,406 childhood autism,407 psychosis,408 schizophrenia,409 and psychiatric disorders in general.410

Various studies have also correlated the likelihood of spontaneous abortions and birth complications with the level of fear, anxiety, and guilt in pregnant women411 as well as disturbances in attitudes toward the child within them.412 Research has also shown a connection between various psychological factors and preterm delivery.413

For instance, premature delivery is more likely to occur in women who have negative attitudes toward the pregnancy, were emotionally immature, had unresolved conflicts toward their mothers, a history of traumatic experience with a previous pregnancy, a high level of anxiety, feelings of inadequacy in female roles,414 difficulty in accepting the pregnancy, poor communication with their fetus (or none),415 lack of a spouse,416 husbands who offered little or no support,417 and an initial negative reaction to their first menses.418

Indeed, the sum total of research seems to indicate that potentially any emotional stress to the mother can lead to complications of various types,419 not only after birth but even before birth. For instance, mothers under severe emotional distress are likely to have hyperactive fetuses420 and mothers who are anxious422 or emotionally upset421 are likely to have fetus's suffering from tachycardia.

One study illustrated the effects on 28 fetuses ages 18 to 36 weeks in response to their mother's reactions to an earthquake.423 Using ultrasonography, the researchers were able to observe the intense hyperkinesia in all of tile fetuses which lasted from 2 to 8 hours. Other studies424 have also connected fetal behavior to maternal emotional state.

What allows the affect state of the mother to effect the child she is carrying are the neuroendocrinological interactions of the endocrine system and the nervous system, particularly a group of hormones called catecholamines,425 including epinephrine, norepinephrine and dopamine.

Beginning in 1925, W.B. Cannon426 found that fear and anxiety could be biochemically induced in animals. His method was simple; he withdrew the blood and thus the catecholamines of already fearful and frightened animals and injected them into calm and relaxed animals. Within seconds and in the absence of any fear or anxiety producing stimuli, these animals began to act fearful and anxious. Cannon discovered that the catecholamines acted like "a circulating fire alarm system,"427 provoking all the physiological responses to fear and anxiety, particularly those of the sympathetic division of the autonomic nervous system.

This identical process allows the developing embryo and fetus to be affected by the mother's affective processes. When the gravida is anxious or fearful, various hormones, including adrenaline, flood into the blood stream and easily cross the placental barrier, thus provoking, biochemically, the physiological reaction to anxiety and fear in the fetus.428 The mechanism that allows this process to work begins with the mother's brain, which is sensing and perceiving the environment.

External circumstances, actions and thoughts are perceived in the cerebral cortex and subsequently affectively reacted to in the hypothalamus. The hypothalamus, in turn, directs the endocrine system and the autonomic nervous system to produce affect-appropriate physiological changes. For instance, sudden fear in a pregnant women quickly results in the hypothalamus directing the sympathetic division of the autonomic nervous system to make the heart beat faster, the palms to sweat, the blood pressure to rise, the pupils to dilate and the muscles to tense. The hypothalamus also directs the endocrine system to flood the woman's body with hormones,429 which as noted above, pass through the placenta to the fetus.

What is so important about this process is the effect it can have on the developing embryo and fetus. The various hormones released by the endocrine system, while variously reversible in adults, can be more-or-less irreversible at certain critical periods in development during the embryonic and fetal stages.

Sontag, in an early study titled "War and the Maternal-Fetal Relationship"430 observed that the babies of women whose husbands were serving in the armed services and thus daily threatened with death tended to be crankier and have an array of physical problems. He theorized that the intra-uterine environment of constantly worrying mothers would have a deleterious effect on a whole generation of infants. Sontag coined the term "somatopsychics"431 to describe the way "basic physiological processes affect the personality structure, perception, and performance of an individual."

Thus, the developing fetal morphological apparatus is influenced by the intra-uterine environment in such a way as to predispose certain psychological processes following birth.

Several studies432 have found what seems to be discriminations of stressors by the maternal-fetal unit. Stott found that no negative effects, either physical or emotional, seemed to be present in the children of mothers who had suffered fairly intense, but brief stressors (ie. witnessing a violent dog fight, suffering a scare at work, having an older child run away for a day).433 The argument that the brief exposure of the fetus to the "bath of neurohormones" necessarily limits the possibility of negative effect and this was true. But Stott and others433 have also found that intense, long-term, stress did not always result in post-natal deficiencies.

When prolonged stress did not directly threaten the mother (ie. illness of a close relative) there seemed to be no ill effects while stressors that did effect the potential well-being of the mother435 seemed to produce problems. Stott found that 10 out of 14 women suffering from personally threatening stressors which were long-term delivered babies with some physical or emotional problem. Two characteristics were deemed to be significant in the problem-causing stressors: "they tended to be continuous or liable to erupt at any time and they were incapable of resolution."436

Verny, in commenting on Stott's study, writes:

The only way to make sense of the difference [between the two groups subjected to long-term stress] is in terms of perception. In one case, the children were able to sense that while very real, their mother's distress was not threatening to her or them; in the other case, they sense, accurately, that her distress was a threat.437

Thus, some kind of fetal perceptual apparatus is assumed to enable the ability to distinguish between threatening and non-threatening neurohormones. One possible mechanism that might explain this is through a concomitant ongoing exchange between mother and fetus that communicates the positive vs. negative feelings of the mother herself to the child.

