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Pregnancy Denial and Early Infant Development: a Case-Control Observational Prospective Study

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Pregnancy Denial and Early Infant Development: a Case-Control Observational Prospective Study Auer et al. BMC Psychology (2019) 7:22 https://doi.org/10.1186/s40359-019-0290-3 STUDY PROTOCOL Open Access Pregnancy denial and early infant development: a case-control observational prospective study Julie Auer1, Coralie Barbe2, Anne-Laure Sutter3, Dominique Dallay4, Laurianne Vulliez5, Didier Riethmuller6, Violaine Gubler7, Valérie Verlomme8, Stéphanie Saad-Saint-Gilles9, Alain Miton10, Emmanuelle Tessier11, Olivier Parant12, Julie Le Foll13, Agnès Bourgeois-Moine14, Sylvie Viaux15, Marc Dommergues16, Gisèle Apter17, Joëlle Belaisch-Allart18, Anne Danion19, Israël Nisand20, Olivier Graesslin21, Alexandre Novo1, Julien Eutrope1 and Anne-Catherine Rolland1* Abstract Background: The denial of pregnancy is the non-recognition of the state of the current pregnancy by a pregnant woman. It lasts for a few months or for the whole pregnancy, with generally few physical transformations. In this study, we will consider the denial of pregnancy as a late declaration of pregnancy (beyond 20 weeks of gestation) as well as a lack of objective perceptions of this pregnancy. The main objective of this study is to explore the relationship between pregnancy denial and the development of the infant (attachment pattern of the infant, early interactions of mother-infant dyads, and early development of the infant). Methods: The design is a case-control prospective study, which will compare two groups of mother-infant dyads: a “case” group with maternal denials of pregnancy and a “control” group without denials of pregnancy. A total of 140 dyads (mother + infant) will be included in this study (70 cases and 70 controls) and followed for 18 months. The setting is a national recruitment setting with 10 centers distributed all over France. The follow-up of the “cases” and the “controls” will be identical and will occur over 5 visits. It will include measures of the infant attachment pattern, the quality of early mother-infant interaction and infant development. Discussion: This study aims to examine the pathogenesis of pregnancy denial as well as its consequences on early infant development and early mother-infant interaction. Trial registration: Clinical Trial Number: NCT02867579 on the date of 16 August 2016 (retrospectively registered). Background There is no consensus concerning the definition of Definition of pregnancy denial pregnancy denial. First, there is no consensus on the Described in the 1970s [1, 2], pregnancy denial occurs as threshold date from when the pregnancy is considered the unconsciousness of being pregnant for several denied if unacknowledged. On the one hand, some au- months or throughout the entire period of pregnancy. thors consider that the threshold date is beyond the first Usually, body transformations are not clearly noticeable. trimester: 14 weeks of amenorrhea [4, 5], beyond 21 The prevalence of this symptom is estimated to be 1 weeks of amenorrhea [6] or beyond 20 weeks of preg- case of denied pregnancy in 475 births [3]. nancy [3]. On the other hand, some authors consider a much longer duration. For example, Friedman proposed the end of the third trimester as threshold date [7]. Second, besides duration, denial may be incomplete. * Correspondence: [email protected] 1Service de Psychothérapie de l’enfant et de l’adolescent, Pôle Two types of pregnancy denial have been proposed: par- Femme-Parents-Enfant, Av du Gl Koenig, Centre Hospitalier Universitaire, tial denial with late pregnancy discovery (after 5 month 51092 Reims Cedex, France of pregnancy) and total denial with pregnancy discovery Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Auer et al. BMC Psychology (2019) 7:22 Page 2 of 7 while delivering [8]. Third, the encountered terminolo- as on his pattern of attachment? We hypothesize that gies differ from author to another, including pregnancy the attachment and the development of the infant to be denial and pregnancy negation [9]. Dayan describes born, as well as the quality of mother-infant interaction, pregnancy negation as “a large range of occurrences, are disturbed when the woman presents a denial of preg- which are the refusal or incapacity of a pregnant woman nancy. Specifically, we expect these consequences to be to admit her condition” [10]. These difficulties in prop- stronger with a longer duration of pregnancy denial. erly defining pregnancy denial reflect