INFANTICIDE

Psychosocial and Legal

Perspectives on Mothers Who Kill

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INFANTICIDE
Psychosocial and Legal
Perspectives on Mothers Who Kill

Edited by

Margaret G. Spinelli, M.D.

Washington, DC
London, England

Note: The authors have worked to ensure that all information in this
book is accurate at the time of publication and consistent with general
psychiatric and medical standards, and that information concerning drug
dosages, schedules, and routes of administration is accurate at the time of
publication and consistent with standards set by the U.S. Food and Drug
Administration and the general medical community. As medical research and
practice continue to advance, however, therapeutic standards may change.
Moreover, specific situations may require a specific therapeutic response
not included in this book. For these reasons and because human and
mechanical errors sometimes occur, we recommend that readers follow
the advice of physicians directly involved in their care or the care of a
member of their family.
Books published by American Psychiatric Publishing, Inc., represent the views
and opinions of the individual authors and do not necessarily represent the
policies and opinions of APPI or the American Psychiatric Association.
Copyright 2003 American Psychiatric Publishing, Inc.
ALL RIGHTS RESERVED
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Library of Congress Cataloging-in-Publication Data
Infanticide : psychosocial and legal perspectives on mothers who kill /
edited by Margaret G. Spinelli.1st ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 1-58562-097-1 (alk. paper)
1. InfanticidePsychological aspects. 2. InfanticideSocial aspects.
3. Women murderers. 4. MothersPsychology. 5. Postpartum
depression. I. Spinelli, Margaret G., 1947
[DNLM: 1. Infanticidepsychology. 2. Depression, Postpartum
psychology. 3. Infanticidelegislation & jurisprudence. 4. Mothers
psychology. W 867 I437 2002]
RG852 .I53 2002
364.15230852dc21
2002071116

British Library Cataloguing in Publication Data

A CIP record is available from the British Library.

To Erik, Keith, Bob, and Phil,

for their belief in my journey

In memory of
Professor Ramesh Channi Kumar

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Contents
Contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Margaret G. Spinelli, M.D.
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xxiii

Part I
Epidemiology and Historical
Legal Statutes
Chapter 1
A Brief History of Infanticide and the Law. . . . . . . . . . . . . . . . . . . . . . 3
Michelle Oberman, J.D., M.P.H.

Chapter 2
Epidemiology of Infanticide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Mary Overpeck, Dr.P.H.

Part II
Biopsychosocial and
Cultural Perspectives on Infanticide
Chapter 3
Postpartum Disorders: Phenomenology, Treatment Approaches,
and Relationship to Infanticide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Katherine L. Wisner, M.D., M.S., Barbara L. Gracious, M.D.,
Catherine M. Piontek, M.D., Kathleen Peindl, Ph.D., and
James M. Perel, Ph.D.

Chapter 4
Neurohormonal Aspects of Postpartum Depression and Psychosis. . . 61
Deborah Sichel, M.D.

Chapter 5
Denial of Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Laura J. Miller, M.D.

Chapter 6
Neonaticide: A Systematic Investigation of 17 Cases . . . . . . . . . . . . 105
Margaret G. Spinelli, M.D.

Chapter 7
Culture, Scarcity, and Maternal Thinking. . . . . . . . . . . . . . . . . . . . . 119
Nancy Scheper-Hughes, Ph.D.

Part III
Contemporary Legislation
Chapter 8
Criminal Defense in Cases of Infanticide and Neonaticide . . . . . . . . 133
Judith Macfarlane, J.D.

Chapter 9
Medical and Legal Dilemmas of Postpartum Psychiatric Disorders. . . 167
Cheryl L. Meyer, Ph.D., J.D., and Margaret G. Spinelli, M.D.

Chapter 10
Infanticide in Britain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Maureen N. Marks, D.Phil., C.Psychol., A.F.B.P.S.

Part IV
Treatment and Prevention
Chapter 11
How Could Anyone Do That?: A Therapists Struggle With
Countertransference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Anonymous

Chapter 12
The Mother-Infant Relationship: From Normality to Pathology. . . . 209
Pamela Meersand, Ph.D., and Wendy Turchin, M.D.

Chapter 13
The Promise of Saved Lives: Recognition, Prevention, and
Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Margaret G. Spinelli, M.D.
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257

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Contributors

Barbara L. Gracious, M.D.

Assistant Professor of Psychiatry, University of Rochester Medical Center, Strong Memorial Hospital, Rochester, New York
Judith Macfarlane, J.D.
Practicing Attorney, Human Services Division, The City of New York Office of the General Counsel, Legal and Government Affairs Division, New
York, New York
Maureen N. Marks, D.Phil., C.Psychol., A.F.B.P.S.
Senior Lecturer, Sections of Perinatal Psychiatry and Psychotherapy, Institute of Psychiatry; Consultant Adult Psychotherapist, Perinatal Services, South London and Maudsley NHS Trust, Institute of Psychiatry,
London, England
Pamela Meersand, Ph.D.
Assistant Professor of Psychology, Columbia University; Director, Therapeutic Nursery, The New York Presbyterian Hospital; Faculty Member,
The Parent-Infant Program of the Institute for Psychoanalytic Training
and Research, Columbia University, New York, New York
Cheryl L. Meyer, Ph.D., J.D.
Associate Professor of Law and Psychology, Wright State University School
of Professional Psychology, Dayton, Ohio
Laura J. Miller, M.D.
Associate Professor of Psychiatry, Chief of Womens Services Division,
University of Illinois at Chicago, Chicago, Illinois
xi

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Infanticide: Psychosocial and Legal Perspectives

Michelle Oberman, J.D., M.P.H.

Professor of Law, DePaul University College of Law, Chicago, Illinois
Mary Overpeck, Dr.P.H.
Epidemiologist, U.S. Maternal and Child Health Bureau, Rockville, Maryland
Kathleen Peindl, Ph.D.
Assistant Professor of Psychiatry, Thomas Jefferson University, Philadelphia, Pennsylvania
James M. Perel, Ph.D.
Professor of Psychiatry and Pharmacology, University of Pittsburgh Medical Center, Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania
Catherine M. Piontek, M.D.
Assistant Professor of Psychiatry and Human Behavior, and Obstetrics and
Gynecology, Thomas Jefferson University, Philadelphia, Pennsylvania
Nancy Scheper-Hughes, Ph.D.
Professor of Medical Anthropology; former Chair, Department of Anthropology; Director, Graduate Program in Critical Studies in Medicine,
Science, and the Body, University of California at Berkeley, Berkeley,
California
Debra Sichel, M.D.
Instructor, Harvard University Medical College; Director of Helsia Womens
Health Center, Boston, Massachusetts
Margaret G. Spinelli, M.D.
Assistant Professor of Psychiatry, Columbia University College of Physicians and Surgeons; Director, Maternal Mental Health Program, and Research Psychiatrist, New York State Psychiatric Institute, New York, New
York
Wendy Turchin, M.D.
Assistant Professor of Psychiatry, Cornell University; Director, Pediatric
Mental Health, The New York Presbyterian Hospital; Faculty Member, The
Parent-Infant Program of the Institute for Psychoanalytic Training and
Research, Columbia University, New York, New York

Contributors

xiii

Katherine L. Wisner, M.D., M.S.

Professor of Psychiatry, Obstetrics and Gynecology and Pediatrics, Womens
Behavioral HealthCARE, University of Pittsburgh Medical Center, Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania

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Introduction
Margaret G. Spinelli, M.D.

The infants life is a vulnerable thing and depends to a great extent

on the mothers good will. Sara Ruddick . . . has captured the contradictions well in noting that mothers, while so totally in control of the
lives and well being of their infants and small babies, are themselves under the dominion and control of others. Simultaneously powerful
and powerless, it is no wonder that artists, scholars, and psychoanalysts can never seem to agree whether mother was the primary
agent or the primary victim of various domestic tragedies. And so
myths of a savagely protective maternal instinct compete at various
times and places with the myth of the equally powerful, devouring,
infanticidal mother.
Nancy Scheper-Hughes (1992)

aternal infanticide, or the murder of a child in the first year of life

by its mother, is a subject both compelling and repulsive. The killing of
an innocent elicits sorrow, anger, and horror. It is a crime. It demands retribution. That is the law.
Yet the perpetrator of this act is often a victim too, and that recognition makes for a more paradoxical response. On one hand is the image of
a defenseless infant, killed by the person on whom he or she depended
for survival. On the other is the image of a mother, insane, isolated and
imprisoned for a crime unthinkable to many. These competing images
elicit ambivalence, if not outrage.
Such contradictions are a theme of this book, the production of which
was motivated by the dearth of up-to-date, research-based literature on this
tragic cause of infant deaths. As I introduce this subject, I ask the reader to
xv

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Infanticide: Psychosocial and Legal Perspectives

share in a difficult task: to reach beyond rage, to stretch the limits of compassion and enter the minds of mothers who kill their babies. I do so in
the hope that advancing the knowledge base and stimulating inquiry in
this neglected area of maternal-infant research will save young lives.
The paucity of research-related reports on this tragic and arguably preventable cause of infant mortality demands action. Thus, my initial goal
in compiling the existing knowledge base is to provide a framework
within which can be designed research strategies for early identification
and treatment of women at risk of committing infanticide and for prevention of maternal infanticide.
My secondand more practical and immediategoal is to assist mental health and law practitioners who participate in the court cases of
women accused of infanticide. Scant literature is available for the mental
health professional who is facing the challenges of the criminal court
system or for the attorney who must understand the implications of psychiatric diagnoses as defenses for infanticide and neonaticide. I hope this
book can serve as a preliminary resource.
Historically, society and the law have treated infanticide with ambivalence (Lagaipa 1990; Oberman 1996). In Biblical times, infanticide was
sanctioned as a method of human sacrifice and population control. In the
early seventeenth century, infant murder became so prevalent that laws
were enacted and severe punishments, including execution, were imposed
on mothers (especially unmarried women) who killed their babies. In
1647, Russia assumed a more humane position, and by 1881, all European
states except the United Kingdom had followed suit. In 1922, Britain
passed the Infanticide Act (amended and expanded in 1938), changing the
relevant charge from murder to manslaughter and proscribing sentences of
probation and mandatory psychiatric treatment for women found guilty.
Canada has almost identical legislation. At present, the infanticide laws in
most countries allow for lenient sentencing and psychiatric treatment.
In contrast, a woman convicted of infanticide in the United States may
face a long prison sentence or even the death penalty. Because of the scarcity of psychiatric treatment in our overcrowded prison system, these
women serve their time and exit the system in their childbearing years with
the same psychopathology that brought them into it in the first place.
This work was in the early phase of production when the nation was
riveted by the news that Andrea Yates drowned her five children (ages 6
months to 7 years) in the bathtub of her Houston, Texas, home (CourtTV
2002). Perhaps no other case demonstrates the paucity of medical and
legal understanding of postpartum psychosis and associated infanticide
than that of Yates v. Texas. The tragedy of the Yates family parallels the
theme of this book.

Introduction

xvii

Andrea Pia Yates was a registered nurse who became a stay-at-home

mom who home-schooled her children. She was a champion swimmer,
high school valedictorian, and a devoted and loving mother. Although she
was consistently pregnant and /or breast feeding over the past 7 years, she
cared for her bedridden father as well as her own growing family: Noah
7, John 5, Paul 3, Luke 2, and Mary 6 months.
Mrs. Yates also had a history of psychiatric illness. She blocked her
thoughts when she felt Satans presence and heard Satans voice tell her
to pick up the knife and stab the child after Noahs birth in 1994. She
told no one because she feared Satan would hear her and harm her children. She also worried that some of her doctors might be Satan or be influenced by Satan. Two suicide attempts after her fourth pregnancy were
driven by attempts to resist Satanic voices commanding her to kill her
infant.
Six months after the birth of her fifth child, her family recognized
that Andrea Yates appeared catatonic. In the month before she killed
her children, her friend noticed that she walked around the house like a
caged animal.
After two psychiatric hospitalizations, Andrea Yates continued to deteriorate. When her psychiatrist discontinued her antipsychotic medication 2 weeks before the tragedy, she became floridly psychotic. Cartoon
characters called her a bad mother. She was no longer able to resist the
commanding voices in her head. Satan directed her to kill her children to
save them from the fires and turmoil of hell.
Yates was charged with capital murder with possible penalty of death.
She requested a razor to shave her head and reveal the mark of the beast
666 that she believed was on her scalp. I am Satan, she said.
It took the jury 3 hours to return a guilty verdict. The prosecution
sought the death penalty. After 35 minutes of deliberation, the jury selected
life in prison.
My personal impetus for embarking on this book grew from my experience as a perinatal psychiatrist who has had professional involvement
in infanticide cases in the judicial system. The scarcity of contemporary
research and literature on childbirth-related psychiatric diagnoses available to mental health and legal professionals leaves room for great doubt
that the system is functioning justly or effectively or humanely. And because diagnostic guidelines for postpartum disorders are limited, decisions about guilt, sentencing, and potential for treatment often rest in the
hands of the judicial community. The existing literature does not support
alternatives to assist the court in this process.
In a court of law, expert witness testimony must be founded on scientific standards that are recognized in the professional psychiatric commu-

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Infanticide: Psychosocial and Legal Perspectives

nity. Yet the defenses available for women alleged to have committed
infanticide are limited to early and outdated literature. Motivated by a desire to address the lack of current and usable resources, I began this project
by focusing on the psychiatric and legal implications of infanticide.
As work progressed, a panoply of contributors with expertise in infanticideclinicians, scholars, academicians, researchers, clinical and forensic psychiatrists and psychologists, pediatric psychoanalysts, attorneys, an
anthropologist, and an epidemiologistexpanded my early vision of this
book. Together, they have painted a broader and far richer picture: They
have provided a preliminary biopsychosocial and legal model of maternal
infanticide. They have explored the unique biological roles of women and
examined their combined psychosocial, psychodynamic, and caregiving
roles. They have suggested directions and described strategies for research, treatment, and prevention of infanticide.
The first part of the book introduces historical and epidemiological
data. Michelle Oberman, who is a researcher and academician in the fields
of law, public health, and infanticide, describes historical legal statutes of
infanticide and the evolution of contemporary legislation. She presents a
compelling discussion of the contrasting legal views of infanticide in the
United States, United Kingdom, and other Western countries. Professor
Oberman and Cheryl Meyer have amassed and classified the largest database of female perpetrators of infanticide in the United States. Drawing
from hundreds of cases, Professor Oberman provides an overview of a new
typology and associated characteristics in mothers who kill (Meyer and
Oberman 2001).
Mary Overpeck, an epidemiologist, describes the most recent statistics on maternal infanticide and calls attention to the problems of underreporting and the lack of available documentation. Professor Overpeck
identifies problems of ascertainment, particularly in early neonatal deaths,
and describes future methods of investigation to facilitate description of
risk as well as improved prevention.
The five chapters that make up the books second part illustrate the
biopsychosocial and cultural underpinnings of infanticide. The authors explore clinical diagnosis, symptom recognition, risk factors, and biological
precipitants as well as alternative motives such as cultural infanticide.
Chapter 3 was developed to assist the attorney or the mental health professional in understanding the implications of postpartum psychiatric illness
as they relate to infanticide. It is a comprehensive review of psychiatric
disorders associated with childbirth written by an international perinatal
expert and researcher, Katherine Wisner, and her colleagues. Dr. Wisner
and her colleagues provide a review of the most recent literature on differential diagnoses, etiology, evaluation, and state-of-the-art treatment on

Introduction

xix

childbirth-associated psychiatric illness. They emphasize and illustrate a

sensitive and thorough inquiry into infanticidal ideation.
In Chapter 4, Debra Sichel, a perinatal psychiatrist and clinician, provides the most recent data and clinical applications of underlying physiological mechanisms associated with childbirth. Dr. Sichel emphasizes
neurohormonal mechanisms of the acute hormone withdrawal state as
the initial etiological trigger affecting brain chemistry and mental status
changes associated with delivery.
Chapters 5 and 6 examine neonaticide, or child murder within 24 hours
of birtha topic that is often sensationalized in news media coverage. In
Chapter 5, Laura Miller shares her expertise in the psychopathology of
pregnancy denialwhich often precipitates neonaticideand distinguishes
three types of denial and potential sequelae. In Chapter 6, I describe the
first systematic evaluation of the cases of 17 women alleged to have committed neonaticide. I also identify a prodrome of similar phenomenology,
psychopathology, presentation, and family history in a subset of neonaticidal mothers.
Chapter 7 illuminates how economic and cultural realities can contribute to the prevalence and even acceptance of maternal infanticide.
In this chapter, Nancy Scheper-Hughes, former chair of the Department
of Anthropology at the University of California, Berkeley, recounts her
experience on the Alto do Cruzeiro (Hill of the Crucifix), the shantytown region of Northeastern Brazil. Professor Scheper-Hughes invites us
into a culture in which the high expectation of death produces patterns
of nurturing that differentiate those infants thought of as thrivers from
those thought of as born already wanting to die. The survivors and
keepers are nurtured, while the stigmatized or doomed infants are allowed to die of neglectangels . . . freely offered up to Jesus and His
Mother in order to preserve the limited resources for stronger, older children and working adults.
Contemporary legislation is the central theme of the third part. Chapter 8 is authored by practicing attorney Judith MacFarlane, who describes
the present standard for the insanity defense in the United States and its
relevance to infanticide and neonaticide. This chapter is an excellent resource for the attorney or the expert psychiatric witness who is preparing
for an infanticide or neonaticide case in the criminal court system. In
Chapter 9, law professor and psychologist Cheryl Meyers and I discuss
the American criminal and civil courts discrepant treatment of postpartum
psychiatric disorders. We contrast the admissibility of postpartum syndromes on womens behalf in the civil courts (as in child custody suits)
with their inadmissibility in criminal cases. In Chapter 10, Maureen
Marks, lecturer in psychiatry at the Institute of Psychiatry at the Mauds-

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Infanticide: Psychosocial and Legal Perspectives

ley Hospital in England, describes current controversies over Englands

Infanticide Act and discusses that countrys strategies for preventing and
treating postpartum disorders through services such as health visits to the
home and inpatient mother and baby units.
The final chapters focus on clinical experiences with mothers as perpetrators, mothers and infants at risk, and early treatment and prevention. In
Chapter 11, a perinatal expert, psychotherapist, and faculty member of
a major academic institution anonymously describes a 2-year psychodynamic treatment of a woman awaiting trial for neonaticide after a denied
pregnancy associated with rape. This therapist describes initial negative
countertransference reactions, the limitations on dynamic work against
the backdrop of an impending murder trial, the risk of decompensation,
timely decisions to support rather than confront defenses, and termination issues at the time of the patients incarceration.
The closing chapters explore pregnancy and early parenting as the
peak time for prevention and intervention. In Chapter 12, two child psychoanalysts, Pamela Meersand and Wendy Turchin, focus on normal motherinfant attachment as baseline in an attempt to understand the pathological
changes that occur when bonding fails. They emphasize early intervention
through evaluation of mothers-at-risk and mother-infant psychotherapy.
My epilogue on prevention (Chapter 13) suggests that the foregoing
body of knowledge may be used as a stepping-off point for desperately
needed inquiry into the neglected area of maternal infanticide. I emphasize early identification of mothers at risk and prevention of pathological
sequelae.
A theme conspicuously absent from this book is paternal infanticide
and filicide (murder of a child under 5 years of age). Although parents are
the most likely perpetrators of infanticide, little information on paternal
filicide exists in the literature (Marks and Kumar 1993). The existing literature on infanticide by fathers consists of small-sample case studies of male
perpetrators in various settings (Campion et al. 1998; Cordier 1983; Kaye
et al. 1990; Marleau et al. 1999; Martin 1984). Only four cases of paternal
neonaticide have been reported in the literature (Kaye et al. 1990).
Although infanticide may be viewed as an act of child abuse (Lowenstein 1997), and males are responsible for half of these crimes, child abuse
by fathers is a neglected area of study. Of 66 studies of child abuse published in the literature over 5 years, 28 included only mothers; 2 included
fathers, and the 36 remaining articles neglected to mention sex differences (Martin 1984). Haskett et al. (1996) reviewed 126 articles of maltreatment from 1989 through 1994; males were included in fewer than half
(47.7%) of 77 reviewed articles. Only 3 studies included males, yet 40 involved female participants.

Introduction

xxi

Reports suggest that men are more likely to use violence as a method of
murder and more likely to receive longer prison sentences than are women
(Marks and Kumar 1993). At least one report suggests that men are more
likely to kill spouses along with children (Byard et al. 1999). In general,
the treatment resources for abusing men are inadequate, and therefore
there is little or no potential for prevention.
Sex differences in reporting are not easily explained, especially since the
subject of infanticide is generally underrepresented in the literature. One
factor may be that childbirth is universally identified as a time of vulnerability for women. Postpartum disorders affect 10%15% of new mothers. Kendell et al. (1987) demonstrated that the peak lifetime prevalence
for psychiatric disorders and hospital admissions for women occur in the
first 3 months after childbirth, the identical time frame for the occurrence of 50% of infanticides. Why do we continue to neglect this field of
research?
Whether the cause of maternal infanticide is postpartum psychiatric
illness, dissociative disorder and denial of pregnancy, substance abuse,
child neglect, or child abuse, women at risk of committing infanticide are
presenting to us in antepartum, postpartum, and well-baby clinics, hospitals, and other settings. Absent research-based information on the temporal relationship between childbirth and infanticide, and a clinical
framework for understanding the diagnosis and phenomenology that underlie infanticide, we are, in all likelihood, missing the signs of potential
tragedy.
I offer this book as a springboard and inspiration for research aimed
at classifying infanticide according to the biopsychosocial model of psychiatry and contemporary diagnostic criteria. Therein lies the hope of
prevention and the promise of saved lives.

References
Byard RW, Knight D, James RA: Murder-suicides involving children: a 29-year
study. American Journal of Forensic Medicine and Pathology 20:323327,
1999
Campion JF, Cravens JM, Covan F: A study of filicidal men. Am J Psychiatry 145:
11411144, 1998
Cordier J: The child, privileged victim of crimes of passion. Victimology 8(12):
131136, 1983
CourtTV: Texas mom drowns kids. Available at http://www.courttv>com/trials/
yates. Accessed March 2002.
Haskett ME, Marziano B, Dover ER: Absence of males in maltreatment research:
a survey of recent literature. Child Abuse Negl 20:11751182, 1996

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Infanticide: Psychosocial and Legal Perspectives

Kaye NS, Borenstein NM, Donnelly SM: Families, murder, and insanity: a psychiatric review of paternal neonaticide. Journal of Forensic Sciences 35:133
139, 1990
Kendell RE, Chalmers JC, Platz C: Epidemiology of puerperal psychoses. Br J
Psychiatry 150:662673, 1987
Lagaipa SJ: Suffer the little children: the ancient practice of infanticide as a modern moral dilemma. Issues Compr Pediatr Nurs 13:241251, 1990
Lowenstein LF: Infanticidea crime of desperation. Criminologist 21(2):8192,
1997
Marks MN, Kumar R: Infanticide in England and Wales, 19821988. Med Sci Law
33:329339, 1993
Marleau JD, Poulin B. Webanck T, et al: Paternal filicide: a study of 10 men. Can
J Psychiatry 44:5763, 1999
Martin JA: Neglected fathers: limitations in diagnostic and treatment resources
for violent men. Child Abuse Negl 8:387392, 1984
Meyer CL, Oberman M: Mothers Who Kill Their Children. New York, New York
University Press, 2001
Oberman M: Mothers who kill: coming to terms with modern American infanticide. American Criminal Law Review 34:1110, 1996
Ruddick S: Maternal Thinking: Toward a Politics of Peace. Boston, MA, Beacon,
1989
Scheper-Hughes N: Death Without Weeping: The Violence of Everyday Life in
Brazil. Berkeley, University of California Press, 1992

Acknowledgments

This book would not have come together without the contributions,
assistance, encouragement, patience, and good humor of many people.
To start, I am grateful to my colleagues Drs. Katherine Wisner, Jean
Endicott, and Debra Sichel, each of whom is a dedicated, internationally
known expert in the field of womens mental health. I deeply value their
friendship and their encouragement and support of this project.
I next want to acknowledge Professor Ian Brockington for his scholarly contributions to our field, Dr. Richard Brown for his confidence in
my endeavor, attorney Michael Dowd for his dedication to defending
those in need, and the late Dr. Susan Hickman for her pioneering work
with young mothers.
I remain always grateful to Drs. Joanne Woodle and Orli Etingin, to
Mary Hanrahan, and to the Boorman and Tomei families.
I am thankful to the faculty of the Columbia Psychoanalytic Center for
Training and Research for giving me the opportunity to study and to appreciate the analytic significance of this project.
My heartfelt appreciation goes to the distinguished authors who contributed chapters to this book. They have brought considerable insight
and expertise to this project, and I thank them for giving of their time and
talent.
I also value the efforts of the members of Depression after Delivery,
Postpartum Support International, and the Marc Society for the Prevention and Treatment of Postpartum Disorders. Their courageous work to
assist mothers and families affected by postpartum mental illness is inspiring.
I thank Dr. Carol Nadelson, former editor-in-chief of American Psychiatric Press, who proposed this book and helped make it a reality; her
successor, Dr. Robert Hales, who took it to completion; Madeline Beusse,
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Infanticide: Psychosocial and Legal Perspectives

who edited portions of the book; Suzy Blumenthal, for her assistance; and
the staff at American Psychiatric Publishing, for their patience and cooperation.
I want to recognize the sorrow and the courage of the women and families whose stories of childbirth-related mental illness are recounted in or
helped shape this book. Their experiences broadened the contributing authors and this editors understanding of postpartum mental illness and infanticide. By sharing their stories with us, the people directly affected by
postpartum psychiatric illnesses suggest and illuminate the path for professional progress toward treatment and prevention.
Finally, I hope this book in some way honors the memory of the late Professor Ramesh (Channi) Kumar, who headed the Department of Perinatal
Psychiatry and the Mother-Baby Unit at the Maudsley and Royal Bethlem Hospitals, the Institute of Psychiatry, in London, England. Channi,
as friends and colleagues knew him, possessed not only great integrity but
also enthusiasm and energy that attracted professionals from around the
world to the field of mother-infant mental health. He was a kind physician who loved his patients and dedicated his life to mothers and infants
everywhere. For those of us who were graced by his presence, he remains
a vital source of inspiration.
This work was supported by a National Institute of Mental Health Research Scientist Development Award for Clinicians (Grant #1K20 MH
01276-01).

Part

Epidemiology
and Historical
Legal Statutes

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Chapter

A Brief History of
Infanticide and the Law
Michelle Oberman, J.D., M.P.H.

Submitted to Samuel Bard, M.D., president[,] and the trustees and

professors of the College of Physicians and Surgeons of the University of the State of New York:
The science of Medical Jurisprudence, of which the subject of the following Dissertation (Infanticide) form[s] an important branch, lays
claim to the attention of every one who feels any concern in the pure
administration of justice. To the Physician, it recommends itself consideration even still more interesting. . . . In most criminal trials for
poisoning, drowning, infanticide etc., the testimony of the Medical
witness must necessarily in a great measure decide the fate of the accused. It cannot, therefore[,] but be obvious how useful and even
indispensably necessary it is for him to possess an intimate acquaintance with a branch of knowledge whose object it is to supply him
with the means for forming just inductions and correct decisions whenever he may be called into a court of justice or before a coroners inquest.
Inaugural dissertation on infanticide, publicly defended for the degree of
Doctor of Medicine by John B. Beck, A.M., sixth day of April, 1817

Portions of this chapter are reprinted from Meyer CL, Oberman M: Mothers Who
Kill Their Children: Understanding the Acts of Moms from Susan Smith to the Prom
Mom. New York, New York University Press, 2001. Copyright 2001, New York
University Press. Used with permission of New York University Press.

Infanticide: Psychosocial and Legal Perspectives

nfanticide is not a random, unpredictable crime. Instead, a quick survey

of history reveals that it is deeply embedded in and responsive to the societies in which it occurs. The crime of infanticide, or child murder in the
first year of life, is committed by mothers who cannot parent their child
under the circumstances dictated by their unique position in place and
time. The factors in such circumstances vary from poverty to stigma to
dowry, but the extent to which infanticide is a reflection of the norms
governing motherhood is a constant that links these seemingly disparate
acts.
One seeking to make sense of the persistence of infanticide in contemporary society would do well to understand the manner in which cultural norms have shaped this crime throughout history. This same history
also reveals the seemingly inconsistent and even incoherent manner in
which societies have responded to infanticide. However, as a result of
viewing together both the persistence and consistency of infanticide and
the societal responses to it, we are afforded a perspective that permits us
to reconcile the act of infanticide with the body of laws that govern infanticide in societies throughout the contemporary world.
Toward that end, I provide here a brief chronological review of the sociocultural imperatives underlying the crime of infanticide in various cultures. The aim is not to provide a comprehensive record of the crime of
infanticide, but rather to illustrate the intricate relationship between a
societys construction of parenthood and mothering and its experience of
infanticide. Special attention is paid to the manner in which distinct societies have understood, rationalized, and punished infanticide.

Infanticide in Ancient Cultures

Although little is known about actual infanticidal practices in ancient
cultures, such as which parents killed their children and under what circumstances, archeological evidence suggests that infant sacrifice was commonplace among early people, particularly insofar as it enabled them to
control population growth and to minimize the strain placed on society
by sickly newborns (Langer 1974; Moseley 1986).
Records from the Babylonian and Chaldean civilizations, dating from
approximately 4000 to 2000 B.C., constitute the earliest written historical references to infanticide. But perhaps the richest historical records of
infanticide in ancient cultures emanate from ancient Greece and Rome.
It seems clear that infanticide was widely practiced in these societies,
with the reasons used to justify these actions ranging from population
control to eugenics to illegitimacy. Ancient Greco-Roman literature rou-

A Brief History of Infanticide and the Law

tinely refers to the exposure of unwanted newborns. Exposure helped to

prevent overpopulation, and, because those exposed often were either sickly
or disabled, the practice was viewed as eugenic in nature (Moseley 1986).
Under Roman law, infanticide became less of a civic virtue or imperative
than it was a private matter. Fathers were given the absolute legal authority to govern all matters falling within their domestic purview (Moseley
1986).
Infanticide also was common to non-Western ancient cultures. For example, female infanticide was a common practice in early Muslim and preIslamic culture in seventh-century Arabia. Scholars attribute this to the
status of women as property in that society (Chaudhry 1997). In addition, some speculate that in order to spare a female child a life of misery,
mothers frequently disposed of their female babies (Chaudhry 1997).
The advent of Islamic rule called for the abolition of female infanticide. Nonetheless, there is little reason to believe that call was heeded.
Over the ensuing centuries, the traditional Indian dowry system, requiring that a womans family make a sizeable gift to the grooms family upon
marriage, constituted a powerful incentive to avoid having female offspring (Chaudhry 1997). Despite efforts to reform or even abolish the
dowry system, it is entrenched in Indian culture. As such, even today, the
birth of a daughter automatically triggers the pressure of saving a suitable
dowry. If a family cannot provide a suitable dowry, it risks social ostracism.
Among poor rural families, the persistence of female infanticide and sexselective abortions of healthy female fetuses is attributable to this fear
(Bumiller 1990).
Traditional Chinese culture also reveals a long history of female infanticide. Female children have long been regarded as less valuable, as Confucian doctrine does not permit women to carry on the familys name or
otherwise honor the familys ancestors (Lee 1997). As such, daughters from
both poor and rich families are vulnerable to infanticide (Kellum 1974;
Langer 1974; Lee 1998; Moseley 1986; Trexler 1973).
This traditional limit on womens value was compounded by the Chinese adoption, during the Qing dynasty of the eighteenth and nineteenth
centuries, of the practice of giving a dowry to the grooms family upon the
marriage of a daughter. This practice, at first confined to the wealthy
classes, served to enhance the preference for sons among wealthy families
and caused a shocking increase in female infanticide among the dynastic
families. Over time, it spread so extensively that estimates suggest a full
10% of daughters born into Qing dynasty families were killed at birth. As
in India, the practice of female infanticide continues in contemporary
China. In 1979, China implemented a policy of one child per family in
an effort to stem rapid population growth. This policy triggered a dra-

Infanticide: Psychosocial and Legal Perspectives

matic rise in the abandonment and infanticide of baby girls as well as a

rise in the abortion of female fetuses (Greenhalgh and Li 1995). The
customs favoring sons are so deeply entrenched that female infanticide
persists, in spite of the Chinese governments attempt to reform the underlying cultural norms and laws thought to contribute to son preference
(Mathew 1997).

Infanticide in Medieval JudeoChristian Society

In 318 A.D., when the Roman Empire converted to Christianity, Constantine declared an end to patria potens, the absolute right of the father
over his children, and infanticide was declared to be a crime. Yet, all indications are that infanticide remained commonplace throughout early
Christian society (Langer 1974; Moseley 1986). Vital records, kept by
churches throughout Europe during the Middle Ages, show ample evidence of sex-selective infanticide. Additional evidence of the prevalence
of infanticide emerges from occasional references to the crime in medieval handbooks of penance. These describe the sin of overlying a child
(i.e., lying on top of the child and suffocating him or her); this sin is included in a list of the venial or minor sins, such as failing to be a good
samaritan or quarreling with ones wife (Kellum 1974). From the ninth
to the fifteenth century, the standard penance for overlying was 3 years,
with 1 of these on bread and water, compared with 5 years, with 3 on
bread and water, for the accidental killing of an adult. Scholars consider
this casual mention and lenient treatment of infanticide to be evidence of
its relatively commonplace nature (Moseley 1986).
Infanticide in early Judeo-Christian Europe was associated with the familiar factors of poverty and scarce familial resources. In addition, Christianity brought with it a new set of pressures that encouraged infanticide.
Specifically, the Catholic Churchs profound religious and cultural hostility to nonmarital sex and childbearing became an additional factor associated with infanticide. The Catholic Church dictated that a child born
to an unmarried woman was to be deemed illegitimate (Deuteronomy
23:2). As a result of the churchs condemnation of nonmarital sexual
relations, medieval society virtually disregarded the illegitimate child.
Illegitimate children were deprived . . . of the ordinary rights of man
(Satava 1996). But it was not only the children who were stigmatized by
illegitimacy. Unmarried mothers suffered considerable social approbation for bearing a child out of wedlock, regardless of how they came to
be impregnated (Mendlowicz et al. 1998).

A Brief History of Infanticide and the Law

Sixteenth- and seventeenth-century European society penalized sexual offenses such as bastardy and fornication. The penalties for these
crimes were particularly harsh in England. For example, in 1576 Parliament passed a poor law that punished impoverished parents of bastard
children. These laws punished, through public whipping and/or imprisonment, mothers who refused to identify the men who fathered their illegitimate children (Hoffer and Hull 1981).
Fear of punishment under these laws created an obvious incentive to
conceal a sexual affair as well as a resulting pregnancy. This incentive was
particularly intense for unmarried women whose jobs were jeopardized
as a result of a pregnancy. For example, the commonplace nature of sexual harassment against women employed as domestic servants fostered a
perverse and tragic link between sexuality, pregnancy, and infanticide.
(Kellett 1992).
The link between illegitimacy and infanticide during this era in European society was so widely acknowledged that, to a large extent, infanticide
was considered a crime committed exclusively by unmarried women. In
fact, the earliest criminal laws pertaining to infanticide refer solely to the
crime of bastardy infanticideinfanticide committed by an unmarried
woman (An Act to Prevent the Destroying and Murthering of Bastard
Children 1623). The punishment for this crime ranged from burial alive
to drowning and decapitation (Moseley 1986). Interestingly, during the
witchcraft inquisition, the crime of infanticide was widely attributed to
witches, and the gruesome punishments meted out to supposed witches
also were received by those convicted of infanticide (Trexler 1973). Because of the laws focus on bastardy, married women generally were not
convicted of infanticide (Moseley 1986).

Infanticide and British Legal History:

A Case Study in Ambivalence
An overview of British legal history for the 300 years between 1623 and
1922 provides a vivid illustration of that societys ambivalence in responding to the crime of infanticide. In 1623, Parliament passed a law
making it a capital offense to conceal the birth of an illegitimate child
whether still- or livebornby a secret disposition of its body (Hoffer and
Hull 1981). This law essentially reversed the presumption of innocence,
requiring that unless a defendant could produce an eyewitness to testify
that the baby was stillborn, the jury must find that she murdered the
child (Oberman 1996). Obviously, few women could meet this test, as it
is hard to imagine that a woman inclined to hide her illegitimate preg-

Infanticide: Psychosocial and Legal Perspectives

nancy would choose to have someone witness the birth. Nonetheless,

given the high infant mortality rates of that era, it is inevitable that the
law had the effect of condemning to die a large number of women who
had attempted to conceal their pregnancies and then either miscarried or
gave birth to stillborn fetuses (Backhouse 1984).
In its first years of operation, this law generated a tremendously high
number of convictions. Indeed, two historians of the era suggest a 225%
increase in the rates of infanticide indictments in the 28 years following
its passage (Hoffer and Hull 1981). Nonetheless, there is no evidence to
suggest that the law had any deterrent effect on the crime of infanticide. Instead, after several decades of enforcement of the Jacobean law,
juries began refusing to convict these women by adopting several widely
accepted defenses to the crime (e.g., a woman could defend herself
by showing she had linen for the baby, which was taken to mean that
she wanted it to survive) (Hoffer and Hull 1981). As a result, by the early
1700s, British conviction rates for infanticide reverted to the relatively
low rates seen in the early 1600s, prior to the laws passage (Hoffer and
Hull 1981).
Finally, in 1830, Parliament passed a new infanticide statute requiring
that the prosecution in an infanticide case prove that the baby had been
born alive (43 Geo ch 5853 [Eng 1803]). In the event that the state could
not prove this, the woman received a maximum sentence of 2 years for
the crime of concealing the birth of an illegitimate child. If convicted of
infanticide, however, the woman was sentenced to death. As a result, this
lesser offense became the overwhelming preference of juries in infanticide trials, and courts regularly returned verdicts of not guilty despite
overwhelming evidence to the contrary (Backhouse 1984).

Twentieth-Century Responses to
Infanticide: The Medical Model
Until the start of the twentieth century, societal responses to infanticide
indicate that it generally was viewed as a crime committed by desperate
and/or immoral women. The twentieth century introduced a dramatic
new perspective on the crimethat of illness (see Chapter 3: Postpartum
Disorders). Two late-nineteenth-century French psychiatrists, Jean-Etienne Esquirol and Victor Louis Marc, first posited the notion that there
might be a causal relationship between pregnancy, childbirth, and subsequent maternal mental illness (Mendlowicz et al. 1998). Others quickly
adopted their research, and almost immediately people around the world
began to associate infanticide with mental illness. Nowhere was this vi-

A Brief History of Infanticide and the Law

sion more powerfully embraced than in England, where the infanticide

statutes of 1922 and 1938, taking into account the impact of pregnancy
and birth on the mothers mental status, recognized infanticide as a distinct form of homicide.
The British Infanticide Act of 1922 (amended and expanded in 1938)
requires that mothers who can show that they suffered from a postpartum mental disturbance be charged with manslaughter rather than
murder (Infanticide Act 1938) (see Chapter 10: Infanticide in Britain).
As this is relatively easy to demonstrate, the vast majority of women convicted of infanticide receive sentences associated with manslaughter, most
commonly probation, and are required to undergo counseling rather than
to serve time in prison (N. Walker 1968).
The British statute has been replicated in slightly varying forms in at
least 22 nations around the world (Oberman 1996). Many nations have
statutes specific to infanticide; all but one of these make infanticide a less
severe crime than ordinary homicide (Oberman 1996).
Americans have been far less sanguine with regard to the adoption of
a medical model for understanding infanticide. To date, there are no statutes (federal or state) governing infanticide. Nor do American medical
experts agree about the nature of postpartum mental disorders and their
capacity to cause infanticide (American Psychiatric Association 1994).
The result is that U.S. law governing infanticide is remarkably inconsistent. The only medical explanation for infanticide on which medical
experts in the United States and around the world agree is the relatively
rare disorder known as postpartum psychosis. Postpartum psychosis is
characterized by a dramatic break with reality, accompanied by hallucinations or delusions (see Chapter 3). Women who kill their infants during an episode of postpartum psychosis tend to manifest these symptoms
at an extreme level.
Consider Sheryl Massip, a California woman who was convicted of killing her 6-week-old son. At her 1987 murder trial, the prosecution proved
that she threw her son into oncoming traffic, picked him up, and carried
him to her garage, where she hit him over the head with a blunt object
and then killed him by running him over with her car (Lichtblau 1990).
As is typical of other cases of postpartum psychosisrelated infanticide,
Massip continued to display severely disordered thinking after she killed
her child. She told investigators that a black object with orange hair and
white gloves, who wasnt really a person, had kidnapped the baby (Lichtblau 1990).
Postpartum psychosis presents unique problems for the criminal justice system because it is brief in duration and because, even if the condition is untreated, symptoms may disappear within several months of

10

Infanticide: Psychosocial and Legal Perspectives

onset (OHara 1987). For example, by the time of her trial, Massip was
no longer psychotic. Nonetheless, the jury was troubled by the notion
that she could simply go free, after having killed her son. It therefore convicted Massip of second-degree murder and sentenced her to prison. Two
months later, the judge overturned the verdict, acquitting Massip on the
grounds that she was insane at the time of the murder. Because she was
no longer insane, the judge allowed Massip to go free (A Mother Tells
Why She Killed Her Son 1994).

Contemporary Responses to
Infanticide in the United States
Despite the medical communitys growing acceptance of postpartum
psychosis, it is clear that this disorder explains only a very small minority
of the infanticides that occur annually in the United States and elsewhere. Indeed, when one examines the body of contemporary cases involving mothers who kill their children, it is evident that none of the
excuses of generations pastpoverty, stigma, disability, or mental illnessfully explain the persistence of infanticide. Some speculate that
the only women who commit infanticide are those who are either insane
or simply evil.
For example, Linda Chavez, president of a Washington-based think
tank, refers to women who commit infanticide as monster-women and
suggests that welfare policy may be linked to infanticide (Chavez 1995).
In support of her point, she quoted then U.S. Representative Newt Gingrich, who asserted in response to a particularly gruesome murder case
that [w]elfare policy has created a drug addicted underclass with no sense
of humanity, no sense of civilization and no sense of the rules of life
(Chavez 1995). Contrast these remarks with those of psychiatrist Park
Elliott Dietz, who theorizes that [n]o amount of stress alone can account
for women killing their children. . . . It doesnt come from who you hang
out with, what your opportunities in life are or how much money you
have. It comes from something being wrong with the person (quoted in
Smith 1991).
My research, which involved culling and sorting hundreds of contemporary accounts of infanticide from the media and legal databases, suggests that neither of these explanations adequately accounts for the
persistence of infanticide (Meyer and Oberman 2001). Instead, one finds
five broad categories of contemporary infanticide cases (Table 11), all of
which are responsive to the societal construction of and constraints on
mothering.

Contemporary typology for infanticide/filicide

Type of infanticide

Maternal characteristics

Other characteristics

Neonaticide

Young or immature
Emotionally isolated from partner
Limited potential for economic independence
Limited economic independence
Limited social support
Psychological profile: battered woman
Limited economic means
Burdened with parenting
Overwhelmed by economic obligations
Inattentive or distracted parenting

Pregnancy concealed or denied

No prenatal care
Unattended birth
Violent and/or abusive male partner

Assisted/coerced

Neglect-related

Abuse-related

Completely accidental death

Chronic child abuse

Lack of parental impulse control
Death unintentional
Especially high risk for abuse at mealtimes and bedtimes

Mental illnessrelated Acute: postpartum-onset depression or psychosis

Socially isolated
High expectations of mothers capacity to parent
Alone with the baby
Guilt over inability to cope
Chronic: schizophrenia; lifelong depression and psychosis
Child protection agency errors often a major factor
Socially isolated
Placing children with ill mothers
Incapable of parenting without assistance
Suicidal women: may be trying to protect their children
by taking them with them to heaven

A Brief History of Infanticide and the Law

Table 11.

11

12

Infanticide: Psychosocial and Legal Perspectives

Neonaticide
Neonaticide, or the killing of ones offspring within the first 24 hours of
life, is a crime that typically involves young women who determine, correctly or not, that they would be completely cut off from their social
support network were they to disclose their pregnancies. Subsequent
psychiatric evaluation of these girls reveals that many suffer from severe
dissociative states associated with a history of early abuse and chaotic
family life (Spinelli 2001). For various reasons, including religion, culture, money, ambivalence, and immaturity, these girls are unable or unwilling to pursue the alternatives of abortion or adoption. Denial of their
pregnancy is so profound that, day after day, they ignore the impending
birth of their child.

Assisted/Coerced Infanticide
A second category of infanticide involves women who kill their infants or
children in conjunction with their male partners. These cases predominantly involve women whose intimate partners are violent and abusive.
Often, the women are themselves caught in the cycle of an abusive relationship and are unable to act to protect themselves or their children.
Their behavior may be readily understood through the lens of research
on battered women, which provides ample description of the fears that
trap women in abusive relationships (L. E. Walker 1979).

Neglect-Related Infanticide
A third category of infanticide cases involves mothers whose infants die
as a result of neglect (Meyer and Oberman 2001). In these cases, the
childs death is, for the most part, due to the mothers having been distracted. For example, many contemporary cases involve babies who die
when their mothers are taking care of other taskstasks that frequently
are also related to parenting. A common example is a baby who is left in
the bathtub or in the care of a still-young older sibling while the mother
is in the kitchen cooking.
It is critical to note the way in which the societal construction of
motherhood shapes our response to these crimes. In the past, these
deaths might have been viewed as tragic accidents. Today, they are homicides. Mothering has thus become more than simply a full-time job. According to the unwritten rules that govern the role of mother, one must
be constantly vigilant, losing all thought of self-interest. Here again, it
seems absurd to explain these womens actions by terming them either

A Brief History of Infanticide and the Law

13

insane or evil. Indeed, an attempt to do so eclipses important insights

about the circumstances that give rise to these childrens deaths.
The two remaining categories of infanticidethose related to child
abuse and those growing out of mental illnessillustrate the devastating results of a system that relies on a single individual to parent under the unwritten rules that govern the role of mother. To be sure, some women can
parent under extremely challenging circumstances, because their support
networks and coping skills are sufficiently strong. Others, however, are not
prepared for this task.

Abuse-Related Infanticide
Another category of infanticide cases involves women whose abuse of
their child leads to his or her death. Often these women abuse their children with some regularity, and the deaths of these children occur during
efforts to discipline that go awry (Meyer and Oberman 2001). Although
cases of chronic child abuse carry with them a unique horror, even among
infanticide cases, it is important to note that there are regular, even predictable, patterns to these childrens deaths. Indeed, epidemiologists have
demonstrated the specific hours during each day when children are most
at risk of death by homicide (Chew et al. 1999). These periods coincide
with mealtimes and bedtimes, events that often are, even in stable, loving
households, accompanied by stress, arguments, and the need to discipline
(Chew et al. 1999). As such, one might temper the inclination to dismiss
these mothers as simply evil and, instead, observe that women who kill
their children in abuse-related infanticides are affected by the extraordinarily demanding tasks associated with child care. Seen from this angle,
many of the abuse-related cases seem to involve mothers who lacked the
impulse control of their peers, but the impulse that motivated these killings is surprisingly commonplace.

Mental IllnessRelated Infanticide

The final category of infanticide cases involves women with severe mental
illness, whether acute or chronic, who clearly are not prepared for the task
of mothering. A significant depressive or psychotic episode may render a
woman unable to generate the continual flow of selfless compassion and
patience that children demand. Likewise, a woman with a chronic mental
impairment may be constitutionally incapable of meeting the demands of
parenting in isolation, without external support. Tragically, there are numerous infanticide cases involving severely impaired women who were expected to care for their children, essentially alone (Abandoned to Her
Fate 1995; Report of the Independent Committee 1993).

14

Infanticide: Psychosocial and Legal Perspectives

Infanticidal Jurisprudence
in the United States
Because the United States lacks a statute such as Englands that treats infanticide cases alike on the basis of an explicit justification for mitigating
the severity of this crime, each case tends to be viewed on its own merits.
The result has been a tendency to treat each infanticide case as exceptional rather than to recognize the profound similarities that underlie the
many contemporary infanticide cases. Often, the media seem to play a
powerful role in dictating the defendants blameworthiness and even in
determining the resolution of these cases (Meyer and Oberman 2001).
The result is that U.S. infanticide jurisprudence is incoherent and often arbitrary. Sentences range wildly, with women convicted of substantially equivalent crimes, such as neonaticide, receiving sentences that vary
from probation with counseling to life imprisonment (Oberman 1996).
The fact that the United States lacks a statute to dictate an appropriate
punishment for infanticide need not imply that we must tolerate this
level of randomness in resolving these cases. Judges and juries faced with
infanticide cases must take into consideration the extent to which a given
individual is morally blameworthy.
The central task of the criminal justice system in punishing infanticide
cases is to ascertain the purposes to be served by punishing these women.
There are three basic justifications for punishment: deterrence (both general and specific), retribution, and rehabilitation. General deterrence refers to the notion that punishing a given defendant will serve to deter
others who might be contemplating committing the same crime. Given
all that we know about the crime of infanticide, this rationale for punishment seems almost absurd. The mothers who commit infanticide seem
relatively desperate, and there is little reason to believe that they spend
time contemplating the potential consequences of their acts. Instead, infanticide seems for the most part to be a spontaneous crime, reflecting a
loss of control rather than a cool-headed calculation.
Specific deterrence endorses the punishment of an individual who has
committed a crime on the grounds that this will deter that individual
from committing the same crime again in the future. When applied to
certain categories of infanticide, this argument may have some merit.
One might argue, for example, that the mother whose child is killed after
prolonged abuse must be punished in order to ensure that she understands the limits the law places on disciplining children. On closer examination, though, specific deterrence has limited relevance to many of the
other categories of infanticide. For instance, the woman with either acute

A Brief History of Infanticide and the Law

15

or chronic mental illness at the time she killed her child does not need
the law to deter from killing again in the future. On the contrary, she is
much more likely to need treatment for her condition.
The second major justification for punishment is retribution. This ancient rationale is predicated on societys right to punish one who unjustifiably harms another. Struck by the need to cry out against the deaths
of these innocent children, it is obvious why society might be inclined to
invoke this rationale in punishing infanticide. To the extent that retribution is justifiable, there must be clearly delineated lines of blame. This is
precisely not the case with infanticide, though, as it so often seems difficult to allocate blame to a single individual. Instead, these cases often
leave one with a sense that there might be more than one blameworthy
party.
Consider the following case illustration, introduced earlier: In the
weeks preceding her sons death, numerous others were aware of Sheryl
Massips deteriorating condition. Her lawyer noted that
[f]or two weeks, Sheryl Massips family recognized something was wrong
with her. Her husband . . . sent her away to her mothers home to spend
a night, to get some rest, because they thought that would solve the problem. She came back, he sent her away again. On . . . the Monday before
she killed her child, she came home from spending the night with her
mother, and she went to the doctor and said, Doctor, whats wrong with
me? Im hallucinating. I cant sleep. Something is wrong with me. Help
me. He looked at her and said, Oh, youre just suffering from baby
blues, [and] gave her a couple of Mellarils. (A Mother Tells Why She
Killed Her Son 1994)

There is no doubt that during her psychotic episode, Massip was incapable of caring for her son. Her family and her physician all were on
notice that she was in crisis, and all attempted to comfort her. Nonetheless, none of them took the time to evaluate in a serious manner the gap
between her present abilities and the caregiving tasks she was required to
perform when left alone with her child. Had any one of these three people recognized her needs, they could readily have identified a course of
action that would have saved her sons life.
The final justification for punishment is that it is necessary in order to
rehabilitate the individual defendant. In view of the overcrowded and underfunded conditions that prevail in U.S. prisons, it is difficult for anyone
to argue that a woman who commits infanticide is likely to be rehabilitated for society by virtue of incarceration. Indeed, the sort of treatment
that these women are likely to needmental health services, parenting
classes, substance abuse treatmentare in particularly scarce supply in

16

Infanticide: Psychosocial and Legal Perspectives

womens prisons. A woman is much more likely to find these services

outside of prison, and a judge can most certainly require a woman to obtain any or all of these services as a condition of probation. In essence, this
is the British legal systems approach to punishment for this crime. Its experience of 80 years of using probation in lieu of incarceration suggests
that probation is at least as effective at preventing or deterring infanticide
as is incarceration, and it is considerably more efficient and cost-effective
(Edwards 1986; Wilczynski 1991).

Conclusion
In considering how society should best respond to a woman who has
committed infanticide, the key question to ask is why we are punishing
this woman and what we seek to gain by virtue of this punishment. At
times, what we gain by punishing her may be no more than an opportunity to vent our rage at a life so needlessly lost. At those times, it is imperative to consider the underlying policies that have contributed to that
lost life. This is not to say that those who commit infanticide are blameless, but rather that, as seen against the backdrop of the construction of
motherhood, on some occasions this terrible crime may be all but inevitable. The task, then, in a civilized and compassionate society, is to determine how to deal justly with those who kill their children and, more
importantly, how to mobilize all of our resources to prevent these needless deaths in the future.