Numerous studies have examined the role of maternal attitudes,438 particularly attachment439 toward the fetus growing within them. One study440 examining 2000 pregnant women found that the single greatest factor in neonatal outcome was the attitude of the mother toward her child.441 The subjects in this study all had the same quality and quantity of prenatal care, were equally educated, and were of the same social and economic class.

Lukesch and others442 have found that the infants of mothers were accepting of their pregnancies and who looked forward to the arrival of the baby were much more likely to give birth to a emotionally and physically healthy child than mothers who had negative attitudes towards the pregnancy and were "rejecting."443

Another study444 on 141 pregnant women duplicated Lukesche's results. Using various psychological tests, Rottman divided the pregnant women into 4 groups. Results with the two extremes were clear, with "Ideal" mothers (who both consciously and unconsciously wanted their unborn children) having the easiest pregnancies, the most trouble-free births, and the most physically and emotionally healthy infants. "Catastrophic" mothers (who both consciously and unconsciously were rejecting of their unborn children) "had the most devastating medical problems during pregnancy, and bore the highest rate of premature, low-weight, and emotionally disturbed infants."445

Two other groups of mothers emerged, called "Ambivalent" (consciously wanting while unconsciously rejecting) and "Cool" (consciously rejecting while unconsciously wanting) mothers. The former gave birth to an unusually large number of neonates who suffered from behavioral and gastrointestinal problems, while the latter gave birth to babies who tended to be apathetic and lethargic.

Verny hypothesizes that regardless of the various stresses that these women went through, the acceptance or lack of acceptance by the mother is somehow perceived by the fetus and that among those fetuses who felt accepted, a measure of maternal "support' and "acceptance" was evident enough which somehow enabled them to better cope with the stresses that emerge.
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334Ryder, "Vagitus Uterinus," American Journal of Obstetrics and Gynecology 46 (1943): 867-872.

335M. Thiery. A. Le Sian Yo, M. Vrijens, and D. Janssens, "Vagitus Uterinus," Journal of Obstetrics and gynecology of the British Commonwealth 80 (1973): 153-185.

336A. Pieper, Cerebral Function in Infancy and Childhood (New York: Consultants Bureau, 1963).

337Humphrey, "Function of the Nervous System During Prenatal Life," 751-796.

338S.L. Friedman, C. Zahn-Waxler and M. Radke-Yarrow, "Perceptions of Cries of Full-term and Preterm Infants," Infant Behavior and Development 5 (1982): 161-173.

339Chamberlain writes the following regarding a personal communication in 1983 from H.M. Truby: "The . . . cryprints, as unique as fingerprints, revealed how distinctive and communicative these sounds ie. cries] were . . . [the] baby cry spectrograms were so detailed and so unique that they could tell if it was a first child or if it had been a problem pregnancy; even marital conflict in utero would be reflected in the infant's language in life." (Chamberlain, "The Cognitive Newborn," 53).

340B.M. Lester and C. F.Z. Boukydis, eds., Infant Crying: Theoretical and Research Perspectives (New York: Plenum, 1985); H.M. Truby and J. Lind. "Cry Sounds of the Newborn Infant," Newborn Infant Cry/Acta Paediatca Scandinavica, ed. J. Lind (1965): Supplement 163,1965.

341O. Wasz, J. Lind, V. Vuorenkoski, T. Partanen and E. Valanne, The Infant Cry: A Spectrographic & Auditory Analysis (London: Spestics International Medical Publications/William Heinnemann Medical Books, 1968).

342P.S. Zeskind and B.M. Lester, "Acoustic Features and Auditory Perceptions of the Cries of Newborns With Prenatal and Perinatal Complications," Child Development 49 (1978): 580-589.

343V. Vuorenkoski, J. Lind, T. Partanen, J. Lejeune and O. Wasz-Hockert, "Spectrographic Analysis of Cries from Children with 'Maladie du Cri du Chat'," Annales Paediatricias Fenniae 12 (1966): 174-180.

344O. Wasz-Hockert, M. Koivisto, M. Vuorenkoski, T. Partanen, and J. Lnd, "Spectrographic Analysis of the Pain Cry in Hyperbilirubinemia," Biology of the Neonate 17 (1971): 260-271.

345K. Juntunen, P. Sirvio, and K. Michelsson, "Cry Analysis of Infants with Severe Malnutrition," European Journal of Pediatrics 128 (1978): 241-246: B.M. Lester, "Spectrum Analysis of the Cry Sounds of Well- Nourished and Malnourished Infants," Child Development 47 (1976): 237-241.

346F. L. Porter, R.H. Miller and R.E. Marshall, "Neonatal Pain Cries: Effect of Circumcision on Acoustic Features of Perceived Urgency," Child Development 57 (1986): 57, 790-802.

347C.E. Izard and P. Read, eds.. Measuring Emotions In Infants and Children, vol.2 (New York: Cambridge Univ. Press, 1986), 93-123.

348Papousek, M. Papousek, and B.J. Harris, "The Emergence of Play in Parent-Infant Interactions," in Curiosity Imagination & Play On the Development of Spontaneous Cognitve and Motivational Processes, eds. D. Gorlitz and J.F. WohIwill (New York: Erlbaum Associates, 1986), 214-246.

349This is an acronym for "Rapid Eye Movement", so designated due to the rapid eye movements occurring behind closed or partially closed eyelids.

