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C Thynne,G Gaffney,M O'Neill,M Tonge,C Sherlock
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Ir Med J. 2012 Sep;105(8):263-5
C Thynne1, G Gaffney1, M O’Neill2, M Tonge1, C Sherlock1
1University College Hospital, Newcastle Rd, Co Galway
2Psychology Department, HSE West, St Marys HQ, Castlebar, Co Mayo
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Abstract
A target group of women who concealed their pregnancy (n=43) was compared to an aged-matched control group (n=30) that experienced a crisis pregnancy. Comparisons were also made with a larger dataset (n=6363) of births in University Hospital Galway (UHG) (normative group). Data was analysed using the Chi-square test and the Kolmogorov-Smirnoff two-sample test. The number of women from the target group that were from a rural background was 28 (65%), compared to 10 (33%) from the control group. The number of women from the target group that feared a negative parental reaction to the pregnancy was 34 (79%), compared to 12 (40%) from the control group. The birth weight in the target group was 400g lower than the normative birth weight. The average age of women who concealed was 8 years lower than the normative age. The prevalence of concealed pregnancy in UHG was one in every 148 births.
Introduction
In clinical practice, it is not uncommon that a pregnancy remains unrecognised up to the end of the first trimester, especially for primiparous women who are unfamiliar with the symptoms of pregnancy1. However, from the point of view of obstetric practice, a pregnancy that remains un-booked in the second and third trimester is considered highly unusual and can pose a severe threat to the life and health of the child and mother involved2. Reported risks to an infant who does not receive antenatal care are, prematurity, lower birth weight, an increased likelihood of being admitted to a neonatal unit and a higher peri-natal mortality rate than control groups3,4. Obstetric literature in this area highlights that a better understanding as to why women postpone or desist antenatal care is important for the health and well being of the baby and mother involved1. Concealment of pregnancy has been noted to be one of the reasons why a pregnancy remains un-booked2. Antenatal care is often foregone or delayed in a concealed pregnancy and concealed pregnancy has been linked with infanticide5,6 and thus the exploration of this phenomenon was considered to have clinical significance and relevance.
Methods
A retrospective case control study was carried out from January 1st 2003 to December 31st 2004. All participants to be included in the study had been referred to the social work department in University Hospital Galway (UHG). The criteria for inclusion in the target group defined a concealed pregnancy as a woman who presents for antenatal care past 20 weeks gestation not having disclosed her pregnancy to her social network1,2. The control group (n=30) were selected based on age matching criteria, from all crisis pregnancies, which had been referred to the social worker department. The definition of a crisis pregnancy used is as defined by the Crisis Pregnancy Agency as “a pregnancy which is neither planned nor desired by the woman concerned and which represents a personal crisis for her”7. Peri-natal measures included birth weight and admission rates to the neonatal intensive care unit (NICU). Socio-demographic data for both groups was collated from social work notes and included maternal age, martial status, level of education, employment status, disclosures post delivery, perceived parental reaction, decision post delivery regards parenting and original family domain. A working definition of the terms rural and urban were agreed by the researcher and social work practitioners, with rural being a village or town with 3000 inhabitants or less.
Normative data from booked deliveries was available from the Obstetrics and Gynaecology UHG Annual Clinical Report and where appropriate this data was compared to the data available from the target group. Due to the very large difference in sample size between the target group (n=43) and the larger normative group (n=6363) the larger sample was reduced to n=100 by using the percentages as numbers rather than the actual number 63638.Categorical data was analysed using Chi-square test. An alpha level of .05 was used for all statistical tests. For ordinal data, the Kolmogorov Smirnoff two-sample test was applied.
Results
Twenty-five (58%) of the women in the target group only disclosed to their family and social network post delivery while thirteen (30%) of the target group were also un-booked. None of the deliveries in the control group were un-booked and all had disclosed their pregnancies prior to 20 weeks gestation. A summary of the findings are given in table 1. The mean weight of infants in the target group was not found to be significantly lower than those infants in the control group. Although the distributions were similar the target group had a higher proportion of birth weights of 2-3kg. However the birth weight of the target group was found to be significantly lower than the birth weight of the infants in the normative group. D =0.19, P<0.001(Figure 1).