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Lee J: 6.3 brides for seven brothers (one quarter of humanity: Malthusian mythology and Chinese reality 17002000). The Economist, December 19, 1998,
pp 5658
Lichtblau E: Appeal argued in postpartum case. Los Angeles Times, May 24, 1990,
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Mathew P: Case note: Applicant A v. minister for immigration and ethnic affairs:
the high court and particular social groups: lessons for the future. Melbourne Univeristy Law Review 21:277330, 1997
Mendlowicz MV, Rapaport MH, Mecler K, et al: A case-control study on the socio-demographic characteristics of 52 neonaticidal mothers. Int J Law Psychiatry 52:209218, 1998
Meyer C, Oberman M: Mothers Who Kill Their Children: Understanding the
Acts of Moms From Susan Smith to the Prom Mom. New York, New York
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Moseley KL: The history of infanticide in Western society. Issues Law Med
1:346357, 1986
A mother tells why she killed her son. Larry King Live (CNN television broadcast), L King interviewing M Grimes, criminal defense attorney for Sheryl
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Oberman M: Mothers who kill: coming to terms with modern American infanticide. American Criminal Law Review 34:1109, 1996
OHara MW: Postpartum blues, depression and psychosis: a review. J Psychosom Obstet Gynaecol 7:205227, 1987
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Infanticide: Psychosocial and Legal Perspectives

Satava SE: Discrimination against the unacknowledged illegitimate child and the
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Smith L: Experts seek reasons behind irrational crime. The Los Angeles Times,
October 15, 1991, A25
Spinelli MG: A systematic investigation of 16 cases of neonaticide. Am J Psychiatry 158:811813, 2001
Stuart Bastard Neonaticide Act, 21 James I, c 27 (Eng 1624)
Trexler R: Infanticide in Florence: new sources and first results. History of Childhood Quarterly 1:100102, 1973
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Wilczynski A: Images of women who kill their infants: the mad and the bad.
Women and Criminal Justice 2:7188, 1991

Chapter

Epidemiology of Infanticide
Mary Overpeck, Dr.P.H.

The child shall be registered immediately after birth and shall have
the right from birth to a name.
Article 7, United Nations Convention on the
Rights of a Child (1989); quoted in Scheper-Hughes 1992

nfanticides resulting from maternal behavior may be among the least

well documented deaths in the United States. Problems inherent in reporting systems and the nature of the deaths limit our knowledge about
prevalence and the relationship of perpetrators. One study of infants dying before their first birthday based on nationally available death certificate records found that nearly one infant is killed every day (Overpeck et
al. 1998). However, the prevalence in the United States may be double
that number (Herman-Giddens et al. 1999; McClain et al. 1993). Estimates made by McAllen and Herman-Giddens on the basis of in-depth
inter-agency record reviews in North Carolina and Missouri projected
underascertainment of fatalities of young children due to child abuse and
neglect in the United States (Ewigman et al. 1986; Herman-Giddens et
al. 1999). These and other state studies found that prevalence counts of
infanticides and other child fatalities from abuse or neglect based on only
death certificates were seriously lacking (California Department of Justice 1997).
Moreover, perpetrator identity is limited on death certificates and other
records. Only one cause of death on certificates addresses childhood battering and maltreatment and provides codes to designate the relationship
19

20

Infanticide: Psychosocial and Legal Perspectives

of the perpetrator, including a parent. More than 90% of infant deaths

assigned this classification between 1983 and 1997 were left with the relationship unspecified (Centers for Disease Control and Prevention
2000; Overpeck et al. 1998).

Perpetrators
What do we know about perpetrators of infanticide? Special studies have
been required to describe perpetrator identity and circumstances of
deaths among infants and young children. Such studies are usually completed at local levels or as part of clinical case studies. Reviews of traumatic deaths among young children indicate that most infant homicides
are carried out by parents or stepparents, and a slight majority are attributable to males (Christoffel 1990; Jason 1983; Kunz and Bahr 1996;
National Center on Child Abuse and Neglect 1997). Some state and local
studies have found that mothers are the perpetrators in the majority of
cases only for homicides during the first week of life (Jason et al. 1983;
Kunz and Bahr 1996; Sorenson and Peterson 1994). These early deaths
for whom the mother may be responsible are the primary focus of concern in this chapter. However, such cases may be the least likely to be
reflected in our official data systems.
The Bureau of Justice Statistics (2000) of the U.S. Department of
Justice has compiled national-level information on perpetrators in cases
for which police reports have been filed. Again, these data show that the
majority of perpetrators are males who are related to the infants and
young children. However, perpetrator relationship for deaths occurring
in the first week or months of life was not specified for infants killed before their first birthday.
Police reports are not filed in all cases examined by medical examiners
or coroners who complete death certificates, even when a determination
has been made that homicide was the cause (Inter-Agency Council on
Child Abuse and Neglect 1998). Therefore, prevalence estimates based
on police or legal system reports tend to show fewer infanticides than do
counts from state or local vital statistics agencies.

Reporting of Infant Deaths

At the national level, we rely on death certificates submitted by state vital statistics agencies for annual total counts by cause and age at death
(Kowaleski 1997; Rosenberg and Kochanek 1995). Infant death most frequently refers to deaths occurring prior to the first 12 months of life

Epidemiology of Infanticide

21

(Hartford 1992; United Nations 1955). Infant deaths may be further categorized as neonatal (under 28 days of age) and postneonatal (28 days
through 11 months of age). Neonatal deaths are further categorized as
late (728 days of age) and early (under 7 days of age).

Cause of Death
Cause of death on certificates is specified by medical examiners or coroners
according to the International Classification of Diseases, Ninth Revision
(ICD-9; World Health Organization 1977). Classification is generally organized as due to a natural, a traumatic, or an unknown cause. Infanticides are classified as part of traumatic deaths according to external cause
codes (E codes), which describe the mechanism of death, such as suffocation or blunt-force trauma (National Center for Health Statistics 1987).
These external causes are further classified by intent.
The category traumatic deaths includes deaths due to suffocation or
asphyxiation as well as fatal injury due to being struck, shaken, dropped,
burned, drowned, poisoned, and so forth (World Health Organization
1977). It also includes deaths from neglect, abandonment, and extreme
exposures. For deaths from external causes, the medical examiner or coroner may designate a death as intentional, as unintentional, or as due to
undetermined intent. The last designation is supposed to be used only if
the examiner is unwilling to classify a death as unintentional because of
the suspicious nature of the death but does not expect to have enough
information to classify it as intentional. Table 21 shows the distribution
of infant injury deaths classified as intentional or due to undetermined
but suspicious intent from 1990 through 1997. The latter deathsthose
classified as due to undetermined intentrepresent about 4% of all injury deaths to infants.
About one-third of the deaths resulted from battering or other maltreatment. The next primary cause is from assault (28%), with no indication of the means used to assault the infant. About 13% were killed by
suffocation or strangulation. Drowning, criminal neglect, and firearms
each accounted for about 3%4%. The homicides do not include deaths
from abandonment, neglect, or exposure classified as unintentional (60
cases from 1990 through 1997).
If further investigation is to be done because cause or intent is not
clear, the examiner may classify the finding as pending at the time the
certificate is originally filed. In this case, intent, and possibly even cause,
may be left unspecified on the certificate. Any subsequent legal findings
to determine intent may differ from the designation on the certificate.
Although the certificate should be amended in the state vital statistics

22
Table 21.

Infanticide: Psychosocial and Legal Perspectives

Infant injury deaths classified by intent and cause of
homicides: United States, 19901997

Cause of homicides (E codes for intentional

and undetermined intent)
Total
Battering, other maltreatment (E967, E987)a
Assault, unspecified means (E968.9, E988.9)
Suffocation/strangulation (E963, E983)
Drowning (E964, E984)
Criminal neglect (E968.4)a
Firearms (E965, E985)
Arson (E968.0, E988.1)
Cuts and stabbing (E966, E986)
Other specified causes

Number

Proportion,
%

3,077
1,054
859
387
118
96
90
39
39
395

100.0
31.3
27.9
12.6
3.8
3.1
2.9
1.3
1.3
12.8

Classification not used for deaths from undetermined intent. Sixty additional deaths not
included were classified as due to unintentional neglect and abandonment (ICD code
E904).
Source. Centers for Disease Control and Prevention WONDER compressed mortality
files for 19901997.

agencies, state files submitted for annual national statistics on cause of

death may not include amendments because of the time required for investigations and amendments (Overpeck et al. 2002).
Cases for which a cause is not shown in the national data also have
higher proportions of infant deaths occurring soon after delivery when
compared with other unexpected infant deaths, which include deaths
from sudden infant death syndrome (SIDS) and traumatic causes. Deaths
from natural causes, including prematurity, should be classified elsewhere.
From 1990 through 1997, 14% of deaths from unknown causes happened during the first day and week of life (10% and 4%, respectively),
compared with 4% of deaths classified as unintentional injury (2% and
2%, respectively) or less than 1% of SIDS deaths (Centers for Disease
Control and Prevention 2000).
From 1990 through 1997, 6,686 infant deaths were classified with
unknown cause, a number comparable to the number of unintentional
injury fatalities (6,853) and more than twice the number of fatalities classified as intentional or suspicious (3,007). The proportion and number of
infant deaths in the first day and week of life classified with unknown
cause are higher than the proportion and number of those classified as
intentional or suspicious. It is apparent from the relatively high proportion of neonatal deaths with unknown causes that national and state statistics are missing probable homicides or other traumatic deaths that

Epidemiology of Infanticide

23

meet the pattern consistent with deaths related to maternal behavior

proximal to time of birth. Also, an analysis of linked birth and death certificates available since 1983 (Overpeck et al. 2002) found that for deaths
of unknown cause occurring in the first weeks of life, compared with later
deaths, it was less likely that birth certificates were available for linkage.

Age at Death
An analysis of risk factors for probable homicides during the first year of
life from 1983 through 1991 did not specifically address infants killed
proximal to the time of birth, partly because it was based on deaths for
which birth certificates could be found to provide additional risk factor
information (Overpeck et al. 1998, 1999b). These linked certificates represented 98% of all recorded deaths. Even so, the analysis showed that
among infant deaths classified as intentional or due to suspicious intent,
one-fourth of the infants were dead by the end of the second month of
life, and one-half were dead by the fourth month (National Center for
Health Statistics 19881999).
A more recent review of all traumatic infant deaths from 1990 through
1997 from intentional or suspicious but undetermined circumstances
(probable homicides), as classified by medical examiners or coroners,
showed that 8% of the infants died in the first day, and an additional 2%
died during the first week (Centers for Disease Control and Prevention
2000) (Figure 21). About 15% of probable infant homicides occurring
before the first year of life occurred during the first month.
These data support concerns that many of the deaths around the time
of delivery involve infants whose mothers deliver outside of hospitals.
The study of data available on birth certificates since 1989 and linked to
death certificates for 19891991 and 19951996 provides better information on births occurring in clinical settings with assistance from
trained birth attendants (Overpeck et al. 2002). In the 5 years of data
available from linked files, 5% of homicides involved infants not delivered
in clinical settings (hospitals, doctor offices, or clinics) and delivered
without a trained birth attendant (doctor, nurse-midwife, or other midwife). About 90% of deaths of infants who were not delivered in clinical
settings or by trained attendants occurred during the first week of life,
and about two-thirds occurred in the first day. Since unattended births
are less likely to have a birth certificate issued, many deaths during the
first day and week of life are probably unattended and possibly hidden.

24

Infanticide: Psychosocial and Legal Perspectives

Figure 21. Age at death for infants dying from intentional or suspicious
causes, United States, 19901997.
Source. Centers for Disease Control and Prevention WONDER compressed mortality file
for 2000.

Risk Factors for Infanticide

The analysis of risk factors associated with infant homicides from 1983
through 1991 discussed in the previous section used linked death and
birth certificates to provide information about maternal, infant, and, to a
lesser extent, paternal characteristics (Overpeck et al. 1998). For that
study, 2,776 probable homicides were identified from the ICD-9 coding
of cause of death and intent. Available birth certificate variables were reviewed on the basis of suggestive findings from earlier state-level and
clinical studies or from elevated relative risks. The maternal and infant
factors predictive of homicide finally were selected on the basis of increased relative risks and adequate numbers for stable estimates. Availability of a large national database allowed assessment of the magnitude
of the problem and implications for public health interventions.
The infants at highest risk were the second or subsequent children born
to mothers younger than 17 years (relative risk [RR] = 10.9) or mothers
aged 1719 years (RR = 9.3) (both comparisons with firstborn children
of mothers aged 25 years or older). Similar risks were evident for second
or subsequent children born to mothers aged 1719 years (RR = 9.3).
These infants at highest risk represented 17% of U.S. infant homicide victims. The combined effects of maternal age and birth order as the highest
risk factor were consistent for blacks and whites.

Epidemiology of Infanticide

25

Other separate risk factors included maternal age younger than 15

years (RR = 6.8; comparison with mothers 25 years or older) and no prenatal care (RR = 10.4; comparison with care begun in the first or second
month of pregnancy). Of all infants whose mothers had no prenatal care,
almost 15% were at highest risk (5.8% of mothers were younger than 17
years, and 8.8% were aged 1719 years with two or more children). Of
the highest risk mothers, 11% had no prenatal care.
Maternal education at time of birth also was a risk factor for infant
homicide. Infants whose mothers did not complete high school were
greater than eight times more likely to be killed than those whose mothers
completed 16 or more years of school. However, the relationship between
maternal education and infant homicide is confounded by age, since many
mothers younger than 17 years have not yet had the opportunity to complete 12 years of education. Births to mothers younger than 17 years accounted for about one-fifth of all homicides among infants whose mothers
did not complete 12 years of education. After mothers younger than 17
years who had not had a chance to complete high school were excluded,
maternal education of less than 12 years was still a high risk factor (RR =
8.0; comparison with mothers with 16 or more years of school). A similar
comparison was made after mothers aged 19 years or younger were excluded, because childbearing could have delayed the completion of their
education. For infants of mothers aged 20 years or older who did not complete high school, the relative risk of homicide was seven times greater than
that for mothers who had 16 or more years of school.
Paternal factors were not addressed in this study on infant homicide
because so much information on fathers was missing on birth certificates
linked to homicide death cases. A review of later data through 1996
showed that about 40% of homicide cases with linked certificates were
missing any information on fathers, compared with only 13% of all birth
certificates. This lack of information is probably indicative of some of the
strongest underlying risk factors for infant homicide that are not measured on birth and death certificates. Lack of data on fathers probably indicates unstable supportive relationships, particularly when the mothers
are very young. Since studies of perpetrators have indicated that males,
and particularly related males, are responsible in the majority of cases, the
role and preparedness of other household members as infant caregivers
require further exploration.

Getting Better Information

Why is the prevalence of infanticide underestimated? What are the issues
surrounding the measurement of early neonatal deaths? Since the phe-

26

Infanticide: Psychosocial and Legal Perspectives

nomenon of maternal infanticide is the concern addressed in this chapter,

and because mothers are more likely to be perpetrators only in the first
week of life, ascertainment of these early neonatal deaths requires some
emphasis.

Problems in Ascertainment for Early Neonatal Deaths

When an infant body is found with signs that death occurred in proximity
to the period of delivery, the question may be raised about whether the delivery resulted in a live birth. If after an autopsy or other examination the
examiner decides that there were signs consistent with life, a death certificate would be issued (Hartford 1992; Kowaleski 1997). If the examiner
decides that there are not signs of a live birth, a fetal death registration is
completed. This may be particularly problematic for premature births
prior to 28 weeks of gestation, when life outside the uterus would be difficult without clinical intervention. It may also be difficult in cases in
which the body has deteriorated considerably prior to examination.
Fetal death registrations historically have been required in most states
for gestations of at least 20 weeks or when weight is more than 500 grams.
Registration requirements are changing because of our technological capability to save infants delivered at less than 500 grams, but the issue of
probable viability without clinical intervention is most important to examiners for bodies retrieved without knowledge of maternal health care
status (Kowaleski 1997; National Center for Health Statistics 1978). Therefore, it is important to consider that a number of pregnancy outcomes
could be classified as either live births or fetal deaths when the mother
did not deliver in a clinical setting (hospitals, centers, clinics or offices) or
with a trained attendant such as a doctor, nurse-midwife, or other midwife.
Preliminary analysis of linked birth and death certificates for 1989
1991 and 19951996 shows that about 8% of infants dying from infanticide were not delivered in clinical settings, compared with less than 1%
of total live births. About 5% of infants killed in the first year of life were
not delivered by trained attendants, compared with 1% of all live births.
This information is not available for death certificates for which no corresponding birth certificate could be found for linkage.
Perinatal deaths (including both fetal and infant deaths) should be
considered when addressing the problems of hidden pregnancies. One
perinatal mortality definition that includes only early neonatal births (<7
days of age) and fetal deaths for gestations at more than 28 weeks duration might be appropriate for reviewing potential prevalence of such deliveries (Hoyert 1995). Fetal death registrations have generally not been

Epidemiology of Infanticide

27

reviewed for causes related to traumatic deaths, including abandonment or

neglect.
Natural causes associated with prematurity or extremely short gestational age are the leading cause of infant death, particularly in the first day
or week of life (Hoyert 1995). This may be a factor in the determination
that an infant livedthe requirement for a decision by a medical examiner or coroner to issue a death certificate. Even when this determination
is made for extremely premature deliveries, classification of cause of death
may be difficult, resulting in ambiguity in measurement of probable homicides occurring during the early neonatal period (Overpeck et al. 1999a).

Underestimation of Prevalence
The state studies of prevalence tracked the possible sources of underascertainment by reviewing records from vital statistics, medical examiner
or coroner records, law enforcement files, and social service registries
(California Department of Justice 1997; Ewigman 1986; Herman-Giddens
et al. 1999). The discrepancies found among state-level data sources may
have resulted from 1) inability to report, such as when an infant disappears but no body is found or there is disagreement as to whether to
designate the death as a homicide; 2) failure of involved agencies to properly categorize or code information; and/or 3) inadequate gathering of
case information for drawing accurate conclusions (California Department of Justice 1997).
The California report was performed by comparing information from
different agencies about circumstances of unexpected childhood deaths
(California Department of Justice 1997). The formation of such interagency teams to review these deaths is relatively recent (Durfee et al.
1992). Most states now have authorizing legislation for child fatality review teams, although many of these teams do not perform statewide reviews, nor do they necessarily review all unexpected deaths.
Infanticides also may be attributed to SIDS or unintentional injury
deaths in a small proportion of cases. With the decrease in SIDS deaths associated with changes in sleep position in recent years, the American Academy of Pediatrics suggests that the proportion of SIDS deaths attributable
to infanticide may be increasing (American Academy of Pediatrics 2000).
Some researchers have estimated that child abuse and neglect was involved
in 5%20% of SIDS cases (Emery 1993; Ewigman et al. 1986), while others disagree (OHalloran et al. 1998). Ewigman et al. (1986) concluded
that child abuse and neglect in children under age 5 years may have been
involved in 7%27% of injury deaths reported from 1983 through 1986 in
Missouri as unintentional and in at least 5% of deaths attributed to SIDS.

28

Infanticide: Psychosocial and Legal Perspectives

In addition, traumatic deaths classified as due to an undetermined but

suspicious intent on death certificates because intentionality could not be
determined are frequently ignored in prevalence estimates and homicide
studies. Yet, careful review of such cases indicates that they always should
be considered (Christoffel et al. 1985; Sorenson and Peterson 1994; Sorenson et al. 1997). Fatalities classified with undetermined intent had risk
profiles that more closely resemble profiles for intentional deaths than profiles for unintentional deaths (Overpeck et al. 1999a). Fatalities with undetermined intent had larger relative risks in the highest risk categories
than did either intentional or unintentional injuries. Elevated risks occurred
for infants of mothers with the least education, no prenatal care, young
maternal age, and single marital status, as well as for infants who are second or later born, premature, black, or American Indian.

Conclusion
Risk profiles and prevalence issues are relevant only when they assist in
targeting highest risk mothers and families for interventions that assist
communities in prevention of traumatic fatalities or nonfatal child abuse
and neglect. For some traumatic deaths, the issue of intent may be problematic, particularly when the events occur during moments of distraction or high emotion or under the influence of alcohol or other drugs
(Overpeck and McLoughlin 1999). We do not have a source of information that sufficiently describes the circumstances of birth and death in
enough cases to include familial and personal attributes as risk factors for
deaths perpetrated by mothers. However, intent may be peripheral to
both the act and the injury mechanism for purposes of interventions in
high-risk cases. Interventions that address multiple risk factors should be
made early in pregnancy, or even before conception. We need to replicate research on interventions that address social support, the caregiving
environment, and behavior modification (Committee on the Assessment
of Family Violence Interventions 1998). These interventions include a
delay between conceptions to better space childbearing, completion of
maternal education, and reduction in drug and alcohol abuse.
Obviously, knowledge of the etiology of deaths resulting from maternal behavior, based on our current sources of information, is limited, particularly for those infants dying in proximity to delivery. Wissau (1998)
suggested that postpartum depression must be considered in cases in
which the mother is responsible for infant deaths. The issues surrounding
infant deaths occurring in the first weeks of life is discussed thoroughly
in this volume.

Epidemiology of Infanticide

29

The American Academy of Pediatrics (1999) has called for improved

comprehensive death investigation of sudden, unexpected deaths in order
to provide proper death certification for children. The Academy emphasizes the continuing need for careful, timely review of deaths attributable
to SIDS and trauma by appropriately constituted review teams. Better
dissemination of information about circumstances around fatalities from
child death review investigations should improve the official reporting
and description of risk factors and thereby facilitate development of better interventions to prevent infanticide.

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Part

II

Biopsychosocial and
Cultural Perspectives
on Infanticide

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Chapter

Postpartum Disorders
Phenomenology, Treatment Approaches,
and Relationship to Infanticide
Katherine L. Wisner, M.D., M.S.
Barbara L. Gracious, M.D.
Catherine M. Piontek, M.D.
Kathleen Peindl, Ph.D.
James M. Perel, Ph.D.

The type of insanity most commonly observed amongst these lunatic

criminals is delusional mania. As a rule they are demonstrative and
noisy, obscene in language, degraded in behavior, and subject to outbursts of paroxysmal violence. . . . The maniacal affection is often
associated with delusions of suspicion and persecution and with aural and visual hallucinations; perversions of the sense of smell and
taste . . .
[It seems evident,] from a study of the Broadmoar cases, that infanticide occurs much more frequently in connection with the insanity of
lactation. . . . In such a condition those in attendance would naturally
remove the child and guard against the contingency of danger.
These tragedies are frequently preventable. Although the patient
is, as a rule, sanely conscious of many things and usually coherent, it

This work was supported by National Institute of Mental Health grants (MH-57102
and MH-60335) to Dr. Wisner and a Psychopharmacology Core Center grant
(MH-30915) to Dr. Perel.

35

36

Infanticide: Psychosocial and Legal Perspectives

begins to dawn on the friends that the mind is gradually giving way,
yet owing to some perverse reasoning they defer placing her under
asylum care and treatment, even if the woman herself begs to be
safeguarded.
John Baker, M.D. (1902)

ostpartum mood disorders are common and are seen frequently by

health care professionals who serve women of childbearing age. In a prospective study, OHara et al. (1984, 1990) found that 12% of postpartum
women had illnesses that fulfilled Research Diagnostic Criteria (RDC;
Spitzer and Endicott 1978) for major or minor depression, both of which
require impairment in usual function. Cox and colleagues (1993) found a
clustering of new cases in a sample of women within 5 weeks after childbirth when compared with a control sample of nonchildbearing women.
We (Wisner et al. 1993) studied a large sample of women who presented
to an urban psychiatric hospital over a 2-year period. We categorized
women as having childbearing-relatedonset episodes (occurring during
pregnancy or within 3 months of birth or termination) or non-childbearingrelated episodes. The proportion of women with childbearing-related
onset illness among women aged 1544 years was 9%. When the sample
was restricted to women who had ever experienced a pregnancy, one of
seven women (14%) who sought care was experiencing an episode related to childbearing. Women incur major risk for psychiatric morbidity
along with the responsibility for childbearing.
The ratio of the number of psychiatric hospital admissions immediately
after childbirth to the number before birth is a measure of the relative risk
for serious psychiatric episodes associated with childbirth in a population.
The relative risk for hospitalization within 90 days of birth is 3.8; within
30 days of birth it is 6.0. The comparable risk figures for first-time mothers
are even higher: 5.8 and 10.9 within 90 and 30 days, respectively (Kendell
et al. 1987). Women are more vulnerable to psychosis in the postbirth period than at any other time during the female life cycle. In the first 30 days
after birth, a woman is 21.7 times more likely to develop psychosis than in
the 2-year period prior to childbirth. If she has not had a child before, she
is 35 times more likely to develop psychosis (Kendell et al. 1987). The
magnitude of these relative risks demonstrates that postpartum psychiatric
morbidity is a major public health problem.
Recognition and treatment of maternal psychiatric disorders must become a priority on the public health agenda if we are to achieve the goal

Postpartum Disorders

37

of reducing the risk of maternal morbidity and infanticide. In this chapter,

we review information about postpartum disorders and present cases to
illustrate symptom presentations. Our objective in this chapter is to integrate the research literature with our clinical experience in the hope that
clinical care and public health policy for childbearing women will be improved and that further research will be stimulated.

Epidemiology and Nosology

We begin with a discussion of a basic question: what are postpartum disorders? The answer is far from simple. Historically, postpartum depression and psychosis were differentiated by the predominance of depressive
or psychotic features and by symptom severity. However, current conceptualizations dictate that depression and psychoses are distinct psychiatric illnesses, not merely different severity levels of the same disorder.
We will analyze the two components of the question: first, what does the
term postpartum mean, and second, what specific disorders occur in the
postpartum period?
An international meeting was held in Satra Bruk, Sweden, in 1999 to
review issues related to the classification of postpartum disorders (Elliott
2000). Both epidemiological studies and clinical experience were reviewed. Epidemiologists have defined the duration of postpartum on the
basis of judgments about the break point between increased risk for psychiatric illness postbirth and baseline risk for psychiatric episodes in
women of childbearing age. Paffenbarger and McCabe (1966) found an
explosive peak of psychiatric admissions in the first month postpartum.
Kendell and colleagues (1976, 1981, 1987) extensively investigated the
association between childbirth and psychiatric contact in a population of
women. They linked birth and psychiatric registries for contacts 2 years
before and after a birth and found a significant peak in the rate of contact
for both depressive and psychotic illnesses in the 90-day period after
childbirth. Although it fell rapidly thereafter, the rate of admission remained significantly higher throughout the 2-year postpartum period than
it had been before birth.
Serious postpartum disorders have a rapid onset and progression of
symptoms. Rapidity of onset is supported by data from the work of Kendell et al. (1987). In a sample of 111 women with symptoms beginning
in the first 90 days postbirth, onset was distributed as follows: 49% of the
sample within 7 days, 79% within 30 days, and 94% within 60 days. Data
from our studies confirmed our clinical suspicion that decompensation
after initial symptoms also was rapid. Mothers responses to Schedule for

38

Infanticide: Psychosocial and Legal Perspectives

Affective Disorders and Schizophrenia (SADS; Endicott and Spitzer

1978) interview item #215 (length of time from first sign of development
of the major syndrome to gross impairment in social or occupational
functioning) were reviewed. Times to decompensation were as follows:
<2 days (n = 18, 47%), 2 days to <1 week (n = 4, 11%), 1 week to <2 weeks
(n = 2, 5%), 2 weeks to <1 month (n = 3, 8%), 1 month to <2 months
(n = 4, 11%), and >2 months (n = 7, 18%).
The two major international psychiatric diagnostic systems vary in
their definitions of postpartum. The International Classification of Diseases (ICD-10; World Health Organization 1992) permits designation as
mental and physical disorders associated with the puerperium only if the
disorders have onset within the first 6 weeks after birth and do not meet
criteria for disorders classified elsewhere (Elliott 2000). The current version of the Diagnostic and Statistical Manual of Mental Disorders, DSMIV-TR (American Psychiatric Association 2000), allows the designation
with postpartum onset to be made as specifier for a limited number of
diagnoses that begin within the first 4 weeks postpartum.
In summary, the time definition of postpartum can be set at 90 days
according to epidemiological studies, 6 weeks by ICD-10, and 4 weeks by
DSM-IV-TR. However, the Satra Bruk group noted that international
investigators use definitions of up to 1 year postpartum, particularly if
services for new mothers are tied to the definition. The conclusion of the
Satra Bruk group was that research into the etiological significance of
birth to psychiatric episodes would be aided by systematic recording of
specific time of onset or exacerbation after birth for a variety of disorders.
The term postpartum onset may be an appropriate specifier for multiple
diagnoses. For example, the postpartum period is a high-risk time for the
first lifetime onset of anxiety disorders such as panic disorder (Sholomskas
et al. 1993; Wisner et al. 1996b) and obsessive-compulsive disorder
(Sichel et al. 1993; Williams and Koran 1997). A new multiaxial profile
for postpartum disorders was suggested as a research endeavor (Guedeney 2000). The system is a descriptive scheme that emphasizes the importance of context, dyadic processes, and familial system function and
child temperament and development.
These classification systems set the stage for the second question: what
are the types of psychiatric episodes that occur in the postpartum period?
The majority of serious illnesses that begin in the postpartum period are
mood disorders (Kendell et al. 1976, 1981, 1987). Of 120 women admitted within 90 days of birth, 80% received diagnoses of mood disorders.
In these studies, 38% of the women had major depression, 17% had minor depression, 18% had mania, 4% had schizoaffective mania and 3%
had schizoaffective depression, 3% had schizophrenia, 11% had unspecified

Postpartum Disorders

39

functional psychosis, and 6% had personality disorders or other illnesses.

Among women with a previous history of admission for psychiatric illness, the highest risk for another postpartum admission was for women
with bipolar disorder (manic depression): 21.4% of deliveries to women
with bipolar disorder were followed by another admission, as compared
with 13.3% of deliveries to women who had experienced major depression.
Episodes of psychosis with acute postpartum onset are also predominantly mood disorders. Brockington et al. (1981) found that 91% of
women with postpartum psychosis had mood disorders as defined by
RDC. In a group of women who were treated preventively in the postpartum period with lithium, Stewart et al. (1991) found that 91% had
conditions that met the RDC for mood disorders. Benvenuti et al. (1992)
found that 90% of a sample of 30 psychotic women had illnesses that fit
DSM-III-R criteria for mood disorders. An interesting observation is the
high frequency of bipolar and cyclical schizoaffective episodes that occurred in these samples. The frequencies of bipolar plus schizoaffective
disorder in these studies were, respectively, 51% (Brockington et al.
1981), 63% (Stewart et al. 1991), 57% (Benvenuti et al. 1992), and 72%
(Wisner et al. 1995).
Conversely, 40%70% of women with established bipolar disorder will
have a recurrent episode postbirth (Bratfos and Haug 1986; Reich and
Winokur 1970; vanGent and Verhoeven 1992). In a family psychiatric history investigation, Whalley and colleagues (1982) tested the hypothesis
that postpartum psychosis is genetically related to manic-depressive disorder. The investigators found no evidence of a genetic distinction between
postpartum psychosis and bipolar disorder. Considering the findings above
and our clinical experience, we concluded that any acute-onset psychosis
in the postpartum period should be considered bipolar disorder and
treated as such until proven otherwise (Wisner et al. 1995).

Clinical Phenomenology
The symptoms of postpartum major depression are the same as those of
major depression that occur at other points in womens lives (Cooper et al.
1988; Wisner et al. 1994). According to DSM-IV-TR (American Psychiatric Association 2000), major depression is defined by the presence of at
least five of the symptoms listed in Table 31, one of which must be either 1) depressed mood or 2) loss of interest or pleasure. The remainder
of the symptoms characterize the physiological rhythm disruptions that
occur in depression, such as sleep and appetite dysregulation. Symptoms

40

Infanticide: Psychosocial and Legal Perspectives

Table 31.

Symptoms of major depression

(1) Depressed mood (often accompanied by anxiety)

(2) Markedly diminished interest or pleasure in activities
(3) Appetite disturbance (usually loss of appetite with weight loss beyond
expectation postbirth)
(4) Sleep disturbance (most often insomnia and frequent awakenings even
when the baby sleeps)
(5) Physical agitation (more commonly) or retardation
(6) Fatigue, decreased energy
(7) Feelings of worthlessness or excessive or inappropriate guilt
(8) Decreased concentration or ability to make decisions
(9) Recurrent thoughts of death or suicidal ideation
Source.

Adapted from American Psychiatric Association 2000.

must be present for most of the day nearly every day for 2 weeks. The
symptoms must result in a change from the previous level of functioning
and produce significant impairment or distress.
Many of our depressed patients also have described obsessional thoughts.
According to DSM-IV-TR, obsessions are recurrent and persistent thoughts,
impulses, or images that are experienced as intrusive and inappropriate
and cause marked anxiety or distress; they are not simply excessive worries about real-life events, such as ruminations. The person attempts to
ignore or suppress obsessions or tries to neutralize them with some other
thought or action. For example, some mothers have obsessional thoughts
about stabbing their children, and they dispose of every sharp object in
the house. By definition, obsessions are not psychotic symptoms, because
the person recognizes that the thoughts, impulses, or images are a product of her own mind (not imposed by an external force, as might occur
as a symptom of psychosis). Additionally, the obsessional visual images
are brief and are perceived as being in the mind as opposed to in the environment, as in an hallucination. For example, one of our patients described horrifying images of herself and her newborn in a casket.
We hypothesized that these thoughts were more common in postpartum depression than in non-childbearing-related depression (Wisner et al.
1999b). We compared the rates, severity, and type of obsessional thoughts
and compulsions in women with postpartum major depression with those
in women with nonpostpartum major depression. We found that almost
half our sample of depressed women endorsed obsessional thoughts in the
context of major depression. Contrary to our hypothesis, the intensity of
obsessions and compulsions did not differ between the two groups. However, our clinical observation that the character of the obsessional thoughts

Postpartum Disorders

41

differed was supported. Women with postpartum depression had significantly more aggressive obsessional thoughts. These women had violent
thoughts (put the baby in the microwave, drown the baby, stab the baby
with a knife) that they found abhorrent. It is tempting to speculate that
these thoughts, which are violent thoughts specific to the baby, may be
the result of dysregulated serotonin function in the postpartum period
(Wisner et al. 1999b).
Postpartum depression also must be distinguished from the baby blues,
which are very common and occur in 50%80% of women. Symptoms,
which peak on days 45 postpartum, consist of a mild mood disturbance
without the pervasive dysphoria characteristic of major depression. The
blues are transient, resolve by 10 days postpartum, and typically do not
require treatment. However, early onset of postpartum depression can be
difficult to distinguish from the blues, and careful follow-up of the course
of the episode will establish the diagnosis.
Postpartum psychotic disorders can present a diagnostic challenge.
Hallucinations or delusions are required for the diagnosis of a psychotic
process. The symptoms can be fluctuating and variable in type and intensity. Patients have various levels of awareness and insight into their psychopathology, which affects willingness to reveal symptoms.
Postpartum psychoses have been reported to differ from other psychotic episodes because of alterations in cognition and confusion (Brockington et al. 1981; Platz and Kendell 1988; Protheroe 1969; Wisner et al.
1994). Brockington et al. (1981) compared psychoses that began within
2 weeks of childbirth with episodes of psychosis that occurred in women
of the same age in the same hospital. There were significant differences in
three areas: increased manic symptoms, absence of schizophrenic symptoms, and marked confusion in the puerperal group. The confused, delirium-like, disorganized clinical picture of postpartum psychosis has been
observed and reported repeatedly (Brockington et al. 1981; Hamilton
1982). We (Wisner et al. 1994) compared women who had childbearingrelated psychoses and women with non-childbearing-related psychoses.
Our most dramatic finding was from our factor analysis: the childbearing
psychotic women had a high score on the factor we named cognitive
disorganization/psychosis, which contained the following symptoms:
thought disorganization, bizarre behavior, lack of insight, delusions of reference, persecution, jealousy, grandiosity, suspiciousness, impaired sensorium/orientation, and self-neglect. These women displayed prominent
symptoms of cognitive impairment and bizarre behavior. The clinical picture of women with postpartum psychosis was that of an acute-onset
illness that suggested a delirium to physicians, as evidenced by cognitive
examinations (such as drawings of clock faces and figures) and extensive

42

Infanticide: Psychosocial and Legal Perspectives

laboratory evaluations. Women with postpartum psychosis also had more

unusual psychotic symptoms, such as tactile, olfactory, and visual hallucinations.
We (Wisner et al. 1994) speculated that sleep deprivation, which is often extreme during labor and postbirth, might be responsible for this cognitive disorganization. The disorganized state induced by the disruption of
circadian rhythms that sleep deprivation causes (Ehlers et al. 1988) may
play an etiological role in disorganized mood states in vulnerable women.
Sleep deprivation creates a risk for hypomanic or manic states in women
with bipolar disorder. Strouse et al. (1992) used partial sleep deprivation
as a treatment for three women with postpartum psychotic depression.
All three women switched from disorganized depressed states into activated manic or hypomanic states.
Herzog and Detre (1976) suggested that qualitative differences may
exist between postpartum and other psychoses because of the powerful
influence of childbirth and motherhood on thought content. Protheroe
(1969) noted that guilt that involves the child, spouse, or patient is the
most frequent content of delusional thought in women with postpartum
psychotic depression. Common themes were feelings of inability to care
for the new child or not having enough love for either the baby or the
husband. Guilt feelings over infanticidal thoughts were also common.
The patient, a 22-year-old white married woman, was about 4 months
postpartum when her family found her wading in a lake with her infant
in January in the Midwest. Several relatives had been committed to longterm mental health facilities, so the family was very reluctant to bring the
new mother for psychiatric assessment because they thought she would
be institutionalized. On examination, the patient laughed about how hot
it was and how she enjoyed the beautiful sunshine. She called the examiner sister golden-hair and stated that she intended to walk into the lake
again to purify herself. The patient invited the examiner to accompany
her so she could purify the examiner and rid her of sins. She denied any
intent to harm her baby, but she believed that the infant also needed to
be purified in the lake. She endorsed all symptoms of depression and was
disoriented to time and place. Her family described several periods during
which she was grandiose, loud and verbose, and extremely physically active. Her husband was dismayed by the constant sexual demands she
made during those times.

Particularly for disorganized patients, input from the family about behavior is essential for proper diagnosis and management. Postpartum psychosis can be the first manifestation of psychiatric disorder in women.
Acute-onset postpartum psychosis is usually bipolar disorder, as in the
case above, in which the patient exhibited ultra-rapid cycling between

Postpartum Disorders

43

depressed and manic phases with psychotic features. The symptoms can
be misinterpreted by family, friends, and health care professionals as
postbirth adaptation or the common baby blues. In this case, the family
was adamant about caring for the patient at home. They developed a 24hour family observation plan for the mother, and family members provided care for the baby (who was developing well). The woman eventually made a full recovery after treatment with lithium and psychotherapy.
The patient, a 30-year-old surgical nurse, had delivered her infant at the
hospital where she worked. The day after birth, she developed her first
manic episode with psychotic features. She was grandiose a few hours after the birth and told the lactation consultant that she did not need any
help with breast-feeding because she was an expert in the physiology of
lactation. The ward staff found her scrubbing the bathroom walls in an
energized frenzy. When they asked about perineal pain, she exclaimed
that she had cured herself. She refused to stop cleaning the bathroom and
insisted they bring more cleaning supplies. When the nursing staff presented a description of their colleagues behavior to the resident physician, he commented that she probably was just excited about having her
first baby. A few hours later, the patient left the maternity ward and ran
through the halls to the emergency room in her hospital gown. She
danced in the middle of the emergency room and demanded that all the
patients gather around her so that she could cure them of their pain.
When another nurse tried to escort her back to the maternity ward, the
patient kicked her repeatedly. The patient shouted rapidly several times
that she was Mother Mary and that she had the power to cure. She was
restrained and admitted to the psychiatric unit involuntarily.

Training in the recognition and initial management of postpartum

psychosis must become a standard component in the education of maternity service professionals to promote safety and prompt intervention.
A 19-year-old mother was evaluated after an attempted infanticide [Wisner et al. 1996a]. The mother had symptoms of anxiety and depression
after the birth of her child. At her postpartum obstetrical checkup, the
patients husband told the physician that his wife seemed depressed. The
husband stated that the physician told him his wife had the baby blues
and that she would feel better when she resumed her usual activities.
When the baby was about 2 months old, the mother pointed a gun at her
infant. Although several family members urged her (and her husband) to
seek a psychiatric evaluation, she refused because she did not want to be
separated from her infant. Her husband insisted that his wife just do her
job and take care of the baby. The next day the mother became convinced that someone was going to rape and torture herself and the baby
girl. She attempted to poison the infant with a toxic chemical and made
a near-fatal suicide attempt by stabbing.

44

Infanticide: Psychosocial and Legal Perspectives

This type of delusional altruistic homicide (and associated parental suicide attempt) to save mother and infant from a fate worse than death was
described in a review of filicides (Resnick 1969). Resnick was discouraged
by the observation that 40% of the perpetrators of filicide had seen either
psychiatrists or physicians just prior to the tragedy. Sensitive direct questions about thoughts of harm to the infant, as well as harm to self, are imperative in the examination. We inquire as follows: Some women who
have a new baby have thoughts such as wishing the baby were dead or
about harming the baby; has this happened to you? It is important to explore the answer to questions about harm to self or infant carefully. Some
women respond that the baby was unplanned and become tearful about
being overwhelmed in caring for the infant but deny any psychotic symptoms or intent to harm the infant. The risk is much less than with someone
who has a psychosis into which the infant has been incorporated (see case
example below). Other women speak of a specific episode (often at night)
when the baby has been crying and the mother is distressed that nothing
seems to comfort the child. The mother thinks of putting something over
the babys mouth to muffle the crying but does not act on this thought, has
no intent to harm, and has no psychotic symptoms. Again, the risk in this
situation is minimal. Some women who have nonpsychotic depression
have no hope for the future and express thoughts that the baby (and sometimes themselves) would be better off dead, but they deny intent to harm.
Women with severe depression are often presumed to have psychosis
despite lack of specific psychotic symptoms. Another example of misinterpretation of symptoms as psychotic occurs with obsessional thoughts,
which are by definition nonpsychotic, ego-dystonic (not consistent with the
sense of self) intrusive thoughts. As discussed earlier, aggressive obsessional
thoughts are common in women with postpartum depression. Obsessional
thoughts are not associated with increased risk of harm to the infant unless
other factors are present, such as coexisting psychosis or behavior that presents other risks (e.g., severe depression that results in caregiving failure).
A 38-year-old woman who was 6 weeks postpartum presented to our womens
specialty program because she felt that something was wrong. She was
an attorney who was well-dressed, relaxed, and eloquent during the examination. She readily admitted to all symptoms of major depression.
When asked about thoughts of harming her baby, she said that she would
not harm the infant, but that there was a dark shadow within her that
came out and tried to hurt the baby. She explained that she walked on the
porch all day (in winter) with the baby and her 2-year-old son to keep the
dark shadow from coming out. The day before her appointment, she explained that the dark shadow came out and forced her hands to try to suffocate her baby. She was convinced she would have killed the infant if her

Postpartum Disorders

45

crying son had not pulled on her pant leg and brought her back under
control (which banished the dark shadow). She stated that the dark
shadow was a black silhouette that takes over her body movements. She
refused admission and was involuntarily committed. Her husband was angry and defiant about the forced admission until she told him about the
dark shadow, at which point he burst into tears of disbelief.

A womans general appearance and superficial conversation cannot be

used to establish the absence of psychosis. Questions about hallucinations and delusional thought content must be asked sensitively and directly when a woman responds positively to the question about infant
harm, as in this case.

Biological Considerations
Postpartum depression occurs in the context of a physiological milieu
that is distinct from any other in a womans life (see Chapter 4: Neurohormonal Aspects of Postpartum Depression and Psychosis). Although
it is widely believed that there is a hormonal contribution to the etiology
of postpartum depression (Epperson et al. 1999), only one comprehensive study of hormone concentrations in postpartum women has been
published (OHara et al. 1991). Women who developed postpartum depression, compared with nondepressed subjects, had significantly lower
estradiol levels at 2 days postpartum and a trend toward lower mean estradiol levels. Following this line of reasoning, Gregoire et al. (1996)
compared estradiol with placebo for the treatment of postpartum depression. 17--Estradiol 200 g/day was delivered by transdermal patch.
The estradiol-treated group showed a 50% reduction in depression scores
in the first month of treatment (see Chapter 4).
Cizza et al. (1997) proposed that the efficacy of estradiol in treating
postpartum depression is through normalization of corticotropin-releasing
hormone (CRH) secretion. During pregnancy, free CRH levels are elevated because of placental production of CRH, decreased levels of CRHbinding protein, and elevated serum estradiol levels. At delivery, these
sources of stimulation are removed. Coupled with postpartum estrogen
deficiency, a state of hypoactivation occurs. In one study, women who became depressed postpartum, compared with nondepressed women, had
more severe and prolonged blunting of the mean plasma adrenocorticotropic hormone (ACTH) response to CRH (12 weeks postpartum) stimulation (Magiakou et al. 1996). After birth, the hypothalamic-pituitaryadrenal (HPA) axis depends on hypothalamic CRH secretion to maintain
its activity. The promoter of the CRH gene contains estrogen receptor
binding elements that are activated by estradiol therapy.

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Infanticide: Psychosocial and Legal Perspectives

Bloch et al. (2000) published data that provide direct evidence of the
role of reproductive hormones in the development of postpartum depression. These investigators simulated the withdrawal of hormones at
birth by inducing a hypogonadal state in nonpregnant women with leuprolide, adding back supraphysiological doses of estradiol and progesterone
for 8 weeks, then withdrawing both steroids under double-blind conditions. Five of the eight women with a history of postpartum depression
and none of the eight women without a history of postpartum or other
depressive episodes developed significant mood symptoms (see Chapter 4).
The investigators suggested that women with a history of postpartum depression are differentially sensitive to the mood-destabilizing effects of
withdrawal from gonadal steroids at birth.
Biological factors are also believed to contribute to the etiology of postpartum psychosis (Epperson et al. 1999; Wisner and Stowe 1997). Estrogen
has direct and indirect effects on mesolimbic and mesostriatal dopamine
activity that are dose- and time-dependent (Van Hartesveldt and Joyce
1986). Interesting case reports support the importance of estrogen withdrawal and neurotransmitter system recovery following parturition in the
development of psychotic symptoms. Mallett et al. (1989) described a
male transsexual who developed psychosis after estrogen withdrawal.
Hopker and Brockington (1991) studied a woman who developed postpartum psychosis after two pregnancies and also after the removal of a
hydatidiform mole.
Additional clinical studies and observations implicate the role of gonadal hormones, altered neurotransmitter receptor sensitivity, and the rate
at which these systems recover to prepregnancy states in postpartum psychosis. Case reports of the induction of manic symptoms after treatment
with bromocriptine, a dopamine agonist historically used to terminate
lactation, support the hypothesis of altered dopaminergic system sensitivity (Brockington and Meakin 1994; Fisher et al. 1991; Iffy et al. 1989).
Brockington et al. (1988) and others have reported the phenomenon of
premenstrual psychotic relapse in women with postpartum psychosis,
which suggests a role for progesterone in its development or recurrence.
Brockington et al. (1990) also presented the case histories of four women
who had a history of postpartum psychosis with recurrent episodes late
in pregnancy (>36 weeks gestation). Serum levels of progesterone decreases during late pregnancy prior to the onset of labor (Turnbull et al.
1974). These clinical data underscore the contribution of alterations in
gonadal hormones and potential long-term sensitivity alterations associated with pregnancy in the etiology of postpartum psychosis.
The mean corrected and ionized serum calcium values of women with
postpartum psychosis were reported to be significantly higher than those

Postpartum Disorders

47

of a control group of women who were psychiatric patients or psychiatrically healthy postpartum women (Riley and Watt 1985). This finding was
shown only for women who had no personal or family history of psychiatric illness. During treatment, the fall in ionized serum calcium levels correlated positively and significantly with the improvement in symptoms.
The authors concluded that a subgroup of women (about one-third of their
sample) appeared to have a disorder of calcium homeostasis. To our knowledge, this interesting work has not been replicated.

Evaluation and Treatment

What is the appropriate medical evaluation for a woman who presents
with a postpartum-onset disorder? The emergence of an episode of mood
disorder or a psychotic episode in the postpartum period dictates that
medical causes of altered neurological status be investigated. Women with
postpartum major depression should receive a complete review of systems, medical history, and general physical examination and history so
that organic contributions to the mood disorder can be assessed. The use
of prescribed medication (particularly pain medication) and over-thecounter medication, as well as use of drugs and alcohol, must be assessed.
Thyroid studies should be obtained to rule out postpartum thyroiditis, as
should a hemoglobin count to rule out severe anemia. For postpartum
psychosis, we obtain a serum calcium level to rule out hypercalcemia, as
described by Riley and Watt (1985).
OHara et al. (2000) found that interpersonal psychotherapy (IPT)
modified for treatment in the postpartum period was effective in treating
women with depression. The wait-list control subjects (who remained
depressed across time) also responded comparably to IPT when it was
implemented after the waiting period. This research group has collected
information about the subsequent functioning of offspring when mothers
are effectively treated for postpartum depression, which, when published, will be an enormous contribution to the literature.
There are very few systematic data regarding the pharmacological treatment of depression related to childbearing (Table 32). Dean and Kendell
(1981) observed that fewer women with postpartum depression responded to tricyclic antidepressants (TCAs) than did nonpostpartum depressed women.
In the only controlled study, and the only one to compare a form of
therapy with medication, Appleby et al. (1997) found that both fluoxetine
and cognitive-behavioral counseling were effective treatments for postpartum depression. Women were randomized to four groups: fluoxetine

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Infanticide: Psychosocial and Legal Perspectives

Table 32. Treatment for postpartum depression

Study

Treatment

Appleby et al. 1997 Fluoxetine (plus 1 or

6 sessions of CBT)
OHara et al. 2000 IPT
Stowe et al. 1995
Sertraline
Wisner et al. 1999a TCAs

SSRIs

Dosage,
mg/day

Dosage range,
mg/day

20

NA (set dose)

12 weeks
108 37 50100
Nortriptyline: 60125
Desipramine: 200
Imipramine: 250
Sertraline: 100200
Fluoxetine: 2040
Paroxetine: 30

Note. CBT = cognitive-behavioral therapy; IPT = interpersonal psychotherapy; NA =

not applicable; SSRI = selective serotonin reuptake inhibitor; TCA = tricyclic antidepressant.