350Steven M. Reppert, Daniel Henshaw, William J. Schwartz and David R. Weaver, "The Circadian-gated Timing of Birth in Rats: Disruption by Maternal SCN Lesions or by Removal of the Fetal Brain," Brain Research 403 (1987): 398-402; Steven M. Reppert and William J. Schwartz, "Maternal Coordination of Fetal Biological Clock 'in utero,"' Science 220 (1983): 969-971; Steven M. Reppert, David R. Weaver, and Scott A. Rivkees, "Maternal Communication of Circadian Phase to the Developing Mammal," Psychoneuroendocrinology 13 (1988): 63-78.

351H.P. Roffwarg, J.N. Muzio, and W.C. Dement, "Ontogenetic Development of the Human Dream Cycle," Science 152 (1966): 604-619.

352ibid.

353F. Leboyer, Birth Without Violence (New York: Knopf, 1975); R.B. Star. The Healing Power of Birth (Austin, Texas: Star Publishing, 1986).

354Chamberlain, "The Cognitive Newborn," 55.

355P.H. Wolf, "The Natural History of Crying and other Vocalizations in Early Infancy,' DetermInants of Infant Behavior, vol.4., ed. B.M. Foss (London: Methuen, 1978).

356R. Emde, "Towards a Psychoanalytic Theory of Affect, I and II," The Course of Life (Washington DC - US Dept. of Health and Human Services, 1980), 63-112.

357R.B. Eisenberg and A. Marmarou, "Behavioral Reactions of Newborns to Speech-like Sounds and Their Implications for Developmental Studies," Infant Mental Health Journal 2 (1981): 129-138.

358W.F. Johnson, R.N. Emde, B.J. Pannabecker, C. Stenborg, and M.H. Davis, "Maternal Perception of Infant Emotion From Birth to 18 months," Infant Behavior & Development 5 (1982): 313-322.

359J. Kagan, "On Emotion and its Development: A Working Paper," in The Development of Affect, eds. M. Lewis and L.A. Rosenblum (New York: Plenum Press, 1978), 37.

360Powerfully impressive experiences from the mother and her inner and outer world . . . reach the foetus, defining its relation to the intra-uterine reality in ways that persist into adult life." (Lake, "Research into the Pre-Natal Aetiology of Mental Illness, Personality and Psychosomatic Disorders", 5).

361Feelings such as aggression, submission, emptiness, fullness, giving and taking.

362Moss, "Frank Lake's Maternal-Fetal Distress Syndrome: Clinical and Theoretical Considerations," 203.

363Lake describing Mott's position in "The Significance of Birth and Prenatal Events in Individual, Family and Social Life," S1.

364Leon G. Mulders, Guido J. Muijsers, Henk W. Jongsma, and Jan G. Nijhuis, "The Umbilical Artery Blood Flow Velocity Waveform in Relation to Fetal Breathing Movements, Fetal Heart Rate and Fetal Behavior States in Normal Pregnancy at 37 to 39 Weeks," Early Human Develonment 14 (1986): 283-293.

365F. Falkner, "Prenatal Growth: Key Issues," Acta Medica Auxologica 16 (1954): 93-100; P.H. Mussen, J.J. Conger, and J. Kagan, Essentials of Child Development and Personality, 5th ed., (New York: Harper & Row, 1980); C.H. Peckham and R.W. King, "A Study of Intercurrent Conditions Observed During Pregnancy," American Journal of Obstetrics and Gynecology 87 (1963): 609-624; L Saxon and J. Rapola, Congenital Defects (New York: Holt, 1969); G. Stechler and A. Halton, "Prenatal Influences on Human Development," in Handbook of Developmental Psychology, ed. B.B. Wolman (Englewood Cliffs, NJ, 1982), 175-189.

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367M.S. Smith, M.J. Edwards, and J.B. Upfold, "The Effects of Hyperthermia on the Fetus," Developmental Medicine and Child Neurology 28 (1986): 806-809.

368Kenneth S. Holt, "Diets and Development," Child Care: Health and Development 8 (1982): 183-201; B.J. Kaplan, "Malnutrition and Mental Deficiency," Psychological Bulletin 78 (1972): 321-334; Reuben W. Rhees and Donovan E. Fleming, "Effects of Malnutrition, Maternal Stress, or ACTH Injections During Pregnancy on Sexual Behavior of Male Offspring," Physiology and Behavior 27 (1981): 879-862; Susi D. Roedenback, "Prenatal Protein Deficiency and the Development of the Nervous System: II. Neuropsychological Aspects," Revista de Neuro Psiguiatria 37 (1974): 155-168; M. Winick, Malnutrihon and Brain Develooment (New York: Oxford Univ Press, 1976).

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370Theresa A. Fico and Christina Vanderwende, "Phencyclidine During Pregnancy: Fetal Brain Levels and Neurobehavioral Effects," Neurotoxicology and Teratology 10 (1986): 349-354; Judy Howard, Vickie Kropenske, and Rachelle Tyler, "The Long-term Effects on Neurodevelopment in Infants Exposed Prenatally to PCP," National Institute on Drug Abuse Research Monograph Series, Monograph #64 (1986): 237-251; Kenneth R. Kautman, Ruth A. Petrucha and Ferris N. Pitts, "Phencyclidine in Umbilical Cord Blood: Preliminary Data," The American Journal of Psychiatry 140 (1983): 450-452.