the clinical hetero- geneity of the patients. Study objectives The denial of pregnancy calls into question maternal The primary objective of this study is to examine the re- psychological functioning. However, to date, no link be- lationship between pregnancy denial and infant attach- tween any specific psychiatric disorder and denial of ment patterns, early mother-infant interaction and early pregnancy has been established [11]. During our clinical infant development. meetings, mothers who presented a denial of pregnancy The secondary objectives of this research are as follows: report a difficult personal history with many breaks and events described as traumatic. – To explore among women with pregnancy denial the influence of the duration period between the Consequence of pregnancy denial pregnancy announcement and delivery on infant During pregnancy, a mother is getting prepared to meet attachment pattern, early mother-infant interaction her child and build quality interactions through a matur- and early infant development; ational process leading to a psychological reorganization. – To study the factors associated with pregnancy The pregnancy and the birth represent, for the woman, denial, including the type of maternal attachment an essential phase of her psycho-affective development, and the existence of a maternal personality disorder comparable to the adolescence in its somatic, hormonal and/or a psychiatric condition. and psychological changes. In the past, many authors have studied these psychological reorganizations and Methods proposed theories [12, 13]. These psychological reorgani- Trials status zations enable the mother to adapt to her new role and This study has been retrospectively registered in the to create a containing and reassuring environment for European registry (EudraCT 2011-A01498-33) and in her child. For women prone to pregnancy denial, this clinicaltrials.gov (NCT02867579). The recruitments and period of psychological reorganization is almost non-ex- the interventions started on April 2013 and will be com- istent. The first part of the pregnancy’s story is lacking. pleted in April 2019. More recently, a study found that perceiving frequent fetal movements was associated with higher scores of Study design and setting prenatal attachment [14]. Several publications [15–20] This study entitled “Attachment and pregnancy denial” report observations of cases of pregnancy denial. Only is a national multicenter prospective case-control study one retrospective studies focused on the future of the with 13 French investigation centers (Anthony Ile-de- child [21]. To our knowledge, no prospective study has France, Besançon, Bordeaux, Nancy, Paris Bichat, Paris focused on the future of the mother-infant relationship. La Pitié Salpêtrière, Reims, Strasbourg, Toulouse, Amiens, Troyes, Aubagne, Lille). Objectives Study hypothesis Population We put forward the following hypothesis: an insecure at- Inclusion criteria are as follows. In the case group, dyads tachment of the mother would participate or at least are composed of a woman with pregnancy denial and would increase the likeliness of pregnancy denial. These her infant. Pregnancy denial will be defined by a preg- mothers would find it difficult (even impossible in some nancy announcement after 20 weeks of gestation and a cases) to access the experiences of their infants, which lack of objective perceptions of the pregnancy by the are essential in the psychological reorganizations neces- woman. Women with no follow-up of the pregnancy sary during pregnancy to prepare the woman to accept due to geographical, social or administrative reasons her new functions as a mother. (absence of insurance coverage, family conflicts, un- Moreover, the absence or reduction of the duration of employment, and pregnancy hidden to the employer) the usual 9-month period for psychological elaboration will not be included. In the control group, dyads are during the pregnancy calls into question its potential im- composed of a woman without pregnancy denial and pact on the quality of mother-child interactions. Are her infant. The case group and the control group will there consequences on the infant’s development as well be matched on primiparous and non-primiparous Auer et al. BMC Psychology (2019) 7:22 Page 3 of 7 mothers and on premature (birth before 37 GW) and Depression Inventory (BDI) [26] the Edinburgh Perinatal non-premature infants. Depression Scale EPDS [27], of maternal anxiety with Exclusion criteria are as follows: minor women (< 18 the Scale Trait Anxiety Inventory
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