20 mg/day or placebo plus one or six sessions of counseling. Significant

improvement was seen in all four groups. The improvement in the women
who received fluoxetine was significantly greater than that in the women
who received placebo. The improvement after six sessions of counseling
was significantly greater than that after a single session. There was no additive benefit observed in the women who received both treatments.
Stowe et al. (1995) completed an open-label study of the serotonin
selective reuptake inhibitor (SSRI) sertraline in 26 women with postpartum depression. The moderately depressed women were treated with
sertraline at a dosages of 50200 mg/day. Of the 21 women who completed the 8-week study, 20 (95%) demonstrated a response (>50% reduction in initial depression score). These data suggest that women with
postpartum depression may be particularly responsive to SSRIs.
Naturalistic data from our tertiary care clinic support the finding that
SSRIs are superior to TCAs for the treatment of postpartum depression
(Wisner et al. 1999a). The difference in proportions of response was
small (0.2), as would be expected from a comparison of two drugs, both
of which are significantly more effective than placebo. We are conducting
a randomized clinical trial to test the comparative efficacy of an SSRI and
a TCA for postpartum depression and to identify predictors of response
to each class of drug.
Selection of treatment options for women with postpartum depression is based on the past response to treatment (if any), severity of the
episode, presence of breast-feeding, and patient preference. Psychotherapy may be used for mild to moderately severe postpartum depression
and is typically combined with medication in treating women with impair-

Postpartum Disorders

49

ing physiological symptoms, such as sleep continuity disturbance and loss

of appetite. Past successful treatment with a specific antidepressant strongly
dictates the choice of that agent. If the patient has not had drug treatment, the first-line medication choice is an SSRI. These medications generally have low rates of serious side effects and are not toxic in overdose.
The objective of antidepressant treatment is to eradicate the symptoms listed
in Table 31. Full remission with return of the patients previous functional
level is the goal of therapy. Use of sedatives alone for symptoms only, such
as sleep disturbance, is not effective for treating the full syndrome of depression.
A unique aspect of the treatment of women with postpartum depression
is exposure of infants to drugs during lactation. The approach to studying
risk to infants when lactating mothers take antidepressants has been serum level monitoring in mother and nursing infant. The majority of
mother-infant serum levels have been published for the SSRIs sertraline,
paroxetine, and fluoxetine and for the TCA nortriptyline.
In a review, Wisner et al. (1996c) found that TCAs and their metabolites typically were not found in quantifiable amounts in nurslings. On
the basis of infant serum level data and no reported adverse effects, use
of the tricyclic drugs amitriptyline, nortriptyline (Wisner et al. 1997),
desipramine, or clomipramine was recommended for the treatment of
breast-feeding women with depression. There was no evidence of accumulation of tricyclics in infant sera when sampling was repeated. The collective data on serum levels suggested that infants older than 10 weeks
were at low risk for adverse effects from TCAs. The only reported adverse outcome for a TCA occurred in a nursing infant whose mother was
taking doxepin. The 8-week-old infant developed sedation and respiratory depression due to elevated doxepin metabolite.
Several studies about SSRIs during lactation have been published.
Epperson and colleagues (2001) studied the serum levels of two newborns and two infants whose lactating mothers took sertraline at a dosage
of 50 or 100 mg/day. All infant serum levels were less than 2.5 ng/mL of
sertraline or 5 ng/mL of its metabolite. This group also evaluated the
functional effects of these nonquantifiable levels of sertraline in infants
by assessing platelet serotonin. In humans, platelet and neuronal serotonin transporters are identical, and animal studies have shown that SSRIs
cause similar central and peripheral blockade. In the mothers, the expected marked decline in platelet serotonin levels was observed after
treatment, whereas minimal change in these levels was seen in the infants
exposed to sertraline through breast milk.
Stowe et al. (1997) determined the serum concentrations of sertraline
and its metabolite in 11 mother-infant pairs. Eight infants had nonquan-

50

Infanticide: Psychosocial and Legal Perspectives

tifiable concentrations of sertraline, and the other three had levels of

3 ng/mL or lower. The authors frequently found low levels of the metabolite N-desmethylsertraline in infant sera, with five samples being nonquantifiable and nine having levels of 10 ng/mL or lower. Wisner et al.
(1998) studied serum levels in nine mother-infant pairs. Sertraline levels
were less than 2 ng/mL in seven of nine infants and 2.9 ng/mL in one. NDesmethylsertraline levels were 6 ng/mL or lower in seven of nine infants. None of the infants exposed to sertraline during breast-feeding developed adverse effects.
Similar data have been published for paroxetine in mothers and breastfed infants (Hendrick et al. 2001; Misri et al. 2000; Stowe et al. 2000);
no quantifiable concentrations of paroxetine were found in the infant
sera (i.e., <2 ng/mL). Paroxetine does not have an active metabolite.
Colic and serum levels similar to those observed in adults were described in a 6-week-old breast-fed infant (Lester et al. 1993) and an additional two infants (Kristenson et al. 1999) whose mothers were treated
with fluoxetine. Unlike the TCAs, fluoxetine and its metabolite norfluoxetine have very long half-lives (84 and 146 hours, respectively). Therefore, continuous exposure through breast milk carries the potential to
promote newborn serum level development. Kim et al. (1997) reported
maternal and nursling fluoxetine and norfluoxetine serum levels from six
pairs. The mothers had been treated with fluoxetine for 34 weeks. There
were no detectable levels of either compound in four of the six serum
samples from infants aged more than 2.5 months. In the other two infants, norfluoxetine (but not fluoxetine) was detected at levels that were
36% and 3% of maternal levels. The authors concluded that norfluoxetine
was detected in the younger infants because of slow neonatal elimination.
The variability noted in this study has been reflected in the literature,
with some infants of fluoxetine-treated lactating mothers having no apparent difficulties (Taddio 1996).
Breast-feeding during antidepressant therapy is a case-specific riskbenefit decision, and the available data are generally favorable, particularly
for nortriptyline and sertraline. Obtaining a baseline of the infants behavior prior to treatment of the mother helps to avoid interpretation of typical
behavior as new problems. We always advise the mothers to observe the
infants for any new rash, since infants can be allergic to minute amounts of
any allergen, such as small amounts of drug in breast milk. The importance
of parental caregiving, which may be compromised by depression, must be
weighed heavily in the decision-making process. Consultation with the infants pediatrician is standard procedure in our clinic.
Postpartum depression is a model of psychiatric illness that provides
an ideal opportunity for prevention because 1) its onset is preceded by a

Postpartum Disorders

51

clear marker (birth), 2) there is a defined period of risk for illness onset,
and 3) mothers at high risk (those who have had major depression) are
identifiable (Wisner et al. 2001). There are few controlled data to guide
clinicians who must respond to women who are understandably fearful
of postpartum depression. Prophylactic provision of medication postbirth
should be considered; however, the TCA nortriptyline does not confer
protective efficacy when compared with placebo, and the risk for recurrence is about 25% (Wisner et al. 2001). The postpartum treatment plan
should include, at a minimum, monitoring for depression recurrence
with a plan for rapid intervention and consideration of starting the drug
to which the patient responded or an SSRI.
There is little information about the treatment of psychosis in the
puerperal period. Dean and Kendell (1981) reported no difference between puerperal and control cases of manic disorder with respect to the
type of treatment received or to hospital length of stay. Since postpartum
psychosis usually represents bipolar spectrum disorders (Brockington et
al. 1981; Kendell et al. 1987; Wisner et al. 1995), mood stabilizers, such
as lithium or valproate, should be strongly considered in the pharmacological treatment of women with postpartum psychosis. Electroconvulsive therapy is also an excellent choice. In our experience, use of typical
antipsychotic medications alone yields only a partial response in women
with postpartum psychosis. The role of newer atypical antipsychotics,
which have some place in the treatment of mania, has not been explored
in postpartum psychosis.
Ahokas et al. (2000) found that 10 women with ICD-10 postpartum
psychosis had baseline serum estrogen levels that were lower than the
threshold value for gonadal failure. During the first week of sublingual
17--estradiol treatment, psychiatric symptoms diminished significantly.
Until the end of the second week of treatment, serum estradiol concentrations progressively rose to near the values normally found during the
follicular phase, and patients dramatically improved. Reversal of symptoms
in all patients by treating documented estrogen deficiency suggested that
estradiol plays a role in the pathophysiology of postpartum psychosis and
may be therapeutic in this condition. There was a rebound of psychotic
symptoms in one patient who discontinued estrogen treatment. This intriguing study compels replication.
Prevention of recurrent postpartum psychosis has also been investigated. Dean et al. (1989) found a 50% recurrence rate with later births
among women with a history of nonpostpartum as well as postpartum
episodes, compared with a 36% rate among women with only postpartum episodes. Promising data from uncontrolled open trials by Stewart et
al. (1991) and Austin (1992) showed that administration of lithium in

52

Infanticide: Psychosocial and Legal Perspectives

the immediate postpartum period prevented recurrent psychosis. Stewart et al. (1991) treated 21 women with lithium and averted recurrent
psychotic episodes in 19 patients. This 10% recurrence rate is less than
the risk defined by other studies (20%50%). Austin (1992) studied 17
pregnant women with a prior episode of postpartum psychosis. Of 9
women who received lithium prophylaxis, 2 experienced postpartum
mania; in contrast, 6 of 8 women who were not receiving medication experienced manic episodes. Cohen et al. (1995) reported that lithium prevented postpartum episodes in women with bipolar disorder.
Estrogen has been administered to women with previous histories of
puerperal psychosis, and a diminished rate of relapse has been reported
(Bower and Altschule 1956). Hamilton (1982) reported anecdotally that
40 patients who had been given a mixture of estrogen and testosterone at
delivery to suppress lactation did not experience a recurrence of postpartum psychosis (see Chapter 4). Sichel et al. (1995) studied seven women
with histories of postpartum psychosis and four with postpartum major
depression (see Chapter 4). They were treated immediately after delivery
with estrogen, which was tapered gradually. None of the women had histories of nonpostpartum affective illness, and all women were affectively
well through the current pregnancy and at delivery. Despite the high risk
for recurrent illness, only one woman developed relapse of postpartum
affective illness. This low rate of relapse suggested that estrogen may treat
a postpartum withdrawal state that drives acute postpartum psychosis.
When treating postpartum psychosis, the clinician must evaluate the
mothers commitment to breast-feeding. The risk of induction of maternal mania or hypomania because of sleep deprivation due to infant care
must be considered. However, many women are adamant about breastfeeding their infants, and the clinician must take their preference into account when selecting drugs. A partner or family member who is willing
to bottle-feed the baby at night is not available to all women. The American Academy of Pediatrics Committee on Drugs (1994) considers carbamazepine and valproate, but not lithium, to be compatible with use
during breast-feeding. Carbamazepine has been associated with transient
hepatic toxicity and cholestatic hepatitis (Frey et al. 1990; Merlob et al.
1992) in neonates exposed during both pregnancy and breast-feeding.
The infant of a woman who was treated during breast-feeding developed
a carbamazepine level that was 15% and 20% of the total and free maternal levels, respectively (Wisner and Perel 1998). Our group (Piontek et
al. 2000) reported serum levels from six mothers who took valproate
during breast-feeding. The mothers were not exposed during pregnancy.
The women developed levels ranging from 39 to 79 g/mL. Infant serum
levels were low (0.7 to 1.5 g/mL). No adverse clinical effects were ob-

Postpartum Disorders

53

served in the infants. Chaudron and Jefferson (2000) have written an excellent review of issues related to treating lactating women with bipolar
disorder.

Effects of Maternal Mental Illness

on Offspring
What are the mechanisms by which postpartum psychosis can lead to infanticide? The processes through which children are affected by parental
illness are complex (Rutter and Quinton 1984). Genetic factors that increase vulnerability to affective disorder in the offspring contribute. Although some children are resilient, the risk of diagnosable psychiatric
disorder in the offspring of parents with depression and bipolar disorder
is higher than in children of nonpsychiatrically ill mothers (Weissman
et al. 1984). Environmental factors that are correlated with parental psychiatric illness, such as violence, hostility, irritability, and involvement in
parental delusions, are also important predictors of poor outcome (Rutter and Quinton 1984). Children of psychiatrically disturbed parents
have difficulty establishing secure relationships with their mother, have
less adaptive coping skills, are less competent socially, and are more likely
to be abused (Cohler and Musick 1985). Indirect effects of parental
mental illness, such as family disruption, placement out of the home,
impaired caregiving skills, and neglect, affect child development. Other
correlates of parental mental illness, such as marital discord, low socioeconomic status, poor nutrition, and inadequate medical care, interact to
contribute to increased childhood risk.
DaSilva and Johnstone (1981) reassessed 47 women who had developed severe postpartum disorders of mixed diagnostic type over a period
of 16 years. They found 2 cases of maternal suicide, 10 cases of episodes
of self-injury, 2 cases of impaired health in the child that was secondary
to neglect, and 6 cases of infant injury due to abuse. Twenty percent of
the mothers were unable to be the primary caregiver for their children.
These findings are less favorable than those of Protheroe (1969), who
found a favorable outcome in 74% of the cases.
The total dependence of the newborn on the caregiver creates a number of risks. Infanticide by poisoning or force has been discussed earlier in
this chapter. However, infanticide by starvation has also been described
(Meade and Brissie 1985). The serious cognitive disorganization in women
with postpartum psychosis can lead to failure to provide the vulnerable
newborn with life-sustaining needs, such as adequate fluid and nutritional intake, appropriate environmental temperatures, safety, and emer-

54

Infanticide: Psychosocial and Legal Perspectives

gency medical care. Examples are failure to seek medical care for otitis
media that becomes complicated by fatal sepsis, or leaving an infant in a
place accessible to a hostile pet.

Conclusion
How can we reduce the risk of infanticide? The answer to this question
has multiple levels of response. Improved awareness by both health care
professionals and childbearing women must be promoted through education. Unfortunately, media attention often focuses on the negative outcome
(infanticide) rather than on early identification, prevention, treatment,
and research. Childbirth education classes are incomplete without information for expectant mothers about postpartum psychiatric illnesses. A
formal educational module to include in all programs for maternity care
professionals must be developed, piloted, and included as part of specialty certification. Prevention strategies should be offered to women at
risk for postpartum decompensation. Women with a previous episode of
postpartum depression or psychosis and women with bipolar disorder are
at significant risk for recurrence after another birth. At a minimum, postpartum monitoring for the emergence of symptoms should be a collaborative plan between the physician and the patients family.
Because postpartum depression is common in the general population
of new mothers, screening to identify cases for early intervention is another important public health goal. Most screening studies have been
done in the United Kingdom with the Edinburgh Postnatal Depression
Scale (EPDS; Cox et al. 1987), a 10-item self-report questionnaire. We
had the opportunity to assess the EPDS as a screening tool for identification
of postpartum depression. We found that a score of greater than 10 on the
EPDS was a strong and consistent indicator that women had postpartum
depressiona finding similar to those from studies in Europe (Murray
and Carothers 1990; Wickberg and Hwang 1996). Our data strongly suggest that the EPDS can be used as an effective screen for postpartum depression.
We now have tools for screening postpartum depression, and demonstration projects can be implemented to determine the feasibility of
proceeding to nationwide screening programs. Because pediatricians have
more contact than most physicians with new mothers, they are particularly important members of any screening strategy (Seidman 1998).
Aggressive treatment for women who develop the disorder with a
thoughtful plan for family monitoring of the infant for safety or alternative care while the mother recovers is imperative. Inpatient hospitalization in Europe and other countries often includes both mother and infant

Postpartum Disorders

55

as a dyadic target for therapy, but such services have been rare experiments in America (Wisner et al. 1996a). Multi-site randomized clinical
trial investigations of therapeutic interventions for women with postpartum disorders would be a major contribution to the field. Exciting
research possibilities also exist to improve care for women with postpartum disorders. Replication of European and Scandinavian studies suggesting that estrogen may be both a preventive and an acute therapy for
postpartum depression and psychosis is critical. Investigation of the relationship between the massive hormonal stimulation during pregnancy
and the acute postpartum withdrawal state on psychiatric symptoms
holds promise for understanding the etiology of postpartum and other
depressions in women.
Finally, we know little about how a womans symptoms vary across
her reproductive lifetime, and research information is needed for improved longitudinal disease management. If a woman has a postpartumonset depression or psychosis, what mood changes can she expect as she
begins her menstrual cycles postpartum? What if she takes or abruptly
stops oral contraceptive therapy? Clearly she needs to be educated about
the risks and prophylactic options following another pregnancy and
about the likelihood that she will experience other episodes. What is the
most effective educational strategy for such preparation of women and
their families? If a hysterectomy is necessary at a later point in her life,
should she consider preventive therapy? What can she expect during the
menopausal transition? Postpartum disorders are tragedies for women
who suffer them and for their families, and assisting women in using the
experience to improve outcomes over the long term is a highly desirable
goal.
In his report on mental health issued in 1999, Surgeon General David
Satcher emphasized that mental health is fundamental to all health and
that education of the public about mental health is crucial (U.S. Department of Health and Human Services 1999). The last decade of research
and policy development is cause for optimism about improving the mental health of childbearing women. Our ability to provide data and assist
women with decisions about management of mood disorder during
childbearing has increased dramatically. With these successes come new
challenges. Let us prepare to take advantage of the great potential for advancement in the care of childbearing women with depression.

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of joint-admission mother-baby units. Int J Psychiatry Med 26:479493,
1996a
Wisner KL, Peindl KS, Hanusa BH: Effects of childbearing on the natural history
of panic disorder with comorbid mood disorder. J Affect Disord 41:173180,
1996b
Wisner KL, Perel JM, Findling RL: Antidepressant treatment during breastfeeding. Am J Psychiatry 153:11321137, 1996c
Wisner KL, Perel JM, Findling RL, et al: Nortriptyline and its hydroxymetabolites
in breastfeeding mother and newborns. Psychopharmacol Bull 33:249251,
1997
Wisner KL, Perel JM, Blumer J: Serum sertraline and N-desmethylsertraline levels in breast-feeding mother-infant pairs. Am J Psychiatry 155:690692,
1998
Wisner KL, Peindl KS, Gigliotti T: Tricyclics vs SSRIs for depression. Archives of
Womens Mental Health 1:189191, 1999a
Wisner KL, Peindl KS, Gigliotti T, et al: Obsessions and compulsions in women
with postpartum depression. J Clin Psychiatry 60:176180, 1999b
Wisner KL, Perel JM, Peindl KS, et al: Prevention of recurrent postpartum major
depression with nortriptyline: a randomized clinical trial. J Clin Psychiatry
62:8286, 2001
World Health Organization: International Statistical Classification of Diseases
and Related Health Problems, 10th Revision. Geneva, World Health Organization, 1992

Chapter

Neurohormonal Aspects of
Postpartum Depression
and Psychosis
Deborah Sichel, M.D.

The coexistence of the organic state raises an interesting question of

pathologic physiology[:] one immediately asks if there exists a connection between the uterine condition and . . . the mind . . .
Louis Victor Marc (1858)

The emergence of a postpartum psychiatric illness carries ramifications for mother, baby, and family for altered family development, inadequate bonding between mother and infant, and the potential for
subsequent poor attachment (Cooper and Murray 1995; Watson et al.
1984). Postpartum psychiatric illness constitutes a serious complication
of birth, with the most tragic outcomes being infanticide and suicide.
Yet, postpartum disorders often remain undiagnosed and untreated. One
of the reasons may be that once a pregnancy has resulted in a live, healthy
birth, health personnel have not been trained to appreciate how seriously
ill women may become after delivery. In addition, providers may find it
difficult to reconcile a previously well woman with the degree of psychiatric symptoms, so they ascribe problems to normal feelings of inadequacy and early motherhood. Furthermore, a large body of literature has
focused on the womans psychological state, childhood, and personality
structure to account for symptoms. As a result, ill women have often
61

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been characterized as having a personality disorder because there was no

other explanation within the scientific arena to account for the illness.
However, in the past few years, some data that have emerged indicate
neurohormonal alterations associated with postpartum psychiatric disorders. Still in its infancy, the field is advancing, albeit slowly, as it incorporates these new findings. Women who suffer with these illnesses will be
provided with a better understanding of the biological underpinnings of
symptoms. Further, treatments and preventive strategies, both for postpartum psychosis and postpartum depressive illnesses, have emerged,
indicating that a distinct neurobiology is associated with these disorders
(Austin 1992; Cohen et al. 1995; Sichel et al. 1996; Stewart et al. 1991; Wisner and Wheeler 1994). Although no single neurochemical factor has yet
emerged to completely account for this vulnerability, a number of different hormonal factors may contribute to the development of a postpartum illness.
A comprehensive discussion of the classification and nosology of postpartum disorder can be found in Chapter 3 (Postpartum Disorders) of
this volume. Studies of postpartum disorders suggest that some are first
episodes of illness (Bell et al. 1994; Hunt and Silverstone 1995). Other
studies indicate that up to 50% of women with prior histories of mood
disorder are at substantial risk for postpartum episodes and relapse after
subsequent pregnancies (Dean et al. 1989; Klompenhouwer and van
Hulst 1991). Our own clinical experience suggests that prior subclinical
mood disorder is common in many women postpartum. In an unpublished series, 24 of 26 postpartum psychotic women on a mother-baby
unit demonstrated subclinical symptoms of mood disorder for many years
prior to the florid episode of postpartum psychosis (Sichel and Driscoll
1999). Women either had minor depressive illness interspersed with
short-lived major depressive episodes or demonstrated cyclothymic, hypomanic, or bipolar symptoms that were not detected on the usual scales
for bipolar and major depressive illness (Akiskal et al. 2000). Further, the
diagnosis of a long period of mood cycling or hypomanic features prior to
a severe postpartum illness is important, because the rate of suicidality
among women with these features is generally high (Rihmer and Pestality
1999).
Intensive questioning to elicit these features in a postpartum mother
may be crucial, because it may suggest increased risk factors for suicide
and possibly infanticide in this cohort of women. Since many of these
women have never sought psychiatric help, they often deny that they
have any psychiatric history, unaware that their previous mood swing
symptoms are important. It behooves the clinician to identify previous
history, using language the patient can understand. The use of psychiatric

Neurohormonal Aspects of Postpartum Depression

63

jargon like Have you ever had any psychiatric symptoms? or Have you
ever had depression before? may well meet with an answer in the negative because women are not versed in its meaning. The fact that large
numbers of women are prone to decompensation in the early postpartum
period or even later in the postpartum year suggests there are particular
neurochemical mechanisms that underlie the acute onset of illness within
the proximity of childbirth. It is possible that onset of illness more than
3 months after delivery reflects psychosocial factors related to stress and
genetic factors (McEwen 1995).
Jeanne Driscoll and I have also observed that many women whose episodes of depression and/or psychosis were adequately treated and in remission become ill again with the introduction of an oral contraceptive
agent or any depot hormonal preparation such as Depo-Provera, a longacting progesterone. Symptoms range from severe depression to hostility,
agitation, rage attacks, rapid cycling, and frank psychosis. When the contraceptive agent is discontinued, they regain their former treatment response.
The premenstrual period has also been noted to be a time when symptoms recur (Endicott and Halbreich 1988; Pearlstein et al. 1990); the
symptoms can last 714 days prior to the onset of menses. Occasionally,
a patient becomes ill enough to warrant repeat hospitalization.
Steroid hormones constitute a group of compounds that have specific
and designated actions on receptors in the body. For the purposes of this
chapter, the steroids that are pertinent to the neurobiology of postpartum
disorders are estrogen and progesterone, made in the ovary; cortisol (the
stress hormone), made in the adrenal gland; and androgens and testosterone, made in the male testes and in the female ovaries.
The specific conditions of pregnancy and postpartum reflect complex
endocrine states. My purpose in this chapter is to review the state of current knowledge in the neurohormonal arena, even though studies available still reflect a simplistic approach to a very complex psychobiological
system and process.

General Factors and Mood

Disorders in Women
As a group, women are more vulnerable to mood disorders across their
lifetime, experiencing twice the incidence of depression that men do (Kornstein 1997; Weissman and Klerman 1977). This vulnerability is highest
during the childbearing years, with the prevalence rate ranging from 7.5%
to 10.4%. Now, with more sophisticated ways of measuring brain volume,

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involving positron emission tomography (PET) scanning techniques, we

can look at the brains functioning, albeit in a crude way. Some factors
implicated in these higher rates probably involve differences in men and
women at many levels, including different brain structure, organization,
and functioning (Allen et al. 1991; George et al. 1996; Gur and Gur
1990; Harasty et al. 1997) and different responses to stress mediated by
the stress feedback loop in the brain (Young et al. 1993). We have also
been able to discern the multiple effects of estrogen, progesterone, and
other hormones produced during pregnancy on the chemical systems in
the brain (McEwen 1998a).
The known occurrence of specific mood changes at particular times
of the reproductive life cycle (including the premenstrual period, pregnancy, and the postpartum period and during perimenopause and sometimes postmenopause); after surgical removal of the ovaries; and with use
of both depot and oral contraceptives suggests that hormones are implicated at some level in these particular problems (Spinelli 2000). Despite
these observations, to date, large epidemiological studies have not adequately characterized the groups of women for whom mood disorder is
associated with a hormonal event. For instance, what renders women with
various forms of bipolar disorder so particularly vulnerable to hormonal
fluctuations (Blehar et al. 1998), and to what extent are women with major depressive disorder and anxiety disorders predisposed to hormonally
related worsening of their disorders across their lifetime?
One outcome of undertreated and underrecognized postpartum illness is disruption of the mother-infant relationship (Cooper and Murray
1995), and suicide and infanticide are also potential outcomes. Even
when the illness is recognized, inadequate treatment is an ongoing problem, because many clinicians do not treat the illness aggressively enough
to achieve a state of wellness but rather define improvement of symptoms
as a response. When inadequate treatment occurs, a flare-up of symptoms
can lead to worsening of the illness and potential suicide or infanticide
later in the postpartum year. This timing of the recurrence may lead an
investigator to believe erroneously that the act is not related to the postpartum state.
The emergence of scientific data that indicate how the mental state
of the mother is significantly affected by a particular neurochemical vulnerability to the event of childbirth will add scientific weight to the outcome of legal proceedings that occur subsequent to the act of infanticide
(see Chapter 8: Criminal Defenses in the Cases of Infanticide and Neonaticide). Some of the problems encountered by defense attorneys during the trial of a woman who commits infanticide are due to the abysmal
lack of biological data that point to particular neurochemical alterations

Neurohormonal Aspects of Postpartum Depression

65

as a consequence of childbirth. Although infanticide often occurs within

the framework of a postpartum psychotic process in a mother who had
been well, it can also occur within the throes of a nonpsychotic illness.
Identifying and documenting the capacity of the events of childbirth that
are associated with brain dysfunction triggered by neurohormonal changes
is vitally important to the future understanding of psychosis and serious
postpartum nonpsychotic illness, to the development of better treatments, and to prevention. Identification of susceptible groups of women
in obstetric clinics and practices is crucial so that treatment can occur
early and prevention can be achieved.

Depression and Regulation of

Neurochemicals in the Brain
One of the first hypotheses about the etiology of depressive illness involved chemical messenger substances in the brain called the monoamines
or neurotransmitters (Schildkraut et al. 1989). Those involved included
serotonin, norepinephrine, and dopamine. These neurotransmitters carry
signals from one neuron or brain cell to the next. This theory of depression suggested that negative mood states were caused by a deficiency of
these chemical substances.
The monoamine theory was succeeded by the hypothesis that in depression, receptors, which regulate the activity of the chemical messengers, were damaged. These damaged receptors caused depletion of the
neurotransmitters at the synapse or in the space between neurons. The
most recent theory suggests that the primary dysregulation in depression
is within the cell and is directed by genes. The receptor and neurotransmitter problems are secondary to, and a result of, the disorder of the signaling process. Therefore, the underlying cause of depression and manicdepressive illness is one or more defective genes, which are further altered by environment and social and psychological stress factors throughout life (Kendler et al. 1995). These illnesses can manifest at any age,
from childhood to adulthood, with equal prevalence in boys and girls until adolescence, when hormonal shifts signal the onset of puberty. At this
time, depression occurs in females at twice the rate it occurs in males.
Although it is more likely that altered gene signaling occurs between
cells and, ultimately, within a particular pathway, the brain chemicals and
their specific receptors are still involved in the process. The main thrust
of treatment continues to be drug therapy, which targets specific neurotransmitters and their receptors. Treatment may in turn induce more
normal signaling at a gene level.

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Each messenger is made from a specific chemical precursor in the nerve

cell. Dopamine and norepinephrine are made from tyrosine, and serotonin is made from tryptophan. Both estrogen and progesterone have profound effects on these chemical substrates in the brain (Pajer 1995) and
serve as one possible mechanism of hormonal regulation on neurotransmitter activity.

Basic Brain Structure

Sex differences in brain physiology are reflected in the electrical activity
of the brain and are related to the hormonal states of the reproductive life
cycle (Becker et al. 1982; McEwen 1998a). The most primitive brain
structure began as a shaft (brain stem) connected to the spinal cord.
Around and out of this shaft developed a ring of structures, the limbic
brain, also known as the reptilian brain. It is responsible for the sleepwake cycle, appetite, thirst, aggressive impulses, sex drive, memory, body
temperature, and the menstrual cycle. In depression, most of these functions are disturbed. For the purposes of this discussion, the important
structures in the brain stem are the hypothalamus, hippocampus, and
amygdala. Around the emotional brain developed the cortex, which
served the functions of language, judgment, intelligence, reasoning, and
complex thought processes, including the capacity for abstract thought.
Each chemical has its own particular circuit in the brain, arising from
a storage area in the lower or more primitive areas of the brain and progressing through a number of structures in the emotional or limbic brain.
From there, the chemicals progress to the cortex, the most recently evolved
area of the brain.
Until recently, specific neurotransmitter chemicals were associated
with particular psychiatric symptoms. For instance, traditionally, dopamine was associated with psychosis, and serotonin was associated with
depression and obsessionality. However, it is now evident that the explanation is not so clear-cut. Although much research has focused on serotonin, it is clear that other chemicals also play a significant role in
depression (Duman et al. 1997). A substantial role for serotonin in depression was elucidated when the brains of depressed suicide victims
showed decreased levels of serotonin, a reduction in 5-HT receptor activity, and an increase in 5-HT receptor number compared with the brains
of homicide victims (Mann et al. 1989).
These neurotransmitters are stored in vesicles in the nerve cells and
then released into the synaptic cleft, or the space between nerve cells (see
Figure 41). As these chemicals diffuse across to the next nerve cell, they

Neurohormonal Aspects of Postpartum Depression

67

Figure 41. Cascading events in the synaptic space.

Note. MAO = monoamine oxidase.
Source. Reprinted from Sichel D. Driscoll JW: Womens Moods: What Every Woman Must
Know About Hormones, the Brain, and Emotional Health. New York, HarperCollins, 1999,
p. 50. Copyright 1999, Deborah Sichel and Jeanne Watson Driscoll. Reprinted with permission of HarperCollins Publishers, Inc.

stimulate their receptors on the postsynaptic nerve cell membrane. By this

mechanism messages are communicated from one nerve cell to the next.
The entire system in the brain is imbued with a network of checks and
balances, which serve to slow or speed up nerve cell firing. Receptors are
one form of regulation. Some receptors have the ability to release the
chemicals; some enhance absorption back into the cells, and others release enzymes, which break down the neurotransmitters. Two such important enzymes in the brain are monoamine oxidase (MAO) and
catechol O-methyltransferase (COMT). Whereas chemical messengers
such as dopamine, norepinephrine, and serotonin promote neural transmission and communication, receptors and enzymes inhibit neural transmission. Other neurotransmitters, such as -aminobutyric acid (GABA),
also inhibit transmission. This continuous process of facilitation and inhibition contributes to the system of checks and balances within the brain.

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Infanticide: Psychosocial and Legal Perspectives

Hormones themselves constitute yet one more method of regulation.

For example, estrogen and progesterone may facilitate or inhibit the synthesis, degradation, and receptor activity of the above-mentioned brain
chemicals. Estrogen decreases brain MAO and COMT, whereas progesterone increases these enzymes. Theoretically, it follows that estrogen is
more likely to induce improved mood effects, whereas progesterone
would tend to induce depressive symptoms.

Brain-Body Relationships in Depression

Three important circuits permit communication between the brain and
the organs in the body: the hypothalamic-pituitary-thyroid (HPT) axis,
the hypothalamic-pituitary-adrenal (HPA) axis, and, in women, the hypothalamic-pituitary-ovarian (HPO) axis. These axes are mechanisms of
communication between the brain chemicals and hormones and explain
how such communication can create mood and mental status changes.
The axes constitute another system of checks and balances. Each controls a biological cascade of events that effects communication between
the brain and other body functions (Figure 42). Communication occurs
both ways between each target organ and back to the pituitary and hypothalamus in the brain stem.

Hypothalamic-Pituitary-Thyroid (HPT) Axis

Thyroid disorders are also known to affect mood. Women are more vulnerable to thyroid disorders than are men. The relationship between the hypothalamus, pituitary, and thyroid is also involved in depression in women,
in that women appear more vulnerable to hypothyroid and hyperthyroid
states. Thyroid dysfunction has been reported in 30%45% of women who
demonstrate the rapid-cycling form of bipolar disorder (Whybrow 1995).
Because bipolar disorder prior to pregnancy is a significant risk factor for
postpartum psychosis, the state of the thyroid must be taken into account
in assessment and treatment (see Chapter 3: Postpartum Disorders).
One of the most consistent aspects of hormonal differences between
men and women is the abnormally elevated rates of thyroid dysfunction
in women with mood disorder and blunting of the thyrotropin-stimulating hormone (TSH) response to thyrotropin-releasing hormone (TRH)
(Bauer et al. 1993). In general, thyroid disorder appears to be associated
with mood and psychiatric symptoms more frequently in women (Whybrow 1995). Yet, the role of thyroid hormone in the acute induction of any
of the postpartum illnesses remains unclear. Because of the elevated rates
of thyroid illness in women across their lifetime, one would expect some
association of thyroid illness with postpartum depression.

Neurohormonal Aspects of Postpartum Depression

Figure 42.

69

Hormonal relationships in women.

Note. ACTH = adrenocorticotropic hormone; CRF = corticotropin-releasing factor; FSH =

follicle-stimulating hormone; GnRH = gonadotropin-releasing hormone; LH = luteinizing
hormone; TRH = thyrotropin-releasing hormone; TSH = thyrotropin-stimulating hormone.
Source. Reprinted from Sichel D. Driscoll JW: Womens Moods: What Every Woman Must
Know About Hormones, the Brain, and Emotional Health. New York, HarperCollins, 1999,
p. 98. Copyright 1999, Deborah Sichel and Jeanne Watson Driscoll. Reprinted with permission of HarperCollins Publishers, Inc.

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Infanticide: Psychosocial and Legal Perspectives

In fact, Harris et al. (1996) did show an association between postpartum depression and transient thyroid dysfunction, but this does not mean
that the thyroid problem caused the depression. In a further study, Harris
(1999) showed that 3 of 100 postpartum women experienced depression
related to the presence of positive antithyroid antibodies. However, the
author concluded that the depression was not related to the presence of
the thyroid antibodies. Another preliminary study, by Pedersen (1999),
suggested that low thyroid hormone levels in late pregnancy may be related to postpartum mood or psychosis. Because different populations of
women, such as those with a history of bipolar disorder or depression, are
more likely to have different vulnerabilities to altered thyroid function,
the cause is not easy to establish.
The most valuable and important finding about postpartum thyroid
status is the contribution of altered thyroid function to mood. Since adequate response to antidepressants and mood-stabilizing medications is
contingent on normal thyroid function, treatment of postpartum disorders underscores the need to evaluate thyroid function in the postpartum
period. Both conditions must be independently and adequately treated.

Hypothalamic-Pituitary-Adrenal (HPA) Axis

One of the important endocrine links with the brain is the reciprocal connection between the hypothalamus, pituitary, and adrenal gland. This
axis, also known as the stress axis in the body, is activated when the body
is mobilized to meet any stress, physical or emotional.
This stress circuit (fight or flight response) is activated through the
release of norepinephrine and serotonin from their stores in the primitive
brain. Serotonin and norepinephrine stimulate the hypothalamus to release
corticotropin-releasing hormone (CRH), which activates the pituitary
gland to release adrenocorticotropic hormone (ACTH ). ACTH signals
the adrenal gland, sitting on top of the kidney, to release cortisol.
Cortisol is the bodys main stress hormone and is often elevated in depression, suggesting disturbed hypothalamic-pituitary-adrenal regulation. In depression, some brain structures (hippocampus and amygdala)
help to switch off this circuit, bringing the axis back to normal (McEwen
1998b). Hence, many patients with depression are found to have elevated levels of cortisol. With successful antidepressant treatment, the
function of this axis normalizes, and cortisol levels return to normal.
Since we now understand that the HPA axis is involved in depression,
it seems reasonable to examine how cortisol might contribute to postpartum depressive illness. In pregnancy, the plasma concentration of cortisol
increases. A doubling of cortisol occurs in the first trimester, followed by

Neurohormonal Aspects of Postpartum Depression

71

a threefold increase by the third trimester, mainly due to an increase in

transcortin, the protein that holds and binds cortisol.
One test that measures the ability of the brain to switch off cortisol
involves giving the patient dexamethasone, a very potent steroid that ordinarily will reduce cortisol levels. In many patients with depression, it
does not have this effect. We term this lack of effect dexamethasone resistance. Interestingly, the inability to reduce cortisol via this method is also
a characteristic of pregnancy (Nolten and Ruechert 1981).
After delivery, cortisol levels remain elevated for 1215 days, although most women continue to demonstrate this resistance to reduction
of cortisol up to 68 weeks postpartum (Greenwood and Parker 1984).
In women who are vulnerable to the onset of postpartum depression by
virtue of previous episodes of depression, the sustained high cortisol levels may contribute to postpartum depressed mood, because functioning
of this axis, instead of normalizing after pregnancy, may remain abnormal, contributing to postpartum symptoms of depression. At this time it
is not clear how to identify women whose cortisol levels do not normalize
and how increased cortisol is associated with postpartum depression.
Pedersen et al. (1993) showed a more prolonged recovery of the biological mechanisms of the HPA axis in women who are at risk for postpartum
depression. However, Cizza et al. (1997) suggested that in postpartum
depressed women, the reduction of cortisol is resisted for at least 12 weeks.
This may be the result of increased or decreased CRH secretion, which
may suggest a hypothalamic dysfunction (see Chapter 3: Postpartum
Disorders). In contrast to these results, Harris et al. (1996) demonstrated an association between low evening cortisol levels in antepartum
depressed women that continued until the fifteenth day postpartum, although the classic elevation of cortisol secretion twice a day continued.
More recent findings regarding the stress axis and depression after delivery may provide further information about postpartum depression or
psychosis. Douglas (1999) found that a protein chemical called a peptide
inhibits the effects of higher cortisol levels in the brain during pregnancy.
This peptide restraining effect is lost after delivery, so women with a history of depressive illness may develop a severe postpartum mood episode
because of the elevated levels of cortisol after delivery.

Hypothalamic-Pituitary-Ovarian (HPO) Axis

The HPO axis, which involves the hypothalamus, the pituitary, and the
ovaries, is the bodys messenger circuit between the brain and the reproductive system. To maintain the menstrual cycle, gonadotropin-releasing
factor is released from the hypothalamus, which in turn stimulates release

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Infanticide: Psychosocial and Legal Perspectives

of luteinizing hormone from the pituitary. The final event in this chemical
cascade is the rise in levels of gonadal steroids or sex hormones. If a pregnancy occurs, estrogen and progesterone levels gradually rise throughout
the pregnancy until delivery, when the levels are the highest they will
achieve during life. After delivery of the placenta, these levels drop precipitously. Estrogen usually reaches very low levels within 24 hours after
birth. Progesterone takes about 35 days to reach negligible levels.
Estrogen and progesterone influence structures within the brain that
are involved in depression (McEwen and Woolley 1994). Estrogen receptors are widely found in the brainin the hypothalamus, pituitary, front
part of the limbic brain, cortex, and brain stem. In particular, estrogens impact on the brain parallels the effects that antidepressants induce in the receptors, the breakdown enzymes, and the system of checks and balances
(Spinelli 2000). For instance, estrogen reduces the levels of MAO, which in
turn increases levels of serotonin, norepinephrine, and acetylcholine (Pajer
1995). It increases dopamine levels and norepinephine receptor density in
the hypothalamus and decreases cortex norepinephrine receptor density.
Estrogen exerts its influence by entering the cells and activating gene
expression by impacting the DNA. The gene then produces other factors
that directly influence serotonin, norepinephrine, and dopamine levels in
women, thus affecting mood stability. Under the influence of estrogen, certain neurons of the hippocampus are stimulated to grow, actively forming
connections with other neurons, whereas progesterone induces the opposite effect (McEwen and Woolley 1994).
Progesterone increases MAO and COMT levels, increases serotonin
metabolism in the limbic brain, and decreases the risk for seizures. The overall effect is reduced amounts of chemical messengers and potential influence
on the effects that estrogen has on genes. Overall, progesterone tends to
induce depression or dysphoria. Some metabolites of progesterone (e.g.,
allopregnanolone) combine with the GABA complex to produce an antianxiety or calming effect, whereas another form, pregnanolone, combines
to produce an effect in the opposite direction.
Recent studies have focused on how withdrawal of these hormones
acts as a trigger to precipitate the emergence of a postpartum psychiatric
illness through the events of the HPO axis. The endpoint is marked by
the profound effects of estrogen and progesterone on the neurotransmitters and structures involved in depression when their production abruptly
ceases at delivery. Acute withdrawal of the gonadal hormones appears to
induce a range of negative mood effects in vulnerable women (Pajer
1995).
Although we still do not know the specific details of how these withdrawal effects catalyze and induce altered mood effects, a number of stud-

Neurohormonal Aspects of Postpartum Depression

73

ies point to a role for hormone withdrawal in the etiology of postpartum

illnesses. The hormone that appears to have the most profound postpartum effect, because of its antidepressant properties in the brain and its
acute withdrawal after delivery, is estrogen (Wieck et al. 1991).
James Hamilton first explored the role of estrogen in postpartum psychosis in an uncontrolled treatment trial (Hamilton and Sichel 1992).
Fifty women at risk for postpartum depression or psychotic recurrence were
treated with a single, long-acting intramuscular estrogen (dose unspecified). Although at least a third to a half of these patients would have been
expected to experience symptoms, none did. Hamilton also found that
these women were surprisingly free of baby bluesa self-limiting
mood disturbance occurring within 12 weeks after delivery (see Chapter 3). Although there was no long-term follow-up of these patients, the
study suggested that the administration of estrogen immediately after delivery prevented the early onset of illness.
In a subsequent uncontrolled treatment trial, Sichel et al. (1996) administered oral estrogen in a single large dose (10 mg) at delivery, followed by oral estradiol in decreasing doses over 4 weeks. Subcutaneous
heparin was given to prevent any chance of thrombosis with the high
doses of estrogen. Relapse occurred in only one patientwhich is fewer
than the three to five one would have expected (see Chapter 3). None
required psychotropic medications for the first year. In a group of women
who were assessed to be at high risk for recurrent postpartum depression
or psychosis, these results suggest that the estrogen may have acted as a
prophylactic agent, stemming the acute withdrawal of estrogen and allowing them to remain well. Two of the patients subsequently developed
nonpuerperal bipolar disorder, and one relapsed with major depressive
disorder that was unassociated with birth.
Gregoire and colleagues (1996) described the use of estradiol skin
patches 200 g administered in a randomized, double-blind fashion to 61
women who were severely depressed. The treatment group, compared
with the controls, showed improvement, as measured by the Edinburgh
Postpartum Depression Scale (EPDS). The overall treatment effect at
3 months was 4.38 points. Major criticisms of this study were that it was
uncontrolled and nonblinded and that some of the women were still taking antidepressant medication.
A few other studies have reported the efficacy of estrogen in treating
and preventing postpartum illness. Ahokas and colleagues (2000) reported
improvement in 10 women with postpartum psychosis, with recurrence
in 1 patient who discontinued estrogen (see Chapter 3).
Although this research moves our knowledge forward, there is an important need for double-blind, randomized trials in the use of hormonal

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Infanticide: Psychosocial and Legal Perspectives

therapies. The fact that estrogen use postpartum often precludes breastfeeding and may lead to undernutrition in infants who are breast-fed
(Ball and Morrison 1999) must be factored in when treatment or prophylaxis is considered.
Bloch and others recently conducted the first study that indicated direct involvement of the reproductive hormones in the development of
postpartum depression (Bloch et al. 2000). Eight women with a history
of postpartum depression and eight women without such a history had
their menstrual cycles stopped with the use of leuprolide acetate, to which
was added a large dosage of estradiol (4 mg/day, increasing to 10 mg/day)
and progesterone (400 mg/day, increasing to 900 mg/day). Both estrogen
and progesterone were then withdrawn under double-blind conditions.
Women with postpartum depression showed increased symptoms in the
add-back phase of hormones and a peak in the withdrawal phase. Women
without such a history of postpartum depression demonstrated no such
symptom pattern. The authors conceded that this study did not accurately reflect the milieu of the postpartum period but suggested that
some women are particularly vulnerable to the effects that estrogen exerts in the brain. It is still unclear whether the persistent state of low estrogen for 23 weeks after delivery and/or the abrupt withdrawal of
estrogen at delivery induced the depressive symptoms. However, these
findings have important implications for future treatment and preventive
strategies with estrogen.
In an earlier study, OHara and colleagues (1991) reported little difference in levels of free estriol, total estriol, progesterone, and prolactin
in depressed and nondepressed subjects. Levels were drawn at weeks 34,
36, and 38 antepartum and on days 1 through 4 and 6 through 8 postpartum. Wisners group (see Chapter 3) reexamined these data and reported
that mean estradiol levels were lower in depressed subjects, compared
with nondepressed subjects, at all times of assessment. Interpretation of
such results is difficult, because we have no central nervous system measures that would correlate with the lower estrogen levels. Possible explanations are that there was inadequate suppression of the HPA axis in
women who became depressed postpartum or that there is indeed a group
of women who are very sensitive to persistence of lower-than-normal estrogen levels. These findings point to the need for multiple-system examination in future studies.
Another neurotransmitter system implicated in estrogen and mental
status changes is the dopaminergic system. Women who have developed
postpartum psychosis have sensitive dopamine receptors when challenged
by apomorphine, which results in an increase in growth hormone. Since
growth hormone is a measure of hypothalamic dopamine2 receptors, and

Neurohormonal Aspects of Postpartum Depression

75

15 women who demonstrated recurrence of psychosis showed elevations

of growth hormone (Wieck et al. 1991), these findings suggest a role for
abnormal receptor function induced by a withdrawal state of estrogen after delivery.
McIvor and colleagues (1996) reported similar findings in their study,
in which 5 of 14 women who developed depression in the postpartum period demonstrated increased sensitivity of dopamine receptor function and
activity. Both Wieck et al. and McIvor et al. concluded that dopamine activity predicted anxiety and depressive illness in the postpartum period.
Riley and Watt (1985) reported elevated levels of serum calcium in
women with postpartum psychosis (see Chapter 3). This finding, although apparently robust, has not been replicated. It is possible that estrogen modulation of calcium occurs in some postpartum women, but it
remains unclear how this pertains to the occurrence of psychosis.
The fact that postpartum psychosis usually occurs within the first 1
4 weeks after delivery suggests that the findings for a role of the gonadal
hormones in inducing an acutely dysregulated state in the brain are important. In fact, Wisner and Wheeler (1994) described postpartum psychosis prominently associated with disorganization, confusion, delirium,
bizarre behaviors, and unusual hallucinations (both paranoid and auditory)
as somewhat different from psychosis occurring at other times, again implicating an acute, almost toxic brain reaction (see Chapter 3).
Dalton (1985), who administered intramuscular progesterone to 27
women with a previous postpartum depression at delivery and then daily
for 7 days, postulated a role for progesterone withdrawal as a cause of
postpartum depression. The author reported that 6 months after delivery, none of the women had developed postpartum depression, but these
results are inconclusive because of a lack of double-blind conditions.
More recently, progesterone was given to postpartum women at 48
hours after delivery in a randomized, placebo-controlled trial (Lawrie et
al. 1998). Increased depression ratings on the EPDS and the Montgomerysberg Depression Rating Scale and decreased -estradiol levels predicted depression in those women. The authors concluded that administration of progesterone within a short time of delivery is associated with
an increased risk of developing depression and that, therefore, progesterone should not be given to postpartum women.

Conclusion
It is clear that numerous neurohormonal factors contribute to the emergence of affective disorder in pregnancy and in the postpartum period.

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Moreover, a subgroup of women appear to be sensitive to the withdrawal

effects of estrogen and, possibly, progesterone. Given the multiplicity of
beneficial effects that estrogen has in the brain, significant changes are
understandable when these women are subjected to acute hormonal change
in the postpartum period. Contributions of the other hormones, cortisol
and thyroid, are also important, although the exact roles that these hormones play are at this time not entirely as clear as the role of estrogen.
Brain mood homeostatic mechanisms are so complex that an understanding of the contribution of all the parameters, particularly postpartum, is
still in its infancy. However, the new results reviewed in this chapter establish a clear role for alterations in the brain related to the massive
change in different hormone systems in the postpartum period.
Future studies must evaluate multiple systems to clarify the complex
interrelationships that are involved. Such an approach will require cooperation between specialties of perinatal psychiatry and obstetrics and
gynecology. Clearly, the etiology of postpartum mood and psychotic disorders lies in the biological and physiological elements associated with
pregnancy and childbirth.
Psychiatrists, psychologists, and other health care providers must be
cognizant of the neurohormonal underpinnings of severe puerperal psychiatric illness. In addition, it behooves the psychiatric community to educate our colleagues in the criminal justice system about these facts.
Lawyers who represent women with mental illness in the postpartum period must also educate themselves about the new findings so that they
can effectively and fairly represent their clients.
Moreover, expert witnesses are responsible for educating juries in a
manner that provides a greater understanding of the physiological events
involved in the etiology of acute postpartum illnesses. Women must be
accorded this justice in light of the new neurochemical findings described
in this chapter.

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Chapter

Denial of Pregnancy
Laura J. Miller, M.D.

On the uncertainty of the signs of murder, in the case of bastard children . . . though no doubt there will be many exceptions to the general rule, that women who are pregnant without daring to avow their
situation, are commonly objects of the greatest compassion; and generally are less criminal than the world imagine.
William Hunter, M.D., F.R.S.
Read to the members of the British Medical Society, July 14, 1783

nd then the little baby was born, when I didnt expect it; and the
thought came into my mind that I might get rid of it and go home again.
The thought came all of a sudden . . . Thus Hetty Sorrel, a 17-year-old
girl from the village of Hayslope in England in the year 1799, explains
why she killed her newborn infant following a precipitous delivery after
a pregnancy shed never acknowledged. Hetty is a fictional character in
George Eliots novel Adam Bede (Eliot 1859). Yet her experiences of a
forbidden relationship, a hidden pregnancy, the shock of unexpected
birth, and the desperate solution of neonaticide have been all too real for
many new mothers at many times, in many places.
Neonaticide, the killing of a baby by the mother on the day of birth,
is a unique form of infanticide (see Chapter 6: Neonaticide). Neonaticide is often preceded, as it was in Hettys case, by denial and/or concealment of the pregnancy. Understanding pregnancy denial is an important
prelude to understanding and preventing neonaticide.
In this chapter, I describe various types of pregnancy denial. I examine
possible reasons for such denial, including individual and sociocultural
81

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risk factors, and summarize its potential consequences. Finally, I delineate

interventions that can help minimize the risks of neonaticide.

Types of Pregnancy Denial

Denial can be defined as behavior that indicates a failure to accept either
an obvious fact or its significance (Chao 1973). Behavior is emphasized
because a person may cognitively acknowledge a condition (e.g., a medical
illness or a pregnancy) but disavow its implications (Strauss et al.1990).
Denial can occur in the context of a psychiatric illness, such as schizophrenia, bipolar disorder, depression, anorexia nervosa, or posttraumatic stress
disorder (PTSD). It can also occur without any other manifestations of a
psychiatric illness; in such cases, it resembles adjustment disorder (Strauss
et al. 1990).
As with other forms of denial, denial of pregnancy occurs along a
spectrum of severity. Sometimes the existence of pregnancy is cognitively
acknowledged but its emotional significance is denied. Sometimes the
knowledge of pregnancy is briefly recognized but suppressed to the point
of unawareness. Sometimes pregnancy denial becomes grossly delusional,
persisting in the face of any and all proof. The presence and severity of
denial can vary at different times during a pregnancy.
For descriptive purposes, three qualitatively distinct types of pregnancy denial can be identified: affective denial, pervasive denial, and psychotic denial.

Affective Denial
Affective denial is associated with feelings of detachment from the infant. This detachment contradicts the usual heightened emotional state
of the pregnant woman that is associated with the process of early bonding. Women differ greatly from one another in their emotional reactions
to pregnancy (Rofe et al. 1993). Many pregnant women develop a heightened cognitive and emotional sensitivity (Mothander 1992). Most women
also begin a relationship with the fetus that is partly projection and partly
reality-based. For example, a woman may develop the sense that her fetus likes certain foods, prefers certain positions, and has a certain level
and pattern of activity (Zabielski 1994). Many women fantasize about
what their child will be like, select a name, and talk to the fetus. Most
women make behavioral changes, such as wearing maternity clothes,
modifying physical activities, preparing space for their babies, negotiating maternity leaves, and planning for child care. These manifestations of

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83

emotional connection with the fetus can include transient feelings of

indifference, detachment, or resentment. This type of ambivalence during pregnancy is normative and does not constitute clinically problematic
denial.
Affective denial occurs when a woman acknowledges intellectually
that she is pregnant but experiences very few or none of the accompanying emotional and behavioral changes. There is a blunting, rather than a
heightening, of sensitivity. Women with this form of denial continue to
think, feel, and behave as though they were not pregnant. They do not
fantasize about, talk to, or interact with the fetus. They may not wear different clothes or alter their lifestyles in any way. They make no concrete
or emotional preparations for the arrival of a baby.
In its less extreme guise, this type of denial is built into many cultural
practices. In some cultures and religions, for example, babies are not
thought to have souls until a fixed period of time after birth. Such customs, which evolved under conditions in which infant mortality was
high, may cushion people from the emotional devastation of losing newborns (see Chapter 7: Culture, Scarcity, and Maternal Thinking). In cultures without such beliefs, affective denial of pregnancy is seen in just
those situations in which emotional protection is most needed.
Women who have experienced a prior perinatal loss have a higher likelihood of emotionally distancing themselves during a subsequent pregnancy (Phipps 19851986). Women with substance addictions may also
experience affective denial of their pregnancies (Spielvogel and Hohener
1995) that is posited to be due to an attempt to stave off guilt feelings
about harming the fetus while continuing to use addictive substances.
Although affective denial can be adaptive in protecting against overwhelming feelings, it can have adverse consequences. It can compromise
fetal and maternal health by decreasing prenatal care. It can also preclude
a womans emotional readiness for parenthood, which can be experienced as a more abrupt transition after an emotionally blunted pregnancy
experience.
A, a 32-year-old woman, had previously given birth to a stillborn daughter but had never overtly grieved. When she began missing her menstrual
period, she promptly went to a clinic for a pregnancy test, the result of
which was positive. A acknowledged being pregnant but showed no emotion. When family members tried to discuss the pregnancy with her, A
would make an excuse to leave the room. She missed several prenatal appointments before her mother realized this was happening and began to
accompany her to the clinic. When her mother initiated prenatal visits, A
would go along but would never ask questions. A remained expressionless
when her obstetrician had her listen to the fetal heart tones. She would

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not make arrangements either to care for the baby or to have anyone else
care for the baby. Throughout her pregnancy, A showed affect and expressed feelings about other topics; her emotional numbing was specific
to pregnancy.

Pervasive Denial
A more extreme form of denial occurs when not only the emotional significance but the very existence of the pregnancy is kept from awareness.
Often, the possibility of pregnancy, or even definite knowledge of pregnancy, has at some point been in conscious awareness. However, throughout long stretches of the pregnancy, sometimes up to or through the time of
labor and delivery, awareness of pregnancy is suppressed (see Chapter 6).
Even pregnancies that have been confirmed by ultrasound can subsequently remain outside of consciousness if the shock of pregnancy recognition was sufficiently traumatic to induce amnesia (Green and Manohar
1990).
During this type of denial, physical manifestations of pregnancy are
either absent or misinterpreted. Available data suggest that women with
profound pregnancy denial have fewer and less intense physical symptoms
than do other women. There was little or no weight gain in the majority of
women with pregnancy denial in one study (Brezinka et al. 1994). The
womans usual clothing may still fit, so that neither she nor others notice
much change in her body habitus (Bascom 1977). When weight gain
does occur, it may be attributed to other factors (Brozovsky and Falit
1971). Even the most reliable indicator of pregnancy, the cessation of
monthly bleeding, may not occur throughout all or part of denied pregnancies (Bascom 1977; Finnegan et al. 1982). In a series of 27 women with pregnancy denial, most (18) reported vaginal bleeding during pregnancy,
whether irregular spotting, continuous spotting, or regular, menstruation-like bleeding (Brezinka et al. 1994). When amenorrhea is noticed, it
may be attributed to conditions other than pregnancy, such as stress, traveling, or menopause (Bonnet 1993; Brezinka et al. 1994; Milstein and
Milstein 1983). Fetal movements may be attributed to intestinal gas
(Jacobsen and Miller 1998).
Pregnancies denied are also pregnancies concealed. The phenomenon
of collective deception and collusion in denial has been noted in nearly
all cases of profound pregnancy denial. In a series of 27 cases of denied
pregnancies, significant others vaguely suspected pregnancy in fewer than
half and were totally unaware of the pregnancy in all the other cases; in
no case was anyone fully cognizant of the pregnancy (Brezinka et al.
1994). Participation in denial by others can be so profound that a sexual

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85

partner may not have noticed pregnancy despite having had sexual intercourse just hours before labor (Bonnet 1993). Physicians sometimes collude in denial as wellfor example, by attributing amenorrhea to stress
without doing a workup (Milstein and Milstein 1983).
At the end of a denied pregnancy, labor can take a woman by surprise
(Bonnet 1993). Labor pains may be misidentified as gastrointestinal symptoms or the need to have a bowel movement (Arboleda-Florez 1976;
Bonnet 1993; Finnegan et al. 1982; Jacobsen and Miller 1998). Some
women visit emergency rooms with severe cramps and then deliver the
baby (Brezinka et al. 1994); others have unassisted deliveries at home.
Most women with pregnancy denial describe a feeling of dissociation during the birth experience (Finnegan et al. 1982; Wilkins 1985).
Pregnancy denial does not necessarily end with the birth of the baby.
One woman, for example, heard her baby cry and thought someone else
had delivered (Bascom 1977). In another case, placental remnants were
found on examination of a woman who presented to an emergency room
with vaginal bleeding, having no awareness that she had just delivered an
infant (Bonnet 1993). Even women who intellectually accept that they
have delivered a baby sometimes continue to distance themselves from
emotional recognition of this reality (Bascom 1977; Finnegan et al. 1982).
B, a 16-year-old girl, gave birth to a child amid the profound disapproval
of her parents. Her mother helped her raise the child but felt particularly
burdened by this because Bs father was disabled by a heart condition.
Her mother repeatedly told B that if she ever became pregnant again, it
would be the death of her father, because he would surely have a heart
attack.
B had irregular menstrual cycles, so when she began to miss periods,
she did not notice. Several months later, a friend of hers, noticing some
weight gain, wondered aloud if B could be pregnant. B dismissed this
fleeting thought. One day, she developed the sensation that she had to
have a bowel movement. She sat down on the toilet. She later recalled
being in a daze at that time and did not remember the next moments
clearly. The next thing she knew, there was a dead baby in the toilet bowl.