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372Donald E. Hutchings, Theresa A. Fico, and Diana L. Dow-Edwards, "Prenatal Cocaine: Maternal Toxicity, Fetal Effects and Locomotor Activity in Rat Offspring," Neurotoxicology and Teratology 11(1989): 65-69; Jeffrey S. Rosecan and Barbara F. Gross, "Newborn Victims of Cocaine Abuse," Medical Aspects of Human Sexuality 20 (1986): 30-35.

373Brenna H. Bry, "Substance Abuse in Women: Etiology and Prevention," Issues in Mental Health Nursing 5 (1983): 253-272.

374Ira S. Chasnoff, William J. Burns, and Sidney H. Schnoll, "Perinatal Addiction: The Effects of Maternal Narcotic and Nonnarcotic Substance Abuse on the Fetus and Neonate," National Institute on Drug Abuse Research Monooraph Series, Monograph 49 (1984): 220-226: Mary J. Kreek, "Opioid Disposition and Effects During Chronic Exposure in the Perinatal Period in Man," Advances in Alcohol and Substance Abuse 1(1982): 21-53.

375Deborah L Selinger, "Effect of Prenatal Maternal Administration of d-amphetamine on Rat Offspring Activity and Passive Avoidance Learning," Physiological Psychology 11 (1976): 273-280.

376J. Manth, "Side Effects on Fetus and Infant of Psychotropic Drug Use During Pregnancy," International Pharmcopsychiatry 11(1976): 246-260.

377Joan C. Martin, "An Overview: Maternal Nicotine and Caffeine Consumption and Offspring Outcome," Neurobehavioral Toxicology and Teratology 4 (1982): 421-427.

378Cathie E. Alderks, Donovan E. Fleming, and Robert E. Seegmiller, "Prenatal Exposure of Mice to Tobacco Smoke and Ethanol: Preweaning Behavioral and Growth Effects," The Psychological Record 68 (1986): 333-342: David H. Rubin, PA. Krasilnikoff, John M. Leventhal, and Arne Berget, "Cigarette Smoking and Alcohol Consumption during Pregnancy by Danish Women and Their Spouses: A Potential Source of Fetal Morbidity," American Journal of Drug and Alcohol Abuse 14 (1988): 405-417; Edward G. Singleton, Jules P. Harrell, and Lily M. Kelly, "Racial Differences in the Impact of Maternal Cigarette Smoking during Pregnancy on Fetal Development and Mortality: Concerns for Black Psychologists," Journal of Black Psychology 12 (1986): 71-83; LW. Sontag and R.F. Wallace, "The Effect of Cigarette Smoking during Pregnancy upon the Fetal Heart Rate," American Journal of Obstetrics and Gynecology 29 (1935): 77-83; Ann Pytkowicz Streissguth, Donald C. Martin, and Helen M. Barr, "Intrauterine Alcohol and Nicotine Exposure: Attention and Reaction Time in 4-year-old Children," Developmental Psychology 20 (1984): 533-541.

379Joan C. Martin, "Irreversible Changes in Mature and Aging Animals Following Intrauterine Drug Exposure," Neurobehavioral Toxicology and Teratology 8 (1986): 335-343.

380Ernest L. Abel and Barbara A. Dintcheff, "Increased Marihuana-induced Fetotoxicity by a Low Dose of Concomitant Alcohol Administration," Journal of Studies on Alcohol 47 (1986): 440-443; Susan L. Dalterio, "Cannabinois Exposure: Effects on Development," Neurobehavioral Toxicology and Teratology 8 (1986): 345-352; Katherine Tennes, "Effects of Marijuana on Pregnancy and Fetal Development in the Human," National Institute on Drug Abuse Research Monograph Series Monograph #44 (1954): 115-123.

381Abdul N. Ghani, M. Eriksson and B. Kristiansson, "The Influence of Khat-Chewing on Birth-Weight in Full-Term Infants," Social Science & Medicine 24 (1987): 625-627.

382Joseph Yanai and Chaim G. Pick, "Neuron Transplantation Reverses Phenobarbital-induced Behavioral Birth Defects in Mice," International Journal of Developmental Neuroscience 6 (1988): 409-416.

383Melissa Hines and Carl Shipley, "Prenatal Exposure to Diethylstilbestrol (DES) and the Development of Sexually Dimorphic Cognitive Abilities and Cerebral Lateralization," 81-94.

384Claire B. Ernhart, Mary Morrow-Tlucak, Abraham W. Wolf, and Dennis Super, "Low Level Lead Exposure in the Prenatal and Early Preschool Periods: Intelligence Prior to School Entry," Neurotoxicology and Teratology 11(1989): 161-170.

385Heather Murdoch, "Maternal Rubella: The Implications," AEP Association of Educational Psychologists Journal 6 (1954): 3-6.

386Sarnoff A. Medick, Ricardo A. Machon, and Matti O. Huttunen, "Adult Schizophrenia Following Prenatal Exposure to an Influenza Epidemic," Archives of General Psychiatry 45 (1988): 189-192.