* Denotes Statistically significant
Figure 1
The mean age of the women in the target group was 22.9 years (SD =4.8). The age range of women in the target group was similar to the age range in the normative group. However the modal age is lower in the target group than the normative group (Figure 2). A significant difference was found between the ages of the women in these two groups d=0.58, p<0.001. The number of teen pregnancies in the target group was low which highlights that concealed pregnancy is not a phenomenon exclusive to teenagers but women of all ages. There were 7 (16%) admissions to the neonatal unit in the target group compared to 1 (3%) in the control group. This difference was not significant. A chi-square test also yielded no significance difference between the target and control group in relation to the number of previous pregnancies. In the target group 9 (21%) women had given birth previously, which was similar to the proportion of women in the control group (7 women; 23%). However, an interesting finding was that 7 of these 9 women in the target group had also concealed their previous pregnancy. No significance difference was found between the target and control group in relation to relationship status. Over half of the target group and control group were not in a relationship at the time of pregnancy.
No significant difference was found between the groups in relation to education levels or employment status. The majority of the target group (n=37; 86%) and the control group (n= 25; 83%) had attained secondary education. Thirty women (70%) who concealed their pregnancy were either employed or in full time education while 15 (50%) of the control group were in employment or education. Of the women who concealed their pregnancy, 28 (65%) were from a rural background, compared to 10 (33%) from the control group (Figure 3; p<0007). From the target group 34 women (79%) feared a negative parental reaction to the pregnancy compared to 12 women from the control group (40%; p<0.001). On discharge from hospital, a larger proportion of women in the target group placed their children for pre-adoptive fostering (n=14; 33%) than those in the control group (n=4; 13%) However this difference is not significant.
Figure 2
Figure 3: Original Family Background
Discussion
The prevalence rate of concealed pregnancies reported in this study was 1 in every 148 births. This rate is higher than that reported in a Dublin based study (1 in 768 births) carried out in the Rotunda maternity hospital2 and higher than a rate reported from an Irish study based in a rural maternity hospital9 (1 in 403 births). University Hospital Galway (UHG) serves both a city and rural population and this may explain some of the differences in prevalence rates reported in these three Irish hospital based studies. The risk to infants who receive inadequate antenatal care of lower birth weight2-4 was also shown in this study. Some researchers argue that immaturity and inexperience explain a concealed pregnancy11 yet seven of the women had previously concealed a pregnancy. This findings points towards repetitive behaviour that may be better explained as an individuals coping style as opposed to naivety12. Qualitative data from this current study13 highlighted that unsupportive familial and societal systems influenced some women’s decision to conceal a pregnancy. In some of the cases of reoccurring concealed pregnancies the same unsupportive systems may have contributed significantly to the second concealed pregnancy.
Teenagers were not overly represented in either the concealed pregnancy group or the crisis pregnancy group. This finding supports the contention that concealed pregnancy is not exclusively a teenage phenomenon. Therefore, the proposal from a New Zealand based study, which reported that teenaged girls comprised the majority of cases of concealed pregnancy11, was not supported in this Irish sample. The majority of women in the target group were either in third level education or employed at the time of their pregnancy. These finding are contrary to a previous study, which investigated an American sample16 in which the majority of women who concealed a pregnancy were unemployed and had low levels of education.
Fear of parental response has been cited as an explanation as to why women conceal a pregnancy14,15. In this study concealed pregnancy occurred in women aged from 17 to 35 years old and perceived family reaction emerged as one of the most significant reasons for concealing the pregnancy. This finding reveals that fear of family reaction to a pregnancy seems to be a reality for women of various ages and not just a fear that exists during the teenage years. Coupled with the fear of parental reaction a significantly larger number of women who concealed their pregnancy were from rural backgrounds. Rural origin has been reported in a Canadian study as a contributing factor in denial of pregnancy15. Previous studies have found that women concealed their pregnancy as they had planned to have their baby placed for adoption9,14,16. In this study the intention to place their child for adoption was given as one of the reasons why a pregnancy was concealed and several children from the concealed pregnancies were placed for pre-adoptive fostering post delivery.