Psychotic Denial
Women with psychotic disorders may deny pregnancy in a delusional
way. In such cases, physical symptoms and signs of pregnancy generally
occur but are misinterpreted, sometimes in bizarre fashion. One woman
believed, for example, on sensing fetal movements, that her liver and kidneys had become unmoored in her body and were rattling around loose.
Some women have a delusional belief that these sensations are intestinal
gas (Slayton and Soloff 1981).

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Some women acknowledge that something is growing inside them but

do not experience it as a fetus. It may feel to the woman like a blood clot
(Miller 1990) or cancer (Cook and Howe 1984). Psychotic fantasies
about what is inside her body may reflect psychological truths about the
womans emotional reaction to pregnancy. For example, the woman who
believed her internal organs had come loose already had a 1-year-old
baby. After treatment, she was able to explain that shed been feeling
overwhelmed at the prospect of having another baby so soon. She experienced herself as literally coming apart, and she coped with this by
maintaining delusional denial of pregnancy.
Psychotic denial may come and go during the course of a pregnancy.
In addition, an internal contradiction can be sustained during psychosis,
so that a woman can simultaneously maintain that she is pregnant and
that she is not. Women who do not overtly acknowledge pregnancy may
nevertheless allude to it; for example, a pregnant woman with three children denied being pregnant but spoke of a fourth child. Like other
symptoms, psychotic denial can be preceded or exacerbated by identifiable stressors, such as signing consent forms for adoption or learning of
an abnormality on an ultrasound examination of the fetus (Miller 1990).
Unlike women with nonpsychotic denial, women with delusional denial do not usually conceal their pregnancies. Generally, others in their
environment do not collude with the denial (Miller 1990). If a womans
psychotically denied pregnancy goes unrecognized, it is usually because
the woman is so socially isolated that no one takes notice.
C is a 35-year-old woman with schizophrenia who had lost custody of her
first child. She lived with a boyfriend but had had sex with several other
men. Her boyfriend had previously told her that if she became pregnant,
she could no longer live with him. When C began to gain weight, her
mother suspected pregnancy and took her to a clinic, where pregnancy
was confirmed. C denied being pregnant, even after being shown an image of the fetus on ultrasound examination.
Cs mother tried to pressure her into having an abortion, even to the
point of making up a story that C had threatened her with a knife so that
C would be admitted to a hospital in order to have an abortion. However,
C conveyed to hospital staff that if she were pregnant she would not want
to abort the fetus. She carried the baby to term. After delivery, C acknowledged, I guess I really was pregnant. She explained her previous denial
by saying that she was torn between leading a boring, conventional life
(e.g., taking medication, relinquishing her psychosis, being faithful to her
boyfriend, and raising a child) and living the exciting but emotionally
wrenching life of being psychotic, having many lovers, and having babies
whose custody she lost. Unable to resolve this dilemma, she could not accept the existence of the pregnancy.

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Reasons for Pregnancy Denial

Denial has diverse etiologies and contributory factors (Appelbaum 1998).
The presence of denial does not necessarily imply a psychiatric disorder
or a specific psychological conflict. A combination of physiological factors (e.g., irregular menses, few physical symptoms of pregnancy), external stress, and rationalization can cause pregnancy to be denied under
circumstances of minimal to no psychopathology (Spielvogel and Hohener
1995). Nevertheless, certain cognitive and emotional processes appear to
promote the likelihood of pregnancy denial in many cases.

Cognitive Models of Denial

Peoples responsiveness to painful or anxiety-provoking situations falls
along a spectrum from highly reactive (sensitizing) to less reactive (repressing). During pregnancy, women with a repressing cognitive style
report less pain, anxiety, and depression than women with a sensitizing
cognitive style (Rofe et al. 1993). This mental set exerts a more powerful
effect on experienced level of emotional stress during pregnancy than
does socioeconomic status or primiparity. Except among women with
the most extreme repressing style, anxiety, depression, nightmares, and insomnia are frequent normative experiences during pregnancy, especially in
the third trimester. Women who have a characteristically repressing cognitive style may be more apt to manage extreme pregnancy stressors with
denial rather than some other way.
Having a repressing cognitive style, however, does not usually lead to
pregnancy denial unless a conflict or stressor is also fueling the denial. Since
pregnancy and motherhood call for major adjustments of lifestyle, relationships, career, and social role (Brezinka et al. 1994), it is not unusual for conflict and stress related to one or more of these changes to develop.
One cognitive model posits that when conflicts or stressors loom, people appraise the potential dangers they face. This process of appraisal can
be conscious or preconscious. Potential dangers can include the threat of
painful affects as well as physical or external threats. Once this appraisal
is complete, the person chooses a response from his or her available repertoire of coping skills. Some strategies are problem-focused, in that they
alter the relationship between the person and the environment in such a
way as to reduce the threat or garner support. Denial is an emotionfocused, rather than a problem-focused, strategy; threatening information is actively excluded from conscious awareness. This strategy is more
likely to be used when the external situation cannot be altered or when
the person perceives it cannot be altered.

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By reducing extreme anxiety, denial can be helpful. This is especially

the case when it is the initial reaction to frightening news but is not sustained over time (Bluestein and Rutledge 1992). Initial denial can buffer
the shock of the unexpected, giving a person time to collect herself and
to mobilize other defenses. However, this strategy is risky, especially when
sustained over time, because it decreases access to useful information and
often prevents adaptive action (Forchuk and Westwell 1987).
A particular type of conflict that promotes use of denial is cognitive
dissonance (Forchuk and Westwell 1987). This is a situation in which
actions, behavior, or observed facts contradict a deeply held cognitive
conviction. For this painful contradiction to be resolved, something must
changeeither the conviction or the fact. When the conviction is central
to the persons sense of self, the fact may be denied in order for the conviction to be maintained. In the case of pregnancy denial, the conviction
could be something like Only bad girls get pregnant before marriage, and
Im not a bad girl. Rather than disavow that belief, the woman denies the
fact of pregnancy. In the case of psychotic denial, there is often a need to
reconcile antenatal feelings of attachment toward the fetus with the likelihood of being unable to parent the baby after birth. This dissonance between emotions and a reality-based appraisal of the likely outcome may
result in delusional denial of pregnancy (Miller 1990).
Some evolutionary psychologists posit that the ability to conceal emotions has had adaptive value over time and therefore has been retained as
a capability within the human psyche. The most effective way to conceal
emotions from others is to deceive oneself; thus, a capacity for denial could
be adaptive as well. However, it would be useful to store the denied information in case it is needed later. Thus, people may have evolved the
capacity for dissociation in conjunction with denial (Pinker 1997).

Emotional Stressors Related to Pregnancy Denial

In most reported cases of pregnancy denial, two central areas of emotional
stress emerge: conflicts related to sexuality (Bascom 1977; Spielvogel and
Hohener 1995) and fears of interpersonal abandonment. Sometimes these
two are closely intertwined. Pregnancy is a visible, public marker of having had a sexual relationship. Such acknowledgment of sexuality can be
terrifying when past trauma has created profound confusion about sexuality or when cultural or familial attitudes forbid sexuality.
For many women, pregnancy raises fears of interpersonal abandonment and/or losses. In some cases, this is because there have been explicit
threats of abandonment or experiences of loss linked to becoming pregnant. For example, some adolescents who denied their pregnancies had

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been told they would be kicked out of their homes if they became pregnant (Brozovsky and Falit 1971; Oberman 1996), or they had seen harsh
familial treatment of an older relative who became pregnant (ArboledaFlorez 1976; Oberman 1996). In a study of teenagers, delayed pregnancy
testing and associated pregnancy denial were linked to fear of parental response (Bluestein and Rutledge 1992).
Fear of being abandoned by a partner can also contribute to pregnancy
denial. Sometimes the partner is jealous of the fetus or is jealous because
the father of the fetus is a different man (Resnick 1970). Sometimes
tensions arise because the pregnancy arose too early in a relationship
(Brezinka et al. 1994). Sometimes denial occurs after a woman notes behavioral changes in her spouse early in pregnancy. For example, a woman
who cognitively acknowledged but affectively denied her pregnancy related that as soon as she had become pregnant, her husband began to ignore her and spend long hours away from home. Her perception was that
he now figured he no longer had to court her because she was his permanently because of the pregnancy. Anger toward the father of the fetus
may contribute to pregnancy denial (Spielvogel and Hohener 1995), as a
womans means of distancing herself from a difficult relationship. Secure,
committed relationships with the father of the fetus are rare among
women with known cases of pervasive pregnancy denial (Oberman
1996). Communication difficulties with partners are a major reason why
teenagers delay pregnancy testing (Bluestein and Rutledge 1992).
Past or anticipated loss of a child can lead to a womans denying a subsequent pregnancy. In a study of psychotic pregnancy denial, there was a
significant correlation between past or anticipated custody loss and current denial of pregnancy (Miller 1990). Sometimes the strong emotions
from which a woman distances herself with denial show themselves in
the content of delusions. For example, a woman who denied her pregnancy
displayed bland affect when relating her history of miscarriage. However,
she maintained the delusion that machines directed by the doctor who
had treated her were tormenting her by grinding up the products of that
miscarriage (Slayton and Soloff 1981).
A window into the emotions underlying pregnancy denial can be obtained by interviewing women who give birth in hospitals after denied
pregnancies. In one such study (Bonnet 1993), many women recounted
fantasies of violence toward their fetuses. These violent thoughts appeared
in many cases to be related to the womans efforts to get rid of traumatic
associations.
D was a 23-year-old married woman who had recently immigrated to the
United States from Ecuador. She was isolated from her family of origin

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and did not speak English, but she was happy with her marriage and found
a satisfying job. When she became pregnant, she developed intense nausea and vomiting, which rendered her unable to continue working. Her
husband then worked longer hours to compensate, so she felt very isolated. D showed no emotional or behavioral reactions to her pregnancy
until the second trimester, when she began to feel fetal movements. At
that point, she developed sudden angry thoughts toward the fetus, blaming the fetus for her nausea and vomiting and subsequent job loss. She
made three apparent suicide attempts in rapid succession, one by nearly
jumping out a window, one by overdose, and one by drinking cleaning
fluid. Her husband rescued her each time. She later explained that she
had no desire to kill herself but that these actions had been aimed at destroying the fetus. Her overt affect was bland during these events and
while discussing them afterward.

Risk Factors for Pregnancy Denial

Individual Risk Factors
Youth
While women of any age can deny a pregnancy, this phenomenon is most
commonly seen in pregnant adolescents. For example, the modal age of
a sample of 47 women who had committed neonaticide, often after denying their pregnancies, was 17 (Oberman 1996). Denial in this age group
can be put into perspective by understanding how commonly teenagers
delay recognition of pregnancy. In a representative study, the mean delay
in diagnosing pregnancy in a sample of 151 pregnant teens was 4.35
weeks (Bluestein and Rutledge 1992); 45% of the girls in the study sample had difficulty acknowledging that they were pregnant.
Teenagers who are pregnant often first seek medical attention for
nonspecific, misleading complaints. Pregnancy is often missed on first visits to adolescent medical clinics (Causey et al. 1997). Studies of pregnant
adolescents coming to emergency rooms (Causey et al. 1997; Givens et
al. 1994) have found that less than 10% either requested a pregnancy test
or mentioned the possibility of being pregnant. The rest had come for
complaints such as gastrointestinal symptoms, vaginal discharge, or urinary symptoms. About 10% of these pregnant adolescents denied being
sexually active. Some persisted in denying the possibility of pregnancy after being informed of positive pregnancy test results. One result of delayed acknowledgment of pregnancy is that less than 25% of pregnant
teens in the United States receive prenatal care (Causey et al. 1997).

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Passivity
A passive behavioral style has been noted in many women who deny
pregnancy. The passivity begins with the sexual relationship that led to
the pregnancy, in that women may be coerced into sex (Milstein and Milstein 1983; Resnick 1970). On suspecting or learning of pregnancy, some
women who would otherwise have chosen to abort are prevented by
their passivity from seeking abortion (Bonnet 1993).

Intellectual and Knowledge Deficits

For some women, impaired intellectual function contributes to lack of
awareness of pregnancy (Brezinka et al. 1994; Oberman 1996). With other
women, a striking lack of knowledge of the anatomy and physiology of
reproduction, despite normal intellectual capacity, has been observed
(Finnegan et al. 1982). However, pregnancy denial can also be seen in
women with above-average IQ scores and good school performance.

Substance Addiction
Substance addiction can promote pregnancy denial, especially affective
denial. When pregnancy is suspected, some women increase the use of
addictive substances in an apparent effort to block out resultant feelings
of guilt, self-loathing, and depression (Spielvogel and Hohener 1995).
Many addicted pregnant women expect health professionals and family
members to have a punitive attitude; when these women were surveyed,
significantly more women with addiction doubted family support than
did women with other high-risk conditions during pregnancy (Marcenko
et al. 1994). This lack of support, perceived or actual, further serves to
block pregnancy from awareness.
Affective denial of potential adverse consequences to offspring of substance use during pregnancy may persist after delivery. For example, new
mothers who are heavy drinkers overestimate their infants mental and
physical development significantly more often than do new mothers who
are abstainers and light drinkers, a finding not accounted for by education
or socioeconomic status (Seagull et al. 1996).

Other Psychiatric Disorders

From available data, it appears that less than half of women with pervasive
pregnancy denial have psychiatric disorders other than adjustment disorder (Brezinka et al. 1994). Specific psychiatric illnesses appear to affect
pregnancy denial in different ways. Psychotic denial is most commonly

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found in the context of schizophrenia (Miller 1990). Symptoms of depression are associated not only with difficulty acknowledging pregnancy
but also with dissatisfaction with family support while pregnant and with
difficulty communicating with partners about pregnancy (Bluestein and
Rutledge 1992). Eating disorders can promote misinterpretation of the
appetite and weight changes that accompany pregnancy (Bonnet 1993;
Kaplan and Grotowski 1996). Women with sexual abuserelated PTSD
may experience a reemergence of traumatic memories connected to sexuality on suspecting pregnancy (Bonnet 1993; Spielvogel and Hohener
1995). The experience of being examined for pregnancy and being told
of a pregnancy may be so traumatic for such women that they dissociate
and do not register what the physician said (Bascom 1977).

Obstetric/Gynecological Factors
Women who have irregular menses prior to pregnancy may be more prone
not to notice prolonged amenorrhea and are overrepresented in samples
of women who deny pregnancy (Brezinka et al. 1994). Women who take
oral contraceptive pills or intramuscular progestogens may have continued cyclic bleeding, which makes pregnancy more difficult to recognize
(Brezinka et al. 1994; Kaplan and Grotowski 1996). Breech presentation
can produce a less obviously pregnant body habitus, which renders denial
and concealment easier (Brezinka et al. 1994).

Sociocultural Risk Factors

Women of all races, ethnicities, and social classes can deny pregnancies
(Oberman 1996). However, certain familial and sociocultural contexts
appear to foster pregnancy denial as well as resultant neonaticide. The
common thread seems to be that something about the environment in
which a woman becomes pregnant renders her pregnancy highly threatening to her well-being.
Rates of neonaticide have varied widely in different groups of people
during different historical eras (Hrdy 1999; Oberman 1996). Examining
these differences sheds light on sociocultural contexts that promote this
most extreme correlate of pregnancy denial. Neonaticide rates have varied
according to factors such as availability of birth control, abortion, environmental resources, and child care help. Circumstances in which a woman
cannot choose not to be pregnant, might be abandoned or punished if
pregnant, or has insufficient help or resources to raise a child promote
neonaticide. Since it is more difficult for a mother to neglect, abandon,
or kill an infant to whom she has become emotionally attached, many

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93

mothers faced with these desperate circumstances pave the way for rejecting their babies by failing to acknowledge pregnancy. Frank denial is
part of a spectrum of maternal emotional distancing from offspring
whose existence might pose great risks to their mothers.
A common thread in nearly all known cases of pervasive pregnancy
denial is social isolation (Finnegan et al. 1982; Green and Manohar 1990;
Oberman 1996). Even women surrounded by people may not feel emotionally connected to any of them. In many cases, the dread of being pregnant is associated with growing up in families, cultures, or religious
contexts that stigmatize out-of-wedlock conceptions (Arboleda-Florez
1976; Finnegan et al. 1982; Green and Manohar 1990; Milstein and Milstein 1983; Resnick 1970; Spielvogel and Hohener 1995). The cultural
prohibition may be so intense that prenuptial pregnancy becomes literally unthinkable (Bonnet 1993).

Consequences of Pregnancy Denial

Obstetric Complications
Any degree of pregnancy denial may delay the diagnosis of pregnancy and
the initiation of prenatal care (Kinzl and Biebl 1991). In a study of pregnant adolescents, for example, difficulty acknowledging pregnancy was the
only factor exerting a significant influence on delayed testing; race, education, financial barriers, and psychiatric symptoms did not (Bluestein and
Rutledge 1992). By delaying prenatal care, pregnancy denial can contribute to higher incidences of preterm labor, perinatal mortality, and lowbirth-weight infants (Joyce et al. 1983). One study, for example, found
that mothers of very-low-birth-weight infants were 54% more likely than
controls to have denied their pregnancies (Sable et al. 1997).
Some of the risks associated with pregnancy denial come from a womans
failing to protect herself and her fetus from toxins or potentially harmful
conditions she might otherwise avoid. These include alcoholic beverages,
cigarette smoke and tobacco products, radiation, teratogenic drugs, excessive job stress, or overly vigorous exercise (Brezinka et al. 1994; Kinzl
and Biebl 1991). Other risks stem from a womans failure to recognize
warning signs of pregnancy complications (Brezinka et al. 1994; Kinzl
and Biebl 1991). For example, unrecognized premature rupture of membranes can lead to infection. Uterine contractions, whether premature or
from term labor, may be erroneously attributed to gastrointestinal discomfort; this can lead to precipitous or unassisted delivery.

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Infanticide: Psychosocial and Legal Perspectives

Neonaticide
Neonaticide (see Chapter 6) is strongly associated with pregnancy denial
(Saunders 1989; Spinelli 2001). Sometimes, confronted with a baby for
whom she was not emotionally prepared, the mother actively kills her
newborn (by, for example, battering or strangulation) (Bonnet 1993). In
other cases, she does not actively attempt to kill the baby, but she does nothing to prevent the baby from dying. The most common way babies die
after denied pregnancies is by being delivered into toilets and drowning
(Green and Manohar 1990; Kellett 1992; Milstein and Milstein 1983;
Mitchell and Davis 1984). In other cases, the baby may fall to the floor
and sustain a skull fracture if the mother delivers from a crouching or
standing position without assistance (Kellett 1992).
In some cases in which mothers have actively brought about their
newborns deaths, there were aggressive fantasies toward the fetuses
prior to the birth. Some of these fantasies become enacted in the form of
aggressive behavior directed toward the fetusfor example, a woman forced
to confront a previously denied pregnancy may punch her abdomen (Kent
et al. 1997). Sometimes such behavior can result in fetal injuries and/or
placental abruption. In some cases in which women have later been able
to discuss their fantasies, there is evidence to suggest that their behavior
was prompted by identifying with an imagined aggressor. For example,
some women did to their babies what they feared their own mothers
would do to them (Bonnet 1993).
In many cases of neonaticide following denied pregnancies, the mothers appear to have killed their babies while in dissociative or near-dissociative states. Memory for the act is often hazy. Many women make little
or no effort to conceal their acts.

Postpartum Psychiatric Problems

There is some evidence that women who deny pregnancies may be more
vulnerable to postpartum psychiatric symptoms (Uddenberg and Nilsson
1975). In women with preexisting psychotic disorders, a complete absence
of anxiety and depression during pregnancy predicts the development of
postpartum psychosis (McNeil 1988). For some women, the sudden appearance of a baby after a denied pregnancy can lead to PTSD (Jacobsen
and Miller 1998).

Parenting
For most women who acknowledge being pregnant, the psychological transition to motherhood begins during the pregnancy. Many pregnant women

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95

seek out and imitate maternal role models, fantasize about parenting, and
try on different parenting behaviors and attitudes for fit with their selfdefinitions (Zabielski 1994). A woman who is aware of her fetus may develop the seeds of a reciprocal relationship. For example, she may note
the activity patterns of the fetus and may begin to alter her daily rhythms
accordingly. She may find that fetal movement is intensified when she
lies down in one position and that the fetus calms when she lies in another position. In addition, many mothers take steps to learn concrete information and garner support. These steps may include attending classes,
consulting relatives and friends, arranging child care, and having baby
showers. As a result of these behaviors, by the ninth month of pregnancy,
85% of pregnant women in one survey felt that they were mothers already (Zabielski 1994).
None of this preparatory activity can occur during a denied pregnancy. Motherhood comes as a shock in the face of what may have already been stressful life circumstances (see Chapter 6). The nature and
quality of parenting that ensues can be highly variable.
Despite the lack of preparation, a denied pregnancy can be followed
by genuine joy and acceptance of the mothering role (Spielvogel and
Hohener 1995). In a follow-up study of women who had denied their
pregnancies, none of the offspring showed evidence of abuse or neglect,
and only one was in substitute care (Brezinka et al. 1994). Even women
who have committed neonaticide after denied pregnancies can successfully raise other children when circumstances change (Bartholemew
1989; Hrdy 1999; Jacobsen and Miller 1998; Wilkins 1985). Nevertheless, sometimes child welfare or health professionals may consider pregnancy denial, especially with a history of neonaticide, as automatically
indicative of problem parenting. Hospital staff, for example, may try to
convince mothers not to keep their babies after denied pregnancies or
may seek judicial orders for foster placement of the infants (Brezinka et
al. 1994).

Recurrence With Subsequent Pregnancies

For some women, pregnancy denial and resultant neonaticide recur in
later pregnancies (Arboleda-Florez 1976; Bartholemew 1989). The risk
of denying subsequent pregnancies may be greater if the reasons for denying the first pregnancy were never addressed (Joyce et al. 1983). The
risk of recurrence of neonaticide seems higher in cases in which violence
is a habitual part of the mothers life (Resnick 1970).

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Interventions for Pregnancy Denial

Identification
The earlier pregnancy denial is identified, the more opportunity there is
to prevent complications. Within prenatal clinics, affective denial can be
best identified when staff are trained to understand the normal range of
emotional reactions to pregnancy and to pay special attention to women
at high risk for denial (e.g., women with prior pregnancy loss, women
with substance addictions, teenagers with inadequate social support).
Within emergency rooms and general medical clinics, it is important to
remember to include pregnancy in the differential diagnosis of abdominal
and pelvic symptoms. It is also helpful to obtain history from women, including teenagers, in the absence of family members (Malviya et al.
1996) and to obtain collateral history from significant others.

Medication
When pregnancy denial occurs in the context of a medication-responsive
psychiatric condition, such as major depression, bipolar disorder, or schizophrenia, pharmacotherapy can alleviate the denial. The risks of the untreated symptoms, including denial, must be weighed against potential risks
of medication during pregnancy (Miller 1998). In most cases, medication
alone is not sufficient for treating denial, but it can help a woman feel ready
to address the psychosocial problems that are contributing to the denial.

Psychotherapy
Even when a woman is not engaged in formal psychotherapy, a therapeutic stance on the part of health personnel working with her can help elucidate and work through the problems that led to the denial. The most
important part of this therapeutic stance is conveying an open, nonjudgmental attitude. Reprimands or lectures may further alienate a woman
whose emotional isolation may be fueling her denial (Joyce et al. 1983).
Since denial serves a protective function, a helpful therapeutic approach involves trying to understand the psychological purpose for the
denial. Asking the woman directly before she is ready may increase anxiety and does not usually shed light, because she often does not know.
Careful listening over time and use of collateral sources of information
can provide clues. Once the underlying problems have become clear, it is
necessary to find other ways of addressing those problems before the
woman can relinquish the denial.

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97

A therapeutic stance can also guide approaches to the mother-infant

relationship after birth. For example, encouraging a woman to hold her
baby may be frightening, and sometimes dangerous, if she maintains secret violent fantasies toward the infant. Helping her first to articulate the
fantasies and then to link them to traumatic experiences in her own past
may help her to feel ready to hold and care for the baby (Bonnet 1993).
E, a 27-year-old woman in her eighth month of pregnancy, was brought
to a prenatal clinic by her brother because she was losing weight. Her
brother related that she was eating a lotin fact, she was bingeing rapidly
on large quantities of foodbut that almost immediately after eating she
would vomit. She did not try to conceal her bingeing and vomiting and
did not appear to be inducing the vomiting. She had no body image disturbance. Her brother had brought her to the clinic 2 weeks earlier with
the same complaint, and a nurse had lectured about nutrition and had admonished her to eat more slowly for the sake of the baby. E had listened
and nodded, appearing to understand. Since then, however, her brother
noted that her bingeing had intensified and that the vomiting had worsened to the point of weight loss.
This time, instead of lecturing, the nurse asked E open-ended questions about how things had been going for her and listened carefully. E
disclosed that she believed there was no baby inside her. Rather, there was
a devil inside her who was trying to steal all her nutrients, and she was eating rapidly in order to bypass the devil. Es brother revealed that E had a
history of schizophrenia, which had been well controlled until she discontinued medication because of being pregnant.
E agreed to resume antipsychotic medication. However, her delusion
about a devil inside her persisted, as did her bingeing and vomiting, until
a brief course of psychotherapy revealed that an unresolved emotional
problem was fueling her delusion. Ever since she had become pregnant,
E had felt jealous of the attention everyone was paying to the fetus instead
of to her. When she became psychotic, this feeling expressed itself via a
delusion that transformed the fetus into a devil and the emotional nutrients into physical ones. When this became clear, the therapist spoke to
family members, who began paying more direct attention to E and talking
about the baby less. E stopped maintaining her delusional belief and was
able to eat normally.

Prenatal Care
Staff in prenatal clinics can help prevent and recognize pregnancy denial
by paying close attention to the psychological impact on women when a
pregnancy is first diagnosed (Green and Manohar 1990). If pregnancy is
diagnosed early and the woman appears anxious, sad, or stunned by the
news, she can be encouraged to discuss her reactions. Supportive followup visits, including outreach, may be appropriate. If the pregnancy is di-

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Infanticide: Psychosocial and Legal Perspectives

agnosed very late, after a period of initial denial, it can be useful to ask in
a nonjudgmental manner about awareness of bodily changes, life circumstances, and emotional reactions to the pregnancy.
Ultrasound examinations can have a profound emotional impact on
women who are denying pregnancies. The manner in which the examination is conducted can make the difference between having a therapeutic
impact or having a traumatic one. Sometimes viewing a fetus via ultrasound can facilitate maternal role formation (Zabielski 1994). Even psychotic denial can be reversed by a sensitively conducted ultrasound
examination (Cook and Howe 1984), although in women who have
strong emotional reasons to maintain their denial, ultrasound images can
be easily misinterpreted (Miller 1990). For most women, the emotional
impact of ultrasound examinations is more therapeutic when a high level
of information is provided; this can decrease anxiety and increase adherence to prenatal health recommendations (Cox et al. 1987).
F, a 34-year-old woman, became pregnant after having sex with a man
who was not her husband. She had had two prior pregnancies, each resulting in miscarriage. She cognitively acknowledged the current pregnancy but had a striking absence of emotional response or behavioral
preparation. Under pressure from her husband, she finally attended a prenatal visit and had an ultrasound examination. On seeing the image of her
fetus, she cried profusely. She was then able to tell her midwife about her
grief at the prior miscarriages as well as her fear that this was not her husbands child. She entered therapy and was able to emotionally accept the
pregnancy.

Parenting Assessment and Rehabilitation

Some mothers clearly wish to parent their babies after denied pregnancies, and others clearly do not. Many have mixed feelings and could use
help in sorting out their wishes and identifying available support. Information about options such as adoption, foster care, and standby guardianships can be helpful.
Since parenting capability cannot be predicted on the basis of pregnancy denial alone, a comprehensive parenting assessment is indicated
for women who have denied their pregnancies but want to raise their
babies. Optimal assessments rely on direct, systematic observation of
parenting behavior, as well as multiple sources of data (Jacobsen et al.
1997). Parenting questionnaires with adequate reliability and validity can
also be helpful (Budd and Holdsworth 1996). Identifying areas of parenting weakness can lead to parenting rehabilitation efforts such as parenting
classes, parenting coaching, parent support groups, and therapeutic nurs-

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99

eries. When there is a risk of gross neglect or abuse, child welfare agencies
can become involved to protect the baby and provide additional resources for the mother.

Social Support
For many women, inadequate social support is a central reason for having
denied their pregnancies. Helping a woman realistically assess her available social supports can be of great help. If a woman perceives that
significant others will be punitive and rejecting, it is important not to automatically assume that this perception is accurate or inaccurate, but to
help the woman assess its basis in reality. If the womans family and
friends cannot be adequately supportive, linking the woman to community
support structures can supplement her existing support. Many women
who have given birth after a denied pregnancy need help with practical
decisions, such as whom to notify and whether to place a birth announcement in the newspaper (Berns 1982).

Family Planning
Discussing family planning can feel intrusive if premature, in that some
women who have denied pregnancies are not yet ready to acknowledge
that they are sexually active (Berns 1982). This is especially the case for
women who were passive in acquiescing to sex. Women with psychotic
denial may be especially capable of maintaining the belief that they did
not have sexual relations and did not give birth. Nevertheless, women
who lose custody of babies because of psychotic illness often maintain a
tremendous longing for motherhood and can be at high risk of subsequent unplanned pregnancies (Apfel and Handel 1993). In such cases, a
combination of psychoeducation about sexuality and psychotherapy to
help in grieving losses can help some women feel better able to make active choices about sexuality and family planning.
Among women with psychotic disorders, the most common reason
given for not using birth control, even while sexually active and not desiring pregnancy, is that they did not expect to have sex (Miller and
Finnerty 1998). Although this suggests that long-acting, reversible contraceptive methods would be useful options, women with schizophrenia
spectrum disorders are significantly less likely to have ever heard of such
options than nonmentally ill women of comparable educational and socioeconomic background (Miller and Finnerty 1998). Education about
these and other options may help to prevent the type of emotionally
overwhelming pregnancies that necessitate psychotic denial.

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Medicolegal Issues
A pregnant woman is normally assumed to be competent to make informed decisions about recommended medical interventions on behalf of
herself and her fetus. However, a womans competency to make medical
decisions may be compromised by denial of pregnancy (Muskin et al.
1998). If, for example, a woman consents to psychotropic medication or
electroconvulsive therapy for herself but is not able to evaluate potential
risks to her fetus because she denies having a fetus, her capacity to make
a fully informed decision may be impaired (Miller 1994). Cases such as
this nearly always involve psychotic denial, since in cases of nonpsychotic
denial it would be unusual for others to be aware of the pregnancy to the
extent of offering care. Since psychotic pregnancy denial often waxes and
wanes and is not absolute, it is important to ascertain what the woman
decides when she is acknowledging her pregnancy. Collateral historians
may be able to provide information about what the woman would have
wanted had she been fully competent. In cases in which a woman has
profound psychotic denial and is unable to provide informed consent,
some courts will appoint a guardian ad litem to represent the fetus.
Another major medicolegal issue that arises in the context of pregnancy denial is involuntary hospitalization. This problem usually arises
when a woman is in her third trimester of a pregnancy that she is psychotically denying. Without intervention, she may fail to recognize labor
and may deliver precipitously without assistance. This has led some clinicians to characterize third-trimester psychotic denial as an acute psychiatric emergency (Slayton and Soloff 1981) that justifies involuntary
commitment to a hospital (Soloff et al. 1979). Although this may seem
like an extreme measure for a woman who is not otherwise posing harm
to herself or anyone else, the risks of not hospitalizing may be great, as
illustrated in the following case:
G is a 32-year-old woman who was brought to an emergency room by her
boyfriend after she sustained lacerations from having jumped over a fence
without fully clearing the barbed wire. Her wounds were treated, and she
was found to be in a manic episode with psychotic features. She was in
the 36th week of an intrauterine pregnancy, confirmed by physical examination and ultrasound, but she denied being pregnant. She initially agreed
to be admitted to a psychiatric unit and agreed to take antipsychotic but
not mood-stabilizing medication. After 4 days, she was much less psychotic but remained manic. She intermittently acknowledged her pregnancy. At this point, she demanded to leave the hospital. Her boyfriend
and her family members backed her up, promising to take care of her and
threatening to sue hospital staff if they did not discharge her. She had no
suicidal or homicidal ideation and no longer had the sort of delusional

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101

thinking and impulsivity that had prompted her to try to jump the fence.
Accordingly, she was discharged against medical advice. She promptly
discontinued her medication. About a week after discharge, she was found
by a neighbor wandering the streets holding a baby, still fastened to her
umbilical cord, which was dangling from her body. The neighbor brought
G and the baby to a hospital, where the baby was admitted to the neonatal intensive care unit in poor condition, having sustained brain damage
from presumed hypoxia.

Decisions about involuntary commitment of women because of psychotic denial of pregnancy must be made on a case-by-case basis, taking
into account the nature of the patients symptoms, the patients insight
into her illness, her history of adherence to prescribed medication and
other mental health treatment, and her social support.

Public Policy and Health Care Delivery

A relatively recent type of law aims to alleviate the pressures that underlie
pregnancy denial and neonaticide. The first such law, known as Childbirth Under X, was passed in France in 1941 (Bonnet 1993). The law
allows women to deliver babies anonymously in hospitals. A woman using this provision puts an identification card in a sealed envelope, for use
only if she dies in labor. The costs of her labor and delivery are paid with
government funds. Babies born under these circumstances become wards
of the state at birth and are then adopted. Women using this service who
agreed to be interviewed appeared to have feelings and life circumstances
that were very similar to those of women who committed neonaticide.
Because of the apparent success of this program, similar programs and
laws have begun to appear elsewhere, including in the United States (see
Chapter 13: The Promise of Saved Lives).

Conclusion
The manner in which a society supports or condemns pregnant women
has a strong influence on how a woman deals with a pregnancy she cannot adequately manage (Hrdy 1999). Cultures and subcultures in which
it is relatively easy to obtain birth control, abortions, and adoptions have
lower rates of neonaticide. Societies in which women are harshly punished or rejected for becoming pregnant, seeking abortion, or abandoning
babies are more likely to give rise to pregnancy denial and resultant neonaticide. Health care systems that include easily available pregnancy testing
and prenatal care, along with outreach to high-risk groups like teenagers,
can also decrease the likelihood of pregnancy denial (Berns 1982).

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Teachers and school counselors should be knowledgeable about identifying mood and personality changes in adolescents who appear gravid
or who camouflage their physical appearance with oversized clothing.
Women with chronic mental illness who are likely victims of nonconsentual sexual activity and rape are at enormous risk for psychotic denial
of pregnancy.
Denied pregnancies are associated with sequelae such as fetal abuse,
neglect, unassisted labor and delivery, failure to resuscitate, or overt neonaticide. The fact that fetal and infant morbidity and mortality rates may
be reduced implies a need for further education of health care providers
and educators for early recognition of women at risk.

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Chapter

Neonaticide
A Systematic Investigation of 17 Cases
Margaret G. Spinelli, M.D.

The meeting was called to order by Miss Susan B. Anthony. A large

and influential meeting of ladies and gentlemen held in the Hall of
the Cooper Institute . . . convened to take such steps . . . to obtain
the liberation of the unhappy young woman, Hester Vaughan[,] at
present under sentence of death for infanticide. . . . The Platform was
principally occupied by ladies who have been conspicuous in the
Womens Rights movement. Hester Vaughan . . . had been ill and
partially unconscious for 3 days prior to her confinement and a child
was born. Hours passed before she could cry for assistance, and when
she did it was to be dragged to a prison and sentenced to be hanged.
. . . Miss Anthony continued to plead for the liberation of Hester
Vaughan . . .
Working Womens Association Meeting
to protest conviction of Hester Vaughan
News report in WORLD, Philadelphia, PA, December 1868

Neonaticide, or infant murder on the day of birth (Resnick 1970), is

often preceded by denial of pregnancy. Although neonaticide has been
the target of recent media attention, it has never been studied systematically. Well-documented clinical case reports of neonaticide describe a
presentation of pregnancy denial (see Chapter 5: Denial of Pregnancy),
dissociative symptoms, or psychosis (Bracken and Kasl 1976; Brezinka et
105

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al. 1994; Finnegan et al. 1982; Green and Manohar 1990). In this chapter, I describe the first systematic investigation of women charged with
homicide after alleged neonaticide. Using contemporary diagnostic criteria and the biopsychosocial model of psychiatry, I identify risk factors and
clinical presentations that may shed light on mechanisms for treatment,
rehabilitation, and education.
In a court of law, expert witness testimony must be founded on scientific standards that are recognized in the psychiatric community (see
Chapter 9: Postpartum Psychiatric Disorders: Medical and Legal Dilemmas). The defense of women who are alleged to have committed neonaticide is limited to early and outdated literature. In this chapter, I
suggest that common variables exist in a subset of these women. Similarities in history, presentation, and circumstances of pregnancy and delivery suggest a pattern of shared psychopathology (Spinelli 2001). The aim
of this chapter is to encourage further systematic exploration. Using a
contemporary framework for psychiatric diagnosis and treatment, I introduce a preliminary paradigm for understanding denial of pregnancy and
neonaticide (American Psychiatric Association 1994; Resnick 1970).

The Interviews
I performed forensic psychiatric interviews with 17 women who experienced denial of pregnancy followed by secret unassisted deliveries. Sixteen of the women allegedly committed neonaticide, and the remaining
woman allegedly attempted neonaticide. There was a notable similarity
in presentation, phenomenology, and family dynamics.
All of the women were interviewed in the United States. Psychiatric interviews were requested by defense attorneys (7 of the cases), public defenders (6), departments of probation (2), a colleague in psychiatry (1),
and a presiding judge (1). The purpose of the interviews was to determine the mental status of the accused at the time of the alleged offense.
The goal of the evaluations was to determine whether grounds for defense existed or to propose a plan of treatment and rehabilitation in the
case of juveniles. All of the women gave their informed consent and were
cognizant of the purpose of the interviews.
Eleven women were Caucasian, 5 were African American, and 1 was
Asian in origin. The women ranged in age from 15 to 40 years (mean =
23 years, SD = 8 years). Twelve women were from middle-income families, and five were on public assistance. Three of the women had children
from previous pregnancies.

Neonaticide: A Systematic Investigation of 17 Cases

107

In an effort to provide some quantitative measure of dissociative symptoms, the Dissociative Experiences Scale (DES; Carlson and Putnam
1993) was administered to each woman. The DES is a valid, reliable
screening instrument that rates general dissociative experiences before
and during pregnancy. A mean DES score of 1520 suggests increased
risk for dissociative disorder.

Clinical Findings
The psychiatric presentations of the women who were alleged to have
committed neonaticide share similar characteristics (Table 61). Secret,
unassisted deliveries were associated with dissociative psychosis (in 10
cases), dissociative hallucinations (14), and intermittent amnesia at delivery (14) (Steingard and Frankel 1985; Van der Hart et al. 1993). The
women experienced delivery as watching themselves in a depersonalized
state with little or no pain. Their characterological pictures were framed in
a family dynamic of role confusion, emotional neglect, denial, and boundary violations, as illustrated in the following case:
Table 61.

Neonaticide and denial of pregnancy

Denied pregnancy
Minimal or no physical changes of pregnancy
Depersonalization/autoscopy
Dissociative hallucinations
Labor: unassisted, minimal or no pain
Intermittent amnesia
Brief psychosis (+/)
Childhood trauma (+/)
Poor insight and abstract ability
Good girlno history of sociopathy
Childlike, infantile
Family dynamic
Social isolation and suspicion of others
Boundary violations
Emotional neglect
Isolated, rigid or overtly chaotic
Parental relationships: strained, estranged, or even bizarre
Father: intrusive and prone to jealousy
Mother: cold and hostile
Note.

+/ = may or may not be present.

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Infanticide: Psychosocial and Legal Perspectives

W, a 16-year-old high school student, delivered a full-term infant into the

toilet of her family bathroom. During her pregnancy, she was depressed
and unable to function at school. Despite her chaotic home, she was an
honor student who was active in theater and basketball. Both parents
abused drugs and alcohol and separated before she was born. F, her older
brother of 6 years, protected her from her mothers abuse and kept boys
at a distance. W shared a bed with him until she was 16 years old, when
she moved into her mothers bed coincident with her pregnancy. Although the probation department suspected that F had impregnated her,
W denied incest or his paternity. W was too frightened of her mother to
disclose her pregnancy.
W describes dissociative hallucinations during pregnancy and delivery
as a running commentary of voices inside her head. W explains, I felt the
pregnancy was not real. At times, the voice is me arguing with me and at
other times, it is me arguing with my mother. W you should tell her. Another voice disagrees: No W. Dont tell her because you dont know what
shes going to do. Just go to her. No, dont think about it. Then a motherlike voice warned, Bitch, I hate you. Ill kill you. When labor began, W
attributed food poisoning to her abdominal pains: I tried to feel the
babys heart beat. I thought she was dead. I panicked and threw the baby
out of the window. I forgot about it until the police arrived. On the next
day, it was like it never happened. I felt like I was asleep or like I was in a
coma. I know I did it, but it did not feel like me.
During interview, Ws mother said, I never liked her. I dont know
why. W denied physical abuse by her mother despite reports by relatives
and child protection services.

This case describes a picture of pregnancy denial in a young unmarried adolescenta good girl in a chaotic and dysfunctional family who
fail to notice her pregnancy. She denied abuse despite official reports to
the contrary. An almost painless delivery takes place in her family bathroom. Classical dissociative hallucinations in commentary represent the
self and the dissociative other.

Denial of Pregnancy
Although every woman in this clinical sample denied the fact of her pregnancy, a spectrum of disavowal was described (see Chapter 5), and several themes were outlined. Five denied knowledge of their gravid state
until the delivery itself. Twelve described intermittent awareness of the
intolerable reality, which was subsequently recompartmentalized. One
woman had psychotic denial.
For some, pregnancy had been conscious for a brief period and then
was denied throughout pregnancy and even delivery. Others became
aware of their pregnancy late in gestation, convinced that the delivery
was only a miscarriage. Physical symptoms of pregnancy were absent or

Neonaticide: A Systematic Investigation of 17 Cases

109

misinterpreted. Family members, friends, and even live-in boyfriends did

not realize the women were pregnant.

Depersonalization
Depersonalization accounts for the unusually low level of pain. Twelve
women denied awareness of pain, and 5 described pain as minimal or
not bad. They went through labor quietly in the family home while
others were in adjacent rooms.
On the evening of her delivery, J went through labor in the bathroom, a
place that she describes as a black tunnel. She watched herself, powerless to direct her body below to perform what she wanted. Her observing
self could not influence her participating self. I could hear myself scream,
but sound was not coming out of my mouth.

Although depersonalization is described as a dissociative symptom,

this phenomenon is also described as autoscopy (see Neppe and Tucker
1989). Autoscopy involves illusions or hallucinations of self (symptoms)
that are assigned to the atypical psychosis. The double is not an imposter
but another self that is colorless and transparent but with a defined outline.

Dissociation
Kluft (1990) describes dissociation as the internal struggle and confusion
over the nature of ones self-representation or identity.
C disclosed her pregnancy to no one, including her fianc. She states that
now I find it hard to remember how I felt. I didnt realize something was
wrong. It is not you these things are happening to. You push everything
away with no conscious effort. On the inside, you desperately hope that
someone else will recognize something is wrong.

Dissociative Hallucinations
The internal confusion over identity is frequently characterized as an internal conversation with another identified object (Kluft 1990). Dissociative
hallucinations are interactive dialogues between the observing self and participating self that are not concerned with problem solving (Steinberg et al.
1991). Fourteen (82%) of the women experienced dissociative hallucinations as a commentary of internalized voices distinct from psychotic hallucinations, which are heard outside of the head. One woman recalled, It
was like I was a third party. They had control over my decisions.

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Labor and Delivery

With the onset of labor pains described as symptoms of the flu or food
poisoning, the women expect only a bowel movement. Fourteen experienced amnesia for various aspects of the birth, which they reexperienced
as a dream or coma. When they resumed conscious awareness, they insisted the baby was dead. When the women were confronted with the
unbelievable reality of the infant (Bonnet 1993; Brozovsky and Falit
1971), the usual dissociative defense was insufficient in the face of such
trauma. Because the reality was intolerable, a brief dissociative psychosis
occurred. On reintegration, they could not account for the dead infant.
Although some may have killed the infant during the dissociative psychotic state, neonates born under such hazardous conditions without
prenatal care or resuscitation are already in a perilous circumstance.
On the night of her delivery, V attributed her abdominal cramps to menstruation. While in the shower, she described vaginal pressure and bleeding and felt something come out. She reported minimal discomfort:
When I saw the babys head and body, I did not realize it came from me.
It did not hurt, and I did not feel unusual. I could see it but not feel it. It
was not happening.

Dissociative Psychosis
The inability to mount a successful dissociative response may result in psychosis (Hollender and Hirsch 1964). Fifteen women experienced brief amnesia, 10 of these women described associated psychotic symptoms at the
sight of the infant (Brezinka et al. 1994; Green and Manohar 1990).
Once called hysterical psychosis, dissociative psychosis is associated with
amnesia and is experienced as a waking dream that cannot be differentiated from normal perceptions (Van der Hart et al. 1993). The egos inability to cope with the trauma of delivery apparently causes a break with
the very reality denied (Steingard and Frankel 1985). Such individuals with
immature ego development use primitive defenses and are therefore predisposed to experience brief psychotic episodes.

Dissociative Experiences Scale

The mean (22.5 7.8) DES scores (Carlson and Putnam 1993) of this
small clinical sample support an increased rate of dissociative psychopathology before and during pregnancy. Twelve of the women (71%) had
DES scores greater than 15, which suggests existing dissociative disorders. The unusually high DES scores for 2 women suggest malingering.

Neonaticide: A Systematic Investigation of 17 Cases

111

One woman, hostile at interview, refused to endorse psychopathology and

had a score below the mean cut-off (6). Three other women had DES
scores of 12, 14, and 14.33.

Family Dynamics
In each case the familys denial of the pregnancy supported existing psychopathology complicated by role confusion, boundary violations, and
emotional neglect (Courtois 1988). Social isolation and suspicion of
others were themes reported during patient and family interviews.
Family dynamics were portrayed as explicitly chaotic or rigid and religious, seemingly intact to others. Interestingly, this picture is similar to
that of abusive families, as described by Dietz et al. (1999) and Courtois
(1988).
Parental relationships were strained, estranged, or even bizarre. Fathers were intrusive and prone to jealousy or abuse. Mothers presented
as cold, hostile, and withdrawn or as absent due to physical illness, substance abuse, or psychopathology.
Although sexual abuse is denied, S and her parents describe an intense relationship between S and her father. Her mother prefers to have them
away as much as possible. S and her father feel hated by the mother and
believe she is nuts. Ss father spends all his time at home, except mealtimes, in the barn, where S joins him for company. Paradoxically, the
mother reports her and her husbands marital relationship as good.

The inappropriate actions of Ss father were illustrated during the interview when he moved a chair across the room and sat down with his
knees touching the interviewers chair. He had to be asked to return his
chair to the former position.
Daughters were parentified substitutes for their mothers and yet presented as childlike and even infantile. College and other opportunities for
growth and independence were discouraged. Most of the women were isolated except for having a superficial or chance relationship with the babys
father, who usually remained unidentified. Neediness and poor self-esteem
made these women vulnerable to abusive relationships. Fourteen of the
women were good girls with no history of sociopathy, problems with the
law, violence, or irresponsible behavior. To the contrary, they were honor
students, champion swimmers, and volunteers. Two older women had previous legal problems and/or a history of alcohol abuse.

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Infanticide: Psychosocial and Legal Perspectives

Childhood Trauma
Nine of the 17 women (53%) reported a history of overt childhood sexual
trauma; in 7 of the cases, the trauma was corroborated by independent
sources. Nine of the 17 women (53%) reported physical abuse, while 11
(65%) experienced either sexual or physical trauma. Emotional abuse
(Courtois 1988) was prominent in all homes. Many of these women, protective of abusive parents, idealized these relationships as perfect, good,
or close.
Although B denied sexual abuse, her father was terminated for showing
pornographic films to his adolescent employees.

Corpse
Many women demonstrated bizarre behaviors with their infants corpse.
Some made no effort to hide the corpse from authorities, whereas others
placed them in dumpsters. Often, the woman kept the dead infant close
to her. Some returned to bed with their dead infant, where they remained until discovered.
Airport police arrested J for murder when she carried her dead baby in a
knapsack, planning to bring her home to France.
Fifteen-year-old B wrapped her baby in a towel and returned to bed.
When her cousin asked what was on the bed, she replied, Its a dolly.
Although M denied psychotic symptoms, she transported her babys corpse
to a shared office file cabinet. After 2 weeks, the foul odor prompted the
staff to pry open the locked file, where they found the putrefied and maggot-ridden corpse. During her interview at the sixth postpartum month,
M was indifferent to the peculiar nature of her actions.

Cognition
In general, the women presented as much younger than their ages and
possessed almost no ability to problem solve. They lacked abstract ability
and insight into their dilemma. Judgment was poor. They had nonsensical or paradoxical attitudes toward pregnancy. Although school records
were usually unavailable, most young women had limited intelligence, a
lack of general knowledge, poor cognitive skills, and few resources for
coping. Three had available school records with reported formal IQ; each
had a Full Scale IQ of 84, which placed them in the 14th percentile, representing the low-average range of intellectual ability.

Neonaticide: A Systematic Investigation of 17 Cases

113

The Biopsychosocial Model

Dissociation/Trauma Paradigm and Denial of Pregnancy
Denial is an attempt to avoid an intolerable reality. Psychotic denial is a
primitive defense commonly found in psychotic patients and, less frequently, in healthy adults under unusually severe stress (Slayton and
Soloff 1981). Denial frequently occurs during major illness such as myocardial infarction. Denial of pregnancy (see Chapter 5) has been described
in cross-cultural contexts, in incest victims (Silverblatt and Goodwin 1983),
in psychotic women (Miller 1990), and in women with dissociative disorders (Van der Hart et al. 1991).
For a fact to be denied, prior knowledge of the fact must exist. When
the women admitted even brief knowledge of their pregnancy, their denial was interpreted as a manipulation. Denial resulted when intolerable
emotions were aroused by their conscious awareness of pregnancy and
culminated in disavowal (Van der Hart et al. 1991). Pregnancy is intrinsically frightening for women with dissociative disorder. Janet (1907)
suggested that patients rarely have a precise notion of what is wrong with
them and consequently ignore their own dissociative symptoms. Janet
emphasized retraction of the field of consciousness that limits their ability
to focus on one idea at a time or to plan for options. They resort to the
attitude of la belle indiffrence dune hysterique.
The findings in this small sample suggest that dissociative disorder
precipitates pregnancy denial. Although these data argue for a common
presentation, there is likely heterogeneity in the psychopathology of women
who commit neonaticide.
Findings in this sample are similar to those of case reports of pregnancy
denial, which describe similar phenomenology in a subset of neonaticidal
women (Brezinka et al. 1994; Green and Manohar 1990; Spinelli 2001).
However, cases published in isolation that use various interview techniques preclude reliable and replicable data collection. The presentation
of pregnancy denial requires systematic investigation.
Brezinka et al. (1994) observed 27 women in an obstetrical environment who professed disavowal of pregnancy until term or the onset of
contractions en route to the hospital. Although neonaticide was not the
outcome for these women, pregnancy was denied until birth. Many of the
women claimed to have no symptoms of pregnancy, whereas others attributed symptoms to other causes.
Brozovsky and Falit (1971) described evanescent awareness by adolescents from strict families who colluded in denial. The authors argued

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Infanticide: Psychosocial and Legal Perspectives

that when birth makes denial impossible, the adolescents respond with
acute disorganization and psychosis, at which time they murder the infant.
Finnegan et al. (1982) described three cases of denied pregnancy with
a brief psychotic break at delivery. Most striking was the case of a 39year-old woman who presented in labor and was told by the obstetrician
that she was pregnant. She replied, Thats ridiculous, and then immediately delivered an infant who succumbed after 1 minute. Emergency
resuscitation efforts by staff went unnoticed by the patient. She was discharged from the hospital after 3 days, denying pregnancy and delivery.
Bonnet (1993) described unthinkable pregnancies with similar findings in psychodynamic evaluations of 22 adoptive motherswomen who
experienced denial of pregnancy only to interpret signs of labor as food
poisoning or illness. Four women were accused of neonaticide. Consistent with this case series, the family dynamic described was one of neglect
in violent or incestuous homes as well as failure to recognize the pregnancy. Sexual abuse was experienced by 20% of Bonnets sample, compared with 53% of the sample described in this chapter.
Although vulnerable to ego disruption, these women maintain reality
testing that breaks down under overwhelming circumstances (Hirsch and
Hollender 1969). This sudden psychotic disintegration (Martin 1971) is
associated with amnesia.
Because underlying reality testing is maintained, rapid reintegration
follows (Bonnet 1993; Martin 1971) when reality is tolerable (i.e., the infant is dead). Psychosis and amnesia resolve, leaving the woman confused
over the sight of the dead infant, who has succumbed without benefit of
resuscitation or has been murdered by the mother.