387E.J. Mulder, G.H. Visser, D.J. Bekedam and H.F. Prechtl, "Emergence of Behavioral States in Fetuses of Type-1 Diabetic Women," Early Human Development 15 (1987): 231-251; Steven S. Robertson, "Infants of Diabetic Mothers: Late Normalization of Fetal Cyclic Motility Persists After Birth," Developmental Psychobiology 21(1986): 477-490; Steven S. Robertson and Leroy J. Dierker, "The Development of Cyclic Motility in Fetuses of Diabetic Mothers," Developmental Psychobiology 19 (1986): 223-234; Uttam K. Saha, Malaya Gupta, and D. Sengupta, Studies on the 'in vitro' Effect of Doxepin on Cholinesterase and Monoamine Oxidase Activity of Human Fetal Brain," IRCS Medical Science Psychology and Psychiatry 14 (1986): 597-598; Uttam K. Saha, Trishna Sengupta, Chabi Dutta, and Amitava Chakrabortyl, "In vitro Effect of Haloperidol on Cholinesterase Activity of Human Fetal Brain," IRCS Medical Science Psychology and Psychiatry 14 (1986): 461-462; G.H. Visser, D.J. Bekedam, E.J. Mulder, and E. Van-Ballegooie, "Delayed Emergence of Fetal Behavior in Type-i Diabetic Women," Early Human Development 12 (1985): 167-172.

388David Bellinger, Alan Leviton, Christine Waternaux, and Herbert Needleman, "Longitudinal Malysis of Prenatal and Postnatal Lead Exposure and Early Cognitive Development," New England Journal of Medicine 316 (1987): 1037-1043.

389Ronald G. Kaczmarek, Roscoe M. Moore, and Kenneth G. Keppel, "x-ray Examinations During Pregnancy: National Natality Surveys, 1963 and 1980," American Journal of Public Health 79 (1989): 75-77; Toshiaki Tachibana, "Effects of Prenatal X-irradiation on Open-field Behavior in Rats: Application of Randomized Fostering Technique and Mapping Results," The Journal of General Psychology 113(1986): 379-392; Ikuo K. Takeuchi and Yoshiko K. Takeuchi, "Congenital Hydrencephalus Following X-irradiation of Pregnant Rats on an Early Gestational Day," Neurobehavioral Toxicology and Teratology 8 (1986): 143-150.


390Van den Bergh cites Whitehead's study in 1867 on the effect of maternal emotions on fetal behavior as pivotal in the beginning of the "modern" research into this effect. (B.R.H. van den Bergh, "The Influence of Maternal Emotions During Pregnancy on Fetal and Neonatal Behavior," Pre- and Peri-Natal Psychology Journal 5 (1990): 119-130).

391L.W. Sontag, "The Significance of Fetal Environmental Differences," American Journal of Obstetrics and Gynecology 42 (1941): 996-1003.

392Review articles of the effect of maternal stress on the developing infant include the following: B. Carlson and R.C. La Barba, "Maternal Emotionality During Pregnancy and Reproductive Outcome," International Journal of Behavior Development 2 (1979): 342-376; J. Istvan, "Stress, Anxiety, and Birth Outcome: A Critical Review of the Evidence," Psychological Bulletin 100 (1986): 331-348; B. R.H. van den Bergh, "Der Psychische Toestand van de zwangere en de Prenatale Ontwikkeling: Literatuurstudie en schets van een heuristische Model," Tijdchrift vor Orthopedagogie en Klinische Kinderpsyhvhologie 8 (1983): 18-37.

393J.A. Dodge. "Psychosomatic Aspects of Infantile Pyloricstenose," Journal of Psychosomatic Research 16 (1972): 1-5.

394A. J. Ferreira, "The Pregnant Woman's Emotional Attitude and its Reflection on the Newborn," American Journal of Orthopsychiatry 30 (1960): 553-561.

395Gary B. Glavin, "Prenatal Maternal Stress: Differential Effects upon Male and Female Offspring Responses to Restraint Stress as an Adult," Pavlovian Journal of Biological Science 19 (1984): 57-159; E.K. Turner, "The Syndrome in the Infant Resulting from Maternal Emotional Tension During Pregnancy," The Medical Journal of Australia 4 (1956): 221-222.

396L.W. Sontag, "Implications of Fetal Behavior and Environment for Adult Personalities," Annals of the New York Academy of Sciences 134 (1966): 782-786.

397E.A. Farber, B. Vaughn, and B. Egeland. "The Relationship of Prenatal Maternal Anxiety to Infant Behavior and Mother-Infant Interactions during the First 6 Months of Life," Early Human Development 5 (1981): 267-277.

398B.E. Vaughn, C.F. Bradley, L.S. Joffe, R. Seifer and C. Barglow, "Maternal Characteristics Measured Prenatally are Predictive of Ratings of Temperament 'Difficulty' On the Caret Temperament Questionnaire," Developmental Psychology 23 (1987): 152-161.

399A. Davids, R.H. Holden and G. Gray, "Maternal Anxiety During Pregnancy and Adequacy of Mother and Child Adjustment Eight Months Following Childbirth," Child Development 34 (1963): 993-1002.

400Alex J. Crandon, "Maternal Anxiety and Obstetric Complications," Journal of Psychosomatic Research 23 (1979): 109-11; Luigi Grassi and Stefano Caracciolo, "Rischio psicobiologico in gravidanza e parto," Medicina Psicosomatica 28 (1983): 301-320.

401G. Peterson, L MehI, and J. McRae, "Relationship of Psychiatric Diagnoses, Anxiety and Stress with Birth Complications," in Prenatal and Perinatal Psychology and Medicine Edited by Peter G. Fedor-Freybergh and M.L. Vannessa vogel (Park Ridge, NJ: The Parthenon Publishing Group, 1988), 399-416: Ronald O. Rider, David Rosenthal, Paul Wender, and Helene Blumenthal, "The Offspring of Schizophrenics: Fetal and Neonatal Deaths," Archives of General Psychiatry 32 (1975): 200-211.