This study found that the prevalence of concealed pregnancies was higher in UHG than in previous studies in Irish maternity hospitals, which highlights that concealed pregnancies are relatively common. Risks to the infant cited in cases of un-booked and denied pregnancy such as lower birth weight were also echoed. It was found that concealed pregnancy occurs across a wide age range but that it is most common in women in their early twenties. Women who concealed their pregnancy were predominately single and tended to be educated and in employment or an educational setting. Having a rural background was found to be a significant factor as to whether someone concealed their pregnancy and perceived family reaction was also found to be a significant factor contributing to the process of concealment. Additionally, the reoccurrence of concealment is also an important finding and suggests that if a woman conceals a pregnancy on one occasion she may be more at risk of concealing future pregnancies. These finding have clinical implications for the practitioners working with this population. Further international research may help clarify prevalence rates and which specifically cultural nuances play a part in explaining the occurrence of concealed pregnancy.
Correspondence: C Thynne
Adult Mental Health, Tuam Day Hospital, Toghermore Campus, Tuam, Co Galway
Email: [email protected]
References
1. Wessel J, Endrikat J, Buscher U. Elevated risk of neonatal outcome following denial of pregnancy: Results of a one-year prospective study compared with a control group. J Perinat Med. 2003; 31: 29-35.
2. Treacy A, Byrne P, O’Donovan M. Perinatal outcome in un-booked women at the Rotunda hospital. IMJ. 2002; 95: 44-47.
3. Rodie VA, Thompson AJ, Norman JE. Accidental out of hospital deliveries: Obstetric and neonatal case control study. Acta Obstet Gynecol Scand. 2002; 81: 50-54.
4. Brezinka C, Hunter O, Biebl W, Kinzl J. Denial of pregnancy: Obstetrical aspects. J Psychosom Obstet and Gynaecol. 1994; 15:1.
5. Stotland NE, Stotland NL. Denial of pregnancy. Primary Care Update for Ob/Gyns, 1998; 5: 247-250.
6. Spinelli MG. A systematic investigation of 16 cases of neonaticide. American Journal of Psychiatry. 2001; 158: 811-813.
7. Statutory Instrument No 446 of 2001, Crisis Pregnancy Agency Establishment Order. 2001, Government Publications, Dublin.
8. Howitt D, Cramer D. An introduction to statistics in psychology. 2nd ed. Essex: Pearson Education; 2003.
9. Conlon C. Concealed Pregnancy: A case study approach from an Irish setting. Dublin: Crisis pregnancy Agency; 2006; 15.
10. University College Hospital Galway Obstetrics and Gynaecology UCHG Annual Clinical Report. 2005. Galway: Health Service Executive Western Area.
11. Kaplan R, Grottowski, T. Denied pregnancy. Australian and New Zealand Journal of Psychiatry. 1996. 30: 861.
12. Green CM, Manohar SV. Neonaticide and hysterical denial of pregnancy. British Journal of Psychiatry. 1990. 156: 121-123.
13. Thynne C, O’Neill M, Gaffney G, Tonge M, Sherlock C. Exploring the experience of women who undergo a late disclosure of pregnancy. http://www.lenus.ie/hse/handle/10147/210730
14. Treacy A, Byrne P. Concealed pregnancy. Modern Medicine. 2003; 3: 31-32.
15. Finnegan P, Mc Kinstry E, Robinson GE. Denial of pregnancy and childbirth. Canadian Journal of Psychiatry. 1982; 27: 672-674.
16. Friedman SH, Heneghan A, Rosenthal M. Characteristics of women who deny or conceal pregnancy. Psychosomatics. 2007; 48: 117-122.
17. Chapman R. Endangering safe motherhood in Mozambique: Prenatal care as pregnancy risk. Social Science and Medicine. 2003; 57: 355-374.
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Author's Correspondence
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No Author Comments
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Acknowledgement
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No Acknowledgement
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Other References
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No Other References
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