Biological Model
The hypothalamic-pituitary-ovarian (HPO) axis influences biological substrates in the central nervous system (CNS) and end organs such as the
ovaries (Wisner and Stowe 1997). On the one hand, the gonadal hormones
regulate chemical events in the brain; on the other hand, CNS changes influence hormone fluctuations.
The concept of pregnancy denial is often met with disbelief because
it is associated with the absence of physical signs and symptoms such as enlarged abdomen and breasts and amenorrhea. That psychic stimuli may
produce observable endocrine change has been suggested by Gerchow
(1957; quoted in Harder 1967) and others. Starkman and colleagues
(1985) described a similar but reverse psychophysiological phenomenon
in hysterical pregnancy or pseudocyesis.

Neonaticide: A Systematic Investigation of 17 Cases

115

Pseudocyesis is manifested when the desire for pregnancy induces the

onset of pregnancy symptoms such as amenorrhea, lactation, colostrum
secretion, increased abdominal girth, and the subjective experience of
fetal movements (Cohen 1982). Moreover, an enlarged uterus and softened congested cervix have been detected on pelvic examination (Brown
and Barglow 1971). These findings suggest underlying psychophysiological
mechanisms, which may be common to both states, whereby pregnancy
denial and hysterical pregnancy have similar neurohormonal underpinnings but opposite somatic manifestations.
Cohen (1982) hypothesized that CNS changes influence the HPO
axis in pseudocyesis to inhibit follicle-stimulating hormone and luteinizing hormone, which suppress ovulation. At the same time, prolactin
supports the persistent lutenization of the corpus luteum. This theory is
supported when depletion of brain biogenic amines induces lactation and
amenorrhea in humans and reserpine induces pseudocyesis in animals.
The potential for similar but opposite neurohormonal processes may endorse denial of pregnancy as a mirror image of pseudocyesis.
Whether the denial and associated CNS changes are powerful enough
to influence the biological manifestations of pregnancy is unclear. However, the fact that the HPO axis regulates estrogen and progesterone,
both of which are implicated in the physical changes of pregnancy, and oxytocin bonding hormone, which reverses rat infanticidal activity (Insel
1992), supports a psychobiological theory of pregnancy denial.

A Psychodynamic Paradigm
Freud (18931995/1955) suggested that hysterical psychosis is a failure
of repression in response to a current stress caused by eruption of material that is wholly or partially out of awareness. In a transient hysterical
psychosis (Hollender and Hirsch 1964), conflict is severe, environmental
escape routes are barred, and there is an inability to manipulate or influence the factors contributing to the conflict situation (labor and delivery).
The hysterical character has a limited repertory of responses available for
coping. As anxiety mounts, an altered ego state, along with hallucinations
or delusions, is experienced as a manifestation of ego disruption. This
breakdown of ego boundaries impairs the ability to evaluate reality or to
distinguish what is outside from what is inside.
Brozovsky and Falit (1971) suggested that neonaticide develops out
of disorganized ego states when denial is so tenaciously clung to even
when it is no longer tenable (upon the birth of the child). In Kleinian
terms, mother is the bad object. The girl identifies with the aggressor
mother, while the infant represents the patient herself. She kills the infant

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Infanticide: Psychosocial and Legal Perspectives

what she has always feared would be done to her.

Bonnet (1993) provided a psychodynamic formulation for 27 cases of
denial of pregnancy. She suggested that the women discovered the fetus
when the mechanism of denial had become less efficient and decompensation resulted. Bonnet hypothesized that the presence of the fetus triggered the reemergence of traumatic childhood memories connected to
sexuality and revealing sexual pleasure. The boundaries between the fetus and the psychic experience became fluid. Rather than confront the
traumatic unthinkable past, they eliminated the fetus. They could not
make the connection with their traumatic childhood and put it into
words.

Conclusion
The preliminary data presented in this chapter suggest a method of systematic evaluation based on contemporary diagnostic criteria. Recognition that a diagnostic dilemma exists is the first step in the resolution of
the diagnostic differential between dissociative pathology and sociopathy. Classification of symptoms with a common presentation and course
suggests a need for phenomenological studies. Once psychopathology is
identified, strategies for treatment and prevention can be devised. Such
programs could mobilize support systems and facilitate family intervention, prenatal care, family planning, adoption alternatives, and parenting
classes (Miller 1990).
Risk management is a concern for the professional who treats or testifies in these cases. Questions posed by the court may involve other living children or future pregnancies. Guidelines do not exist. In this case
series, one woman had previously killed a neonate after a prior denied
pregnancy. One woman is safely and successfully raising another child.
Questions about treatment, rehabilitation, and parenting potential cannot be answered by systematically collected data. Decisions are based on
clinical judgment and individual case evaluations.
Although this clinical inquiry is limited by the small sample size, it is
the only sample of alleged neonaticides systematically evaluated and reported. The DES is a valid and reliable objective test that can be used to
determine the risk for dissociative disorder. On the other hand, malingering is a primary concern in this population, for whom secondary gain
plays a pivotal role. Use of the Structured Clinical Interview for Dissociative Disorders (SCID-D; Steinberg et al. 1991) should be considered in
future studies. Objective personality, neurocognitive testing, and tests of
personality, intelligence, and malingering should be performed.

Neonaticide: A Systematic Investigation of 17 Cases

117

In the absence of treatment, these women leave prison in their childbearing years with the same psychopathology that brought them into the
system. This investigation is intended to provide a preliminary framework for designing research strategies for development of clinical trials.
Neonaticide remains a subject of both psychiatric and judicial debate.
Further systematic and scientific inquiry is warranted.

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Endocrinol 15:7789, 1997

Chapter

Culture, Scarcity, and

Maternal Thinking
Nancy Scheper-Hughes, Ph.D.

Maternal behavior begins in love, a love which for most women is as

intense, confusing, ambivalent, and poignantly sweet as any they will
ever experience.
Sara Ruddick (1980, p. 344)
So perhaps there is a middle ground between the two rather extreme
approaches to mother lovethe sentimentalized maternal poetics
and mindlessly automatic maternal bonding theorists on the one
hand, and the absence of love theorists on the other. Somewhere
between these extremes lies the reality of maternal thinking and
practice grounded in specific historical and cultural contexts, bounded by different economic and demographic constraints.
Nancy Scheper-Hughes (1992, p. 356)
Maternal practices always begin as a response to the historical reality of a biological child in a particular social world.
Sara Ruddick (1980, p. 348)

This chapter is an abridged version of Chapter 8 of the authors book Death Without Weeping: Mother Love and Child Death in Northeast Brazil (Berkeley, University of California Press, 1992). Abridged and reprinted with permission from The
Regents of the University of California and University of California Press. Copyright 1992, The Regents of the University of California.

119

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This chapter is about culture, scarcity, and maternal thinking. It explores maternal beliefs, sentiments, and practices as they bear on child
survival on the hillside shantytown of Alto do Cruzeiro (Hill of the Crucifix). The argument builds on an earlier and controversial article I wrote
on this topic (Scheper-Hughes 1985), which I have since restudied, rethought, and mulled over with the women of the Alto on three return field
trips since 1987.
I trust I can do greater justice to the topic than when I began. If, however, I cannot establish here some basis for empathy, for a shared understanding of sentiments and practices that seem so very different from our
own and therefore so profoundly disturbing, then I have failed. One difficulty for the reader is that over the years I have come to participate in the
worldview expressed by these women. Their sentiments and practices now
seem to me all quite commonsensical and predictable. I must struggle to recapture a sense of the initial strangeness so as to identify, at least initially,
with the readers possible reluctance to accept a set of practices driven by
an alternative womanly morality, one that will seem quite foreign to many.
It is a dilemma common to all ethnographic writing: how do we represent
the other to the other? But here the stakes are very high indeed.
The ethnographer, like the artist, is engaged in a special kind of quest
through which a specific interpretation of the human condition, an entire
sensibility, is forged. In the act of writing about culture, what emerges is
always highly subjective, partial, and fragmentary but also deeply felt. Socalled participant observation has a way of drawing the ethnographer into
witnessing a kind of human life that she or he might really prefer to avoid.
Once there, the ethnographer may not know how to go about getting out
except through writing, which in turn draws others into the process as
well, making them party to the act of witnessing.
Because of the difficult subject of this research, I am forced to create
a pact with the reader. These are not ordinary lives that I am describing.
Rather, they often are short, violent, and hungry lives. Reading this report
entails a descent into a Brazilian heart of darkness, in a town called Bom
de Jesus. As this chapter begins to touch on and evoke, as Peter Homans
(1987) noted, some of our worst fears and unconscious dreads about human nature, the reader may feel righteous indignation. Conversely, what
is an appropriate and respectful distance to take toward the subjects of
my inquiry, one that is neither so close as to violate their own sense of
decorum, nor so distancing as to render them the mere objects of anthropologys discriminating, and sometimes incriminating, gaze? I begin, as
always, with stories, because storytelling, intrinsic to the art of ethnography, offers the possibility of a personal, yet respectfully distanced, rendering of events.

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121

Mother Love and Child Death

The subject of my study is love and death on the Alto do Cruzeiro, specifically mother love and child death. What effects do deprivation, loss, and
abandonment have on the ability to love, nurture, trust, and have and keep
faith in the broadest terms? I treat the individual and the personal as well
as the collective and cultural dimensions of maternal practices in an environment that is hostile to the survival and well-being of mothers and infants. I argue that a high expectancy of child death is a powerful shaper of
maternal thinking and practice, as is evident, in particular, in the delay of
attachment to infants, who are sometimes thought of as temporary household visitors. This detachment can be mortal at times, contributing to the
severe neglect of certain infants and a failure to mourn the death of very
young babies. I am not arguing that mother love, as we understand it, is deficient or absent in this threatened community, but rather that its life history, its course, is different, shaped by overwhelming economic and
cultural constraints. In its attempts to show how emotion is shaped by political and economic context as well as by culture, this discussion can be
understood as a political economy of the emotions.
What I discovered while working as a medic in the Alto do Cruzeiro
during the 1960s was that while it was possible, and hardly difficult, to
rescue infants and toddlers from premature death, from diarrhea and dehydration, by using a simple sugar, salt, and water solution, it was more
difficult to enlist the mothers themselves in the rescue of children they
perceived as ill-fated for life or as better off dead. It was more difficult
still to coax some desperate young mothers to take back into the bosom
of the family a baby they had already come to think of more as a little
winged angel, a fragile bird, or a household guest or visitor than as a permanent family member. And so Alto babies, successfully rescued and
treated in the hospital rehydration clinic or in the crche and returned
home, were sometimes dead before I had the chance to make a followup house call. Eventually I learned to inquire warily before intervening:
Dona Maria, do you think we should try to save this child? or, even more
boldly, Dona Auxiliadora, is this a child worth keeping? And if the answer was no, as it sometimes was, I learned to keep my distance.
Later, I learned that the high expectation of death and the commensurate ability to face death with stoicism and equanimity produced patterns
of nurturing that differentiated those infants thought of as thrivers and
keepers from those thought of as born already wanting to die. (Bhattacharyya 1983; Scrimshaw 1978). The survivors and keepers were nurtured,
while the stigmatized or doomed infants were allowed to die a mingua,
of neglect. Nonetheless, the mortally neglected infants and babies I am re-

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ferring to here are often (although not always) prettily kept washed and
combed, and their emaciated little bodies are dusted with sweet-smelling
talcum powders. When they die, candles are often propped up in tiny
waxen hands to light their way to the afterlife. At least some of these little
angels have been freely offered up to Jesus and His Mother, although
returned to whence they came is closer to the popular idiom.

Ambiguities of Mother Love:

Lordes and Zezinho
In 1966 I was called on to help Lordes, my young neighbor, deliver a
child. The baby was a fair and robust little tyke with a lusty cry. But while
Lordes showed great interest in the newborn, she ignored Zezinho, an
older child who spent his days miserably curled up in a fetal position and
lying beneath his mothers hammock. Zezinhos days seemed numbered.
I finally decided to intervene. When I took Zezinho away from Lordes
and brought him to the relative safety of the crche, Lordes did not protest. The crche mothers laughed at my efforts to rescue a crianca condenada (condemned child). Zezinho himself resisted the rescue. The crche
mothers said, If a baby wants to die, it will die. There was no sense in
frustrating him so.
The boy finally relented; he began to eat with minimal interest. Indeed, it did seem that Zezinho had no gosto, no taste for life. Gradually,
Zezinho developed an odd and ambivalent attachment to me. Once he
became accustomed to it, Zezinho liked being held, and he would wrap
his spindly arms tightly around my neck. As the time approached to return Zezinho to his mother, my first doubts began to surface. Could it be
true, as the crche mothers hinted, that Zezinho would always live in the
shadows, looking for death, a death I had tricked once but would be unable to forestall forever?
When I returned to Bom de Jesus and the Alto in 1982 to be among the
women who formed my original research sample, Lordes was no longer living in her lean-to but was still in desperate straits. Zezinho was now a young
man of 17. Much was made of my reunion with Lordes and Zezinho. Zezinho laughed the hardest of all at these survivor tales and at his own nearmiss encounter with death at the hands of an indifferent mother who
often forgot to feed and bathe him. Zezinho and his mother obviously
enjoyed a close and affectionate relationship, and while we spoke, Zezinho
draped his arm protectively around his little mothers shoulders.
Love is always ambivalent and dangerous. Why should we think that
it is any less between a mother and her children? And yet, it has been the

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123

fate of mothers throughout history to appear in strange and distorted forms.

Mothers are often portrayed as larger than life, as all-powerful, and sometimes as all-destructive. Or mothers are represented as powerless, helplessly dependent, and angelic. Historians, anthropologists, philosophers,
and the public at large are influenced by old cultural myths and stereotypes about childhood innocence and maternal affection as well as by their
opposites. The terrible power attributed to mothers is based on the perception that the infant cannot survive for very long without considerable
nurturing, love, and care, and historically that has been the responsibility
of mothers.
Whenever we try to pierce the meanings of lives very different from our
own, we face two interpretive risks. We may be tempted to attribute our
own ways of thinking and feeling to other mothers. Any suggestion of radically different existential premises (such as those, for example, that guide
selective neglect in Northeast Brazil) is rejected out of hand as impossible
and unthinkable. To describe some poor women as aiding and abetting the
deaths of certain of their infants can only be seen as victim blaming. But
the alternative is to cast women as passive victims of their fate, as powerless, without will or agency. Part of the difficulty lies in the confusion between causality and blame. There must be a way to look dispassionately at
the problem of child survival and conclude that a child died from mortal neglect, even at the mothers own hands, without also blaming the mother
that is, without holding her personally and morally accountable.
Attributing sameness across vast social, economic, and cultural divides is a serious error for the anthropologist, who must begin, although
cautiously, from a respectful assumption of difference. Here we want to
direct our gaze to the ways of seeing, thinking, and feeling that characterize these womens experience of being-in-the-world and, as faithful
Catholics, their being-beyond-this-world.
Seen in the context of a particular social world and historical reality,
the story of Lordes and Zezinho conveys the ambiguities of mothering on
the Alto do Cruzeiro, where mortal selective neglect and intense maternal attachment coexist. These same neglectful mothers can exclaim, as
Lordes did, that they live only for their grown children, some of whom
survived only in spite of them. In so doing, these women are neither hypocritical nor self-delusional.

Holding On and Letting Go

Sara Ruddick (1980) has suggested that although some economic and social conditions, such as extreme poverty or social isolation, can erode ma-

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Infanticide: Psychosocial and Legal Perspectives

ternal affection, they do not kill maternal love. Her understanding of

mother love carried resonances of Winnicott (1986) as she referred to the
metaphysical attitude of holdingholding on, holding up, holding close,
holding dear (Ruddick 1980).
But here I want to reflect on another set of meanings and practices of
mothering. Among the women of the Alto, to let go also implies a metaphysical stance of calm and reasonable resignation to events that cannot
easily be changed or overcome. I asked Doralice, an older woman of the
Alto who often intervened in poor households to rescue young and vulnerable mothers and their threatened infants, What does it mean, really,
to say that infants are like birds? She replied,
It means that . . . well, there is another expression you should know first.
It is that all of us, our lives, are like burning candles. At any moment we
can suddenly go out without warning [a qualquer momento apaga].
But for the infant this is even more so. The grown-up, the adult, is very
attached to life. One doesnt want to leave it with ease or without a struggle. But infants are not so connected, and their light can be extinguished
very easily. As far as they are concerned, tanto faz, alive or dead, it makes
no real difference to them. There is not that strong vontade to live that
marks the big person. And so we say that infants are like little birds, here
one moment, flying off the next. That is how we like to think about their
deaths, too. We like to imagine our dead infants as little winged angels flying off to heaven to gather noisily around the thrones of Jesus and Mary,
bringing pleasure to them and hope for us on earth.

Perhaps we should say hoped for by Doralice, because she added

this disclaimer: Well, this is what we say, this is what we tell each other.
But to tell you the truth, I dont know if these stories of the afterlife are
true or not. We want to believe the best for our children. How else could
we stand all the suffering?
And so, a good part of learning how to mother on the Alto includes
knowing when to let go of a child who shows that he or she wants to die.
The other art is knowing just when it is safe to let oneself go enough to
love a child, to trust him or her to be willing to enter the luta that is this
life on earth.

A Criana Condenada
What does it actually mean to let go of a baby? What is the logic that informs this traditional practice? Alto mothers spoke, at first covertly, of a
folk syndrome, a cluster of signs and symptoms in the newborn and
young baby that are greatly feared and from which mothers (and fathers)
recoil. Inevitably, premature death is in the cards for these babies, and par-

Culture, Scarcity, and Maternal Thinking

125

ents hope that it will be a rapid and not particularly ugly death. They
certainly do not want to see their little ones suffer. These hopeless cases
are referred to by the general and euphemistic terms child sickness
(doena de criana) and child attack (ataque de menino). Mothers avoid
repeating the specific and highly stigmatizing names or descriptions of
the conditions subsumed under child sickness and child attack. These
include gasto (wasted, spent, passive), batendo (convulsed), olhos fundos
(sunken eyes), doena de co (frothing, raving madness), pasmo (witless),
roxo (red), plido (white), susto (soul shocked), corpo mole (body soft, uncoordinated), and corpo duro (body rigid, convulsed).
The infant afflicted with one or more of these dangerous and ugly
symptoms is generally understood as doomed, as good as dead, or even as
better off dead. Consequently, little is done to keep him or her alive. The
sequelae of a folk diagnosis of child sickness may be understood as a folk
tradition of passive euthanasia, not uncommon to the people of the Alto.
The vast majority of all deaths occur in the first 12 months of life; the condemned child syndrome is in reality the condemned infant syndrome.

Difference and Danger: Stigma,

Rejection, and Death in Other Cultures
I approach the topic of stigma as it is related to child attack and child death
with some trepidation, for I do not wish to add to the burden of lives already pushed close to the margins of endurance. But fear and rejection of
certain condemned babies result in infant and child death on the Alto
do Cruzeiro. Stigma involves all those exclusionary, dichotomous contradictions that allow us to draw safe boundaries around the acceptable and
the desirable in order to contain our own fears about sickness, death and
decay, madness, and violence. These tactics of separation allow us to say
that this person is gente, one of us, and that person is other, barely human, if at all.
Cultural responses to defective newborns are varied. The African
Nuer studied by E. E. Evans-Pritchard (1956) referred to the physically
deformed infant as a crocodile child and to twins (another kind of birth
anomaly) as birds. Few Nuer twins or crocodile infants survived, and
when they died, Nuer said of them that they swam or flew away. Birds
return (or are returned) to air, and amphibious infants return (or are returned) to water, the medium in which each really belongs.
Elsewhere, physically different and stigmatized infants may be rejected as witch babies or as fairy children. Among the rural Irish of
West Kerry, old people still speak of changelings, sickly or wasted little

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Infanticide: Psychosocial and Legal Perspectives

creatures that the fairies would leave in a cot or a cradle in the place where
the healthy human infant should have been (Eberly 1988; ScheperHughes 2000). Irish changelings, like Nuer bird-twins, were often helped
to return to the spirit world from whence they came, in some cases by
burning them in the family hearth.
Carolyn Sargent (1987) studied birth practices among the West African Bariba of the Peoples Republic of Benin, where until very recently a
traditional form of infanticide was practiced to rid the community of
dangerous witches held responsible for all manner of human misfortune.
Witches were believed to present themselves at birth in the form of
various physical anomalies, among them breech presentation, congenital
deformity, and facial or dental abnormalities. Such infants were traditionally exposed, poisoned, or starved. When the Bariba came to live in ethnically diverse urban communities and to give birth in modern hospitals,
the killing of stigmatized witch infants was, of course, prohibited. Instead, such marked infants now live, carrying their stigmas with them and
suffering an inordinate amount of consequent physical abuse and neglect.
Witch babies grow up into witch children and, later, into community
scapegoats, blamed for all manner of unfortunate events.
Dorothy and Dennis Mull, a husband-wife, anthropologist-physician
team, worked in the mid-1980s among the Tarahumara Indians of the
Sierra Madre mountains in Mexico. The Mulls discovered a common
Tarahumara belief that gazing at an unattractive deformity can cause
susto, magical fright, and soul loss. The presence of physical abnormalities
put the whole community at risk of serious illness, so that allowing a
damaged neonate to die was understood as a kind of public health measure (Mull and Mull 1987).
In the Brazilian Amazon, infanticide was normatively practiced by some
Amerindian peoples in the interests of social hygiene. Today, the Brazilian
church and state intervene, as they do in most parts of the world. Nevertheless, Thomas Gregor reported that infanticide is still practiced today, although covertly, by the Mehinaku Indians in the case of twins, illegitimate
births, or infants with birth defects. At birth each infant is carefully examined: We look at its face, at its eyes, its nose, and at its genitals, its rectum,
its ears, its toes and fingers. If there is anything wrong, then the baby is forbidden. It is disgusting to us. And so it is buried (Gregor 1988).

Sacrifice and the Generative Scapegoat

Indeed, this is the very same advice that Dona Maria the midwife gives
to Alto mothers in cases of suspected child sickness or child attack in a

Culture, Scarcity, and Maternal Thinking

127

newborn. Dona Maria bases it on her own sad experience: It is harsh to

say this, but sometimes, I warn the new mother right away, This one we
wont need to wash, no.
The afflicted infant or small baby is isolated. She or he will often remain hidden away in the folds of a too-large hammock. Although slowly
starving to death, such babies rarely demand to be fed or held. Many such
babies die alone and unattended, their faces set into a final, startled grimacean ultimate sustothat they will take with them into their tiny
graves. A mothers single responsibility is to thrust a candle into the dying
infants hands to help light the path on the journey to the afterlife. After
the hurried burial of such a baby, the older children, who form the funeral
procession, come home and change their clothes to remove all traces of the
stigmatized illness.
I do not wish to suggest, however, that poor Brazilians are more prone
to stigmatizing the sick or the different than we are. Social life in rural
Northeast Brazil tends, if anything, to be more, rather than less, tolerant of
human difference than elsewhere. The sickly and the disabled who survive
childhood are, with few exceptions, well integrated into public and community life. Meanwhile, madness circulates freely in the marketplace and in the
downtown plazas of Bom de Jesus in the form of known and tolerated village fools, clowns, and madmen and madwomen. There is little to exclude
them from active participation in town life. What motivates the social exclusion and induced death of a criana condenada is not hate but sacrifice.
In a way, we can consider the offered-up angel-babies of Bom de Jesus as
prototypic generative scapegoats, sacrificed in the face of terrible domestic
conflicts about scarcity and survival. The Christian notion of the sacrificial
lamb provides a means of deriving meaning from the otherwise senseless
assertions women made to the effect that their babies had to die.
In such societies, where a 30%40% mortality is expected in the first
year of life, the normative practice of infanticideor weeding out, as it
werethe worst bets for survival enhances the life chances of healthier
siblings. From the safe distance of the affluent first world, it is difficult to
refrain from child saving efforts when our own cultural values promote
the idea of the intrinsic right to life of each individual person born, no
matter how malformed, how unattractive, or how frail. There is no intent
here to discredit these humanitarian values, but rather to suggest that
they are not universally shared and that they are context- and culturespecific. We might want to question the relatively greater stress (and value)
placed on the rescue of newborns and very young children over the rescue of older children, adolescents, and adults in our societyvalues that
I was unconsciously translating into practice in the Brazilian shantytown
context.

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Child Maltreatment
Korbin (1981) reported on cross-cultural patterns of child maltreatment
and found that child battering was rare or absent in sub-Saharan Africa, in
the South Pacific, among Native Americans in the North and South Pacific, and among Native Americans in North and South America. Conversely, Korbin noted in her introduction that intentional cruelty and
sadism toward toddlers and older children seem to be phenomena of more
technologically advanced industrial societies. The doomed neonate in traditional societies practicing infanticide is pitied, not hated. Some indigenous societies fail to recognize the sickly, deformed, or wasted infant as a
fully human creature. In contrast, child abusers in industrial societies perpetrate malicious child battering as a hostile attack on the defective child.
I would not want the reader to confuse the Brazilian shantytown practice of letting go a weak or sickly child born of an ethos of survivalist
triage with malicious child abuse in the United States that is sometimes
directed against an ungainly, unattractive, slow, or disabled child. Rather
than their behaviors being forced by economic exigency, the abusing parents in more affluent societies may simply feel themselves shamed or
otherwise reduced by the presence of less than excellent or beautiful or
below average children and may lash out in perverse anger at the offending child. It is also true, of course, that some parents are simply violent and abusive.

Conclusion
Anthropological thinking defies boundaries. Insights come to us by way
of cross-cultural juxtaposition, making the strange seem familiar and the
familiar seem strange. Cultural responses to birth defects are shaped by
reproductive and parenting goals that are themselves influenced by bioevolutionary, demographic, political, economic, and ecological constraints.
The ethnoeugenic infanticide practiced in some traditional societies in
response to the birth of infants viewed as anomalous, different, and dangerous has all but disappeared in the contemporary urban context, and the
vigilance of child protective service workers and clinicians has done much
to eradicate mortal forms of selective neglect directed against abnormal
children. Yet, the physical and psychological abuse of some of these stigmatized children remains a feature of societal life in the United States
(Gil 1970).
But what of mothering in an environment like the Alto where the risks
to child health and safety are legionso many, in fact, that mothers must

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129

necessarily concede to a certain humility, even passivity, toward a

world that is in so many respects beyond their control? Among the mothers of the Alto, maternal thinking and practice are often guided by another, quite opposite metaphysical stanceone that can be called, in
light of the womens own choice of metaphors, letting go. If holding has
the double connotations of loving, maternal care (to have and to hold),
on the one hand, and of retentive, restraining holding on or holding back,
on the other, letting go also has a double meaning. In its most negative
sense, letting go can be thought of as letting loose destructive maternal
power, as in child battering and other forms of physical abuse. But malicious child abuse is extremely rare on the Alto do Cruzeiro, where babies
and young children are often idealized as innocents who should not be
physically disciplined or restrained. But letting go in the form of abandonment is not uncommon on the Alto, and an occasional neonate is
found from time to time in a backyard rubbish heap.
But, ultimately, I remained frustrated. The folk category of child sickness was impossibly loose, fluid, elastic, and nonspecific. It was ambiguous. How could a mother be certain that she was dealing with a case of
nontreatable gasto as opposed to an ordinary case of pediatric diarrhea?
It might be suggested, somewhat provocatively, that the current epidemic of child abuse (from which physically different and unattractive children suffer more than their share) may actually represent, in
part, a paradoxical effect of the suppression of the former, traditional patterns of selective neglect directed against babies seen as ill-fated for survival. I have elsewhere explored the meanings and consequences of the
transition from traditional tolerant to contemporary child abuse tolerant societies (Scheper-Hughes 1987). The differences between allowing
certain neonates to die for economic, ecological, or ethnoeugenic reasons
in a traditional society and the hostile battering of a stigmatized child in a
modern industrialized society need to be emphasized. The two patterns
are not only distinct but nearly mutually exclusive. They represent the
difference between cultural norm and cultural pathology, between human exigency and malicious intent.

References
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Eberly SS: Fairies and the folklore of disability: changelings, hybrids, and the solitary fairy. Folklore 99:5977, 1988
Evans-Pritchard EE: Nuer Religion. Oxford, UK, Oxford University Press, 1956

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Infanticide: Psychosocial and Legal Perspectives

Gil DG: Violence Against Children: Physical Child Abuse in the United States.
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Gregor T: Infants are not precious to us: the psychological impact of infanticide
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Homans P: Comments on Nancy Scheper-Hughess Mother Love and Child
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Ruddick S: Maternal thinking. Feminist Studies 6:342367, 1980
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Scheper-Hughes N: Culture, scarcity, and maternal thinking: maternal detachment and infant survival in a Brazilian shantytown. Ethos 13(4):291317,
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Scheper-Hughes N: Death Without Weeping: The Violence of Everyday Life in
Brazil. Berkeley, University of California Press, 1992
Scheper-Hughes N: Saints, Scholars and Schizophrenics: Mental Illness in Rural
Ireland, New Expanded Edition. Berkeley, University of California Press,
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Scrimshaw S: Infant mortality and behaviour in the regulation of family size. Population and Development Review 4:383403, 1978
Winnicott DW: Home Is Where We Start From: Essays by a Psychoanalyst. New
York, WW Norton, 1986

Part

III

Contemporary
Legislation

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Chapter

Criminal Defense in Cases of

Infanticide and Neonaticide
Judith Macfarlane, J.D.

In those unhappy cases of the death of . . . children, as is every action

indeed that is either criminal or suspicious, reason and justice demand an enquiry into all the circumstances; and particularly to find
out from what views and motives the act proceeded. For, as nothing
can be so criminal but that circumstances might be added by the
imagination to make it worse; so nothing can be conceived so wicked
and offensive to the feelings of a good mind, as not to be somewhat
softened or extenuated by circumstances and motives. In making up
a just estimate of any human action, much will depend on the state
of the agents mind at the time; and therefore the laws of all countries make ample allowance for insanity. The insane are not held to
be responsible for their actions.
William Hunter, M.D., F.R.S.
Read to the members of the British Medical Society, July 14, 1783

The killing of an infant by its own mother is an act that at once captivates and repels popular attention. Flying in the face of mother love, infanticide both shocks common notions of decency and calls out for
punishment at law. Yet, many infanticides are committed not by women

The views expressed in this chapter are those of the author and not necessarily
those of The Council of The City of New York Office of the General Counsel.

133

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intent on callously ridding themselves of their children but rather by women

who are experiencing a psychosis precipitated by gross postpartum mental illness. That a woman suffered some form of mental illness at the time
of the killing calls into question her criminal culpability.
Postpartum mental illness has been the subject of study for centuries.
Modern debates center primarily on whether postpartum mental illnesses
can properly be considered as clinical entities, separate from other mental
disorders that may be experienced at any time by either men or nonpregnant
women (e.g., schizophrenia, affective psychosis). Whatever answer results
from this unfolding debate, the fact remains that observable, clinical symptoms of mental illness appear in some women during the puerperium. The
degree of that mental illness runs the gamut from psychosis arriving on the
heels of delivery to postpartum depression that may or may not be associated
with psychotic symptoms (see Chapter 3: Postpartum Disorders).
In some cases, the postpartum mental illness a woman suffers is so severe that it leads her to cause the death (either by affirmative act or by
omission) of her newborn or infant, turning her not only into a subject of
psychiatric interest but into a criminal defendant as well. In the United
States, a woman accused of killing her newborn or infant is typically charged
with some gradation of homicide. All homicide statutes contain a criminal intent requirement (mens rea) that the prosecution must prove beyond a reasonable doubt in order to obtain a conviction. For example, a
murder statute applied to a woman who kills her newborn or infant may
require that the prosecution show that she intentionally killed her infant
or newborn. Depending on the facts of her case, her defense attorney
may raise a number of defenses, such as involuntary act, diminished capacity, or insanity, in fighting the prosecutions intentionality claim.
These defenses are used to show that at the time of the killing, the woman
did not possess the level of intent to kill specified by the statute under
which she is prosecuted or that she was unable to refrain from the impulse to kill because her mental faculties were undermined by mental illness, namely a postpartum mental disorder.
In reviewing the facts of any given case of infanticide or neonaticide,
a defense attorney must take extreme care to ascertain whether his or her
client was suffering from any mental illness at the time of the killing so
that he or she may consider asserting a suitable defense to the crime.
Clearly, the final determination of whether the defendant actually suffered from one of these disorders can be made and attested to only by a
psychiatrist. However, the defense attorney is likely to be one of the first
individuals to come into contact with a woman accused of killing her infant or newborn and will be sufficiently informed of the facts surrounding the case to suspect mental illness as a potentially exculpating factor.

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Therefore, it is critical that the practitioner seeking to defend his or her

client in such a case be familiar with the psychiatric attributes frequently
apparent in cases of neonaticide and infanticide.
The aim of this chapter is to consider those mental illnesses consistently appearing in cases of neonaticide and infanticide within a framework of criminal law defenses in an effort to offer guidance to the defense
attorney exploring available defenses. In this chapter, I pay particular attention to those features that are most critical to establishing a defense of
diminished capacity, involuntary act, or insanity in a criminal trial. These
disorders will then be applied to the above-mentioned criminal law defenses to illustrate how they may work to undermine the prosecutions
claim that a woman intentionally killed her newborn or infant. A successful
defense would result in acquittal, conviction for a lesser offence, or a verdict of not guilty by reason of insanity or guilty but mentally ill.
Since homicide statutes in American jurisdictions are distinguished
only by degree, neonaticide and infanticide are not recognized as kinds of
homicide but rather are terms used informally to designate the victim
(see Chapter 1: A Brief History of Infanticide and the Law and Chapter 6:
Neonaticide). In this chapter, I maintain a distinction between infanticide and neonaticide, not only to highlight the unique clinical qualities
inherent in the two cases but also to identify the victim. The terms postpartum depression and postpartum psychosis are used to describe aggregate
symptoms often present in women who commit infanticide.

Clinical Considerations in
Neonaticide and Infanticide
Certain patterns have emerged from documented cases of neonaticide.
Typically, mothers who commit neonaticide are teenagers or young
women (Green and Manohar 1990). While neonaticides are most often
committed by women between the ages of 16 and 38, close to 90% of the
killings are committed by women under 25 years of age (Brockington
1996; Kaye et al. 1990). Another significant factor is the marital status of
the mother: less than 20% are married (Kaye et al. 1990). These women
usually have had no prior contact with the criminal justice system (Brockington 1996; Kaye et al. 1990). Studies indicate that women who commit
neonaticide do not suffer from any preexisting mental illness such as schizophrenia or depression and typically are not suicidal (dOrbn 1979;
Green and Manohar 1990; Kaye et al. 1990; Saunders 1989). Even more
striking than demographic similarities among women who commit neonaticide are the behavioral and psychological features apparent in this

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group. These features have been so consistent as to lead one group of

investigators to view them as falling within a discrete clinical entity
(Brozovsky and Falit 1971).
Certainly, the most significant similarity in cases of neonaticide is the
denial of pregnancy through psychotic or hysterical mechanisms
(Brockington 1996; Spinelli 2001). This denial occurs throughout the
pregnancy and, in some cases, even continues after childbirth. Although
in the case of a normal, albeit unsought, pregnancy the recognition of the
pregnancy is often delayed, some women accused of neonaticide continue
to disavow their pregnancy even through the childbirth itself (Brockington
1996; Finnegan et al. 1982; Jacobsen 1999).
Like neonaticide, infanticide horrifies our most basic sensibilities. However, it is clear that the postpartum mental illness suffered by some
women leads them to kill their infants during a period of psychosis. At
the outset, it is important to note that postpartum mental illness consistently evades tidy classification. Perhaps the most prominent reason for
this resistance is the plasticity of the illness and the waxing and waning
of its presentation: psychotic symptoms such as delusions and hallucinations may abruptly surface, followed by periods of deep depression, only
to be replaced with psychoses.
The delusions in postpartum psychotic depression are usually related
to pregnancy and childbirth are often accompanied by suspicion and
themes of possession (Attia et al. 1999; Brockington 1996; Hamilton et
al. 1992). These delusions, coupled with homicidal ideation (Wisner et
al. 1994), present great danger to the newborn or infant. Examples of delusions in these cases include the womans belief that she is being controlled by outside forces, that her thoughts are not her own and are
inserted into her mind by other people or beings, that the infant is the
devil incarnate, that the baby has not yet been born and is still within the
womb, and that the child is going to be kidnapped.
Hallucinations are also extremely common in these cases (Attia et al.
1999; Brockington 1996; Hamilton et al. 1992; Sneddon 1992). These
hallucinations are dangerous because they frequently involve themes regarding the death or murder of the infant (see Chapter 3). Hallucinations
may be auditory, visual, tactile, or olfactory (Attia et al. 1999). Command hallucinations, typically auditory, may direct the woman to kill
herself or her infant. Visual hallucinations can take the form of, for example, a smoke- or fire-filled room and can lead the woman to believe
that her baby will die if not rescued, causing her to throw her baby in water in an attempt to save him or her. As is the case with delusional thinking, hallucinations can act as the precipitating event leading to the death
of an infant when a mother acts on the basis of those hallucinations.

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Perhaps the most remarkable aspect of postpartum psychotic depression is its lability. Symptoms are those of an organic psychosis associated
with confusion, delirium, and marked mood changes characteristic of depression or panic (Attia et al. 1999; Hamilton 1992).

Neonaticide and Infanticide as

Criminal Acts
Punishment for neonaticide and infanticide is almost as old as the crimes
themselves. At first widely accepted (if not encouraged) on eugenic grounds
(Kumar and Marks 1992) and pressures of overcrowding and overpopulation (Kaye et al. 1990), infanticide slowly became the subject of legal
censure. Arguably more a mechanism for regulating the sexual behavior
of women than for curtailing high rates of infant deaths at the hands of
their mothers, neonaticide and infanticide prosecutions yielded varied
punishments, from diets of bread and water for 1 year (Kumar and Marks
1992) to penance terms of 15 years, public whippings (Brockington 1996),
or execution.
In countries such as England and Canada, women accused of neonaticide or infanticide are prosecuted under statutes that specifically address
those crimes. Prosecution of women under these statutes has resulted in
lenient sentencing, with probation and psychiatric treatment as common
outcomes (Oberman 1996). Indeed, no woman found guilty of infanticide has been incarcerated in England for over 50 years (Barton 1998).
Similar statutes making infanticide a lesser crime than murder have been
enacted around the world: Austria, Colombia, Finland, Greece, India, Italy, Korea, New Zealand, New South Wales, the Philippines, Tasmania,
Turkey, and Western Australia all have statutes whose effect is to recognize infanticide as a less culpable form of homicide (Oberman 1996).
In the United States, early laws regarding infanticide focused primarily on determining punishment, usually quite harsh, for infanticidal
mothers. The gradual evolution from harsh punishment in cases of infanticide to more lenient treatment of these women, similar to those reforms
in England and across the world, has not yet occurred in American jurisdictions. The failure of American law to evolve toward a more lenient
treatment of infanticidal women reflects a larger problem than simple
ambivalence toward how these women are treated by the criminal justice
system, although that is certainly a factor. As a nation comprising numerous autonomous states, no single sweeping reducing statute comparable
to the amended and expanded British Infanticide Act of 1938 can be established, since each state has the power to adopt criminal laws within its

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jurisdiction as it sees fit. Hence, unlike their British counterparts, American mothers accused of killing their infants have never enjoyed a single
law uniformly applied throughout the United States that automatically
reduces the degree of homicide in cases of infanticide or neonaticide from
murder to manslaughter. To date, no American state has a statute similar
to the British Infanticide Act. Thus, in cases in which a woman has been
suspected of killing her infant or newborn, criminal charges have ranged
from first-degree murder, a felony, to the unlawful disposal of a corpse, a
misdemeanor (Oberman 1996).
Since no de jure acknowledgment of the special nature of these killings and their relationship to postpartum mental illness exists in the
United States, American women have had to expose that reality themselves on a case-by-case basis. That is, in order to submit evidence that
would tend to negate the prosecutions claim that she acted with an intent to kill, an American woman accused of killing her newborn or infant
while suffering from a postpartum mental illness must raise a defense
such as insanity or diminished capacity. In the following subsection, I discuss the treatment of neonaticide and infanticide in American courts by
way of several case studies.

Neonaticide in the Courts

Despite its relatively common occurrence, neonaticide has generated little case law. One explanation for this dearth may be that the bodies of
dead newborns are rarely discovered because of the secret nature of their
disposal. Another explanation may be that a neonaticide is difficult to attribute to any one person when the pregnancy was not, for whatever reason, disclosed or apparent to others. Indeed, one researcher was able to
give the identity of the mother of a dead and discarded newborn in few
er than half of 62 cases (Brockington 1996). Many neonaticides remain
unpublicized because the cases disappear through the pretrial plea-bargaining process or because of poor media coverage (Oberman 1996,
p. 26). Even when cases are decided and appealed, the court may have
failed to issue a written opinion. Finally, the scarcity of appeals in these
cases may reflect . . . that the outcomes are relatively lenient (Oberman
1996). Given the stakes involved in a retrial, a woman convicted of neonaticide who is sentenced to community service, probation, or counseling has no real incentive to appeal. The following is a summary of two
reported cases of neonaticide.
Having complained of intense menstrual cramps, a 15-year-old, Ms. Doss,
gave birth alone in the bathroom of her home (her mother was at the
store buying menstrual provisions for her daughter). When Dosss mother

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returned home, she heard small cries coming from the kitchen. She discovered a newborn baby wrapped in plastic and placed on top of a trash
can. Dosss mother promptly brought her daughter and the newborn to
the hospital. At the hospital, the newborn died of multiple stab wounds
inflicted to its chest.
At her trial, Doss claimed that she had been unaware of her pregnancy until she began her eighth month because she had continued to
menstruate until that point. Her mother also denied knowledge of the
pregnancy. The trial court concluded that the wounds had not occurred
as a result of her attempts to detach the umbilical cord from the newborn
and that Doss had intentionally stabbed the newborn. Doss was convicted
of first-degree murder and sentenced to 30 years in prison.

On appeal to the Appellate Court of Illinois (People v. Doss 1987),

Doss challenged her conviction on several grounds. First, she contended
that the prosecution had supplied insufficient evidence to support a conviction of first-degree murder and that she should instead have been convicted
of involuntary manslaughter, which carried a far less lengthy sentence. The
court rejected her argument, stating that the Illinois first-degree murder
statute required a mental state that showed that in performing the acts
that cause[d] death, [the] accused kn[ew] that such acts create[d] a strong
probability of death or great bodily harm (People v. Doss 1987). The
court construed the statute to mean that the prosecution needed to show
not that Doss had specifically intended to kill the newborn, but rather
that the action was voluntarily and willfully done and would naturally
lead to the newborns death (People v. Doss 1987). The court concluded
that the stab wounds were not the result of an attempt to detach the
umbilical cord, but instead had been intentionally dealt by Doss and constituted sufficient evidence to support that the acts leading to the newborns death had been voluntarily and willfully done.
Doss also argued that her conviction should be reduced from firstdegree to second-degree murder on a justification theory. Doss asserted
that the shock and fear of family disgrace (People v. Doss 1987) created
by the delivery and birth of the newborn led her to unreasonably believe
that the killing of the newborn was justified. The court held that a reduction of Dosss conviction of first-degree murder to second-degree murder
under a justification theory could occur only if she was able to prove that
either she was acting under a sudden and intense passion resulting from
serious provocation, or she believed the circumstances, if they existed,
justified the killing (People v. Doss 1987). However, the court dismissed
her argument that she was acting under the heat of passion once confronted by the reality of the birth, holding that a young child cannot
cause the serious provocation required of second-degree murder (People
v. Doss 1987). Dosss conviction was upheld.

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Bernadette Reilly gave birth unattended to a baby girl. She spent the remainder of the day of the delivery in her bed, weak from continuous bleeding. Her landlady persuaded her to go to a hospital later that evening. On
examination, hospital staff realized that she had just given birth hours before. Reilly denied having given birth to the hospital staff and the police.
A subsequent search of her room unearthed her dead newborn wrapped
in a garbage bag, along with a pair of scissors and a book on childbirth.
During subsequent questioning, Reilly admitted to giving birth to the
child but that the baby did not move or cry after being born. Reilly said
that she shook the baby to try to revive it, but it never awoke. An autopsy
revealed that the newborn died from injuries inflicted by a blunt object.
Reilly was charged with criminal homicide and child endangerment.

At her trial, Reilly asserted the insanity defense and presented two
psychiatrists who each testified that Reilly suffered a brief reactive psychosis at or immediately following the birth, causing her to break from
reality (Commonwealth of Pennsylvania v. Reilly 1988). Both psychiatrists concluded that Reilly was insane at the time of the newborns
death. The prosecution did not present any evidence rebutting Reillys
insanity defense. Nonetheless, her defense was rejected by the trial court,
and she was found guilty of third-degree murder and child endangerment. She was sentenced to 310 years in prison. The Supreme Court of
Pennsylvania affirmed her conviction.

Infanticide in the Courts

The earliest reported case in which a postpartum mental disorder was
used as the basis of an insanity defense is the 1951 case of State v. Skeoch:
Dorothy Skeoch was accused of suffocating her 6-day-old baby when he
was found dead with a diaper tied around his neck. Skeoch was charged
with murder. Initially, Skeoch maintained that a robber had broken into
her house, whereupon she fainted and awoke to find some of her possessions stolen and her baby with a diaper tightly tied around his neck. However, when further questioned by the police, Skeoch confessed to killing
the infant. At her trial, Skeochs husband and mother-in-law testified that
she appeared to be insane immediately after the birth of the infant and
on the day of his death. Moreover, a neurologist and psychiatrist testified
that she was suffering from postpartum psychosis with infanticide, a
mental disorder that frequently occurs with the delivery of a child. (State
v. Skeoch 1951)

Notwithstanding this testimony, Skeoch was convicted of murder and

sentenced to 14 years in prison. On appeal, her conviction was reversed by
the Supreme Court of Illinois on the grounds that the prosecution failed to
rebut Skeochs claim of insanity. The court held that even though there

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is a governing presumption of sanity in all cases, once Skeoch admitted

evidence sufficient to raise a reasonable doubt as to her sanity at the time
of the crime, the presumption of sanity no longer applied, and the State
was required to show that she was sane beyond a reasonable doubt as a
necessary element of the crime (State v. Skeoch 1951).
The following summarizes a widely publicized California case tried in
1987:
Sheryl Massip threw her 6-week-old infant in front of a moving car. When
the driver of the car swerved and avoided the baby, Massip drove over the
infant herself. She threw the corpse in a garbage can. At first, Massip told
the police that her infant had been kidnapped, but later she confessed to
having run over her infant.
At trial, it was revealed that Massip had been suffering from extreme
mental illness in the 6 weeks after the birth of her child. Her infant cried
frequently, causing Massip to be confused and to have feelings of worthlessness and inadequacy because she could neither determine the cause of
his crying nor make his crying stop. After experiencing a seizure, Massip
spent a weekend at her mothers house, where she experienced visual and
auditory hallucinations. She continued to have these hallucinations upon
her return home. On the day of the killing, she took her son on a walk.
While walking, she heard voices telling her the baby was in pain and to
put him out of his misery; she felt as if she were in a tunnel and everything
was moving slowly. She was watching her own actions from outside herself (People v. Massip 1990). Massip then threw the infant in the path
of an oncoming car. When the car avoided the baby, Massip picked him
up and walked with him, but did not remember what he looked like. At
this time she saw him as a doll or an object, not a person (People v. Massip 1990). She brought the baby to her own car and ran him over.

Massip was charged with second-degree murder. She entered two pleas,
not guilty and not guilty by reason of insanity. After 6 days of deliberation, the jury found her guilty of second-degree murder, finding that she
was sane at the time of the offense (Barton 1998). Massip moved for a new
trial, and the trial court reduced her conviction from second-degree murder to voluntary manslaughter. The court additionally set aside the [previous] finding of sanity, entering a new finding of not guilty by reason of
insanity (People v. Massip 1990). This judgment was affirmed, and Massip was required to attend an outpatient treatment program.

Criminal Law Defenses

Because our criminal law requires that a culpable state of mind be proven
to justify a conviction, defenses such as insanity, diminished capacity, and
the involuntary act are available to a defendant to counter the prosecu-

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tions proof of criminal intent and either negate the mens rea (guilty
mind) element of the crime charged, show that the defendant did not
know what she or he was doing at the time of the act, or simply show that
the defendant was unable to control her or his behavior. Evidence to this
effect ultimately compels the trier of fact (the judge or jury hearing the
case) to decide that the defendants true state of mind at the time of the
offense was not criminally blameworthy and therefore does not meet the
mental element required for a conviction (Table 81).
Table 81.

Criminal law defenses

Defense

Requirements

Insanity
MNaghten
Cognitive focus

At the time of the crime, the defendant suffered a

mental disease, disability, or defect that caused her to:
Not know right from wrong;
OR
Fail to appreciate the nature and quality of her actions.

Model Penal Code At the time of the crime, the defendant suffered from a
Cognitive /
mental disease, disability, or defect that caused her to:
volitional focus
Lack substantial capacity to appreciate the criminality
of her conduct;
OR
Fail to conform her conduct to the requirements of the
law.
Involuntary act

At the time of the crime, the defendant suffered from

a mental disease, defect, or disability that caused
conduct that was not a product of her deliberate
effort.

Diminished capacity

At the time of the crime, the defendant suffered from a

mental disease, defect, or disability. Since she suffered
from such as disease, defect, or disability at the time
she committed the act, she was incapable of forming
the intent (e.g., specific intent to kill, malice aforethought, premeditation) required by the statute under
which she is prosecuted.

The literature on postpartum mental illness makes a convincing case

that women who kill their newborns and infants suffer from distinct and
recognized mental disorders at the very time of the killing. These disorders
bear directly on the mothers ability to form the mens rea required for a
conviction under any given homicide statute. Successful use of the involuntary act, diminished capacity, or insanity defenses works to undermine

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the proof of mens rea mounted by the prosecution and thus reduces the
offense under which the defendant can be convicted, serves as a mitigating factor at the time of sentencing, or even leads to acquittal. These defenses are affirmative defenses, which place the burden on the defendant
to raise the defense and, depending on the jurisdiction, to prove it by
some considerable degree (usually by a preponderance of the evidence)
(Robinson 1984).

Involuntary Act
The involuntary act defense, or automatism, is presented when a criminal
act occurred at the precise moment when, because of a physical or mental
disability, the person accused of the criminal act was unable to control her
or his actions. A typical example of a crime committed involuntarily is the
person who kills while sleepwalking. A defendant who asserts the involuntary act defense is essentially claiming that the action causing the criminal
act was performed without a connection between her muscles and her
mind (Robinson 1984). Although the specific formulation of the defense
differs between jurisdictions, it can be summarized as such: An actor is excused for his conduct constituting an offense if, as a result of (1) any mental
or physical disability, (2) the conduct is not a product of the actors effort
or determination (Robinson 1984, p. 260). The involuntary act defense is
recognized in almost every American jurisdiction (Robinson 1984).
It is critical that the defense establish proof of a disability, as it makes
the punishable conduct blameless because it was in no way intended by
the actor. However, since the number of physical and mental disabilities
that may bring about an involuntary act is virtually limitless, an exhaustive list of qualifying disabilities does not exist (Robinson 1984). This
lack of specificity
might be justified on the ground that the lack of control in many involuntary act cases is so complete and dramatic that no other requirement is
needed to assure blameworthiness. It is irrelevant whether the muscular
movement comes from a grand mal seizure or from a reflex action. Such total lack of volition is an obvious and convincing ground for exculpation.
(Robinson 1994, pp. 897898)

Hence, the disabilitys severity is scrutinized to determine whether the

lapse in control rises to a level that makes the defendant blameless.
Instances of unconsciousness (People v. Newton 1970) and dissociative
states (People v. Lisnow 1978) have been accepted by courts as severe
enough to satisfy the disability requirement imposed by the involuntary act
defense (Robinson 1984).

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Diminished Capacity
The diminished capacity defense involves the defendants use of a mental
disease or defect to negate the mens rea element of the crime charged
(Robinson 1984). Diminished capacity is a failure-of-proof defense,
meaning that the mental disease or defect claimed by the defendant
made it impossible for her or him to formulate or possess the mental state
required for a conviction under the statute with which she or he is charged
(Robinson 1984). Consider, for example, a woman who is charged with
first-degree murder for the death of her 6-week-old infant in a state that
defines first-degree murder as premeditated. It may be shown that during
the 6 weeks leading up to the infants death and during the infants death
itself, the woman was experiencing severe hallucinations and psychoses,
making it impossible for her to plan and premeditate her infants murder.
When a defense of diminished capacity is successful, the final result is the
mitigation or elimination of criminal culpability, since the prosecution cannot show that the defendant possessed the requisite criminal intent beyond a reasonable doubt (Barton 1998). Thus, diminished capacity is
employed by a defendant to show that, because of a mental disease or defect, she did not have capacity to form the intent specified by criminal
statute under which she is charged, thereby negating the mens rea element of the crime.
In most cases, however, the diminished capacity defense offers but a
partial victory, since most homicide statutes engulf lesser-included
offenses that contain lesser culpability requirements (Robinson 1982,
p. 475). Therefore, the failure of proof of the greater offense often leads
to a conviction based on the lesser offense (e.g., murder to voluntary
manslaughter). In the rare instance when there is no lesser included offense, or if the mental illness also negates an element of any lesser included offense, the mental illness will prevent conviction altogether
(Robinson 1982, p. 476).

Insanity
Although controversial, the insanity defense, in one form or another, is recognized by all American jurisdictions. In honoring insanity as an excuse
to criminal conduct, our society has recognized . . . that none of the
three asserted purposes of the criminal lawrehabilitation, deterrence
and retributionare satisfied when the truly irresponsible, those who
lack substantial capacity to control their actions, are punished (United
States v. Freeman 1966). Thus, despite frequent and vehement attacks,
such as the one mounted in the wake of the Hinckley verdict of not guilty

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145

by reason of insanity after Hinckleys shooting of President Ronald Reagan, the insanity defense has been preserved and is generally seen as
essential in a system that punishes only when moral responsibility is
present.
The two main formulations of the insanity defense used by American
jurisdictions are the MNaghten test (MNaghtens Case 1843) and the
Model Penal Code/American Law Institute (MPC) test (Model Penal
Code 1985).