402Ervin S. Batchelor, Jr., Raymond S. Dean, Jeffrey W. Gray, and Stanley Wenck, "Classification Rates and Relative Risk Factors for Perinatal Events Predicting Emotional/Behavioral Disorders in Children," Pre- and Peri-Natal Psychology Journal 5 (1991): 327-341.

403R.S. Dean and J.W. Gray, Maternal Perinatal Scale (Muncie, Ind.: Ball State Univ., 1985).

404Using an odds ratio developed by Mantel (N. Mantel, "Chi-square Tests With One Degree of Freedom: Extensions of the Mantel-Haenszel Procedure," Journal of American Statistics 56 [1963]: 690-700), this study found, for instance, that maternal smoking throughout the pregnancy resulted in a odds ratio of 4.34 (ie. mothers who smoked during pregnancy are 4.34 times likely to have a child who eventually ends up being diagnosed as behavioral or emotionally disordered. The score for stress throughout pregnancy was 4.22 and was higher than other factors such as low birth weight (3.37), preterm delivery (2.75), edema throughout the pregnancy (2.04), too little weight gain (1.74), hypoxia (1.18), mother over 35 years old (1.14) and maternal ingestion of alcohol (.63).

405R. Cocchi, M. Felici, L Tonni, and G. Venanzi, "Behavior Troubles in Nursery School Children and Their Possible Relationship to Pregnancy or Delivery Difficulties," Acta Psychiatrica Belgica 84 (1984): 173-179; Alan De Sousa, "Causes of Behavior Problems in Children," Child Psychiatry Quarterly 7 (1974): 308.

406Christopher K. Varley, "Attention Deficit Disorder (the hyperactivity syndrome)" A Review of Selected Issues," Journal of Developmental and Behavioral Pediatrics 5 (1984): 254-258.

407J. Finnegan and B. Q Neonatal Factors and Infantile Autism," Journal of Child Psychology and Psychiatry 20 (1979): 119-128; F. Foulatier, "L'Enfant Autiste et la Metacommunication," Evolution Psychiatrique 52 (1987): 471-481; Christopher Gillberg and Carina I. Gillberg, "Infantile Autism: A Total Population Study of Reduced Optimality in the Pre-, Peri-, and Neonatal Period," Journal of Autism and Developmental Disorders 13 (1983): 153-166; Anne Mason-Brothers, Edward R. Ritvo, and Barry Guze, "Pre­, Peri- and Postnatal Factors in 181 Autistic Patients from Single and Multiple Incidence Families," Journal of the American Academy of Child and Adolescent Psychiatry 26 (1987): 39-42.

408E.F. Torry, S.P. Hersh, and K.D. McCabe, "Early Childhood Psychosis and Bleeding During Pregnancy: A Prospective Study of Gravid Women and Their Offspring," Journal of Autism and Childhood Schizophrenia 5 (1975): 289-297.

409Sarnoff A. Medick, Josef Parnas and Fini Schulsinger, "The Copenhagan High Risk Project, 1962-86, Schizophrenia Bulletin 13 (1987): 485-495: Thomas A. Ritzman, "Schizophrenia, It's Cause and Cure," Medical Hypnoanalysis Journal 4 (1989): 27-37; C.N. Rutt and D.R. Olford, "Prenatal and Perinatal Complications in Childhood Schizophrenics and Their Siblings," Journal of Nervous and Mental Disorders 152 (1971): 324-331.

410M.O. Huttunen and P. Niskanen, "Prenatal Loss of Father and Psychiatric Disorders," Archives of General Psychiatry, 4 (1978): 429-431. This study compared the rates of mental illness between two groups of Finnish men, one who had lost fathers while they were in utero and another who had lost fathers in early infancy. The first group had a much higher incidence of all psychiatric disorders, particularly schizophrenia, indicating that something other than mere "nurture" was taking place.

411Z. Golanska and A. Bacz, "The Psychological Effects of Maternal Attitudes in Cases of Repeated Unfavorable Pregnancy Outcome," in Prenatal and Perinatal Psychology and Medicine, eds. P.G. Fedor­Freybergh and M.L.V. Vogel (Park Ridge, NJ: The Parthenon Publishing Group, 1988), 93-97.

412E. Goshen-Gottstein, Marriage and First Pregnancy (London: Tavistock Publications, 1969); V. Laukaran and B. Van den Berg, "The Relationship of Maternal Attitude to Pregnancy Outcomes and Obstetrical Complications. A Cohort Study of Unwanted Pregnancy," American Journal of Obstetrics and Gynecology 136 (1980): 374-379.

413A. Blau, B. Slaff, K. Easton, J. Welkowitz, J. Springham, and J. Cohen, "The Psychogenic Etiology of Premature Births," Psychosomatic Medicine 25 (1963): 201-211; L. Gunter, "Psychopathology and Stress in the Life Experience of Mothers of Premature Infants. A Comparative Study," American Journal of Obstetrics and GynecoIogy 86 (1963): 333-340.

414X. De Muylder, "Attitudes Maternelles en cas de Travail Prémature," in Memoire de License en Sexologie (Louvain: Université de Louvain, 1988).

415Clara M. Riley, "Teaching Mother/Fetus Communication: A Workshop on how to Teach Pregnant Mothers to Communicate with their Unborn Children," Pre- and Peri-Natal Psychology Journal 3 (1988): 77- 86.