MNaghten
The MNaghten test, or the right and wrong test, was derived from the
landmark English case of the same name decided in 1843. Under MNaghten, to raise a successful insanity defense, the defendant must clearly prove
that at the time of the committing of the act, the party accused was laboring under such a defect of reason, from disease of the mind, as not to
know the nature and quality of the act he was doing; or, if he did know
it, that he did not know he was doing what was wrong (MNaghtens
Case 1843). The focus of the MNaghten test involves nothing other than
the cognitive capacity of the defendant to appreciate her actions. A defendant is judged insane only if she can prove that, because of a mental
disability, she either did not know right from wrong at the time she committed the ultimately criminal act or did not understand the nature and
quality of the act.
Despite criticisms that the test is too rigid, many states continue to
use the MNaghten rule as their test for insanity. Some few jurisdictions,
such as Tennessee, have broadened MNaghten by adding the irresistible
impulse test, which relieve[s] [one] of criminal responsibility when his
mental condition is such as to deprive him of his will power to resist the impulse to commit the crime (Graham v. State 1977).

Model Penal Code

The MPC provides that [a] person is not responsible for criminal conduct if at the time of such conduct as a result of mental disease or defect
he lacks substantial capacity either to appreciate the criminality [wrongfulness] of his conduct or to conform his conduct to the requirements of
law (Model Penal Code 1985). The MPC approach has been adopted by
about half of the states and the majority of the federal circuit courts of
appeal (Robinson 1984). The approach to insanity in the MPC enjoys
widespread appeal because it views the mind as a unified entity and
recognizes that mental disease or defect may impair its functioning in
numerous ways (United States v. Freeman 1966), as opposed to the com-

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partmentalizing vision of MNaghten. Thus, one prong of the MPC test

focuses on cognitive aspects of behavior, while the other focuses on volitional aspects of behavior.
Therefore, evidence that a mental disorder suffered at the very moment
of the crime caused the defendant to lack the substantial capacity to appreciate the wrongfulness of her or his conduct satisfies the cognitive aspect
of the MPC test. Alternatively, proof that a mental disease or defect left the
defendant unable to conform her or his conduct to the requirements of the
law, notwithstanding any recognition on the defendants part that what she
or he was doing was wrong, satisfies the volitional prong of the MPC test.
The satisfaction of either the cognitive or the volitional prong is grounds for
an insanity verdict in a MPC jurisdiction.
Involuntary act, diminished capacity, and insanity are defenses that
can be used by a woman accused of causing the death of her infant or
newborn while she was suffering from a postpartum mental disorder.
Both the MNaghten and the MPC tests require that the defendant have
a medically recognized mental disorder at the time of the offense to support the assertion that her conduct was not criminally culpable and therefore blameless (Robinson 1984). This disability requirement lends the
necessary credibility to this objectively unconfirmable claim of abnormality (Robinson 1984, p. 287). The recognition of the disability by both the
medical profession and the public at large (namely, a jury) serves a dual
purpose: On the one hand, the disability requirement provides the basis
for excusing the defendant of criminal liability for her actions in her particular case; on the other hand, the disability requirement serves as a limited
exception to the general proscription against criminal behavior, thereby
preserving that very prohibition of conduct in persons of sound mind
(Robinson 1984).

Using DSM to Satisfy the Disability

Requirements in Criminal Defenses
In this section, I discuss postpartum mental disorders apparent in cases of
infanticide and neonaticidedisorders that may serve to satisfy the disability requirement in the involuntary act, diminished capacity, or insanity
defenses. This discussion is not intended to be exhaustive and is limited to
aspects of the disorders that are germane to asserting one of the abovediscussed defenses.
The involuntary act, diminished capacity, and insanity defenses require that a mental disability be proved. Although professional recognition of the disability is not, by itself, dispositive of whether a defendant

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is ultimately judged to be mentally unsound at the time of the crime for

legal purposes, courts require that the mental disability claimed by the
defendant be one that is recognized by the psychiatric community. For
example, in Stephanie Wernicks case (described later in this section), the
court refused to hear evidence of neonaticide syndrome because it had
not yet been generally accepted in the field of psychiatry (Barton 1998).

DSM-IV and the Postpartum-Onset Specifier

The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition
(DSM-IV) is a classification of mental illness developed for use by clinicians in diagnosing mental disorders in their patients. Compiled by the
American Psychiatric Association, DSM-IV reflects a consensus about
the classification and diagnosis of mental disorders (American Psychiatric
Association 1994). (A text revision of DSM-IV, referred to as DSM-IV-TR,
was published in 2000 [American Psychiatric Association 2000].) Although DSM-IV cautions that clinical diagnosis of a DSM-IV mental
disorder is not sufficient to establish the existence for legal purposes of a
mental disorder, mental disability, mental disease, or mental defect
(American Psychiatric Association 1994, p. xxiii), the mental disorders
listed in DSM-IV are routinely used and relied on by lawyers, expert witnesses, and judges in making that determination.
Notwithstanding considerable evidence that postpartum mental illnesses are marked by symptoms peculiar only to them (Kumar and Marks
1992), and that we may observe the common usage of terms such as postpartum depression and postpartum psychosis by practitioners around
the country (Hamilton et al. 1992), these conditions have not yet been
fully recognized by the American Psychiatric Association as discrete mental illnesses capable of providing a differential diagnosis. Instead, they are
officially regarded as mental disorders with postpartum onset. Similarly,
although the literature on neonaticide has identified an aggregation of
psychiatric symptoms that defines these cases, neonaticide syndrome has
not yet been recognized in the DSM system.
The association between childbirth and maternal mental illness has,
however, been formalized by the American Psychiatric Association in
DSM-IV. The American Psychiatric Association formalized that associationan association wholly lacking in previous editions of the manual
by including a postpartum-onset specifier for a number of mood and psychotic disorders catalogued in DSM-IV. Currently, episodes of several
disorders are considered to have a postpartum onset if they occur within
4 weeks of childbirth (American Psychiatric Association 1994). In its
discussion of the postpartum-onset specifier, DSM-IV points out that

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postpartum mental illness is more commonly labile than nonpostpartum

cases. However, although DSM-IV includes only a postpartum-onset
specifier for these cases, it discusses aspects of postpartum mental illness
in other than temporal terms. For example, DSM-IV also points to the
frequent presence of delusions (e.g., believing that the infant is the devil),
suicidal ideation, and obsessional thoughts regarding violence to the child
in these cases (American Psychiatric Association 1994). The postpartumonset specifier is the most recent consensus in the debate over the presence of unique phenomenology of severe postpartum psychiatric illness
(Miller et al. 1999).
Since postpartum psychosis and neonaticide syndrome do not exist as
officially recognized disorders, they cannot be used, standing alone, to
satisfy the disability requirement in any of the criminal law defenses discussed earlier. However, the neonaticide literature indicates that the disorders appearing in cases of neonaticide share features with a number of
disorders, including depersonalization disorder, dissociative identity disorder not otherwise specified, and brief psychotic disorder. Similarly,
infanticide frequently is committed by women with major depressive disorder, bipolar mood disorder, or major depressive disorder with psychotic
features that include the above-mentioned postpartum-onset specifier.
These disorders are listed in DSM-IV as recognized mental disorders and,
as such, can be used to satisfy the disability requirement in the criminal
law defenses. Since they are recognized as distinct disorders in the psychiatric community, they are powerful tools in establishing the mental
disability, disease, or defect necessary to plead a defense such as insanity
or to prove involuntariness or diminished capacity. The relationship
between these mental disorders and criminal law defenses is described
below.

Application of Disabilities Featured in

DSM-IV to Criminal Defenses
The neonaticide literature is replete with showings of cognitive impairment,
delusions, automatism, disorientation, hallucinations, grossly disorganized
behavior, and catatonia. These behaviors are symptomatic of depersonalization and brief psychotic disorder and can serve as the mental disease
or defect that negates the mens rea required for first-degree murder (e.g.,
the defendant, in a catatonic state, could not have the capacity to form
the intent required for first-degree murder).
Depersonalization disorder can be asserted as the disability required to
plead the involuntary act defense. Depersonalization disorder is the expe-

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149

rience of persistent or recurrent episodes of depersonalization, changed

self-perception, dreamlike states, and an inability to control behavior.
These symptomsbeing an automaton, feeling like an outside observer
of mental and physical efforts, and experiencing the sensation of lacking
control of ones actionsfit squarely within the involuntary act defense.
Thus, when a review of the facts of a neonaticide reveals that at the time
of the killing the woman suffered depersonalization disorder, the involuntary act defense should be raised. It should be argued that the dissociative state (depersonalization disorder) is a mental disability that makes
the killing of the neonate not the result of the womans effort or determination. As such, the womans conduct is excused because it was not
within her control. Since the involuntary act defense provides a complete
defense to a crime (People v. Newton 1970), a woman who raises a successful involuntary act defense should be acquitted and excused of all
criminal liability.
Depersonalization disorder can also be used to fulfill the disability requirement in an insanity defense in a jurisdiction that follows the MPC
approach to insanity. Since depersonalization disorder may cause a woman
to be unable to control her actions and behavior, a woman can assert that,
as a result of mental disease or defect (depersonalization disorder), she
lacked the substantial capacity to conform her conduct to the requirements of law. If this is proven to the satisfaction of the jury, the woman
may be found insane under the MPC.
When a defendant asserts the defense of diminished capacity, she
need only show evidence that, because of a mental disease or defect, she
was unable to form the requisite intent to commit the crime charged. For
example, since neonaticides are often brought on first-degree murder
charges, a diminished capacity defense would work to introduce evidence
of a mental disease or defect, which would show that the defendant did
not have the capacity to form the intent statutorily required for a firstdegree murder conviction.
Major depressive disorder with or without psychotic features, bipolar disorder, or schizophrenia may include symptoms such as delusions, hallucinations, and disorganized speech or behavior. In an infanticide case, a
defendant can use one of these disorders to establish the disability requirement in her defense of diminished capacity or insanity under MNaghten or
the MPC. For example, a woman suffering from hallucinations and delusions may be assessed as having had a psychotic disorder at the time of
the killing of the infant. If so, she may use that disorder to satisfy the disability requirement in a claim of diminished capacity or insanity.
In a MNaghten jurisdiction, if the woman can show that, because of
a defect of reason or disease of the mind, she did not know right from

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wrong at the time of the crime or that she did not understand the nature
and quality of her act, she will be judged legally insane. In an MPC
jurisdiction, evidence of a psychotic disorder is useful to satisfy either the
volitional or the cognitive aspect of the MPC test. The cognitive impairment demonstrated in the literature on postpartum psychosis (e.g., hallucinations, delusions or disorganized behavior) is clearly relevant as to
whether the defendant had the substantial capacity to appreciate the
criminality of her conduct. Similarly, the volitional aspect of the MPC
test can also be satisfied by a defense based on a psychotic disorder, because a woman with such a disorder can be expected to act on the basis
of delusions, an impairment of ones ability to conform ones conduct to
the law.
A psychotic disorder can be used as the foundation of the diminished
capacity and insanity defenses in a case of infanticide or neonaticide.
When the diminished capacity defense is employed, the defendant need
only show evidence that, because of a mental disease or defect, she was
unable to form the requisite intent to commit the crime charged. For
example, since neonaticides and infanticides are often brought on firstdegree murder charges (Oberman 1996), a diminished capacity defense
using a psychotic disorder as the requisite disability would work to show
that the defendant did not have the capacity to form the intent statutorily
required for a first-degree murder conviction, such as premeditation.
As described earlier, an insanity defense in a MNaghten jurisdiction
focuses on the cognitive capacity of the defendant. Generally, if the defendant can show that, because of a defect of reason or disease of the
mind, she did not know right from wrong at the time of the crime or that
she did not understand the nature and quality of her act, she will be judged
legally insane. Evidence of a psychotic disorder is probative of the issue
of the defendants state of mind at the time of the infanticide. DSM-IV
includes delusions and hallucinations and disorganized behavior as criteria for a diagnosis of brief psychotic disorder of postpartum onset. Critically, and especially with regard to the requirements of the MNaghten
test, DSM-IV suggests that supervision of the individual may be necessary to protect the individual from the consequences of poor judgment,
cognitive impairment, or acting on the basis of delusions (American Psychiatric Association 1994, p. 302; emphasis added). DSM-IV does not
provide a detailed list of the stressors that commonly lead to such a disorder, but it does note that [t]he precipitating event(s) [of the psychotic
break] may be any major stress and adds that the diagnosis should note
whether the psychotic break occurred within 4 weeks postpartum
(American Psychiatric Association 1994, p. 302).

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The MPC test has both a cognitive aspect and a volitional aspect, the
satisfaction of either being grounds for an insanity verdict. The cognitive
aspect rids the defendant of criminal responsibility when it can be shown
that the defendant suffered from a mental disease or defect that caused
her or him to lack the substantial capacity to appreciate the wrongfulness
of her conduct. The volitional aspect rids the defendant of criminal responsibility when it can be shown that, because of a mental disease or defect, the defendant was unable to conform her or his conduct to the
requirements of the law.
Evidence of a psychotic disorder, such as brief psychotic disorder, is
useful to satisfy the cognitive aspect of the MPC test. The cognitive impairment demonstrated in the literature and acknowledged by DSM-IV
(e.g., hallucinations, delusions) is relevant to whether the defendant had
the substantial capacity to appreciate the criminality of her conduct. Similarly, the volitional aspect of the MPC test can be satisfied by a defense
also based on the presence of a psychotic disorder. Case studies suggest
that although many of the homicides are actively and positively inflicted
by the mother, in many cases the mother fails to rescue her baby from a
toilet or is unable to move subsequent to the delivery and thus leaves the
child to die. Similarly, depersonalization disorder may be a good defense
under the MPCs volitional approach, since this dissociative state leaves the
mother with the sensation that she is unable to control her own movements (e.g., sensory anesthesia, sensation of lacking control over ones
own actions).

Emergence of a Neonaticide Syndrome?

Case Illustration
A New York State court was the first to discuss, in the case summarized
below, the aggregate symptoms commonly present in cases of neonaticide (e.g., denial, dissociation) as a potential neonaticide syndrome.
Stephanie Wernick, a student living in a college dormitory, awoke several
times one night because she was bleeding heavily (Wernick Brief 1996).
Throughout the night, Wernick went to the bathroom to tend to the
bleeding, which she attributed to heavy menstruation. Two dorm residents heard quiet cries coming from the bathroom and went to investigate. They found Wernick in a bathroom stall, standing in a pool of blood.
When they asked whether Wernick was sick, she replied that she was fine
and asked them to get her a tampon. She stayed in the stall for an extended period, during which time her friends checked on her. Later, her
roommate found her in the shower. Wernick later asked her to dispose of

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an untied bag that she said was filled with her soiled clothes. Unbeknown
to the roommate, the bag contained the body of a newborn boy. When
Wernick finished her shower, she went to her room, leaving the bathroom
without cleaning the blood from the floor. She went to bed and, since she
had not yet delivered the placenta, continued to bleed through the night.
Later that night, a college custodian found the bag containing the
newborn. He called the police. Given the dramatic events of the night,
the bag was easily traced back to Wernick. The first police officer on the
scene (who was also an emergency medical technician) described Wernick as appearing in shock, pale green [in] appearance[,] agitated, shivering while wrapped up in a blanket in a room described as very hot, lying
in bed with blood on the sheets (Appellate Brief on Behalf of DefendantAppellant Stephanie Wernick 1996). Despite the urging of her friends,
Wernick refused to go to the hospital, stating that she had to take a final
exam in the morning. Eventually, she consented to be taken to the hospital by ambulance. While in the ambulance, Wernick began to speak about
the delivery and told the ambulance technician that she delivered a baby
in the toilet, wrapped the baby in a pink towel, cleaned herself up with
toilet paper, took a shower[,] and when she came out of the shower, the baby
was gone. (Appellate Brief on Behalf of Defendant-Appellant Stephanie
Wernick 1996)

Wernick was charged with first- and second-degree manslaughter. At

her trial, the prosecution offered evidence that Wernick had asphyxiated
the newborn by stuffing toilet paper down his throat (People v. Wernick 1995). Her attorney asserted the insanity defense, claiming that she
lacked substantial capacity to know and appreciate the nature and consequences of her conduct or that such conduct was wrong (People v. Wernick 1995). To establish her defense, several expert witnesses testified
about Wernicks mental state at the time of the crime and testified that
upon giving birth, [she] suffered from a brief reactive psychosis because
she could no longer deny the reality of her pregnancy and that during
this psychotic state, [she] was able to perform purposeful acts, such as
stuffing toilet paper in the infants mouth, but that she was unable to appreciate the nature and consequences of her conduct (People v. Wernick
1995). The experts testimony tended to establish that (1) she completely
denied the existence of her pregnancy, (2) such denial occurs in almost
all cases in which women kill their newborn infants immediately after
birth, and (3) in a large number of those cases the women believed that
they were not pregnant (People v. Wernick 1996).
Foreseeing an attempt by the defense to assert a neonaticide syndrome as proof of Wernicks insanity, the prosecution had moved for an
evidentiary proceeding so that the court could determine whether this
so-called syndrome had gained sufficient acceptance from the psychiatric
community to be admissible in court. The defense opposed the hearing,

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stating that it had no intention of eliciting testimony from its experts regarding neonaticide syndrome. No evidentiary hearing was held, and the
court therefore ruled that evidence tending to support the existence of a
neonaticide syndrome or relying on the existence of such a syndrome
could not be elicited during the trial. To allow such testimony, the court
reasoned, would allow a neonaticide syndrome to be used as evidence
without it first having to pass the rigors of an evidentiary hearing aimed
at gauging the syndromes acceptance in the scientific community. The
court relied on an earlier New York case, stating
[I]n an insanity defense case, the existence of a mental disease or syndrome or the validity of a theory of human behavior must be generally accepted in the field of psychiatry or psychology before experts may discuss
such matters in their testimony at trial. If general acceptance has been attained, a psychiatric expert then must be permitted to state a diagnosis
and to give a reasonable explanation for a finding that the defendant does
or does not suffer from the mental disease, or that that person is or is not
affected by the syndrome, or that a theory of human behavior does or
does not explain the defendants conduct. (People v. Weinstein 1992)

Since no evidentiary hearing was held on neonaticide syndrome, the

court permitted the defense experts to testify only to their observations
of Wernick and to their opinions of her conduct at the time of the killing
and to the basis of their opinion (e.g., literature on the subject). The trial
court made separate evidentiary rulings on the expert testimony, sustaining the prosecutions objections each time the experts testimony seemed
to refer to neonaticide syndrome. After one such objection, the trial
judge explained:
I am not preventing the witness from testifying as to the basis of his opinions. I am just preventing him, as I said, from setting up a specific profile
that he has gleaned from the literature, as to why young mothers, or
mothers kill their babies. . . . Certainly, the Doctor can testify as to this
specific defendant, and what led him to his conclusions, based upon his
own experiences, his reading of the literature, his studies of her, without
quoting this common theme from the literature. (People v. Wernick
1995)

At the conclusion of the trial, Wernick was convicted.

Wernick raised several issues on appeal. First, she maintained that the
trial court had wrongfully excluded portions of expert testimony relating
to her mental state at the time of the crime. The New York Appellate
Division affirmed the trial courts ruling on the admission of the expert
testimony, stating that testimony was excluded where it tended to show
that she suffered from neonaticide syndrome. Since no formal evidentiary

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hearing determining the general acceptance of neonaticide syndrome

within the psychiatric community was held, the defense experts could
not present evidence supporting the existence of such a syndrome or that
Wernick had suffered from it at the time of the crime.
Wernick also argued that the trial courts refusal to admit the experts
testimony on neonaticide syndrome violated New York Criminal Procedure Law, which provides that psychiatrists or psychologists must be allowed to clarify and explain their diagnoses and opinions. The appellate
court dismissed this contention, holding that the trial courts rulings did
not prevent the defenses expert witnesses from referring to their experiences as practitioners or their reading of relevant literature when
explaining their diagnosis, but rather prevented the defenses expert witnesses from plugging Wernicks symptoms into a larger, untested, and
theretofore unaccepted profile of neonaticide syndrome.
The appellate courts decision was appealed to the New York Court
of Appeals, the states highest court. Wernick argued she had been denied
her due-process rights when the trial court had refused to allow her expert witnesses from referring to the basis of their testimony (scientific literature on neonaticide). Wernick argued that her expert witnesses had
not attempted to testify that she suffered from neonaticide syndrome or
that such a syndrome even exists. Rather, they intended to testify that she
had suffered a brief reactive psychosis and attempted to explain that diagnosis by referring to relevant literature. Wernick further argued that
her expert witnesses had merely attempted to show that clinical studies
have established patterns of conduct of young women, reflecting certain
similar characteristics, who have suffered from a genuine pathological denial of their pregnancies and subsequently killed their newborns immediately after birth (People v. Wernick 1996).
The court rejected this argument, characterizing it as a refined strategy to allow the jury to hear evidence of neonaticide syndrome without
the syndromes having to be tested for its general acceptance in the scientific community. Turning to a section of the New York Criminal Procedure Law, which provides that psychiatrists or psychologists must be
allowed to clarify and explain their diagnoses and opinions, the court
concluded that precedents controlling that rule endorsed the policy that
evidence offered by a psychiatric expert be of a kind established as generally accepted in the profession as reliable and that New York Criminal
Procedure Law does not do away with the need for a evidentiary hearing
in instances when a party seeks to present novel scientific or psychiatric
or medical evidence (People v. Wernick 1996). The Court of Appeals
affirmed Wernicks conviction.

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The Need for Syndrome Evidence: Syndromes

Generally and Rape Trauma Syndrome
DSM-IV defines a syndrome as a grouping of signs and symptoms, based
on their frequent co-occurrence, that may suggest a common underlying
pathogenesis, course, familial pattern, or treatment selection (American
Psychiatric Association 1994, p. 771). In the courtroom, syndrome evidence is used when it is both relevant to an issue of fact that is in dispute
and helpful to the finder of fact in reaching a verdict (People v. Taylor
1990). Critics of syndrome evidence claim that it addresses issues that
juries are competent to understand without the help of complicated expert testimony. Proponents argue that the main strength of syndrome
evidence is that it counters misconceptions about human behavior that,
if unexplained, could eventually lead to erroneous decisions about the
conduct. In other words, syndrome evidence serves to contextualize behavior for the purposes of legal judgment. A look at the commonly accepted rape trauma syndrome (RTS) is illustrative of the point.
RTS is a process of reorganization that occurs as a result of rape. The
reaction to this life-threatening situation causes a syndrome of psychological, physical, and behavioral reactions (Burgess and Holmstrom
1974). Among other things, RTS is used in the courts to explain why a
rape victim may remain silent after the rape and not expeditiously report
it to the authorities. RTS has gained acceptance in courtrooms around the
country.
A New York Court of Appeals case held that RTS is admissible in
New York courts to explain why a rape victim might not appear distraught after being raped (People v. Taylor 1990). The court recognized
that popular misconceptions about the effects of rape on a rape victim
make jurors less likely to believe accusations made by a victim who did
not immediately report the rape to the authorities. Underlying this misconception is the idea that rape is so offensive to bodily integrity that a
person who does not promptly report a rape is fabricating her or his accusations, when in fact prompt complaint is contrary to most . . . victims experiences (Torrey 1991). Any given pool of jurors could hold
such misconceptions about how a person who has been raped should
act, however contrary to reality those conceptions may be. Absent an explanation of such conduct, it is likely that jurors would use those misconceptions to inform their decision to believe or disbelieve the testimony of
a person who is claiming that she or he was raped.
While acknowledging RTS as a therapeutic concept (People v. Taylor
1990), the court maintained that, as an aggregate of symptoms and behaviors accepted within the scientific community, RTS could be helpful

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to a jury in deciding an issue of disputed fact. The court supported its position by noting that patterns of response among rape victims are not
within the ordinary understanding of the lay juror (People v. Taylor
1990) and can therefore be explained by an expert witness. The court in
this case limited the use of RTS to explain why a complainant might not
have seemed distraught after the assault and expressly banned the use of
RTS as proof that a rape actually occurred. Other courts have held that
RTS is admissible to explain a delay in the reporting of the rape by the
victim (People v. Hampton 1987).
RTS is not included in DSM-IV as a disorder. However, rape is recognized as a traumatic stressor that may lead the victim to suffer from posttraumatic stress disorder (PTSD), a disorder featured in DSM-IV. The
fact that RTS is considered to fall within the umbrella of PTSD lends RTS
the requisite credibility (general acceptance within the relevant scientific
community) necessary for expert testimony to be admissible.
RTS is an example of the use of syndrome evidence to aid the finder
of fact in deciding a contested issue. Syndromes help juries to explain
behavior by fitting that behavior within a larger perspective of similarly
situated people. The aim of such evidence is to provide the jury with information that may well be outside their common experience or knowledge. Despite the general perception and criticism of syndrome evidence
as explaining issues the jury already understands and has been traditionally allowed to determine on its own, a laypersons knowledge cannot be
assumed. Syndrome evidence
differ[s] from the traditional use of expert testimony because [it does]
not seek to educate the jury about a field with which the ordinary person
is unfamiliar, such as a scientific process or specialized field of knowledge.
Instead, [this] type . . . of psychological testimony address[es] an area
once thought to be the one exclusive area of juror expertisejudgments
about peoples mental states, and how those mental states are reflected in
a persons behavior. In some sense this testimony is subversive, because it
questions societys existing morals by countering conventional myths and
misconceptions of human nature. (Murphy 1992, pp. 281282)

Syndrome evidence serves as a powerful means of combating myths

by allowing experts to testify to knowledge [that] would enable the jurors to disregard their prior conclusions as being common myths rather
than common knowledge (Murphy 1992, p. 298). Although such knowledge is perhaps subversive, it is nonetheless necessary in order to fully
contextualize a womans behavior in the face of fundamentally extraordinary circumstances, such as a sexual assault or even a denied pregnancy.
As long as a court is able to determine that syndrome evidence passes

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standards of reliability and admissibility, that the evidence is relevant to

determining the fact at hand, and that it is narrowly admitted so as not
to usurp the function of the jury, syndrome evidence serves as probative
evidence that aids the finder of fact in coming to an informed conclusion
on a disputed issue.

Novel Scientific Evidence and Admissibility

Before novel scientific evidence, including syndrome evidence, can be admitted as evidence at trial, it must undergo a hearing outside the presence
of the jury so that its reliability can be assessed. There are two courtestablished tests for this purpose: the older is the Frye test, used in many
state jurisdictions; the more recent is the Daubert test, which was enunciated by the U.S. Supreme Court and is controlling in the federal court
system (Table 82).
Table 82. Tests of admissibility
Admissibility standard

Admissibility factors

Frye test

Is the evidence generally accepted?

Identify the field under which the proffered
testimony falls;
AND
Determine whether the underlying theory offered
in the experts testimony is generally accepted
by the appropriate scientific community. Note
that the methods from which the theory is
derived and implemented must be generally
accepted in such community.

Daubert testa

Judge as gatekeeper: Is the evidence reliable and

relevant?
In order to be admissible, evidence must be:
Reliable and relevant; and
Assist the trier of fact to understand or determine
a fact in issue.
Some factors to consider:
Has the theory or technique been tested?
Has the theory or technique undergone the rigors
of peer review and/or publication?
Does the theory or technique have a known or
potential rate of error?
Has the theory or technique gained general
acceptance from the appropriate community?

The Daubert test applies to scientific, technical, and specialized knowledge.

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Frye v. United States articulated the general acceptance standard,

which served as the governing test for the admissibility of scientific evidence
in the federal court system until its abrogation by the Supreme Court in
1993. Frye articulated the principle of general acceptance as the litmus
test of reliability:
Just when a scientific principle or discovery crosses the line between the
experimental and demonstrable stages is difficult to define. Somewhere
in this twilight zone the evidential force of the principle must be recognized, and while courts will go a long way in admitting expert testimony
deduced from a well-recognized scientific principle or discovery, the
thing from which the deduction is made must be sufficiently established
to have gained general acceptance in the particular field in which it belongs. (Frye v. United States 1923, p. 1014)

The holding in Frye provided federal courts with a standard to use in

deciding whether or not novel or controversial scientific evidence would
be admissible. The Frye standard involves two parts: First, there must be
a theory that is generally accepted in the appropriate scientific community. . . . Second, there must be methods, implementing the theory, which
are generally accepted in the appropriate scientific field (Ebert 1993,
p. 224). Therefore, in determining the reliability of novel scientific evidence, the court must first identify the field under which the proffered
testimony falls. The court must next determine whether the underlying
theory offered in the experts testimony is generally accepted by the appropriate scientific community.
The general acceptance standard articulated in Frye was adopted by
most state courts. Although only a district court decision, Frye has proven
to be a tenacious holding: even though the U.S. Supreme Court held in
Daubert v. Merrell Dow Pharmaceuticals, Inc. (1993) that Frye had been
superseded by the adoption of the Federal Rules of Evidence, many state
courts continue to employ the Frye test in determining the admissibility
of scientific evidence in their respective jurisdictions.
Prior to its 1993 decision in Daubert v. Merrell Dow Pharmaceuticals,
Inc., the U.S. Supreme Court had never ruled on the place of scientific
conclusions in the law. Instead, the Court had historically relied upon
the conclusions of scientific research without any consideration of the
validity of the methods that produced those conclusions (Laurens and
Walker 1996, p. 841). Daubert came to the U.S. Supreme Court from a
California tort action claiming that the plaintiffs had suffered birth
defects because of Bendectin exposure. The trial court refused to allow
the plaintiffs to admit expert testimony, based on live animal studies,
pharmacological studies, and re-analysis of previously published epi-

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demiological (human statistical) studies (Daubert v. Merrell Dow Pharmaceuticals, Inc. 1993), to contradict the defendants claim that there
was no link between the use of Bendectin and human birth defects. The
U.S. District Court for the Southern District of California refused to hear
the plaintiffs evidence because it did not meet the requirements delineated by the Frye test: the petitioners evidence on Bendectin was not
sufficiently established to have general acceptance in the field to which
it belong[ed] (Daubert v. Merrell Dow Pharmaceuticals, Inc. 1993).
On review of the lower courts ruling in Daubert, the U.S. Supreme
Court held that Frye had been superseded by the adoption of the Federal
Rules of Evidence, which codifies the rules of evidence to be used in all
federal courts. The Court specifically pointed to the language in the Federal Rules regarding the admissibility of relevant evidence, expert testimony, and the bases for the expert opinions in holding that Fryes general
acceptance standard had not been incorporated into the Federal Rules.
With respect to expert testimony, at the time the Daubert decision was
rendered, Federal Rule 702 stated, If scientific, technical, or other specialized knowledge will assist the trier of fact to understand the evidence
or to determine a fact in issue, a witness qualified as an expert by knowledge, skill, experience, training, or education, may testify thereto in the
form of an opinion or otherwise (Federal Rules of Evidence 1998). The
Court reasoned that Fryes rigid general acceptance requirement would
be at odds with the liberal thrust of the Federal Rules and their general approach of relaxing the traditional barriers to opinion testimony. (Daubert v.
Merrell Dow Pharmaceuticals, Inc. 1993).
However, although the U.S. Supreme Court refused to incorporate
Fryes general acceptance standard into the Federal Rules of Evidence,
it did not allow for the unfettered introduction of evidence. In clarifying
the Federal Rules of Evidence standard, the Court listed two requirements that must be met by a party seeking to introduce novel scientific
evidence. First, the relevance and reliability of the evidence continue to
be threshold requirements. Second, a trial judge must determine at the
outset . . . whether the expert is proposing to testify to (1) scientific knowledge that (2) will assist the trier of fact (judge or jury) to understand or
determine a fact in issue (Daubert v. Merrell Dow Pharmaceuticals, Inc.
1993).
The Court provided a number of factors that courts could use in the
determination of whether the reasoning or methodology underlying the
testimony is scientifically valid and of whether that reasoning or methodology properly can be applied to the facts at issue (Daubert v. Merrell
Dow Pharmaceuticals, Inc. 1993). One of the factors to be considered is
whether the evidence can be tested. The Court stated, Scientific meth-

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odology today is based on generating hypotheses and testing them to see

if they can be falsified; indeed, this methodology is what distinguishes
science from other fields of human inquiry (Daubert v. Merrell Dow
Pharmaceuticals, Inc. 1993). Another factor is whether the theory or
techniques being identified have been subjected to the rigors of peer review and publication. Still, the Court recognized that, although publication and peer review may be considered in determining the admissibility
of the evidence, the lack of either is a relevant, though not dispositive,
consideration in assessing the scientific validity of a particular technique
or methodology on which an opinion is premised (Daubert v. Merrell
Dow Pharmaceuticals, Inc. 1993). A third factor is the known or potential
rate of error . . . and the existence and maintenance of standards controlling
the techniques operation (Daubert v. Merrell Dow Pharmaceuticals, Inc.
1993). Lastly, the Court noted that recourse to the general acceptance
standard might be used to determine the validity of scientific evidence,
although, like peer review and publication, it is not dispositive. In a later
case, the U.S. Supreme Court noted that the factors articulated in Daubert for use in determining whether novel evidence is reliable were intended to be helpful but not definitive (Kuhmo Tire Company, Ltd. v.
Carmichael 1999).
It is important to note that in 2000, Federal Rule 702 was amended
to read as follows:
If scientific, technical, or other specialized knowledge will assist the trier
of fact to understand the evidence or to determine a fact in issue, a witness qualified as an expert by knowledge, skill, experience, training, or
education, may testify thereto in the form of an opinion or otherwise, if
(1) the testimony is based upon sufficient facts or data, (2) the testimony
is the product of reliable principles and methods, and (3) the witness has
applied the principles and methods reliably to the facts of the case. (Federal Rules of Evidence 2001)

The Advisory Committee notes accompanying Rule 702 explain that

the rule was amended in response to the standards set forth in Daubert
and subsequent decisions and point out that the 2000 amendment affirms the trial courts role as gatekeeper and provides some general standards that the trial court must use to assess the reliability and helpfulness
of proffered expert testimony. The amended Rule 702 is capacious enough
to require consideration of any or all of the specific Daubert factors where
appropriate. Hence, under the amended Rule 702, the principles articulated in Daubert and subsequent cases persist as indicators to be used in
assessing whether testimony proffered by an expert witness is reliable
enough to go to the jury (Table 82).

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161

Neonaticide Syndrome: Frye and Daubert

The recognition of a neonaticide syndrome would serve to contextualize
recognized mental disorders (e.g., depersonalization disorder, brief psychotic disorder) within a larger framework of characteristics typical in
cases of neonaticide, such as denial of pregnancy. However, as the Wernick case makes clear, neonaticide syndrome will not be admissible in
court until it has undergone a Frye or Daubert hearing (depending on the
jurisdiction) to test its credibility as evidence. Since neonaticide syndrome has not yet undergone either of these tests in a court of law, its
success at this point is purely speculative. However, the factors that would
most likely be considered in a Frye or Daubert determination of the acceptance of neonaticide syndrome as evidence may be identified.
In a Frye jurisdiction, neonaticide syndrome would be checked against
the general acceptance standard. It is difficult to say whether the literature on neonaticide reveals sufficient agreement in the psychiatric community that a neonaticide syndrome in fact exists. A review of the available
literature demonstrates that neonaticides are considered to be a distinct
clinical entity (Brozovsky and Falit 1971), with numerous characteristics
repeatedly surfacing in the case studies on women who kill their newborns.
In addition, besides the characteristics themselves, there are recognized
mental disorders alluded to in the literature on neonaticidefor example, brief psychotic disorder and depersonalization disorder. It is beyond
dispute that these two disorders are generally accepted within the scientific community according to the Frye standard: they are contained in
DSM-IV, the authoritative book on mental disorders compiled by the
American Psychiatric Association. The relevant articles on neonaticide
appear in the major professional journals and are open to peer review. Of
course, these considerations would also be supported by the testimony of
psychiatrists who could affirmatively state whether neonaticide syndrome
is in fact a legitimate syndrome with clinical dimensions.
In a Daubert jurisdiction, the inquiry would focus more broadly on
whether neonaticide syndrome is reliable and relevant. Since neonaticide
syndrome would be used as evidence to support the existence of a mental
disease or defect for the purposes of mounting a defense to a charge of
homicide, it would certainly be considered relevant. The second and more
difficult issue is the reliability of neonaticide syndrome. The factors considered under a Daubert approach include the testability of the evidence, the rate of error and existence of standards by which the method
is controlled, whether the theory has been subjected to peer review and
publication, and the general acceptance of the theory within the relevant
scientific community.

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If neonaticide syndrome were to be considered as falling underneath

the umbrella of either brief psychotic disorder or depersonalization disorder (much like RTS is understood as falling underneath the umbrella of
PTSD), the inquiry on methodology would center primarily on whether
DSM-IV reflects the use of an accepted methodology, namely, the formulation of hypotheses and their subsequent testing for falsification. Surely,
DSM-IV meets those standards. Furthermore, as noted in the discussion
on Frye earlier in this chapter, articles on neonaticide are published in the
professions leading journals and are thus exposed to peer review, a factor
that the U.S. Supreme Court in the case of Daubert considered probative.
Finally, the testimony of psychiatrists in the field conclusively affirming
or disaffirming neonaticide syndrome would be crucial, given that there
is no direct mention of a neonaticide syndrome in the literature.

Conclusion
It is clear from the research on the subject that a number of mental disorders, however they may be defined, often occur during the puerperium and
can be so strong as to lead a new mother to kill her newborn or infant. However, while in theory it is easy enough to plug these disorders into governing affirmative defense statutes in order to achieve the necessary mental
disability requirement, the end result of exculpation in one form or another
is not as automatic or clear-cut as it would seem. Because of the shortcomings of the law and psychiatry, these cases of infanticide and neonaticide often end in the conviction and prolonged incarceration of a woman who,
when all is said and done, was mentally ill at the time she caused the death
of her child. Witness the case of Bernadette Reilly, whose insanity defense
was rejected notwithstanding compelling evidence that she suffered brief
reactive psychosis, a disorder recognized in the DSM classification. Reilly
was found guilty of third-degree murder and was sentenced to 310 years
in prison (Commonwealth of Pennsylvania v. Reilly 1988).
The obstacles, sometimes even failings, of the law and psychiatry with
respect to the just treatment of women accused of murdering their newborns and infants are manifold. First, the United States does notindeed,
cannothave an infanticide statute similar to that of England or Canada
that provides de jure acknowledgment of postpartum mental illness and
would apply universally to all infanticides prosecuted under state law. Such
a statute would have to be established on a state-by-state basis through
each states own (often protracted) legislative process (Katkin 1992).
Because no statute in the United States regards infanticide as a crime
qualitatively different from murder, a woman accused of killing her new-

Criminal Defense in Cases of Infanticide and Neonaticide

163

born or infant must invoke that difference by asserting a defense that is

based on (and contingent on) proof that she suffered from a mental disorder at the time of the offense. The success of this undertaking is hampered
by inadequacies in the law. For example, the MNaghten formulation of
insanity focuses solely on the cognitive aspect of the human personality,
even though we are told by eminent medical scholars that . . . [there are]
those who can distinguish between good and evil but who cannot control
their behavior (United States v. Freeman 1966). Approximately half of
the states follow the MNaghten test. Such outmoded conceptions of the
personality and of mental illness as maintained by the MNaghten formulation of insanity severely limit the extent to which a defendant can show
that a mental disability made her unable to conform her conduct to the
law.
Furthermore, the rigidity with which the legal system views mental
illness (Attia et al. 1999, p. 110) poses a major obstacle to successful defenses based on mental disorders. This rigidity is even more amplified
when consensus regarding the existence of a mental disorder has not yet
been reached by the psychiatric community. Thus, only when there has
been agreement within the psychiatric profession as to the existence of a
mental disorder may an expert testify that a defendant had the disorder
at the time the crime was committed. The consensus that would permit
a woman accused of killing her newborn or infant to assert an insanity defense based on a postpartum mental illness, such as postpartum psychotic
depression, has not yet been sufficiently achieved. A woman is left to
support her defenses with a recognized disorder, such as schizophreniform disorder, even though that disorder lends an incomplete and imperfect description of the actual mental state she possessed at the time of the
homicide. It is absolutely imperative, therefore, that the psychiatric profession formalize the aggregate symptoms apparent in the various puerperal mental illnesses so that a woman accused of killing her child in the
puerperium may adequately defend herself by way of using a recognized
postpartum mental disorder as the basis of her defense.
Apart from the more theoretical problems posed by issues such as the
definition of mental disorders or criminal defense formulations, equally
obstructive practical considerations weigh against a woman attempting to
defend herself against homicide charges in the death of her infant or newborn. For instance, the timing of a postoffense psychiatric evaluation is
paramount to assessing the womans mental state at the time of the act
or omission that caused the death of her newborn or infant (Hickman and
LeVine 1992). However, sometimes these examinations are made only
after significant delays. The loss of memory associated with these cases
makes such waiting periods problematic. Furthermore, investigative tactics

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Infanticide: Psychosocial and Legal Perspectives

used by police detectives eager to crack a case may result in the insertion of rationalizations and false or incomplete recollections into the
memory of the woman (Hickman and LeVine 1992)insertions that are
ultimately detrimental to her case. Lastly, and rather ironically, the most
pervasive characteristic of postpartum mental disorders, their changeability, renders it extremely difficult to convince a jury that a woman was insane at the time that she caused the death of her infant when at trial she
appears to be totally normal (Hickman and LeVine 1992).
It is patently unjust that a woman who suffered from a mental disorder at the time she caused the death of her infant be convicted for murder
and sentenced to a long term in prison. However, the penal treatment of
infanticide and neonaticide apparently induced by postpartum mental
disorder will gain uniformity and fairness only when the psychiatric community comes to an agreement on the nature and extent of those disorders.
Postpartum disorders wait to be recognized by the American Psychiatric
Association as codeable mental disorders. Until then, American women
are placed in the unenviable position of asserting imperfect grounds of
mental disability as the basis for their defense and hoping for the best.

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dOrbn PT: Women who kill their children. Br J Psychiatry 134:560571, 1979
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Kaye NS, Borenstein NM, Donnelly SM: Families, murder, and insanity: a psychiatric review of paternal infanticide. J Forensic Sci 35:133139, 1990
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Oberman M: Mothers who kill: coming to terms with modern American infanticide. American Criminal Law Review 34:1110, 1996
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People v Hampton, 746 P2d 947 (Colo 1987)

People v Lisnow, 151 Cal Rptr 621 (Cal App Dept Super Ct 1978)
People v Massip, 271 Cal Rptr 868 (Cal App 4 Dist 1990)
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Robinson PH: Criminal Law Defenses, Vols 12. Minneapolis, MN, West Publishing Co, 1984
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1071, 1991
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of science in law. Virginia Law Review 82:837857, 1996
Wisner KL, Peindl K, Hanusa BH: Symptomatology of affective and psychotic illness related to childbearing. J Affect Disord 30:7787, 1994

Chapter

Medical and Legal Dilemmas of

Postpartum Psychiatric
Disorders
Cheryl L. Meyer, Ph.D., J.D.
Margaret G. Spinelli, M.D.

. . . upon a trial in this country, where we are so happy as to be under

the protection of judges, who by their education, studies and habits,
are above the reach of vulgar prejudices, and make it a rule for their
conduct to suppose the accused party innocent, till guilt be proved.
With such judges, I say, there will be little danger of an innocent
woman being condemned by false reasoning. But danger, in the cases
of which we are now treating, may arise from the evidence and opinion given by physical people, who are called in to settle questions in
science, which judges and jurymen are supposed not to know with
accuracy. Many of our profession are not so conversant with science
as the world may think; and some of us are a little disposed to grasp
at authority in a public examination, by giving quick and decided
opinion, where it should have been guarded with doubt; as character
which no man should be ambitious to acquire, who in his profession
is presumed every day to be deciding nice questions upon which the
life of a patient may depend.
William Hunter, M.D., F.R.S.
Read to the members of the British Medical Society, July 14, 1783

Portions of this chapter are reprinted from Meyer CL, Proano TC: Postpartum
Syndromes: Disparate Treatment in the Legal System, in Its a Crime: Women
and Justice, 2nd Edition. Edited by Muraskin R. Englewood Cliffs, NJ, PrenticeHall, 1999. Copyright 1999, Pearson Education, Inc. Used with permission.

167

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ostpartum disorders date to antiquity (Hamilton and Harberger 1992).

Hippocrates described postpartum psychosis as a kind of madness
caused by excessive blood flow to the brain (Meyer et al. 1999, p. 91;
see also Cox 1988; Lynch-Fraser 1983). An eleventh-century gynecologist, Trotula of Salerno, suggested that postpartum blues resulted from
too much moisture in the womb, causing the brain to fill with water,
which was then involuntarily shed as tears (Mason-Hohl 1940).
It was not until the 1800s that physicians described postpartum syndromes in detail and began to theorize that there was a connection between physiological events and the mind (Hamilton 1989). Esquirol
(1838) wrote the first review of 90 cases relating pregnancy and psychiatric disorders. In the group that had onset within several weeks or more
after delivery, he noticed a high incidence of delirium, similar to our contemporary description, with acute onset of disturbances of perception and
consciousness, disorganization, hallucinations, confusion, delusions, and
marked changeability of mood.
In 1858, Louis Victor Marc published the first textbook on postpartum disorders, Trait de la folie des femmes enceintes (Marc 1858). In a
sample of 310 cases of postpartum psychiatric illness, he identified psychiatric symptoms during pregnancy in 9% of cases; the symptoms manifested within the first 6 weeks after delivery in 58% of the cases and after
6 weeks in 33% of the cases. Although Marc found no distinguishing features in the psychoses during pregnancy, he described unique qualities
and characteristics of postpartum psychoses, which he identified as distinct from other psychoses. Marc believed that wild mania followed by
severe melancholia was a clue to specific organic mechanisms, which he
termed morbid sympathy. He suggested that [t]he coexistence of the
organic state raises an interesting question of pathologic physiology; one
immediately asks if there exists a connection between the uterine condition and disorders of the mind (Marc 1858, pp. 78; quoted in Hamilton 1989, p. 326).
Marcs book became the principal authority on which diagnoses of
puerperal disorders were based. The identified diagnoses were generally
accepted and repeatedly affirmed by other reported cases. Marcs theory, derived from his clinical intuition, rests on the scientific knowledge
of what today we describe as the hypothalamic-pituitary-ovarian (HPO)
axis. He developed his theory prior to the discovery of the endocrine system,
which supports the fact that the physiological mechanisms of reproduction communicate with chemical messengers of the brain through the
biological cascade of events of the HPO axis (see Chapter 4: Neurohormonal Aspects of Postpartum Depression and Psychosis).

Postpartum Psychiatric Disorders

169

In early twentieth-century America, thinking about postpartum disorders changed for unclear reasons, and the psychiatric community split
over the existence of a formal diagnosis. The official word postpartum
was stricken from the diagnostic psychiatric nomenclature (Hamilton
and Harberger 1992) and was therefore not included in the first edition
of the Diagnostic and Statistical Manual of Mental Disorders (American
Psychiatric Association 1952).

Postpartum Psychiatric Disorders:

The Medical Dilemma
The fourth edition of DSM, DSM-IV, includes the word postpartum as
a modifier to diagnoses that occur within 4 weeks of childbirth (American Psychiatric Association 1994; a text revision, referred to as DSM-IVTR, was published in 2000 [American Psychiatric Association 2000]).
The exclusion of official diagnostic criteria is based on the determination
that postpartum phenomenology is not demonstratively different from
other mood and psychotic disorders (American Psychiatric Association
1994). Whether or not the postpartum disorders possess distinctive diagnostic features, these illnesses share both the same underlying neurohormonal pathogenesis and the precipitous event of childbirth. Wisner et al.
(1994) suggest that the precipitous physiological event of hormone depletion is the underlying mechanism for the observed organic psychosis.
The consistently described diagnostic picture includes delirium, impaired
sensorium, and poor cognition. In addition, unusual perceptual experiences such as visual, tactile, and olfactory hallucinations are manifest,
along with a picture of bizarre delusions and hallucinations (see Chapter 3:
Postpartum Disorders). A pattern of waxing and waning sensorium and
mood lability mimics the cycling pattern of bipolar disorder. This picture
supports Kendells findings of increased lifetime psychiatric admissions
for affective psychoses in the immediate postpartum period (Kendell et
al. 1987).
Postpartum psychosis presents as a psychiatric emergency. Whether
mood changeability is associated with bipolar disorder or organic delirium, or both (see Chapter 3), this presentation may disarm even the psychiatric professional. Because moments of complete lucidity are followed
by frightening psychosis for the new mother, the illness may go unrecognized and untreated. Out of shame, guilt, or a paranoid delusional
system, the new mother may not share her bizarre thoughts and fears.
Families may not offer necessary support or seek psychiatric intervention.
It is in this context that acts of suicide and infanticide occur.

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Acute Postpartum Syndromes and Infanticide

Infanticide, like postpartum illness, has occurred throughout history (Oberman 1996). In early centuries, justification for infanticide ranged from
pagan sacrifice (Lagaipa 1990) to population control. When infanticide
practices became increasingly common (see Chapter 1: A Brief History
of Infanticide and the Law), societies adopted laws, and punishments
became increasingly severe. In the seventeenth century, concealment of
a murdered newborn became a capital offense. Penalties were more likely
rendered to unmarried women using such methods as sacking, in which
a woman was placed in a leather sack with a dog, a snake, and a cock and
thrown into the water (Brockington 1996; Oberman 1996).
Events took a turn in 1647, when Russia became the first country to
adopt a more humane attitude toward infanticidal mothers. By 1881, all
European states except England had established a legal distinction between infanticide and murder by assigning more lenient penalties to infanticide (Oberman 1996). In 1922, England passed the Infanticide Act
(see Chapter 1 and Chapter 10: Infanticide in Britain) making infanticide a less severe crime than homicide, with less severe punishment. By
the end of the twentieth century, almost all Western societies had adjusted the penalty for infanticide (Brockington 1996). Through recognition of the unique biological changes of parturition, the charge of murder
has been reduced, in most cases, to manslaughter. Psychiatric evaluation and
treatment are the most frequent outcomes. The American judicial system
makes no legal distinction between the murder of an adult and the murder of a newborn.
For the psychotic woman, decisions may be made by commanding voices
in her head. Her actions may be the result of a paranoid and delusional
belief system. Despite this psychotic state, the mother may not fulfill the
legal definition of insanity as it is determined by the legal system (Meyer
et al. 1999). Insanity is ascertained by additional factors, such as cognition, insight, and judgment (see Chapter 8: Criminal Defense in Cases
of Infanticide and Neonaticide). For example, if the mother acts on command hallucinations, believing that she has no alternative to the directed
behavior, the criteria for insanity may be fulfilled. On the other hand, if
she had more observing ego capacity to resist command hallucinations,
she may not fulfill the criteria for an insanity defense. The following
vignette illustrates a case of postpartum psychosis linked to infanticide
(Brusca 1990; Japenga 1987):
T went from being an honor society member, her schools first female senior class president, and an athletic and sociable person to, later, being a

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171

mother who drowned her second child, a 9-month-old son, in a bathtub.

She claimed she heard voices telling her that her child was the devil. After
T gave birth to her first child, she suffered hallucinations, panic, and obsessions. She attempted suicide by jumping out of a moving vehicle and
then jumping from a 30-foot-high bridge, which led to psychiatric hospitalization. Unfortunately, when she became pregnant with her second
child, her doctors told her to forget about her previous psychosis, saying
that it would not happen again.

This case emphasizes the vital need for education as a method of prevention. How do women like T, invariably described as gentle and loving
mothers, becomekillers? The following case vignette also exemplifies
this paradox.
At 32, F was a middle-class immigrant woman who lived with her husband. F dated depressive symptoms to the 32nd week of pregnancy while
she was on bedrest for premature labor. She became obsessed and guiltridden that she had harmed her baby. And despite a 36-week delivery of
a healthy baby boy, her remorse worsened. By the tenth postpartum day,
she was preoccupied by persistent auditory hallucinations of her babys
cry as if something was smothering him. Neither her husband nor her
sister could provide reassurance. She became sleepless and agitated and
was obsessed by suicidal thoughts and dreams. Various calls for help were
ignored or denied. F said she did not want to wake up. She told her husband, If I hurt my baby please kill me. She asked her sister to take care
of the baby if she died. F, a soft-spoken, gentle woman who frequently
cared for her nieces and nephews exemplified the maternal image. Her
calls for help did not alert her family.
F described the days before the death of her baby, J. On the evening
of his nineteenth day and the last evening of his life, she and the family
took pictures of J, perused the family album, and placed him in the crib.
F woke to the sound of Js cry. She recalled, I was outside . . . water in
front of me . . . then sitting on a couch in the living room. I was not sure
if I was sitting or actually sleeping. My husband asked, Where is the
baby? F told him she left him in the pond.
F was charged with second-degree murder and taken to the county
jail. Fs attorney requested hospitalization for her psychotic client. The
judge was not convinced of Fs insanity and feared giving a message that
women can kill their babies and get away with it. After 6 weeks of incarceration and decompensation without medication, the judge granted a
psychiatric hospital admission. Recognized only as a killer, Fs feet were
shackled to her hospital bed. F pled guilty to manslaughter. She was remanded to a psychiatric facility for a 6-month observation period, then
returned to her home country.

This case exemplifies how the dearth of available knowledge can mold
the circumstances and shape the outcome of these cases. In particular,
this vignette further emphasizes the need for education. Neither F nor

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Infanticide: Psychosocial and Legal Perspectives

her family had knowledge or understanding of postpartum illness. Fs

physician was not alerted to depression by her obsessive ruminations
about her failure as a mother. Fs husband and sister were unable to identify the problem. Her history as a warm and nurturing sister and wife
overshadowed any concern voiced about harming her infant. The planned
pregnancy and joy over the future were inconsistent with the thought of
her as murderer.
Although her attorney pled for hospital admission, the court chose
the county jail. Failure to educate our judicial system led the court to
doubt an existing diagnosis. There were repeatedly missed opportunities
for identification, intervention, and prevention of the tragic circumstances.

Chronic Mental Illness and Infanticide

A frequently ignored factor associated with infanticide is the role of
chronic mental illness. Women with schizophrenia or severe bipolar disorder are often victims of unplanned and unprotected pregnancies. Although the data on pregnancy in women with schizophrenia are limited,
a review by Tekell (2001) described the increase in stressors and the life
events that contribute to the postpartum decompensation of women
with schizophrenia. The danger of chronic illness is illustrated in the following vignette.
At 29 years of age, M was charged with second-degree murder for throwing her 6-month-old infant from the eighth floor window of her apartment complex. Diagnosed with schizophrenia at 19, M had five previous
psychiatric hospitalizations. She was compliant with medications throughout
this recent and uneventful pregnancy. Two days postpartum, M was admitted to a psychiatric facility with florid psychosis and homicidal ideation toward her mother and the infant.
Child protective services placed the infant under the care of Ms
mother, the custodial parent of her 7-year-old son because of homicidal
threats and gestures after his birth. Ms mother accompanied the infant
back to their home state while M remained in the hospital.
On the day before discharge, M was reported as psychotic, aggressive,
and unpredictable but discharged to her home with her mother, who was
encouraged to take M to the nearest hospital. There was no child service
communication or intervention.
On the day of her babys death, while her mother was shopping, M remained home alone with her infant. She said that her baby died because
she twisted her body out of her mothers arms and out of the window.
M was arrested for murder and incarcerated for 4 years awaiting trial.
She was found not competent to stand trial and admitted to a state psychiatric facility.

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173

Unlike postnatal psychosis, with its precipitous onset, a history of

schizophrenia itself signals prevention. Parent-infant programs with psychiatric services for mentally ill mothers are rare. M and her mother spoke
little English. In addition, the stigmatization of the mentally ill in the
general hospital setting may impair communication from antepartum to
postpartum staff. The patients limited cognitive capacities contributed
to problems.
Insufficient mental health screening in antepartum clinics is also a factor in failed care. The breakdown in communication by professional child
care organizations in this straightforward case was striking and led to
tragic circumstances. In this case, child protective services did not communicate with Ms home state for follow-up.

Use of Postpartum Syndromes in the Courts

Criminal Cases
A history of treatment for postpartum syndromes has been admitted into
evidence in both criminal and civil courts (Meyer et al. 1999). Clearly, the
use of postpartum syndromes in criminal cases has gained more publicity.
This could be due to the nature of the crime or to the media frenzy that
surrounds criminal cases involving the mental health of the defendant.
The fact patterns of these cases are chillingly similar (Gardner 1990).
Generally, the defendant has no prior history of criminal activity and often goes to great lengths to become pregnant. In other words, these are
generally planned pregnancies and wanted children. In many cases, the
woman may be experiencing delusions, perceiving the child as a source of
evil. The murders are particularly gruesomefor example, running over
the child with a car or throwing the child in an icy river. Afterward, the
mother often has no recollection of the event and reports the child missing or kidnapped to the police.
In the United States, postpartum syndromes can become a part of criminal proceedings at several points, including evaluation of competency,
pleading, and sentencing. For example, at the outset, the competency of
the woman to stand trial could be at issue. However, most women are not
experiencing postpartum effects at the trial. Moreover, this would probably be an ineffective defense strategy. Since the statute on murder never
runs out, the defendant would likely remain in a treatment facility until
competency is achieved in order for a trial to take place. A treatment facility may be an inappropriate place for most defendants who previously
had a postpartum syndrome because postpartum syndromes are often
transitory conditions.

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More commonly, postpartum syndromes are used to attempt to exculpate or mitigate responsibility of a defendant. At issue is whether the
defendant could have formed the requisite mental intent (mens rea) to
commit murder. If someone was insane at the time of the act, her mental
state may not rise to the appropriate level of intent, making conviction
difficult. Since most of these cases are not federal cases, the jurisdictional
criteria for legal insanity could be used. Each state has adopted tests (criteria) to determine whether particular components were also present at
the time of the defense insanity (see Chapter 9).
Sentencing after the conviction can also be disparate. Because diagnostic guidelines for postpartum disorders are fuzzy, sentences vary from
probation to life in prison or even the death penalty. Brusca (1990) reported that about half the women who raise postpartum psychosis as a
defense are found not guilty by reason of insanity, one-fourth receive
light sentences, and one-fourth receive long sentences.
The lack of clear diagnostic certainty limits the use of postpartum
syndromes in criminal trials and creates further ambiguity in the criminal
courtroom. Improved family and public education would likely change
outcomes. In addition, language barriers affect these cases at every level,
including the ability to report symptoms, interact with others in the community, and obtain legal representation, as well as the subtleties of reporting to professional expert witnesses.

Medical and Legal Dilemmas: Yates v. Texas

The difficulties described in this chapter are well illustrated in the case of
Yates v. Texas (see Introduction, this volume). Andrea Yates drowned
her five children while suffering from a postpartum psychosis. Charged
with capital murder and placed in the county jail (Yardley 2002), Mrs.
Yates was treated with an effective regimen of antipsychotic medication.
By August 3, 2001, her psychosis had lifted and she was found competent to stand trial on September 24, 2001 (CourtTV 2002).
The case of Andrea Yates must be viewed against the political and
legal background of the Texas judicial system and Harris County jurisdiction. Harris County prosecutors have sent more people to death row than
any other county in Texas, a state that has led the nation in executions.
Harris County juries lead the country in death penalty verdicts. As Elaine
Cassell (2002), professor of law and psychology and legal columnist for
CNN, notes, Texass law is derived from the most restrictive legal insanity standard, the MNaghten Rulethe defendant must prove failure to
know the act was wrong. The law could hardly be narrower.
Yates pled innocent by reason of insanity to capital murder. The pros-

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175

ecution asserted that she knew right from wrong at the time of the killings
because she called 911 and her husband after the killings. The responding
officer said that when Yates answered the door, she was breathing heavily,
with her hair and clothes soaked with water, and said, I killed my kids.
The defense maintained that she did not know right from wrong at the
time of killings because she was in a psychotic state (Pies 2002).
To know right from wrong. Two well-respected and highly credentialed
forensic psychiatrists testified as expert witnesses. The witness for the prosecution testified that Andrea Yates was responsible for the deaths of her
children because she knew right from wrong at the time of the act (Grinfield 2002). The primary defense expert and several psychiatrists opined
that Mrs. Yates was unable to know that the act of killing her children was
wrong. The expert for the defense testified, Even though she knew it was
against the law, she did what she thought was right in the world she perceived through her psychotic eyes at the time (CourtTV 2002). She
thought drowning her four sons and her daughter was the only way to save
them from hell. The prosecutor asked, Even in the face of this cruel dilemma she knew it was a sin? Yes, she did, the expert replied.
This legal dilemma is described by Elaine Cassell (2002): What constitutes knowing ones act is wrong in this context? What is knowing?
Does wrong mean, legally wrong or morally wrong? The statute does
not explain, so the jury was left to apply the statutory language to the
facts as it saw fit.
In an interview with the Psychiatric Times (Grinfield 2002), forensic
experts questioned how witnesses for the prosecution and defense could
interpret the insanity defense in polar opposite ways if they used the same
facts and legal basis for interpreting the defense. Expert forensic psychiatrist and medical director of the American Academy of Psychiatry and
the Law (APPL) addressed these concerns about the insanity defense:
we dont have any test to know which people do, can or cant follow
those things [command hallucinations] . . . We are still left to sort of dealing with a certain degree of approximations in those answers (p. 3).
He announced that APPL is scheduled to release its practice guidelines as an attempt to bring consistency to the evaluations of defendants
who are mentally ill. These guidelines, titled Practice Guidelines for Forensic Psychiatric Evaluation of Defendants Raising the Insanity Defense,
will assist forensic experts whose clients assert the insanity defense.
Although the guidelines may settle one problem, the quandary persists: Can we in psychiatry determine with certainty the ability to know
right or wrong from the data? How reliable are retrospective accounts of
a psychotic episode?

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Retrospective recall is suspect under any circumstances in most disciplines. Moreover, psychosis is often associated with amnesia, particularly
in postpartum-onset psychosis. How does one distinguish fact from fabrication or delusion?
The cognitive/disorganization psychosis. In Chapter 3, Wisner states, The
confused, delirium-like, disorganized clinical picture of postpartum psychosis has been observed and reported repeatedly. Wisner describes in
detail her study of puerperal psychosis in which the most dramatic finding was cognitive/disorganization psychosis with impaired sensorium and
orientation, memory, thought disorganization, and prominent cognitive
impairment. This picture of acute-onset delirium was evidenced by cognitive examinations (such as drawings of clock faces and figures) and extensive laboratory evaluations.
Therefore, the expert witness who testifies for a woman with puerperal mental illness must have knowledge of the distinct presentation.
Although postpartum disorders are not considered unique DSM-IV diagnoses, distinctive phenomenology is well described in the literature. The
test of MNaghten used to determine culpability is a test of cognitive
(ability to know) capacity. By definition, a diagnosis of postpartum psychosis assumes impaired cognitive abilities. Therefore, the very factor
(namely, cognition) used to determine culpability is pathognomonic for
the illness itself.
Organic psychosis also implies the presence of a waxing and waning
sensorium, a labile quality that is well documented (see Wisner, Chapter 3).
Practitioners are cautioned about this erratic mental status and mood
changeability, which make actions unpredictable and emphasize the need
for caution when one is evaluating a psychotic mother who has an infant
at home. A mother must be separated from the infant until the psychosis
resolves. The very foundation of the Yates case was based on Mrs. Yatess
mental state after the murders, a point that is mute in presentation of an
ever-changing mental status.
The prosecution determined that Andrea Yates knew right from wrong
because she called her husband and police after the event. This thinking
suggests that we extrapolate backward then predict that she had an intact thought process. A call for help after the event is not indicative of a
normal mental status during the event
The real challenge for psychiatry is to educate the legal profession and
juries about the physiological underpinnings of postpartum disorders and
other psychosesto use the courtroom as a classroom to demonstrate
our scientific and biologically based knowledge and expertise to the jury
and, ultimately, to encourage verdicts based on facts.

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The Yates case epitomizes the shortcomings of the American medical

and legal institutions. Puerperal illness remains markedly understudied
and underdiagnosed in the professional and lay populations.
Clear-cut diagnostic and legal guidelines for psychiatric illness associated with infanticide could likely assist our legal system with these cases.
Americas reluctance to distinguish postpartum disorders may lead to
tragic outcomes for women in the family and society. Moreover, it results
in disparate treatment for women in the legal system overall.

Civil Cases
Since rules of evidence are typically less strict in civil courts, postpartum
syndromes are readily admitted into evidence during civil proceedings
(Meyer et al. 1999). This has created a disparate situation wherein postpartum syndromes can be used to harm women in civil courts, such as
through loss of custody, but are used inconsistently in criminal courts to
mitigate their loss of liberty.
For example, in custody matters, the trial court has broad discretion.
Mental health can generally be considered and weighted in relation to
other factors in custody decisions. It is difficult to estimate how frequently the issue of postpartum syndromes is raised in custody cases, because undoubtedly many mothers abandon their pursuit of custody after
the father makes clear his intention to make their mental health an issue.
In addition, it is impossible to determine how persuasive postpartum syndromes are in judicial decisions, because trial court transcripts are often
inaccessible and opinions are generally not formally written. In the infrequent event of an appeal, the courts opinion becomes more accessible.
If the father raises postpartum syndromes in custody cases, he generally asserts that the mother is an unfit parent because of her history of
postpartum mental illness, even though the mother is not currently mentally ill and may have no other history of mental illness or unfit parenting.
One of the first recorded cases using postpartum syndromes in custody
cases was Pfeifer v. Pfeifer (1955):
The father appealed an order that gave care, custody, and control of the
child to the mother solely on the basis of her potential threat to the child
because of her history of postpartum psychosis. When the couple separated, Kent, their child, went to live with his father and paternal grandparents. Ms. Pfeifer had recently recovered from postpartum psychosis
and was trying to rebuild her life, but she had no home to offer Kent.
Kents grandmother became his primary caregiver. Mr. Pfeifer remarried
and relocated, but Kent continued to live with his grandparents. Ms. Pfe-

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Infanticide: Psychosocial and Legal Perspectives

ifer, who had also remarried, sued and eventually won custody of Kent.
Mr. Pfeifer appealed the custody award, citing the mental instability of
Ms. Pfeifer. At the time of the custody hearing the mother had suffered
no symptoms of postpartum psychosis for 5 years and did not intend to
have any more children.

On appeal, the father claimed there had been no change in circumstances warranting modification of the original custody award. The court
held that
the mother has remained in good mental health for more than two years
without relapse; she has remarried, can offer the child a good home, and
is willing to give up her profession to take care of him and her household.
This change in the circumstance of the mother could in itself justify the
change of custody ordered. Moreover, the father has also remarried and
has moved out of the home of his parents to another neighborhood. The
grandparents, with whom the child remained, have reached an age,
which, notwithstanding their love and devotion, must make them less fit
to educate a child of the age of Kent and compared to them, the mother
has, if she is not unfit to have custody, certainly a prior claim to the child.
(Pfeifer v. Pfeifer 1955)

This case was appealed on questions related to Ms. Pfeifers mental status resulting from a brief episode of postpartum psychosis. Mr. Pfeifers appeal was denied. This case is important for several reasons. First, it was not
Mr. Pfeifer who would have retained custody but the grandparents. Second, Mr. Pfeifer had led Kent to believe his stepmother was his biological
mother. The court felt this posed a danger that Kent would never learn the
identity of his biological mother. Third, Ms. Pfeifers marriage was important to the court because it represented stability; it is questionable whether
the court would have awarded custody to Ms. Pfeifer if she had not remarried, even though the grandparents were becoming too elderly to care for
the child. Fourth, Ms. Pfeifer had no intention of having any more children.
Fifth, Ms. Pfeifer had not had any symptoms for 5 years. It would have
been difficult to deny Ms. Pfeifer custody under these circumstances.
In contrast, consider the following case (In re the Marriage of Grimm
1989):
Susan and Gary Grimm were married for 13 years and had three children.
After the birth of each child, Susan suffered from postpartum depression and
was hospitalized. During these hospitalizations, Susan phoned home daily to
speak with her children and had personal visits with them. Following the last
hospitalization, in 1985, the Grimms separated. During the separation, the
children resided with their father, while the mother lived nearby and visited
daily. Susan washed dishes, laundered and mended clothes, cooked for the
children, and stayed with them at night whenever Gary was working.

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179

The couple petitioned for dissolution and each sought sole custody of
the children. Both were evaluated as excellent parents. However, it is
clear that Susan Grimms postpartum depression was an important factor
in this custody award. Her treating psychiatrist was called to testify regarding her stability. No other testimony regarding the fitness of either
parent was addressed. The court placed custody with Gary.

As in Pfeifer v. Pfeifer (1995), Susan Grimm had not been hospitalized

for a long period prior to the custody hearing. In addition, Susan had
been, and wanted to continue to be, actively involved with the childrens
lives. However, the court placed custody with Gary. Susan appealed and
the appeals court reaffirmed the custody award. It is unclear why the Pfeifer and Grimm cases were decided differently.
In other civil matters, the court has refused to allow testimony regarding postpartum depression to be persuasive. For example, in a 1997 adoption appeal, a biological mother who had given her child up for adoption
asserted that postpartum depression rendered her incompetent to consent to the adoption. The Tennessee Appellate Court stated:
We do not dispute that [the mother] was probably depressed or emotionally distraught following this rather traumatic experience, but it is not unusual for there to be depression and distress following the birth of a child,
even under the best of circumstances. If emotional distress meant that a
parent was always incompetent to consent to an adoption, we would rarely
have adoptions in this state. (Croslin v. Croslin 1997 at 10)

Similarly, in another case, the court did not find that postpartum depression invalidated a womans competency to consent to a postnuptial
agreement:
Kim and Anthony L had a 1-year-old son when Kim gave birth to a daughter, Jill, who was premature and had to be returned to the hospital daily
for a short time after her birth. Kim was caring for both children and preparing to return to work while still suffering from postpartum depression.
Approximately 3 weeks after Jill was born, Kim had to be rushed to the
hospital for severe hemorrhaging. Although she was not admitted to the
hospital, the court acknowledged, [i]t was obviously a very frightening
and traumatic experience (Latina v. Latina 1995 at 19). A few days after
Kim was rushed to the hospital, less than 1 month postpartum, Anthony
presented her with a postnuptial agreement. Regarding the effect of postpartum depression on Kims capacity to consent, the Delaware Family
Court stated:
The break-up of a marriage never comes at a good time, and, as noted in
many earlier opinions, usually separation agreements are signed in a highly
charged atmosphere, thereby necessitating the precautions taken by the

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Delaware courts to ensure the agreements fairness. However, if the courts

could set aside agreements based upon their being signed during the emotional turmoil of a marriage splitting up, no separation agreement would
ever be permitted to stand. Although the court recognizes Wife was
extremely distraught and probably feeling somewhat vulnerable when she
signed the agreement, the Court finds that Wife signed more because she
did not understand the implications of the agreement than because she
was coerced. It should be noted that the second agreement was signed by
Wife approximately six weeks after the first agreement, by which time
Wifes postpartum depression and concern for Jills health should have
lessened. (Latina v Latina 1995 at 19)

The lack of a clear understanding associated with these cases underscores the obligation of psychiatry to educate the court about postpartum
illnesses. These cases reflect the dearth of knowledge about these illnesses,
which leads to inconsistencies in treatment. The fact that a disorder can be
a key factor in one civil case but easily dismissed in another suggests a need
for further clarification through improved research in order to resolve the
continued dilemma for the medical and legal communities.

Medical and Legal Dilemmas

The medical and psychiatric communities share some responsibility for
these discrepancies. First, there are no definitive postpartum diagnostic
criteria. Second, the lack of criteria is compounded by legal ambiguities
in the insanity laws and discrepancies in insanity criteria. When postpartum disorders are asserted in court, the validity and exculpatory capability of these disorders become the subject of dispute between experts.
Courts strive for bright lines, or clear criteria, on which to base decisions. Bright lines are difficult to achieve but reduce ambiguity and subjectivity and provide greater consistency and fairness in decisions. On the
other hand, recognition of postpartum syndromes in the legal system
could result in a slippery slope for the courts. For example, would a woman
accused of child abuse now be able to assert postpartum syndromes as an
exculpatory defense? Would the defense be available for other crimes, such
as larceny or battery?
At first glance it appears that recognition of postpartum syndromes
could lead to such unwieldy outcomes, but it is unlikely. First, this has not
happened in other countries, where the postpartum defense is rarely
used. Second, and more important, defendants with postpartum psychosis have committed very specific crimes with very specific victims. Also,
the trigger is clearly due to one cause, pregnancy, and this cause is not
likely to reoccur with such great frequency. Third, the danger is tempo-

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181

rary. If anything, postpartum syndromes seem to have more specificity

than already recognized defenses, such as posttraumatic stress disorder,
and represent much less of a threat to the integrity of the legal system.
Courts could facilitate preventive action by the medical community
if they would acknowledge the importance of postpartum syndromes in
their opinions. The courts have been able to address this issue directly in
cases involving insurance and disability claims for postpartum syndromes.
As far back as 1964, a court was asked to determine whether postpartum
syndromes represent a sickness or mental illness (Price v. State Capital
Insurance Company 1964). If postpartum syndromes represent a sickness, the level of coverage under insurance and disability is generally expanded. Conversely, if they represent a mental illness, the coverage is
generally restricted. The courts have routinely held that the cause of
postpartum syndromes has not been proven to be physical and the treatment is generally psychological. Therefore, postpartum syndromes are
excluded from coverage (Blake v. Union Mutual Stock Life Insurance
Company 1990). The courts have also found that postpartum syndromes
were outside the scope of pregnancy disability claims (Barrash v. Bowen
1988). The courts could address the issue of classification of postpartum
syndromes in their opinions, which could facilitate a review of the status
of these conditions by the medical and psychological communities as well
as clarify insurance provisions.

Conclusion
Many women are reluctant to report symptoms of postpartum syndromes
to health care professionals (Meyer et al. 1999). This reluctance to seek
help for or even discuss postpartum syndromes makes early detection difficult. However, increased recognition of postpartum syndromes by the
medical and psychological communities would certainly precipitate a
debate on the impact of pathologizing normal processes in women on
womens status overall. In addition, it could be argued that increasing the
role of the psychological and medical community could increase the
power these professions have over women.
It seems unlikely that recognizing postpartum syndromes could worsen
the current situation for women. In fact, recognition of these conditions
could actually benefit women. Recognition of pathology might actually
be necessary in order for women to receive proper treatment, medical or
psychological (Meyer et al. 1999). Without a clear pathology, health care
providers might minimize womens syndromes, which then may go untreated. Therefore, pathology may be seen as a means to an end. Recog-

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Infanticide: Psychosocial and Legal Perspectives

nizing some postpartum syndromes as pathological and not others may

decrease the overall level of pathology assigned to these conditions. The
pathology of postpartum psychosis, which is a rare and serious disorder,
may increase the distinction between this condition and less severe types
of postpartum syndromes, which can be readily treated.
Some may argue that even seeing one type of postpartum syndrome as
pathological does an injustice to women. In response to this argument, it is
important to remember that women with postpartum syndromes are already being stigmatized. It is also important to realize that by increasing
the recognition of postpartum syndromes, we can increase awareness of the
context in which these conditions develop (Meyer et al. 1999). By increasing recognition of postpartum syndromes and acknowledging the social
variables that contribute to them, we could provide women with the help
they need, without viewing their conditions as inherently pathological.
Women should also be encouraged to actively participate in making
decisions that affect their lives. A major concern is that women should not
be identified as victims of their own biological changes. And yet, knowledge of the facts is, in and of itself, empowering. The search for scientific
data and sanctioned diagnostic criteria should include a risk-benefit analysis. The benefit derived from recognition and equitable treatment under
the law far outweighs the risk that women will be perceived as weak. The
greatest risk is that women with these disorders will continue to suffer
tragic consequences unless the potential benefits are met (Meyer et al.
1999).

References
American Psychiatric Association: Diagnostic and Statistical Manual: Mental Disorders. Washington, DC, American Psychiatric Association, 1952
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC, American Psychiatric Association, 1994
American Psychiatric Association: Diagnostic and Statistical Manual of Mental
Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000
Barrash v Bowen, 846 P2d 927 (4th Cir 1988)
Blake v Union Mutual Stock Life Insurance Company, 906 P2d 1525 (1990)
Brockington I: Motherhood and Mental Health. Oxford, UK, Oxford University
Press, 1996, pp 430468
Brusca A: Postpartum psychosis: a way out for murderous moms? Hofstra Law
Review 18:11331170, 1990
Cassell E: FindLaw Forum: the Andrea Yates trial: did the jury do the right thing.
CNN.com/LAWCENTER. Available at www.cnn.com/2002/LAW/03/columns/
fl.cassel.Yates.03.18/. Accessed March 29, 2002

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Cox J: Causes and consequences: the life event of childbirth: sociocultural aspects of postnatal depression, in Motherhood and Mental Illness, Vol 2. Edited by Kumar R, Brockington IF. London, Butterworth, 1988, pp 6477
Croslin v Croslin, Tenn App Lexis 84 (1997)
Esquirol JED: Des maladies mentales consideres sous les rapports medical, hygienique et medico-legal, Vol 1. Paris, JB Bailliere, 1838
Gardner CA: Postpartum depression defense: are mothers getting away with
murder? New England Law Review 24:953989, 1990
Grinfield MJ: Mothers murder conviction turns insanity defense suspect. Psychiatric Times, June 2002, pp 15
Hamilton JA: Postpartum psychiatric syndromes. Psychiatr Clin North Am 12:
89103, 1989
Hamilton JA, Harberger PN: Postpartum Psychiatric Illness: A Picture Puzzle.
Philadelphia, University of Pennsylvania Press, 1992
In re the Marriage of Grimm, Minn App Lexis 143 (1989)
Japenga A: Ordeal of postpartum psychosis: illness can have tragic consequences
for new mothers. Los Angeles Times, February 1, 1987, p 1
Kendell RE, Chalmers JC, Platz C: Epidemiology of puerperal pyschoses. Br J
Psychiatry 150:662673, 1987
Lagaipa SJ: Suffer the little children: the ancient practice of infanticide as a modern moral dilemma. Issues Compr Pediatr Nurs 13:241251, 1990
Latina v Latina, Del Fam Ct Lexis 48 (1995)
Lynch-Fraser D: The Complete Postpartum Guide: Everything You Need to
Know About Taking Care of Yourself After Youve Had a Baby. New York,
Harper & Row, 1983
Marc LV: Trait de la folie des femmes enceintes, des nouvelles accouches et
des nourrices. Paris, J.B. Bailliere et Fils, 1858
Mason-Hohl E: Trotula, eleventh-century gynecologist. Medical Womens Journal 47:349356, 1940
Meyer CL, Proano T, Franz J: Postpartum syndromes: disparate treatment in the
legal system, in Its a Crime: Women and Justice. Edited Muraskin R. Englewood Cliffs, NJ, Prentice-Hall, 1999, pp 91104
Oberman M: Mothers who kill: coming to terms with modern American infanticide. American Criminal Law Review 34:1110, 1996
Pfeifer v Pfeifer, 280 P2d 54 (Cal App 1955)
Pies R: The Andrea Yates case: lessons from Euripides. Psychiatric Times, May
2002, pp 35
Price v State Capital Insurance Company, 134 SE2d 171 (Sup Ct 1964)
Tekell J: Management of pregnancy in schizophrenic women, in Management of
Psychiatric Disorders in Pregnancy. Edited by Yonkers K, Little B. London,
Arnold, 2001, pp 189212
Wisner KL, Peindl KS, Hanusa BH: Symptomatology of affective and psychotic
illnesses related to childbearing. J Affect Disord 30:7787, 1994
Yardley J: Death penalty sought for mother in drownings of children. New York
Times, August 9, 2001, A12

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Chapter

10

Infanticide in Britain
Maureen N. Marks, D.Phil., C.Psychol., A.F.B.P.S.

When a woman by any wilful act or omission causes the death of her
child . . . aged less than a year, but at the time the balance of her
mind was disturbed by reason of her not having fully recovered from
the effect of giving birth to a child or by reason of the effect of
lactationthe offence which would have amounted to murder is
deemed to be infanticide and is dealt with and punished as if it were
manslaughter.
Infanticide Act (1938)

n England and Wales infants under 1 year of age are at much greater
risk (about four times) of becoming victims of homicide than either older
children or the general population (Marks 1996). This figure is based on
official records of infant homicides, so the risk is probably an underestimate, because some infant homicides are never discoveredespecially in
cases when the infant was killed soon after deliveryand others are never
recorded as such. For example, it is generally considered that at least 2%
10% of registered cot deaths are probably homicides (Emery 1985; Knowlden et al. 1985; Wolkind et al. 1993). The actual number of infants recorded as victims of homicide may seem relatively small3040 babies
a year in England and Walesbut it is possible that these homicides are
an extreme indicator of more widespread infant physical abuse that remains undetected.
A better knowledge of the background and causes of infant homicide
may lead to possible prevention of infant homicides as well as infant
185

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Infanticide: Psychosocial and Legal Perspectives

abuse. However, research findings and reports in the scientific literature

tend to be few and fragmentary, or alternatively anecdotal and speculative. There are inevitable difficulties in carrying out research with parents
who have been involved in such tragedies.
In this chapter, I describe how legislation on infanticide differs in various parts of Britain and describe the outcomes of court proceedings in
these systems. I also summarize current attempts to protect infants at risk.

Legislation on Infanticide
In England and Wales, a woman who has killed her infant under a year of
age can be indicted for infanticide (see Chapter 1: A Brief History of
Infanticide and the Law). The legislation that provides for this charge is
contained in the Infanticide Act (1938). Alternatively, the woman can be
charged with murder or manslaughter, as for any homicide offense, in
terms of the more general Homicide Act (1957).
Thus, the term infanticide has a precise meaning in terms of this act.
It applies to the killing of an infant under 1 year of age by its mother.
There is no special legislation for fathers who kill their infants. Note, too,
that the womans mind must have been disturbed at the time of the offense, with the implication that this disturbance is in some way linked to
childbirth and/or lactation.
The Infanticide Act, then, makes special and lenient provision for
women who have killed their infant. This provision rests on two related
assumptions: 1) childbearing disturbs the balance of a womans mind,
and 2) infanticide is likely a consequence of the mental instability associated with childbearing.
There has been ongoing debate in the United Kingdom about the advisability of retaining the Infanticide Act. Proponents of its abolition put
forward a number of arguments (Payne 1995), including the following:
There is no a priori reason why the killing of an infant should be considered as different from the killing of an older child or adult; to do so
implies that infants are not being given equal status and hence equal
protection by the law.
In terms of infanticide legislation, balance of the mind disturbed is
taken to mean less of an abnormality than that usually required to
substantiate a plea of diminished responsibility under Section 2 of the
Homicide Act (1957).
The medicalization of the offense (disturbance of the balance of the
mind . . . by reason of childbirth or lactation) is not justified because it

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187

conceals the contribution of factors such as social and economic circumstances, inadequate knowledge about contraception, difficulties with
child care, and so forth.
The Homicide Act (1957), with its provision for diminished responsibility, has rendered redundant the need for separate infanticide legislation.
Retention of the Infanticide Act encourages tolerance by society of the
killing and harming of infants and inhibits an advance in understanding
of the causes of such offenses.
These seductive arguments oversimplify the issues. To start with,
many would argue that there is a difference between a parent killing his
or her infant and an adult killing another adult. The relationship between
a parent (especially the mother) and an infant has unique characteristics.
Epidemiological data suggest that infant homicides are different from
other homicide offenses. For example, the rate of infant homicide in England and Wales appears to be unrelated to positive social changes associated with a decline in infant mortality, such as improved social and
economic circumstances, nor has the rate of infant homicide fallen since
the liberalization of abortion laws (Abortion Act 1967). Similarly, negative social changes associated with the steadily increasing rate of homicide
observed in the population as a whole have not affected the incidence of
infant homicide (Marks and Kumar 1993).
Proponents of abolition have noted with concern that the number of
women found guilty of infanticide and imprisoned has decreased (Payne
1995). They suggest that judges attitudes and hence sentencing are influenced by the relatively lenient framing of the British infanticide legislation. However, since the introduction of the Homicide Act (1957),
there has been a steady decline in convictions for infanticide and a concomitant increase in convictions of some other homicide offenses (e.g.,
manslaughter or murder) (Marks and Kumar 1993; Parker and Good 1981).
Individuals in the latter cases are more likely to be given prison sentences
(Marks and Kumar 1993). Therefore, under existing legislation, the more
serious infant homicide offenses are already associated with a conviction
other than infanticide.
Rather than abolish the Infanticide Act, what is needed is research into
the reasons that lead the prosecution to bring charges of murder, manslaughter, or infanticide. Further evidence to support this position comes
from a comparison of England and Wales with Scotland. Homicide rates
in Scotland in the general population are consistently higher than in England and Wales19 per million per year (Scottish Office 1993) compared with 11 per million per year (Home Office 1997). In addition,
Scottish legislation and judicial procedure differ from that of England

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and Wales in many ways. In contrast to the law in England and Wales,
Scottish legislation makes no special provision for maternal infanticide. A
mother who kills her infant in Scotland will be charged with either murder or common law culpable homicide as for any other homicide offense.
Mitigating factors, such as the defendants mental state at the time of the
death, will be taken into account as for any other homicide, as will her
fitness to plead in the first place. However, there is no embodiment within
Scottish law of causal links between childbirth or lactation, maternal
mental illness, and infanticide.
So how do infanticide rates in Scotland compare with those observed
in England and Wales? If more harsh legislation is a deterrent, then rates
should be lower. If infant homicide is related to homicide generally, then
rates would be expected to be higher. In an analysis of details obtained
from the Scottish Office concerning all infants under 1 year of age who
were recorded as the victims of homicide in Scotland during the period
from 1978 to 1993, it was found that despite social, cultural, and legal
differences between Scotland and England and Wales, rates of the offense, the characteristics of victims and perpetrators, and the patterning
of both convictions and sentence were similar in the two regions (Marks
and Kumar 1996). This suggests that the contribution of gross cultural,
social, and legal factors to the occurrence of infant homicide may be less
important than other, as yet unidentified, processes.
The infanticide legislation was designed primarily to protect psychotic
mothers from the death penalty if they were convicted of killing their
infants. Why, in principle, should one distinguish between them and non
psychotically depressed mothers (see Chapter 3: Postpartum Disorders)? Very few depressed or psychotic women kill their infants, and we
do not know the factors that render them more likely to do so. The causes
of such relationship problems are unknown but may include a traumatic
childhood and problematic adult social and family relationships, as well
as some physiological dysfunction. However, at present, there is insufficient information available from appropriate systematic studies of the
psychopathology of infanticidal parents to answer such questions.
In my view, the spirit of the Infanticide Act takes into account the
unique psychological circumstances of giving birth to and then caring for
a very young child, an abnormality of mind that is a feature of parenting.
Charging every woman who kills her baby with murder and subjecting
such women to the ordeal of a murder trial may increase the proportion
that are sentenced to imprisonment. Abolition of the act is unlikely to result in a reduction in the number of infants killed or to facilitate research
into the precursors of these crimes, nor is it likely to encourage the development of effective social policy to deal with the problem.

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Neonaticide in Britain
About a quarter of all infant homicides in Britain are of infants within 24
hours of their birth (Marks 1996). The characteristics and causes of the
homicide of these infants (neonaticide) are very different from those of
the homicide of infants older than a day; it is therefore important to distinguish neonaticide from the homicide of infants or older children (see
Chapter 6: Neonaticide). Unfortunately, few official records and epidemiological studies do so, and those that do tend to use different definitions of what constitutes a neonatefor example, up to 1 week of age
or up to 1 month of age. This makes the interpretation of the data obtained difficult and comparisons between studies impossible.
Anecdotal reports and case note studies suggest that demographic
features of neonaticides may also be different from those of homicides of
infants older than a day. For example, compared with parents who kill
older infants, neonaticidal mothers are more likely to be young (under
20), single, and still living at home with parents.
The infants death is more likely to have resulted from inaction rather
than the violent action that often characterizes the killing of older infants: nearly half die from neglect (Marks and Kumar 1993). Mothers
who kill their neonates are treated comparatively leniently by the legal
system in the United Kingdom. In a major proportion of cases, the
mother is never indicted, and those who are usually receive infanticide
convictions (Marks and Kumar 1993).
The most frequent observation about women who commit neonaticide is that the pregnancy had been denied (Brozovsky and Falit 1971;
Green and Manohar 1990) (see Chapter 5: Denial of Pregnancy). This
state of affairs is usually the consequence of an unconscious belief: if you
dont think about it, then the pregnancy will, magically, disappear. Sometimes the woman does not seem to acknowledge even to herself that she is
pregnant. In either case, the woman does not seek medical help and makes
no preparation for the delivery. After the child is born and disposed of,
the mother returns immediately to her normal daily life.
Pregnancy denial may be related to the fact that the biological manifestations of pregnancy sometimes become attenuatedfor example,
there may be reduced change in body contour, continuation of menstrual
bleeding during pregnancy, and no complaints of pregnancy such as nausea or increased urinary frequency (Brozovsky and Falit 1971). The arrival of the baby is thus experienced as a traumatic shock and puts an end
to the denial, and the woman is then confronted with the overwhelming
fear that made the denial so necessary and effective in the first place.

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A 20-year-old single woman had successfully concealed her pregnancy.

She had a previous pregnancy that had also been concealed. This first
baby had been delivered into a toilet at the parental home but had been
rescued by one of the family and subsequently adopted. During her second pregnancy, the woman was able to convince her friends, family, and
boyfriend who knew of the earlier concealed pregnancy that she was not
pregnant. She knew she was pregnant, and yet when labor pains started
(at term) she thought the pains were due to something she had eaten. She
was alone at the time, and the infant was born into the toilet and subsequently died. (The cause of the infants death was never fully established.) The mother placed the infant in a plastic bag and threw this into
a nearby lake. The morning of the infants delivery she returned to work
complaining of a heavy period. The discovery of the infant by a passer-by
set in train the inquiries, which led to the mothers arrest and trial. She
was subsequently convicted of infanticide and sentenced to probation.
The sentence included a treatment provision, namely, that she attend
weekly psychotherapy for a year.
The key psychodynamic features of the therapy work with this
woman involved addressing her denial of her underlying rage and murderousness and her unconscious guilt about these feelings. She was a nice
girlneat and tidy, compliant, hardworking, conscientious. She was always on her best behavior. Unpleasant thoughts and feelings she put to
the back of her mind. It was very difficult for the therapist to be in touch
with her rage, despite the dead baby and despite, too, the violence of material brought to sessions. The latter included, for example, a car accident
(hers), a suicide (a pregnant friends), and a local boys murder of his girlfriend. At times her rage and guilt formed an alliance, and she would do
something violent to herself.
It became increasingly evident that the diagnosis of dissociative disorder given by the psychiatrist in his assessment for the court was accurate.
This was exemplified not only in the way she was unable to experience
her emotional life but also in her impact on the therapist, who knew there
had been a dead baby but found this difficult if not impossible to keep in
mind. A particularly concrete example of her capacity to dissociate occurred about halfway through the treatment. The patient worked in the
catering industry. One day, during the course of her work that sometimes
involved helping out with cooking when the restaurant was very busy, she
noticed blisters on her hand and started to shake. She then realized she
had inadvertently put her hand into the boiling oil she had been cooking
with. She had not felt the pain of the burning until she had seen the blisters. The burns were serious and required hospital outpatient treatment,
after which she went back to work. In the week preceding this event, a
colleague had visited the work place to show people her new baby and
the patient had held the baby.
She was persecuted with guilt, largely unconscious, that was to some
extent addressed in the sessions. She would carry out menial tasks at
work, such as cleaning the toilets, even though she was employed in a
management role. She worked long hours for a pittance without complaining. She said this started when she was first charged: I deserved to

Infanticide in Britain

191

be the lowest of the low and now, well I feel bad if I dont. She believed
she had got away with murder and lived with the constant fear of retribution. This fear of retribution was embodied in a recurring dream. In this
dream she is in her bed, at home which is her mothers house. In her bedroom is a hatch to the loft. In the dream a man peers periodically out of
the hatch. Sometimes there is a rope around her neck and he has the end
of it. The man somehow gets her into the loft. He then removes bricks
from the side of the house and takes her out through this hole. And there
she is nowhere. The man then replaces the bricks in the side of the
house without her in it. What is so terrifying for her about the dream is
to be nowhere. She thinks the dream is about the hangmanabout her
fear that they are going to change their minds about prison.

I use this material, first, to illustrate the extent to which this patient resorted to the defenses of denial and dissociation and, second, to note how
in the absence of sufficient punishment demanded by her super ego, she
lived in fear of punishment and how, when her guilt became intolerable, she
punished herself. A prison sentence may have relieved her of some guilt but
may have made it more difficult for her to make her own restitution. She
and the supportive partner whom she met during the year of her treatment
now have a child. There are no concerns about this child being at risk.
The overrepresentation of women with dissociative disorder in studies of neonaticide mothers may be in part a consequence of not only their
navet but also this particular form of defense. It may be that more mature, worldly, reality-oriented women are more able to successfully conceal an unwanted pregnancy and dispose of the newly delivered infant in
such a way that it remains undiscovered.

Infanticide in Britain
Infants older than 1 day but younger than 1 year tend to be killed by either their mother or their father (see Chapter 2: Epidemiology of Infanticide). In the United States, in Florida, fathers and mothers are equally
likely to be the perpetrator. Jason et al. (1983) analyzed national child
(younger than 18 years) homicide data from the Federal Bureau of Investigation crime reporting system for 1976 through 1979. They found that
mothers killed neonates and that slightly more fathers than mothers
killed infants younger than 1 year. Likewise, in England and Wales (Marks
and Kumar 1993) and Scotland (Marks and Kumar 1996), slightly more
infants are killed by fathers than by mothers. In the England/Wales and
Scotland studies, there was no interaction between sex of perpetrator and
sex of victim: father and mothers were equally likely to kill boys or girls.
Infanticide is usually attributed to either mental illness or child abuse

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Infanticide: Psychosocial and Legal Perspectives

that is, the parent who has killed his or her infant is generally considered
to be either mad or bad. As discussed earlier, in England and Wales
there is particular legislation that applies to a woman who has killed her
child younger than 1 year (i.e., the Infanticide Act [1938]). Implicit in
this legislation is the idea that childbirth may sometimes have a destabilizing impact on mothers minds, that the infant homicide may have occurred under these unstable psychological conditions, and that, therefore,
there may be a case for diminished responsibility for the crime. In contrast, in Scotland and in the United States, mothers who kill their children are charged as for any other homicide offense, with the possibility
that the filicidal mother can plead diminished responsibility within the
usual terms of each countrys homicide legislation. Despite these differences in legislation, in most Western countries the younger the infant, the
greater the likelihood that the offense will be attributed to some form of
mental illness and the perpetrator will be convicted of a less serious offense and given a lighter sentence. This is particularly so for mothers who
kill their infants.
In England and Wales, most mothers who kill their infants are convicted of infanticide and given probation sentences. In contrast, fathers
who kill their infants are usually given prison sentences (Marks and
Kumar 1993). Despite there being no infanticide act in Scotland, the
outcome is similar. Most mothers who kill infants receive noncustodial
sentences, either probation or hospital orders, and most fathers are sent
to prison (Marks and Kumar 1996).
Public records provide limited information about the details surrounding these offenses, so it is difficult to know whether sentencing reflects the circumstances and severity of the crime. Data we obtained from
the Scottish Office included a computer record of the motive for the offense. Mothers were usually recorded as having killed their infant because
of their mental state, whereas the most frequent attribution given to fathers was that of rage (Marks and Kumar 1996). However, we were unable to determine how these motivations were ascribed and whether the
difference between mothers and fathers was due to the circumstances
surrounding the offense or to the effects of gender on the attributions
about the causes of events.

Prevention
An important but difficult aspect in the management of maternal mental
illness is that decisions about treatment have to take into account both the
mothers and her infants well-being. These decisions include judgments

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193

about immediate risk of harm to the infant as well as long-term judgments

concerning the mothers ability as a parent that have to be balanced with
the problems potentially resulting from overly intrusive care, which may
impair the mothers natural and healthy bonding with her infant.
Another difficulty concerns the reluctance of mothers who are experiencing emotional problems to recognize the problems and then to feel
it is safe to seek help for them. Many mothers feel they are not coping
and that they have failed as mothers, and they sometimes fear that should
their mental state become public they could lose care of their child. These
concerns, as well as more general fears about going mad and being stigmatized, mean that women are often reluctant to have contact with psychiatric services. Offers of care, therefore, need to take into account the
acceptability of the form of care delivery to the mother.
Strategies of treatment in the United Kingdom are influenced by the
fact that peripartum women have close contact with obstetric, health visitor, and primary care services. This means that detection of cases and delivery of care are increasingly being carried out at the primary care level
and that there is more psychiatric liaison with these groups in the provision of care for women with infants. Thus, in the United Kingdom, most
mothers are cared for in the community with regular general practitioner
and health visitor contact. A variety of services have been developed for
mothers whose illnesses are more severe. These include psychiatric outpatient contact, day hospital care, and inpatient mother and baby units.

Obstetric Service
Parturient women are in repeated contact with obstetric services, and one
way of targeting women who are depressed or at risk of becoming so is
via these services. For example, at Kings College Hospital in London,
there is an obstetric-psychiatric liaison service that provides a psychiatric
service to perinatal women who are identified at antenatal booking as
having histories of mental disorder. Under this scheme, patients with current or histories of significant psychiatric illness (screened by midwives at
antenatal booking) are offered an appointment with a psychiatrist and are
then monitored by the psychiatrist at regular intervals during the pregnancy and postpartum.

Midwifery Support
Another response to the difficulty in providing accessible care has been
the development of specialist midwifery services for high-risk women
(Kumar et al. 1995). Continuity of care is thought to have a preventive

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role by providing social support to mothers, enhancing the likelihood of

detection of prodromal symptoms, and improving successful follow-up
care if referrals are made to other professionals (Briscoe 1986). There is
evidence, too, that continuity of midwifery care may have direct beneficial effects. It has been shown to reduce postnatal blues (Odent 1984;
see also Chapter 3, this volume), labor times, and obstetric complications
in both mother and baby (Kennell et al. 1991; Klaus et al. 1986; Sosa et al.
1980), and it may also contribute to enhanced maternal postnatal mood.
Indications are that this form of support is very popular with high-risk
women.

Health Visitor Support

Health visitors (nurses who visit patients at home) have become increasingly involved in the detection of postnatal depression and in caring for
women identified as depressed (Holden 1996), either in support groups
(Pitts 1995; Romaine et al. 1995) or individually. Holden et al. (1989)
demonstrated that weekly counseling sessions by trained health visitors
are a successful treatment for postnatal depression. Women identified as
having a postnatal depression were allocated to a control or a treatment
group. Women in the treatment group received eight consecutive weekly
visits from the health visitors. After 3 months, 69% of women in the
treatment group, compared with 38% of the controls, had recovered.

Peer Group Support

Many women find it easier to seek help from nonprofessionals, such as
can be obtained from peer-developed and -run self-help support groups.
In Britain such organizations exist locally (e.g., Newpin in London) and
at a national level (e.g., National Childbirth Trust, Association for Postnatal Mental Illness). Help provided includes befriending, whereby a
member, usually a woman who has herself suffered postnatal mental illness, is introduced to the woman and becomes available to her for help
and support as required; regular telephone chats with members; and support group meetings.

Mother-and-Baby Units
One response to the requirements of severely or psychotically depressed
new mothers has been the joint hospitalization of both mother and baby,
either to general psychiatric admission wards or to specialized motherand-baby units. A preference for joint admission is based on the assumption

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195

that mother-infant separation is damaging to the burgeoning mother-infant relationship and may have deleterious consequences for the childs
development (Bowlby 1969, 1973, 1980). It is thought, too, that the infants presence may facilitate improvement in the mothers mental state
and may even hasten her discharge. Few argue with the benefits of keeping mother and child together; however, intensive programs of community care for postnatally depressed mothers that have been developed
as an alternative to admission are also effective (Oates 1988), as is community care in combination with day hospital support (Cox et al. 1993).

Conclusion
The younger the infant, the more likely the risk he or she will become
the victim of homicide, and the younger the infant, the more likely the
perpetrator will be a parent. Neonaticide is usually committed by mothers and is probably the least preventable of infanticides.
For children older than a day and younger than 1 year, a parent is the
most likely perpetrator of infant homicide. Both mothers and fathers are
at risk, although fathers may be slightly more likely to be, especially if the
father is the main caregiver.
Child abuse fatalities appear to be the most frequent type of infanticide
for younger infants. This usually involves a parent who is not severely mentally ill but whose parenting is, at least in some ways, inherently abusive to
the infant.
As with assessing the risk of violence in psychiatric patients generally,
there are difficulties in assessing the risk of infanticide in a mentally ill parent. Most parents with mental illness do not harm their children. When
they do, the most frequent scenario involves a parent who is suicidal and
who believes the child will also be better off dead.
One of the most important clinical developments in Britain the last
decade or so has been the consequence of a shift in emphasis from parental rights to the rights of the child and parental responsibility in ensuring
that these are adequately met. In the United Kingdom the passing and
implementation of the Children Act (1989) has resulted in important
changes in practice. The key feature of this act is that the welfare of the
child is paramount: when there is conflict, the childs needs have priority
over those of the parent.
There is always sympathy and concern for a woman who has a severe
psychiatric disorder. Often she herself has been the victim of grossly inadequate parenting from which society failed to protect her. Under these
circumstances, the womans caregivers may find it difficult to keep both

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mothers and babys sometimes conflicting needs in mind. A frequently

expressed, and understandable, view is that all mothers need to be given a
chance. A society that asserts and legislates for the primacy of the childs
welfare ensures that it is the baby who is given a chance. This goal may
be best achieved by offering therapeutic interventions aimed at helping a
mother to better protect, care for, and understand her childor, when
necessary, through separation and safe and secure placementrather
than by introducing more punitive legislation.

References
Abortion Act 1967, 15 and 16, 2,c.87. October 27, 1967
Briscoe M: Identification of emotional problems in postpartum women by health
visitors. BMJ 292:12451247, 1986
Brozovsky M, Falit H: Neonaticide: clinical and psychodynamic considerations.
Journal of American Academy of Child Psychiatry 10:673683, 1971
Bowlby J: Attachment and Loss, Vol I: Attachment. New York, Basic Books, 1969
Bowlby J: Attachment and Loss, Vol II: Separation: Anxiety and Anger. New
York, Basic Books, 1973
Bowlby J: Attachment and Loss, Vol III: Loss: Sadness and Depression. New
York, Basic Books, 1980
Children Act. London, Her Majestys Stationery Office, 1989, C41
Cox JL, Gerrard J, Cookson D, et al: Development and audit of Charles Street
Parent and Baby Day Unit, Stoke-on-Trent. Psychiatric Bulletin 17:711713,
1993
Emery JL: Infanticide, filicide and cot death. Arch Dis Child 60:505507, 1985
Green CM, Manohar SV: Neonaticide and hysterical denial of pregnancy. Br J
Psychiatry 156:121123, 1990
Holden J: The role of health visitors in postnatal depression. International Review
of Psychiatry 8:7986, 1996
Holden JM, Sagovski R, Cox JL: Counselling in a general practice setting: controlled study of health visitor intervention in treatment of postnatal depression. BMJ 298:223226, 1989
Home Office: Criminal Statistics, England and Wales 198796. London, Her
Majestys Stationery Office, 1997
Homicide Act. London, Her Majestys Stationery Office, 1957, C45
Infanticide Act, 2 Geo 6, Ch 36 (Eng 1938)
Jason J, Gilliland JC, Tyler CW: Homicide as a cause of pediatric mortality in the
United States. Pediatrics 72:191197, 1983
Kennell J, Klaus M, McGrath S, et al: Continuous emotional support during labor
in a US hospital: a randomized controlled trial. JAMA 265:21972201, 1991
Klaus MH, Kennell JH, Roberson SS, et al: Effects of social support during parturition on maternal and infant morbidity. BMJ (Clin Res Ed) 293(6547):
585587, 1986

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Knowlden J, Keeling J, Nicholl JP: Post neonatal mortality. DHSS Report, London, Her Majestys Stationery Office, 1985
Kumar R, Marks MN, Jackson K: Prevention and treatment of postnatal psychiatric disorders: the role of the midwife. British Journal of Midwifery 3:314
317, 1995
Marks MN: Characteristics and causes of infanticide in Britain. International Review of Psychiatry 8:99106, 1996
Marks MN, Kumar R: Infanticide in England and Wales, 19821988. Med Sci
Law 33:329339, 1993
Marks MN, Kumar R: Infanticide in Scotland. Med Sci Law 36:299305, 1996
Oates M: The development of an integrated community oriented service for severe postnatal mental illness, in Motherhood and Mental Illness. Edited by
Kumar R, Brockington IF. London, Wright, 1988, pp 133158
Odent M: Birth Reborn. London, Souvenir Press, 1984
Parker E, Good F: Infanticide. Law Hum Behav 5:237243, 1981
Payne A: Infanticide and child abuse. Journal of Forensic Psychiatry 6:472476,
1995
Pitts F: Comrades in adversity: the group approach. Health Visitor 68:144145,
1995
Romaine S, Jones A, Watts T: Postnatal depression: facilitating peer group support. Health Visitor 68:153, 1995
Scottish Office: Statistical Bulletin: Criminal Justice Series. Edinburgh, Government Statistical Service, 1993
Sosa R, Kennell JH, Klaus MH, et al: The effect of a supportive companion on
perinatal problems, length of labor, and mother-infant interaction. N Engl J
Med 303:597600, 1980
Wolkind S, Taylor EM, Waite AJ, et al: Recurrence of unexpected infant death.
Acta Paediatr 82:873876, 1993

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Part

IV

Treatment and
Prevention

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Chapter

11

How Could Anyone Do That?

A Therapists Struggle With
Countertransference
Anonymous

The analyst contributes to the working alliance by . . . consistent emphasis on understanding and insight, . . . and by compassionate, empathic, straightforward, and nonjudgmental attitudes.
R. R. Greenson (1988)

first heard of this neonaticide when a television reporter called me to

comment on the news of the mothers arrest. My response was not horror
or sadness, I confess, but annoyance. Why, as an expert on postpartum
depression, do I get these baby-killing calls from the media? Am I on a
Rolodex somewhere that says infanticide, postpartum depression, whats
the difference, call her? As is my policy on these once- or twice-a-year
calls, I explained to the reporter that I couldnt possibly comment on the
mental health or illness of an individual Ive never seen. I was annoyed
because Im sick of hearing neonaticide linked to postpartum depression.
How many depressed new mothers decided to stay sick, I wonder, sure
that asking for help will raise their fitness as safe caregivers?

The author is a reproductive psychiatrist, psychodynamic psychotherapist, and a

faculty member in a large academic medical center. In view of the publicity of
this case, the author has chosen not to reveal her identity and geographical location in order to protect the confidentiality of the patient.