416Richard W. Newton, "Psychosocial Aspects of Pregnancy: The Scope for Intervention," Journal of Reproductive and Infant Psvchology 6 (1988): 23-9.

417Another study found a significantly higher incidence of vomiting and nausea in the first 12 weeks of pregnancy in those women who had poor communication with their husbands and who had stress and doubts about the pregnancy. (George M. latrakis, Gerasimos G. Sakellaropoulos, Anthony H. Kourkoubas, and Stavroula E. Kabounia, "Vomiting and Nausea in the First 12 Weeks of Pregnancy," Psychotherapy and Psychosomatics 49 [1988]: 22-24).

418X. De Muylder and S. Wesel, "Maternal Attitudes and Preterm Labor." in Prenatal and Perinatal Psychology and Medicine, eds. P.G. Fedor-Freybergh and M.LV. Vogel (Park Ridge, NJ: The Parthenon Publishing Group, 1988), 87-92.

419R.E. Laibow, "Prenatal and Perinatal Experience and Developmental Impairment," in Prenatal Psychology and Medicine, eds. P.G. Fedor-Freybergh and M.LV. Vogel (Park Ridge NJ: The Parthenon Publishing Group, 1988), 295-308; C. Michel and Hedi Fritz-Niggli, "Induction of Developmental Anomalies in Mice by Maternal Stress," Experientia 34 (1978): 105-106: C. Spielberger and G. Jacobs, "Emotional Reactions to the Stress of Pregnancy and Obstetrics Complications," in Emotion and Reproduction, eds. L.Carenza and L Zichella (London: Academic Press, 1979), 13.

420A.J. Ferreira, "Emotional Factors in Prenatal Environment," The Journal of Nervous and Mental Disease 141 (1965): 108-118; R.L Mc Donald, "The Role of Emotional Factors in Obstetric Complications," Psychosomatic Medicine 30 (1968): 222-237; Ashley Montagu, Prenatal Influences (Springfield, Ill.: Charles Thomas, 1962). 5. Wolkind, ed., "Pre-natal Emotional Stress - Effects on the Fetus," in Pregnancy: A Psychological and Social Study (London: Academic Press, 1981), 177-194.

421D.E. Copher and C.P. Huber, "Heart Rate Response of the Human Fetus to Induced Maternal Hypoxia," American Journal of Obstetrics and Gynecology 98 (1967): 320-335.

422KA.B. Eskes, "Verloskundige consequenties van niet vermerke rouw over een perinataal gestorven kind," Nederlands Tijdschrift voor Geneeskunde 129 (1985): 433-436.

423lannuruberto and Tajani, "Ultrasonographic Study of Fetal Movements," 175-181.

424Pauline Benson, Betsy C. Uttle, David G. Talbert, and John Dewhurst. "Foetal Heart Rate and Maternal Emotional State,"British Journal of Medical Psychology 60 (1987): 151-154; Van den Bergh, "The Influence of Maternal Emotions During Pregnancy on Fetal and Neonatal Behavior," 119-130; B.R.H. Van den Bergh, "The Relationship Between Maternal Emotionality During Pregnancy and the Behavioral Development of the Fetus and Neonatus," in Prenatal Psychology and Medicine, eds. P. Fedor-Freybergh and M.L.V. Vogel (Park Ridge NJ: The Parthenon Publishing Group, 1988), 131-142.

425Hugo Lagercrantz and Theodore A. Slotkin, "The 'Stress' of Being Born," Scientific American 254 (1988): 100-107. (This study examines the role that catecholamines play in birth, which become quite elevated prior during the birth process.); John A. Moyer, Lorraine R. Herrenkohi, and David M. Jacobowitz, "Stress During pregnancy: Effect on Catecholamines in Discrete Regions of Offspring as Adults," Brain Research 144 (1978): 173-178; Penny Simkin, "Stress, Pain and Catecholamines in Labor: I. A Review," Birth Issues in Perinatal Care and Education 13 (1988): 227-233.

426Verny, The Secret Life of the Unborn Child, 44.

427ibid.

428Fredenck Kruse, "Nos Souvenirs du Corps Maternal," Psychologie Heute (June 1978): 56; David A. Peters. "Effects of Maternal Stress During Different Gestational Periods on the Serotonergic System in Adult Rat Offspring," Pharmacology Biochemistry and Behavior 31 (1988): 839-843.

429Defined as "intercellularly active chemical messengers that are produced in specialized cells and exert biological effects on other cells of the same organism by acting locally or on distant target cells." (G. Dorner, "Significance of Hormone-dependent Brain Development and Pre-and Early Postnatal Psychophysiology for Preventative Medicine," in Prenatal Psychology and Medicine, eds. P. Fedor-Freybergh and M.LV. Vogel [Park Ridge NJ: The Parthenon Publishing Group, 1988], 420).

430Lester W. Sontag, "War and the Maternal-Fetal Relationship," Marriage and Family Living 6(1944): 1-5.

431This term infers the mirror process of "psychosomatics", which refers to the way in which psychological processes effect physiological ones. Verny, The Secret Life of the Unborn Child, 54).

432Dennis Stott, "Follow-up Study from Birth of the Effects of Prenatal Stresses," Developmental Medicine and Child Neurology 15 (1973): 770-787; Dennis Stott and Sandra Latchford, "Prenatal Antecedents of Child Health, Development, and Behavior: An Epidemiological Report of Incidence and Association," Journal of the American Academy of Child Psychiatry 15 (1976): 161-191.

433Several studies have found different results regarding even short-term fetal behavioral response in reaction to induced maternal emotions. One study (B.R. Van den Bergh, E.J. Mulder, G.H. Visser, and G. Poelmann-Wessjes. "The Effect of (induced) Maternal Emotions on Fetal Behavior: A Controlled Study," Early Human Development 19 (1989]: 9-19) found no significant fetal response when their mothers watched a film on delivery, perhaps considered mildly stressing. Two other studies (Nicola Rossi, "La ricerca psicologica di fronte alla vita fetale. Prospettive e metodi di indagine," Eta-evolutiva 26 [Feb 1987]: 65-70; and Nicola Rossi, Paola Avveduti, Nicola Rizzo and Raffaele Lorusso, "Maternal Stress and Fetal Motor Behavior: A Preliminary Report," Pre- and Peri-NataI Psychology Journal 3 [1989]: 311-318) found significant fetal movement in response to their mothers anticipation of an amniocentesis vs. a group of controls. A fourth study (Benson, Little, Talbert, and Dewhurst, "Foetal Heart Rate and Maternal Emotional State," 151-154) found that fetuses of anxious mothers, but not depressed or hostile mothers showed elevated heart rates.

434Anthony E. Reading, "The Influence of Maternal Anxiety on the Course and Outcome of Pregnancy: A Review," Health Psychology 2 (1983): 187-202. Reading found that the impact of anxiety and stress is often moderated by other factors, such as attitudes toward the pregnancy, psychosocial support and appraisal of the threat of the stressor.

435Especially when the source of the stress was a close family member, usually the husband. In another study (Dennis Stott, "Children in the Womb: The Effects of Stress," New Society, [May 1977]: 329-331.) Stott rates a bad marriage or relationship as among the greatest causes of stress. Studying over 1300 children and their families, he estimates that a women trapped by a stormy marriage with an abusive or unsupportive husband runs a 237% greater risk of bearing a emotionally or physically handicapped child as opposed to a woman from a secure, nurturing stable marital environment. Further, Stott found that unhappy marriages tended to produce babies who were on average 5 times more fearful and "jumpy" than offspring from happy marriages. Verny writes that "these youngsters continued to be plagued by problems well into childhood. At four and five, Dr. Stott found them to be undersized, timid, and emotionally dependent on their mothers to an inordinate degree." Verny, The Secret Life of the Unborn Child, 50).

436Verny, The Secret Life of the Unborn Child, 48, quoting Stott, "Children in the Womb."

437ibid.

438Ricoard C. Ainslie, Antal E. Solyom, and Michael E. McManus, "On the Infant's Meaning for the parent: A Study of Four Mother-Daughter Pairs," Child Psychiatry and Human Development 13 (1982): 97-110; John T. Condon, "The Parental-Foetal Relationship: A Comparison of Male and Female Expectant Parents," Journal of Psychosomatic Obstetrics and Gynaecology 4 (1985): 271-284; Sam C. Eggersten and Thomas J. Benedetti, "Fetal Well-Being Assessed by Maternal Daily Fetal-Movement Counting," Journal of Family Practice 18 (1984): 771-781; Anthony E. Reading, David N. Cox, Caroline Sledmere, and Stuart Campbell, "Psychological Changes Over the Course of Pregnancy: A Study in Attitudes Toward the Fetus/Neonate," Health Psychology 3 (1984): 211-221.

439Kathleen F. Gaffney, "Maternal-Fetal Attachment in Relation to Self-Concept and Anxiety," Maternal Child Nursing Journal 15 (1986): 91-101; Ramona T. Mercer, Sandra Ferketich, Katharyn May, and Jeanne Dejospeh, "Further Exploration of Maternal and Paternal Fetal Attachment," Research in Nursing and Health 11 (1988): 83-95; Ben Sjogren and Nils Uddenberg, "Prenatal Diagnosis and Maternal Attachment to the Child-to-Be: A Prospective Study of 211 Women Undergoing Prenatal Diagnosis with Amniocentesis or Chronic Villi Biopsy," Journal of Psychosomatic Obstetrics and Gynecology 9 (1988): 73-87; Colleen M. Stainton, "The Fetus: A Growing Member of the Family," Family Relations Journal of Applied Family and Child Studies 34 (1985): 321-326; J. Hana Wu and Mary A. Schmann, "Fetal Sex Identification and Prenatal Bonding," Psychological Reports 63 (1988): 199-202.

440Monika Lukesch, "Psychologie Faktoren der Schwangerschaft" (Ph.D. diss., University of Salzburg, 1975).

441The second most important variable was that of the quality of a woman's relationship with her spouse.

442John T. Condon, "Psychological and Physical Symptoms During Pregnancy: A Comparison of Male and Female Expectant Roles," Journal of Reproductive and Infant Psychology 5 (1987): 207-219.

443Verny, The Secret Life of the Unborn Child, 48, quoting Lukesch, "Psychologie Faktoren der Schwangerschaft."

444Gerhard Rottman, "Untersuchungen über Einstellung zür Schwanger schaft und zur fotalen Entwicklung," in Pranatale Psycholopie, ed. Hans Graber (München: Kindler Verlag, 1974).

445Verny, The Secret Life of the Unborn Child, 48.

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