201

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Infanticide: Psychosocial and Legal Perspectives

It had been a bad year for neonaticide, with several highly publicized
cases scattered across the country. The reporter didnt want to take no for
an answer. Okay, she said, I know the prom queen thing was partly
about being too young, but this ones a 21-year-old, a junior in college.
My reply was who can ever understand how a mother could ever do that?
My responsehow could anyone do thatdidnt distinguish me from
any other mother hearing of neonaticide, and this sent the reporter on her
way.
The next I heard of Julie was several months later, when a colleague
from another city called to refer her to me for psychotherapy while Julie
was free on bail pending trial. My colleague had conducted a forensic
evaluation for the defense and recommended that Julie receive treatment.
I refused.
I had heard this colleague lecture on neonaticide and knew that she
had collected more clinical data on the phenomenon than anyone else in
the field. I understood her explanationa transient dissociative state in
which the overwhelming shock of a denied and disastrous pregnancy
caused a temporary loss of reality testing. As a fellow psychiatrist demystified of motherhood, I had the greatest respect for her work and admired
her dedication to these most hated mothers. But I could not imagine
finding the empathy to treat someone who had committed neonaticide.
I explained this to her: my countertransference was going to be insurmountable, I knew it already. Like the reporter, she wouldnt take no for
an answer. Trust me, you will find the compassion. She was certain that I
would be able to help her, and besides, she said, if you cant, who can?
The circumstances leading up to the neonaticide were both typical
the patient was from an extremely conservative immigrant background
in which unwed pregnancy was an unimaginable disasterand atypical.
She had been raped shortly before the pregnancy, possibly resulting in the
pregnancy, and that too had been kept secret, almost as shameful in her
family as voluntary intercourse. Given the rape, denial and dissociation
were recently employed defenses against reality too painful for consciousness.
We made a deal: I would see the patient once or twice and decide
whether I thought I could overcome my bias and work with her in psychotherapy.
It took a few months for her to call for an appointment. When she did
finally come for an evaluation, it took approximately 5 minutes for me to
want to bring her home with me. I went from distaste to rescue in an instant. I believe my initial countertransference to Julie (as opposed to my
media-enhanced idea of who Julie must be) was like what I typically ex-

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203

perience with lost kittens. I know that I agreed to see her for evaluation
because of the rape: she had some claim on victimhood and didnt just
belong to my imagined group of young women too narcissistic to deal
with pregnancy.
Julie was accompanied by her mother, who, though stylishly and contemporarily dressed, was extremely traditional at home. As I called Julie
from the waiting room, her attentiveness to her mother was immediately
obvious. It was the first crack in my assumption that only a raging narcissist could commit neonaticide, and this deference would come to be the
major focus of our work together. Julie dressed nicely for her appointmenta typical looking young adult in every way but with this old fashioned respect for the doctor.
She told me her story in bits and pieces, looking like a deer caught in
the headlights, and I was sunk. Nothing about Julie was remotely narcissistic: no self-pity, no rage at others, no indifference, no self-aggrandizement. There was no hint of borderline personality disorder either: she
was a former honor student, a state-ranked athlete, and a woman with many
solid and stable interpersonal relationships.
Julie told me in the first appointment that she was coaching childrens
sports. That she was allowed to work with small children in an affluent,
educated community that has known her all her life and that knows of
the infants death gave her the tiniest fragment of self-respect. She never
verbalized what it was like to be vilified, so hated in the media that even
a psychiatrist who should know better thinks shes a monster, but she alluded to it frequently. Some parents didnt want me to teach their kids
at first, but my old coach stood by me and now I teach them all. This
was her haven: here, alone, she was a loving and giving adult, a safe caregiver of children.
She could not imagine what was happening to her: How could she be
charged with murder? How could she protect her parents from this shame?
How could she believe what is said about her to be true?
Julie was largely amnestic for the events surrounding the death of her
infant, and she related details as told to her. Her present awareness was
profoundly affected by the circumstance of facing murder charges: she
didnt remember the delivery, and her patchy dissociative recall was influenced by a pathologist retained by her lawyer, a prominent expert who
alleged, in contradiction to the official autopsy, that the infant had not
been delivered alive. This was balm for Julie, a way to maintain the sense
of herself as a fundamentally good person.
She did clearly understand that she had not recognized her own pregnancy. (Neither had her roommates, her coach, or her fellow college
athletes who saw her disrobed or in trim athletic outfits throughout the

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school year.) Her clothing size had never changed, and she believed that she
had continued to menstruate throughout the year.
In the course of her treatment, the major focus was her extremely
obedient relationship with her mother. On bail, facing a possible life sentence, Julie was permitted a curfew of midnight, despite the fact that her
social peers would typically not begin a Saturday night evening until 10 P.M.
Julie was aware that as the first born, she was the one expected to conform
most to the rules of her mothers culture, while her younger sister was
permitted marginally more freedom. Julie allowed her mother to decide
which college she would attend, deferred to the expectation that she would
date (and presumably marry) a man from her parents culture, and planned,
as instructed, to return after college to work in the family business.
Throughout the trial preparations, Julie reported her mothers belief that
Julies current predicament was the direct result of her failure to accept
her mothers advice to remain more dutiful.
In some ways, the most difficult countertransference reaction I had
was my own reaction to Julies extraordinary deference to her mother. No
psychiatrist hasnt worked with the nonassertive patient, but it was deeply
distressing to witness Julies repeated compliance with the expectations
of another world. I would find my thoughts drifting to the countless expressions of autonomy that my own children take for granted, the challenging of the rubber rules, the gray zone between the firm nos and the
softer maybes that characterize the daily interactions of American parents and their children. Julie had no rubber rules, no maybes. There were
no details too small to require parental approval and no challenging of parental authority. Rules and parental decisions were law.
My wish to rescue Julie, her kittenhood, was very similar to that which
I often feel when treating adolescents in highly critical and scapegoating
families. I was shocked by what sounded like a relentless use of shaming
as a means of establishing authority. I understand that we only see our
patients families through their eyes, without the parents input, but time
after time, Julie would describe interactions that she recognized as emotionally painful but not as either ill-intentioned or even inappropriate.
She seemed most able to recognize shame and control in her mothers approach to her sister, and a major task of her time on bail was helping her
sister to do what Julie had not done: determine which college she would
attend despite her parents choice of another college. She would occasionally work to convince her mother to allow her younger sister an extra
hour of curfew or to receive phone calls from a boy deemed unsuitable.
Julies vicarious autonomy was, truthfully, endearing.
At times, I wanted to scream at her: just say no! I would have imaginary conversations in my head in which I would ask her exactly what did

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she think would happen if she just stayed out dancingwith girlfriends
until 2 A.M. one morning? Didnt she realize the absurdity of surrendering reasonable freedom when she was probably going to prison? But my
reaction would have compounded her sense of shame, multiplied her
own sense of betrayal that she would even share such family secrets with
me. I would have been another shaming, controlling mother telling her
that what she was doing (obeying) was all wrong, not the way of my culture, not the way that would make me proud of her.
Over time, we were able to speak about Julies American self caught
in a traditional family. I believe that merely probing her mothers ways
calling her dorm room literally every morning and every evening, scrutinizing every unexpected absence, for examplevalidated her sense that
she was not bad for wanting more freedom.
Already virtually boundaryless, Julie was raped shortly before her pregnancy. (Through most of my treatment with her, she believed that the
rape had resulted in the pregnancy, a fact disconfirmed shortly before our
sessions ended when it was discovered that the DNA analysis indicated
that her boyfriend had been the father.) Julie showed more reticence to
discuss the rape than perhaps any other victim Ive treated, with tremendous resistance to recalling any detail. This, too, failed to meet my preexisting stereotype: I expected that she would rationalize the neonaticide
on the basis of victimhood. She simply never went there, in part due to
the severity of her posttraumatic stress disorder and phobic avoidance.
Instead, we discussed the rape as a secret that she could neither know
nor let her parents know prior to her arrest. She never considered telling
her parents that she had been raped. She anticipated that her mother
would blame her for the rape, which indeed seemed more likely than not.
She also feared upsetting her mother, who, I came to believe, was tortured by anxiety and unhappiness. If there was one reason Julie could
state for her obeisance, it was to protect her mother from becoming distressed. Her description of the family dynamics suggested that her father
and her sister also labored to keep her mother from discovering painful
information.
Not surprisingly, her pregnancy would have been a disastrous knowledge for Julie and her mother. Julie was able to explore the reasons her
pregnancy was unknowable to her, why her body and mind cooperated in
keeping Julie from consciously recognizing that she was pregnant. In
part, her American selfthe one who voluntarily became sexually active
at the age of 19was split from her traditional self, who would remain a
virgin until she married with parental approval. She had developed a compartmentalization of her American self. Born and raised in the United
States, Julie had an identity at school, in her sports, and in her work with

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children who were American, a culture valuing autonomy and independence. She watched her peers rebel over issues large and small but lived
her life as a traditionalist, one who remained childlike and undifferentiated by the cultural norms of her citizenship.
In my work with Julie, I sought integration of her experiences and
compartmentalized selves. Ironically, she experienced herself as shameful
when she had so much as a rebellious thought about which television
program to watch but seemed almost clueless as to why she was charged
with a crime. I doubt that my disapproval of a family environment that
forbids its members to seek comfort following rape or unanticipated pregnancy was entirely hidden from her. But I believed that she also understood that I honored her traditional self as much as I did her American
self. Had I insisted that she be a typical young American adult, or had I
criticized her parents values, I do not believe she would have remained
in psychotherapy.
I also believe that my own personal experience with a close family
member who married an immigrant from a very similar culture was useful in managing another countertransference obstacle, that of too readily
accepting its just the way it is with my people. Ive witnessed first hand
the struggle of a strong maternal authority seeking to maintain traditional
family relationships with a daughter married into an American family
that values autonomy and individuation from parental sovereignty. It
would have been easy to excuse Julies denial of pregnancy, with its
disastrous consequences, as cultural and to see her solely as a victim of
cultural conflict. Often, when I would gently inquire as to what she wanted,
felt, and experienced internally in described interactions with her mother,
she would claim deference as just the way it is in families of her ethnicity. I believe my experience watching a healthier struggle with old versus
new ways helped me to challenge the assumption that there was simply
no other choice except protecting her mother from her American self and
deferring to her parents views.
In the background of treatment was the constant threat of incarceration and a murder trial. The reality of threats to her safety and integrity
deeply affected my work with her, especially in terms of her posttraumatic stress disorder. I usually find that the reexperiencing and retelling
of the trauma, while therapeutic in detoxification and necessary for reintegration, lead the patient to feel worse before she feels better. I was
acutely aware of the need to treat Julie with kid gloves: to help her be as
strong as she could possibly be in the face of the anticipated trial. She had
overwhelming decisions to make: should she go to trial, testify on her
own behalf, or accept a plea bargain? I feared that opening the extraordinarily painful memories of her rape, necessary in my view for healing,

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might risk decompensation and literally harm her. For almost a year, the
trial was on again and off again, so I was never certain whether a wound
opened one week could be healed were a trial to start suddenly. I generally chose to support rather than confront defenses. At times, I felt confident that this was the proper course; at other times, I feared that I was
at best missing opportunities and at worst accepting her fragility and immaturity as fact.
The single most painful emotional reaction I had to working with
Julie turned out to have nothing to do with my response to her actions
but rather my firsthand look at what I continue to see today as the grave
injustice done by the legal system to her. Like many psychiatrists, I realize
that at one level the criminal justice system is flawedtoo many of us
have seen the sociopath succeed in feigning insanity as a defense while
the patient with floridly psychotic schizophrenia is incarcerated rather
than treated. But I also believed that the system would do rightthat
while punishment was far more likely than not, mercy and justice would
temper her fate.
In part, my belief that she would receive reasonable and just legal
treatment was based on ongoing resolutions to other highly publicized
neonaticide cases across the country. In the course of our work together,
several defendants were convicted and sentenced to imprisonment that,
although significant, was clearly based on the complexity of these young
womens circumstances. They were sentenced as troubled young adults
with a potential for rehabilitation, not as monsters or willful child murderers. I hoped and believed that Julie would be similarly treated, especially since there was doubt about whether the infant was even living at
birth, and she had highly capable legal representation.
Unfortunately, Julies particular circumstances placed her in an especially vulnerable legal position. For one thing, the local prosecutor where
the case occurred was a high-profile elected official, and the political value
of this particular prosecution was significant. But most important, the local law had been recently changed to criminalize child endangerment,
which carried a mandatory 25-year sentence. In a mock trial, in which
Julie testified, the mock jurors reported that although they did not believe she had committed manslaughter, they compromised on child endangerment, since she had not called 911 at the time of the delivery, even
if the infant was indeed dead already. As would have happened at a bona
fide trial, the mock jurors were not permitted to know that such a conviction would result in a mandatory 25-year sentence. When debriefed,
they were reportedly shocked at such an outcome.
Once the mock jury had convicted her of child endangerment, Julies
lawyer immediately advised her to plea bargain, because it was the sole

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charge, which would have allowed a judge no sentencing discretion. The

risk that a jury would convict her of the seemingly lesser charge of child
endangerment left Julie at too great a risk. In the next few weeks, Julies
attorney negotiated a plea bargain of 10 years, with a minimum of 5 years
served. This was more than double the time to be served in any of the comparable cases that had been in the public eye. The prosecutor and judge
allowed Julie an additional 7 months until reporting for sentencing.
That she was to serve 5 years, deferred by 7 months, made it very clear
to me that her sentence was retribution. A judge or prosecutor who believed that Julie posed a risk to a child would not have reasonably allowed
her to remain free for 7 months following conviction.
Ironically, I started my work with Julie anticipating antipathy. I imagined that she would fail to take personal responsibilitythat she would
expect me to see her as a victim of circumstances who couldnt be held
accountable. Instead, I myself came to see her as a victim of circumstances,
a young woman who experienced a great personal tragedy, one far more
complex in origin than I would have imagined.
But greater still, I believe that Julie has suffered a social tragedy, becoming one of many victims of our cultural need to idealize pregnancy.
As a culture, we regularly project ambivalence about parenting on highly
publicized bad mothers: cocaine addicted women, abusive parents,
mothers who abandon toddlersall serve to receive our hateful impulses
and to simplify the complexity of the nature of the parent-child relationship. When we think about Susan Smith driving her children into the
lake, Marie Osmond with postpartum depression handing her seven children to a housekeeper while she drives up the California highway, or the
high school student who delivers her infant in the bathroom then goes
back to the prom, we quench our thirst for reassurance that we are, will
be, and were raised by unambivalently loving parents. Collectively, we ask,
how could anyone do that, and we are comforted by the certainty that
we could not.
My initial reactionHow could anyone do that?in retrospect
seems to have fed my own unconscious appetite for rejecting bad mothering impulses. I believe I did not want to know the answer to the question. As psychotherapists, we regularly are given privileged access to pain.
We are witnesses to the complexity of human behavior. The answer
what chain of life circumstances, what psychological and social factors
could culminate in such a great tragedyis, not surprisingly, painful.

Chapter

12

The Mother-Infant Relationship

From Normality to Pathology
Pamela Meersand, Ph.D.
Wendy Turchin, M.D.

I made a quilt to keep my family warm. I made it beautiful so my

heart would not break.
Sara Ruddick (1980)

Academic and clinical interest in the mother-infant relationship has

intensified in the last 25 years, giving rise to a burgeoning research literature as well as new psychotherapies. When D. W. Winnicott (1965, p. 55),
the famous psychoanalyst and pediatrician, asserted that there is no such
thing as a baby outside the context of a mother-child dyad, it was considered a radical notion. Developmental research in the 1980s and 1990s
confirmed Winnicotts vision of infancy: the importance of a healthy
mother-baby attachment for social, emotional, and even cognitive functioning in later childhood became widely recognized and today is considered common knowledge.
Mother-infant interaction, with all its complexities, cannot be examined
in isolation. Contemporary thinking places the dyad in an intricate system of parental, child, and social/environmental factors, all in dynamic
interplay; multiple relationships and circumstances wrap around the pair,
impacting mother and child at each stage of development (Emde 1991;
Sameroff 1993). Risks to mother-infant relations may arise anywhere in
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the system as a result of maternal psychopathology or history of trauma,

in response to severe environmental stress, or as a result of problems in
the fit between maternal personality and infant temperament.
Selma Fraiberg coined the now-famous phrase ghosts in the nursery
to describe those painful, early memories that haunt all mothers as caring
for their infants stirs up old longings and fears (Fraiberg et al. 1975). Importantly, as research from multidisciplinary perspectives has elaborated those
ghosts, demonstrating specific variables that place mothers and infants
at risk, new interventions have kept pace. Parent-infant psychotherapy, a
psychodynamic treatment that improves mother-child attachment, has
shown exciting potential for reducing child abuse and neglect. As clinicians become more skilled in the early identification of high-risk mothers,
preventive psychotherapy can be offered in the antenatal period and continued during those critical first months of life.
In this chapter, we aim to arm the reader with information relevant to
early identification of risk and prevention of tragic outcomes, such as child
maltreatment and infanticide. The spectrum of mother-infant relations,
from normal to pathological, is described from both theoretical and clinical perspectives. First, we briefly review those aspects of psychoanalytic
and attachment theory most relevant to current thinking about vulnerable dyads. Next, we examine the complex components of mother-child
interaction in both favorable and high-risk circumstances; clinical vignettes
are used to highlight the reactions of various mothers to the motherinfant situation, with an emphasis on vulnerable dyads. Lastly, we discuss
parentinfant psychotherapy and explore the potential of treatments for
addressing attachment disorders.
Although attachment is a lifelong process, and treatment may be mutative at any point in the life span, we focus here on the earliest months
of life, when the infant is most vulnerable and the mother is in the throes
of adjusting to parenthood. The discussion is largely limited to the relationship between infant and mother; despite a growing body of evidence
that fathers and even nonfamilial caregivers provide crucial early influences, most available research limits itself to mothers and their babies.

The Mother-Infant Dyad in Psychoanalysis and

Attachment Theory: A Historical Review
Psychoanalytic Perspectives
In striking contrast to current thinking, early psychoanalytic views of infancy placed little emphasis on maternal behavior. With the publication of

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his famous Three Essays on the Theory of Sexuality, Freud (1905/1953)

presented a vision of infancy driven by biology: development was seen as
dominated by progressive phases of psychosexual organization. The
infants first relationships were inextricably tied to physical drives, such
as hunger; Mother could achieve importance in the eyes of her baby only
through the role of need-satisfier (Freud 1915/1957). Melanie Klein (1935,
1946) revised this view, suggesting that the newborn is relationship-seeking from the start. However, like Freud, she believed that biological predispositionsin the form of innate, unconscious fantasiesdominated
the infants early experience, relatively unaffected by maternal availability and responsiveness.
It was Winnicott, versed in infant observation from his practice as a
pediatrician, who brought the maternal figure to life. Despite obvious
struggles to position himself within the tradition of both Freud and Klein,
Winnicott posed the radical idea that instinct alone does not govern
infancy and that the ordinary and countless daily interactions between
mother and child form the context in which the childs mental and emotional life develops. Mothers behavioral responses, personality, and attitudes
toward her baby were considered to have a crucial impact on development.
Winnicott described the mothers special state of mind during pregnancy
and early infancythe primary maternal preoccupationas one of exquisite sensitivity to the needs of her baby. The mother, through identification of herself with her infant knows what the infant feels like and so
is able to provide almost exactly what the infant needs in the way of holding and in the provision of an environment generally (Winnicott 1965,
p. 55).
Winnicott and his contemporariesmost notably W. R. Bion and
Margaret Mahlerwere formative for current thinking about both healthy
and pathological early development. For Winnicott, the infants mental
representations of self and others unfolded within the context of the
mothers supportive presence, or her holding environment. The transitional objectthat much-cherished first doll or blanket that brings
comfort much in the same way that the mother doesis a sign of the
emotionally nourished infants capacity to internalize the mothers love,
even without her physical presence (Winnicott 1971). When the infant
is forced to make elaborate accommodations to a demanding or hostile
caregiver in order to maintain her love, a false self (Winnicott 1965) develops in which the child forfeits his or her own spontaneous needs and
wishes. Bions (1970) concept of good mothering assumed the capacity
to contain the infants discomforts and distresses. Mothers calm, timely
responses allow the baby to achieve a gradual tolerance of previously overwhelming experiences, such as hunger; unempathic, ill-timed, or hostile

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maternal responses deprive the infant of the growing capacity to regulate

negative internal states. In Mahlers theory of psychological development
(Mahler et al. 1975), the mothers evenhanded acceptance of the infants
complex needs and demands allows the baby to achieve beginning independence without the paralyzing fear that he or she will lose the mothers
love.
Importantly, the work of these clinician-theorists encouraged psychoanalysts to move beyond a focus on the infants instinctual, intrapsychic
life. All were keen observers of mother-child interaction and saw the dyadic
relationship, rather than the individual infant, as the crucial entity; this
view laid the groundwork for the current practice of parent-infant psychotherapy, in which mother and child are treated together rather than
as separate units.

Contributions From Attachment Theory

After World War II, Renee Spitzs (1945, 1946) pioneering studies of
orphaned babies showed the dramatic effects of maternal deprivation.
Reared in institutions after the loss of their parents, these infants first
exhibited angry protest; despair set in, and they stopped growing, developing, and exploring their environment. Depression, apathy, and even
death resulted. These findings surprised many psychoanalysts who believed that infants were incapable of true attachment and mourning.
John Bowlby was heavily influenced by Klein and others who viewed
infants as innately relationship-oriented. He drew from ethology, most
notably Harlows important demonstration that mother-deprived infant
rhesus monkeys suffered long-lasting social deviance. Postulating a biologically based attachment behavioral system for human infants, Bowlby
suggested that babies are programmed from birth to seek proximity to
their mothers. Sucking, crying, and clinging behaviors designed to elicit
the mothers interest and maintain closeness to her were seen as manifestations of attachment (Bowlby 1969, 1973, 1980). Separation from the
mother was hypothesized to cause severe distress.
Bowlby viewed attachment as an overarching system that organized
infant behavior and development. Like other psychoanalysts, he believed
that infants develop mental representations of relationships, which he
called internal working models; however, he rejected the Kleinian notion that these representations were deeply influenced by unconscious
fantasy and asserted instead that real-life, daily experiences with the
mother determined the infants concepts of self and others. Laid down in
the first months of life, internal working models were carried forward to
influence relationships throughout the life span. The well-parented infant

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would develop positive representations in which the mother was viewed

as a secure base from which to venture forth and explore the world; optimism and self-efficacy would be applied to future relationships with
caregivers, peers, and teachers. By contrast, infants who lacked early empathic mothering would come to view others as disappointing and even
hostile and would see themselves as helpless and unwanted. These lessfortunate babies would approach future relations with avoidance or aggression.
Continuing Bowlbys work, Mary Ainsworth studied the development
of consequences of early mother-infant interaction. In their landmark
study of 26 mother-child pairs, Bell and Ainsworth (1972) demonstrated
that effective maternal response to infant cryingparticularly close
physical contactwas associated with decreased crying at the end of 1
year. Moreover, a mothers overall sensitivity and responsivenessher
ability to read her babys cues, her capacity for timely response, and a positive attitude toward physical contactwas found to predict a secure
mother-child attachment at the end of the first year of life (Ainsworth et
al. 1978). For the first time, an empirical study had confirmed the critical
role of maternal behavior.
Ainsworth and collaborators delineated three attachment categories,
which are now familiar to most child researchers and clinicians. The predominant category, secure attachment, was characterized by babies who
explored comfortably with the mother present, evidenced concern when
she left the room, and showed relief and pleasure on her return. Avoidant
attachment was exhibited by babies who failed to show distress when left
alone with the stranger and who generally ignored their mothers. Resistant attachment described infants who were greatly stressed by separation
and failed to be comforted by the mother on her return. Main and Solomon (1986) added a fourth category, disorganized attachment, to describe
the behavior of babies who show a disoriented, incoherent response to
the stress of separation.
These classifications, easily applied to research, brought attachment
theory into the forefront of empirical work in early child development, a
position it has enjoyed for more than 20 years. Secure attachment has
been shown to predict good developmental functioning in all areas: higher
levels of symbolic play (Slade 1987), positive attitude toward problemsolving tasks (Matas et al. 1978), competent peer relations (Pastor 1981),
positive adjustment to school (Sroufe 1983), and lower chances of psychopathology such as disruptive behavior problems (Greenberg et al.
1993).
Recent attachment studies have pointed the way to early identification of high-risk mothers. This research owes much to the seminal work

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of George, Kaplan, and Main (1985), who identified three styles of adult
attachment: secure, achieved by those adults who present balanced, integrated views of relationships; dismissing, characterized by a tendency to
diminish the importance of others; and preoccupied, typified by overinvolvement with unsatisfying past relationships. Research has demonstrated continuity between attachment status in infancy and patterns of
relating in early adulthood (Waters et al. 2000). Numerous studies in the
1980s and 1990s linked a mothers attachment style to her babys attachment status at 1 year: the secure, dismissing, and preoccupied maternal
styles corresponded to secure, avoidant, and ambivalent child styles, respectively (Main et al. 1985). Demonstrating the use of the antenatal
period for early identification and prevention, Fonagy and colleagues
(1991b) predicted mother-infant quality of attachment at age 1 year
from their assessment of mothers relational style during pregnancy.

Current Views
Current influential theorists integrate concepts from both attachment and
psychoanalytic theory, also drawing on the vast research in infant cognitive and emotional development. Written from his unique vantage point
as both a developmentalist and a psychoanalyst, Daniel Sterns The Interpersonal World of the Infant (1985) stirred wide interest in infancy and offered a new way of looking at the first few months of life. Postulating that
even newborns possess a rudimentary sense of a separate and cohesive self,
Stern proposed that very young infants accrue emotionally laden memories of interactions with mother that lay the groundwork for mental representations of self and other. Developing motor, language, and other
cognitive skills combine with ongoing interpersonal experience, and the
infant develops increasingly complex, integrated notions of the interpersonal world.
Peter Fonagy, a well-known psychoanalyst, suggests that a mothers capacity to contemplate her own and her childs thoughts and feelings
called reflective self-functioningmay be key in the intergenerational transmission of attachment styles (Fonagy et al. 1991a). Mothers with low reflective self-functioning are seen as incapable of viewing the world through
their infants eyes; they are typically concrete, hostile, and unempathic.
Their infants, in turn, fail to develop age-appropriate social abilities.
Current thinking about maternal psychopathology draws from notions
of internal representations from both psychoanalytic and attachment
theory. In their studies of child maltreatment, Crittenden and Ainsworth
(1989) suggested that abusive mothers have mental models of relationships that feature conflict, control, and rejection. Their children tend to

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215

develop patterns of interaction that feature passive compliance or resistance. Neglecting mothers are characterized by models of helplessness in
relation to others; they experience emptiness and depression as dominant
emotions. Neglected children, having learned that they cannot effectively
elicit maternal response, tend to become clingy and demanding or depressed and defeated.
Most recently, additional evidence from neurobiology supports the
critical role of early mother-infant interaction in optimal child development. Studies of Romanian orphans, reared in institutions with minimal
human contact, have linked early maternal deprivation with brain abnormalities, which are thought to have far-reaching consequences for later
social, emotional, and cognitive functioning (Nelson and Bosquet 2000).
Fully consistent with Spitzs (1945, 1946) observations of war-orphaned
infants in the 1940s, these current findings support major tenets of both
object relations and attachment theories. The modern techniques of neuroscience may provide the most compelling evidence to date that, as
Winnicott declared, there is no such thing as a baby without a mother.

Early Mother-Infant Relations: The Beginnings

of Secure and Disordered Attachments
Transactional Model of Risk
Ainsworths landmark studies, summarized earlier, provided empirical
support for the importance of maternal sensitivity in the first months of
life. Since then, a great deal has been learned about the intricate components of dyadic interaction. Daniel Stern and T. Berry Brazelton, a noted
pediatrician, conducted a microanalytic study of mother-child interaction, documenting the moment-by-moment interchanges in the dyad.
Reciprocal, rhythmic patterns of mutual attention and arousal were described as part of the typical face-to-face play behavior of mothers and
their infants (Brazelton et al. 1974; Stern 1974). In positive circumstances, these subtle precursors of childhood turn-taking and even adult
conversational patterns serve as the building blocks of the secure motherinfant attachment.
The transactional approach to child development suggests that ordinary mother-infant interaction can be disrupted by a number of factors in
the parent-child-environment system (Cicchetti 1989); these factors,
which impinge on the dyad, interrelate in complex ways. Environmental
distress, maternal psychopathology, or difficult child characteristics can
disrupt the fine-tuned adjustments that typify maternal behavior. A de-

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pressed and isolated mother may be preoccupied with her own thoughts
and therefore less available to read her infants cues; paired with a fussy,
premature newborn, that same mother may become defeated or angry,
finding the babys cries unbearable.
Using the transactional model for assessing risk of child abuse and neglect, Cicchetti and Rizley (1981) categorize variables that impinge on the
dyad into two domains: potentiating factors stress the dyad and increase risk
for problems, whereas compensatory factors protect against attachment disorders. When potentiating factors are present in several domains (e.g., maternal depression in addition to infant prematurity and poverty), the result
is a dyad at risk for insecure attachment and even child maltreatment. In
contrast, an abundance of compensatory factors, such as adequate financial
resources and a history of close family relations, contribute to a positive attachment outcome; these may even help ameliorate the presence of one or
two difficult conditions, such as infant illness.
Although the transactional model attempts to account for a wide range
of variables in the biological and environmental spheres, not all factors
are necessarily accorded equal weight, and there is no cookbook method
for assessing level of risk. For example, Halpern (1993) suggests that
poverty is a particularly devastating factor that wreaks havoc with childrearing, causing parents to become preoccupied with their difficult circumstances and to suffer an undermined sense of efficacy about their
lives in general. Many clinicians working with high-risk families consider
social isolation to be a key factor in risk for child maltreatment; Pianta
and colleagues (1989) suggest that psychological processes involved in
mothers ability to engage in interpersonal relationships serve a central
causal role in maltreatment (p. 245). On the positive side, a factor such
as treatment may override numerous potentiating ones. Erickson et al.
(1992) suggest that a trusting relationship with a therapist may function
as a protective factor, providing a high-risk mother with new ways of
viewing herself and others. The success of parent-infant psychotherapy
with extremely high-risk dyadsthose with severe environmental stressors as well as maternal psychopathologysuggests that treatment may
buttress healthy attachment in even the most dire circumstances.

Pregnancy: A Critical Time for Assessment of Risk

Describing the enormous psychological requirements of successful adjustment to pregnancy, Cohen and Slade (2000) include 1) a dramatic
reorganization of the womans own identity within the context of her
marriage and society; 2) the ability to view her child as part of her and
yet ultimately separate from herself; and 3) the creation of an internal

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217

representation of the baby that includes negative affects but is primarily

loving and joyful. These involve all aspects of the pregnant womans personality: memories of early experiences with her own mother, conscious
and unconscious fantasies about herself and others, and the capacity for
self-reflective functioning as described by Fonagythat is, the ability to
hold two minds in her mind: her own changing sense of self alongside
her fluctuating and intense affects and the reality of her baby, both part
of and apart from her (Slade and Cohen 2000, p. 30).
Stern (1995) and Benedek (1959) view motherhood as a unique developmental phase. Maternity is seen as providing the opportunity for
forward development via new identities and the reworking of old relationships and conflicts. In The Motherhood Constellation, Stern (1995)
suggested that with the birth of a baby, especially the first, the mother
passes into a new and unique psychic organization (p. 171). However,
women who are too burdened by unresolved past conflicts may not be
able to accept the new role as parent; early trauma and the lack of stable,
internal representations of relationships to others may impede the joy and
excitement that typically balance the fears and anxieties of new motherhood. As early as the antenatal period, she may dread or even deny her
impending maternity (see Chapter 5: Denial of Pregnancy). After birth,
if the mother fails to achieve a sense of parenting competence or is burdened by her own early traumatic experiences, motherhood may instead
become a time of deep conflict and despair.
The following clinical description of a 22-year-old pregnant woman
who is at very high risk illustrates the impact of traumatic history and psychiatric disorder on the attitudes and expectations of the antenatal period:
K, a young woman with a history of both physical and sexual abuse in
childhood, was referred for treatment during the last trimester of her
third pregnancy. During two previous pregnancies, both of which had resulted in low-weight babies who were ultimately removed from her care
for failure to thrive syndrome, she had steadfastly denied she was pregnant through the first two trimesters, even in the face of obvious physical
signs. Now, 32 weeks pregnant with her third child, her refusal to plan
for or even think about the baby caused her obstetrical team extreme pessimism about her ability to parent the next infant.
K had suffered from untreated anorexia and bulimia since adolescence and appeared gaunt. Introducing herself to the therapist, she cheerfully exclaimed, I never know Im pregnant until its practically over. I
think its best that way not to think about the thing too much. She was
preoccupied with fears of gaining weight and openly described her plans
to trick her midwife into thinking she was gaining weight so that Nosy
Nelliell leave me alone about gaining. Asked if she had thought about
the consequences of her poor nutritional status for herself and the infant,

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she replied: If the babys small, itll be quieter. She refused to discuss the
father, select a name for the baby, or in any way prepare herself or her
home (a small room, where she lived as a boarder) for the infants arrival.
Otherwise cheerful and outgoing, she grew listless and apathetic when
the subject of the child was raised. When the therapist realistically stated
her fears that this infant, too, would be removed from Ks care, the young
woman shrugged, although her eyes grew teary at the mention of her first
two children.
Despite her refusal to discuss the infant, Ks fears and fantasies were
revealed through her reports of intensely vivid dreams wherein alien invaders took over her body, distorting it and ultimately causing her death.
The first time her therapist suggested that this might be the way she
viewed the baby, she was shocked; gradually, however, she revealed that
she did, in fact, think of the baby much as she thought of food: getting it
out of her body was her only goal. She was horrified by the very idea of
pregnancy, of having a thing growing inside me, who knows how big it
could get. With few memories from her own childhood, and all of them
unpleasant, K could barely imagine herself parenting an infant: her own
mother had failed to protect her from a dangerously volatile, alcoholic
stepfather.
The therapist continued to state her own concerns in a forthright,
nonjudgmental manner, making clear that it seemed K could barely care
for herself, let alone for a newborn. At the young womans request, she
accompanied K to the next maternity appointment, and for the first time
K showed some interest in the midwifes educational efforts. Concrete
discussions about childbirth and about the needs of newborns helped K
see the pregnancy as real and graspable; this allowed for some fantasies
about the child. As she began to imagine herself with the newborn, K
showed interest in her impending maternity for the first time. Although
her nutritional status remained poor and she had great difficulty picturing
herself as a mother, she was able to engage in some basic planning for the
birth: a crib, some clothing, and finally a name was chosen.

This young woman experienced the growing fetus as such an intolerable threat to her bodily and emotional integrity that for many weeks she
could not acknowledge her pregnancy (see Chapter 5). As in Pollack and
Percys (1999) description of mothers who deny pregnancy, K viewed the
developing child as a persecutory, invasive intruder. After the infant girls
birth, acknowledging that she had felt a tiny suspicion about being pregnant from the start, K vaguely recalled the magical idea that if she denied
the pregnancy long enough, the fetus would go away somehowmaybe
die, maybe just sort of fade. Some months later, she admitted that her
rage toward the fetus was so great she feared she might kill the child after
birth; fear of her own homicidal impulses (which had probably been
acted on, albeit in a somewhat less direct fashion, by her complete failure
to nourish her first two infants) contributed to her need to avoid knowledge of her pregnancy.

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Ks therapist and her maternity team made sure that intensive, comprehensive services were provided at birth: daily home visiting by a
preventive agency and parent-infant psychotherapy with her existing clinician three times per week functioned as a way to monitor the infants
safety as well as to support K in her growing desire to mother her baby.
For the first time K accepted treatment for her eating disorder, and individual, psychiatric treatment for her was added on shortly after the birth.
Although an informal assessment of attachment at 1 year showed a clearly
avoidant style on the part of the infant, the child was healthy and well
developed. Extensive services helped this mother care for her daughters
basic needs and avoid yet another foster care placement.
Over 40 years ago, Bibring (1959) recommended psychotherapy for
women who could not achieve an adequate emotional adjustment to
pregnancy. Without the benefit of modern research, he recognized that
acute distress or apathy in the antenatal period placed the infant at risk.
Today, research has confirmed Bibrings notions, demonstrating that a
womans attitude toward her pregnancy and her notions about her future
child predict later mother-infant attachment status. The growing body of
clinicians trained in assessment of high-risk mothers and schooled in the
principles of parent-infant psychotherapy make real the possibility of
truly early intervention.

Temperament and Mother-Infant Goodness of Fit

From the first moments of birth, the infant brings his or her own unique style
to the mother-child relationship. The well-known researchers on temperament Chess and Thomas (1986) proposed nine dimensions of temperament: activity level, rhythmicity of biological functions, intensity of
affective reaction, predominant mood, persistence, approach-withdrawal
in novel situations, adaptability to changes in routine, sensory threshold,
and distractibility when upset. Infants were then classified according to
three patterns: easy infants were cheerful, followed predictable biological routines, and adapted easily to novel circumstances; difficult babies
had predominantly negative mood and intense reactivity; slow to warmup infants were low in activity and withdrawing in new situations.
These researchers found that temperamental patterns were consistent
over a number of years; for example, infants classified as having difficult patterns were shown to have a higher risk of behavioral difficulties
years later when they entered school (Chess and Thomas 1986; Thomas
and Chess 1977).
Although Chess and Thomas believed that temperament had biological rootsa position endorsed by most theoriststhey emphasized the

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interplay of constitution and environment. Goodness of fit (Thomas et

al. 1968), the match between the infants temperament and the mothers
personality, was seen as crucial. For example, the mother of a very intense, active baby may be either thrilled or overwhelmed by his behavior;
one mother may find her child a smart, inquisitive explorer, whereas another may fear he is going to be impulsive and difficult to handle. One
adolescent mother with a history of conduct disorder described her motorically advanced 7-month-old as a future juvenile delinquent. The following case example of a young, first-time mother with very adequate
emotional and environmental resources serves as an illustration:
Mike kicked constantly in utero. His mother, J, an industrious and vivacious lawyer who cheerfully looked forward to her 6-month maternity
leave, happily anticipated an active newborn. Active he was; however, she
was baffled and upset by how hard he was to soothe. Mike would cry for
hours at a time for much of the day. J was exhausted from trying to calm
him. She would rock him, sing to him, and walk him all around the house.
Frustrated and overwhelmed, she questioned her own competence and
even her decision to have a child. At the worst moments, in tears, she
found herself feeling angry at Mike, as well as at her husband, who failed
to provide any relief from infant care. She called her pediatrician and began to describe her desperation. The doctor examined the infant, determining that he was healthy but easily overstimulated.
The pediatrician suggested that J try making smaller and simpler gestures to comfort him. J began to sing more quietly to Mike, making sure
that the rest of the apartment was quiet. She began to move more slowly
and with smaller motions, even though this did not naturally fit with her
own active style: she loved to dance vigorously with him. Mike responded
to her changes: he began to quiet down for longer periods of time and to
seem more content. J found that she, too, was becoming calmer, and it became easier to read the infants signals. Although he remained difficult to
soothe throughout infancy and had fierce tantrums by 15 months, J felt
she had at least some capacity to help him calm down.

The scenario may have been completely different had it involved a

mother with significant psychopathology, perhaps burdened by her own
history of trauma. High-risk mothers, who often have distorted perceptions about their babies, may interpret temperamentally derived behaviors as intentional and designed to upset them. For example, one single,
socially isolated mother with paranoid tendencies described that each
time her fussy baby cried, she was certain the newborn was wailing out
her disappointment over having an inadequate mother. Feeling accused
and defeated, she avoided the baby more and more, which of course led
the infant to even greater distress and more crying bouts.
J was able to realize that her anger was irrational, even in the midst of

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221

being upset and frustrated, and took steps to get help. A more defensive
mother might become extremely angry at the infant, unswerving in her
belief that the baby meant to undermine her parenting competence. A
vicious cycle might ensue, wherein the mother, feeling more and more
overwhelmed, failed to seek the support of others, such as a pediatrician,
who might help shed a more realistic light on the situation. The result
could be severe isolation, neglect of the baby, or even abuse when the
mother could no longer bear to listen to the childs cries (see Chapter 1:
A Brief History of Infanticide and the Law).

Emotion Regulation and the Role of

Maternal Psychopathology
Both attachment theorists and psychoanalysts recognize the mothers crucial
role in helping the infant gradually learn to tolerate and integrate various
emotional experiences. Abundant studies that illustrate the youngest infants capacity to read and respond to human facial expressions suggest
that from birth, the infant is impacted by the emotional reactions of
those responsible for his or her care. The sense of shared emotional states
is a critical dyadic development. Affective sharing in the first few months
of life takes place largely through face-to-face interactions; more sophisticated forms of sharing develop with the infants increasing cognitive
and motor capacities. At 9 months, joint attention serves as a way to
share interesting, pleasurable experiences as mother and infant look first
at an interesting toy and then at each other. Examining their mothers facial expressions, infants of this age follow her cues about whether or not
an unfamiliar situation is safe or threatening. As language develops, verbal communication becomes a rich, complex way for mothers and babies
to share their experiences.
Maternal depression is a particularly challenging condition for infant
development and for infant-mother attachment. Postpartum depression,
affecting about 15% of women (Seifer and Dickstein 2000), occurs at a
time when mothers are already stressed by the need to adjust to newborn
feeding schedules, lack of sleep, and the general household disruption that
inevitably comes with a new baby. Increased irritability, listlessness, poor
concentration and difficulty focusing on the baby, lack of pleasure in the
infant as well as in the overall environment, and lack of efficacy and selfesteem are typical complaints (see Chapter 3: Postpartum Disorders).
In her often-cited study, Tiffany Field (1984) showed that infants as
young as 3 months respond to maternal mood and are adversely affected
by depressed mothers: they themselves develop passive, depressed styles

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of interacting. When mothers with normal mood were asked to feign depression (i.e., assume a sad face, decrease their responsiveness), their
infants manifested clear signs of distress, with gaze avoidance, negative
affect, and decreased vocalizations. In an earlier study, Brazelton et al.
(1975) found that even 6-week-old infants showed distress and avoidance when their mothers were asked to act withdrawn and depressed
(Brazelton et al. 1975). Furthermore, in her study of postnatal depression
and infant development, Murray (1992) found that maternal depression
predicted higher rates of insecure attachment at 18 months of age.
When the mother functions as a container, as Bion proposed, she
correctly reads her infants expression of emotion, allows herself a spontaneous reaction to it, but then responds in a timely and helpful manner.
For example, confronted with a frequently hungry and very distressed,
crying newborn, the containing mother will experience both the infants
desperation and her own sense of exhaustion and frustration; her manifest reaction, however, is one of calm and sympathy, and she quickly arrives with the desired milk. With an older, verbal baby she may label the
affect state, encouraging his or her ability to symbolize and communicate
emotions. Appropriate, empathic responding in the face of boredom, frustration, and irritation is a complex task for any mother; for a woman with
little ability to control her own emotions or who is emotionally constricted herself, it becomes an impossible demand.
According to Fonagy and colleagues (1995), mothers with low reflective self-functioning fail to provide effective emotional support and guidance for their infants. Describing the chilling impact of a frightening or
withdrawn mother on the young childs capacity to develop shared mental states, they state, In cases of an abusive, hostile, or simply totally vacuous relationship with the caregiver, the infant may deliberately turn
away from the object because the contemplation of the objects mind is
overwhelming, as it harbors frankly hostile or dangerously indifferent intentions toward the self (p. 257).
S was a bright, articulate, but emotionally constricted 25-year-old mother
who wore a fixed smile on her face; her expression did not change when
she discussed sad or distressing material. An extensive psychiatric history
included three significant suicide attempts in adolescence, with lengthy
hospitalizations. As a young child, her alcoholic parents had counted on
her to provide care for several younger siblings. Her role as caregiver had
commenced at age 5 years, when her parents would often leave her and
her siblings alone in the evenings. She recalled being required to execute
household duties in a cheerful manner. Although she denied any memory
of physical abuse, she remembered that protestations or complaints of being tired were met with severe disapproval and verbal threats by the par-

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223

ents. Removed from her parents home at the age of 12, she was separated
from her siblings and placed in a group setting.
Mothering her infant daughter was extremely challenging for S. She
could not tolerate any expression of negative emotion from her infant. Although Lily was placid and content from birth, even her occasional cries
for food were overwhelming for S. However, this mother denied ever feeling irritated or frustrated by the demands of motherhood. She described
the infant as a joy and a gift from God, claiming that she had never
found any undertaking as rewarding as parenthood. A demonstration of
their interaction was provided, 2 weeks into treatment, when Lily had
just turned 3 months of age.
At one point in the session, the infant began to cry softly. S assumed
a fixed expression, avoiding eye contact with the girl, and began to hum
to herself. She busied herself cleaning up toys they had been playing with.
When the babys crying escalated, S began to sing. At the point of Lilys
greatest distress, S maintained a fixed expression and sang a loud, jovialsounding tune without emotion. The therapist suggested that S pick up
the child. S cooperated but stated oddly, She loves my singing; it makes
her happy. She seemed not to notice the distress of the infant at all. Apparently satisfied with being held, Lily ceased crying. When the therapist
later asked S about her reaction to the crying, the mother looked puzzled;
it was clear that she had only a hazy memory of the entire interaction.
Only after many sessions was the therapist able to point out to S that she
was unable to cope with Lilys distress; together they began to acknowledge, label, and respond to the infants cries.

Ss own early history of severe neglect, a condition she had been forced
to accept cheerfully, made it impossible for her to tolerate her babys expressions of distress: the old, repressed longings and rage evoked by her
infants cries were simply unbearable. She responded by enlisting wellentrenched, formerly adaptive patternsnamely, dissociating herself from
powerful, negative affects. This completely prevented S from responding
empathetically to Lily. Her inability to acknowledge Lilys and her own
unhappiness, in addition to her unconscious resentment about once again
assuming the caring role, led to severely misattuned responses to the infants communications.
Psychotherapy, which ultimately helped S link previously disowned
emotional reactions to events, was instrumental in allowing her to achieve
more appropriate responses to her baby.

Maternal Perceptions and Attitudes

Even before their first pregnancy, mothers engage in fantasies about their
children. Fears, wishes, and expectations, deeply influenced by their own
childhood experiences, are brought to mothers first infant interactions.
Mothers with traumatic histories and serious psychopathology often mani-

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fest persistent, distorted ideas about their babies: unrealistic developmental expectations, inappropriate notions about the infants thoughts
and feelings, and projections from unhappy past relationships may dominate their every reaction to their child.
Alicia Lieberman (1992), a well-known infant researcher, describes
how babies become unwitting partners in their mothers unresolved psychological conflicts. First, the mother projects onto her child an unresolved
emotional experience; second, she pressures the child to comply with the
projection (e.g., she may make clear the unspoken threat that maternal
attention and approval are contingent on certain behaviors); and third,
the child accepts and identifies with the maternal expectation. Inhibition
of exploration, recklessness, and precocious competence in self-protection
may result when infants are the focus of maternal projections (Lieberman
and Pawl 1990).
B, a bright and outgoing 17-year-old first-time mother with a history of
sexual and physical abuse, became suicidal during pregnancy on learning (from the guesses of friends) that she was likely to give birth to a girl;
she described despairing of her childs future, because girls are always
victims. After giving birth to a healthy male infant, whom she immediately described as macho, she expressed deep pleasure in his fisted
hands: Hes ready to fight. When a nurse commented that all newborns
hold their hands in the fisted position, she seemed deflated. Several weeks
later, B noted that little Michael was bicycling with hands and feet and
proudly reported to her therapist that he was a tough guy, and going to
ride a motorcycle, like his father. The home-visiting nurse noted that B
played aggressively with the infant, jabbing at him with plastic toys to the
point where the child seemed to wince, as well as avert his gaze and cry;
this made the mother laugh, and she persisted with her game.
Bs interest in promoting what she perceived as a masculine attitude
intensified as the infant gained motor capacities. At 6 months, she was eager to help him practice walking and spent many hours holding him up
by his hands as he attempted to move his legs. She encouraged all sorts of
physical play, generally ignoring him if he was subdued. She spoke
proudly of his attitude and declared that he wasnt going to take anybodys bullshit.
Aside from her obvious pleasure in his physical activities, however, B
showed little actual interest in the baby and did not seem to know much
about him. He was primarily cared for by the maternal grandmother, who
complained that B spent most of her time pursuing her relationship with
the childs father. B clearly knew little about her infants likes and dislikes;
could not describe aspects of his temperament other than to note, laughing, that he was mean; and did not seem to know how to interact with
him unless she was teaching him a motor task or engaging in roughhouse
play.
When the child was approaching his first birthday, B was referred for psychotherapy. By gradually pointing out Bs investment in the boys mascu-

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225

linity and her tendency to equate him with other significant male figures,
Bs therapist was able to bring some of these processes to Bs consciousness, placing them more under her control. To encourage her interest in
all aspects of her sons personality and his developmental skills, the therapist sat with B, and together they observed and commented on the boys
activities. B was surprised to discover certain things about her sonfor
example, his fascination with picture books; she commented, Hes like
me in some ways; I used to love to sit with a book.

This young woman held rigidly dichotomous views about males and
females: men and boys were associated with her volatile and abusive stepfather, while females of all ages were seen as unhappy victims. Even the
commonplace features of her infant sons physical development were interpreted as signs of a tough, masculine attitude. As the baby became a
more active partner in the relationshipthat is, at around 9 months, when
joint attention and social referencing behaviors emergedshe found
ways to communicate her pleasure in active behavior and her expectations that he would follow in the steps of his father, an adolescent delinquent whom she both admired and feared. For example, she would
quickly intrude upon any quiet behaviors (e.g., when he would sit and
handle toys) in order to engage him in motor activities; she was not dissuaded from this even when he would cry from obvious displeasure in being interrupted. Even when he was about to fall asleep, she would often
jostle and awaken him.
Over time, this infant protested less and less his mothers aggressive
interferences. Complying with maternal projections, he was an early
walker and an athletic risk-taker as a toddler. As in Liebermans (1992)
notion of distortion in secure base behavior, he showed a reckless disregard for safety in his approach to the environment. However, along
with winning maternal approval, his macho behaviors placed this infant
in a bind: his mother also began to grow angry with him, seeing him as
defiant and uncontrollable.

The Role of Fathers

Research on the role of fathers lags far behind that of mothers, and paternal
influences are only beginning to emerge as critical. Fathers can complement solid mothering or compensate for maternal weaknesses; during
difficult periods of adjustment, such as the postpartum weeks, the father
can play a crucial role both in his support to the mother and through his
direct care for the newborn. Moreover, the quality of the couples relationship may figure importantly in the severity and chronicity of maternal depression (Campbell and Cohn 1997). Through their naturally more

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rigorous manner of play, fathers provide rich and diverse emotional experiences for infants (Crockenberg and Leerkes 2000). The next few years
should shed increasing light on the direct and indirect impact of fathering
on early child development.

Parent-Infant Psychotherapy:
The Earliest Intervention
Development of a Treatment for High-Risk Dyads
On the basis of years of work with high-risk mothers and their neglected
or abused children, Selma Fraiberg (1980) formulated a new treatment
in which the infants physical presence was a crucial part of the session.
Mother and infant would interact together, displaying their typical patterns of behavior; the therapist would use these interchanges as meaningful points to begin her exploration of the mothers memories and
attitudes. Fully compatible with attachment theorys emphasis on the intergenerational transmission of attachment styles, this innovative treatment also drew heavily from psychoanalytic concepts: interpretation of
the mothers responses to her infant aimed at elucidating underlying, often unconscious issues and anxieties. Ultimately, Fraiberg (1980) sought
to free infants from the distortions and displaced affects engulfing them
in parental conflict (p. 70).
Following Fraibergs seminal work with high-risk dyads, numerous
forms of parent-infant psychotherapy were developed. Stern (1995) noted
that all these forms share the following characteristics: they are generally
brief (312 sessions), they focus on promoting a positive working relationship with the mother, and they concern themselves with impacting those
maternal beliefs and attitudes that are enacted in day-to-day motherinfant interaction. The treatments vary in whether they emphasize concrete interactions or symbolic representations; accordingly, some will
provide straightforward advice and information, whereas others work via
the method of psychoanalytic interpretation.
As described by Stern (1995), the parent-infant therapist selects from
among the various features the dyad displaysawkward interactions, inappropriate maternal expectations, difficult infant temperamentand
chooses one as his or her immediate clinical focus. Through this port of
entry, the therapist approaches the parent-infant system and begins to
work. Depending on the clinical presentation, the therapist may choose
the maternal representations, the infants behavior, the parent-child interaction, or his or her own reactions as the initial entry point for intervention.

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227

A parent-infant psychotherapist who seeks improved mother-infant

interaction as her major goal would likely select the mothers overt behavior as the port of entry. For example, a mother who does not read her
infants initial bids for face-to-face contact, waiting until the childs attention has waned, may experience defeat and disappointment when the
baby finally gets around to responding. The parent-infant specialist
points out her delay and helps her discern the subtle, initial overtures of
her low-keyed baby. The therapist may or may not also explore the mothers
feelings and associations around the issue of the infants approaching her
and the failure of the baby to respond to her awkward sense of timing.
Changes in the mothers gestures toward the baby often lead to changes in
infant responsiveness; ultimately, improvement might occur at a deeper
level (i.e., in the mothers internal representations of how she sees herself
and her child). In this case, the parent may begin to experience herself
as more competent and effective, as well as needed and wanted by her infant.
Lieberman and colleagues (1991) hypothesized that anxious attachment results primarily from affective dysynchronies between mother and
infant; their practice of parent-infant therapy sought to increase maternal
empathy and responsiveness. These researchers designed an eclectic approach for high-risk Mexican mothers with severe social and economic
stressors. Weekly home visitors hoped to improve attachment by encouraging mothers to function as a secure base for their children and sought to
decrease environmental stress by concrete interventions (e.g., help with job
training, English skills, housing). Dyadic improvements included increased
maternal empathy, less avoidance and resistance on the part of children,
and more cooperative, harmonious mother-child interactions.
Drawing on principles of attachment theory and psychoanalysis, Erickson and colleagues (1992) developed a home-based psychotherapy program
that sought to promote healthy parent-infant relationships for high-risk
dyads. These authors emphasize the establishment of a positive therapeutic relationship as a potential way for mothers to develop new working models that reflect an increase in self-esteem and trust in others.
Insight is described as critical in fostering change: by making the unconscious conscious, by facilitating the parents thinking about what was previously automatic or unthought, the therapist hopes to give the parent
greater control over actions (p. 500). Benefits of parent-infant treatment
included decreased maternal depression and anxiety and improved maternal responsiveness to the infants.
Research on the effectiveness of parent-infant psychotherapies is promising, although limited. One well-known evaluation of brief mother-infant
psychotherapy (Cramer et al. 1990) compared the efficacy of two very brief

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treatments. The first, an interpretive psychotherapy, approaches motherinfant disturbances by identifying a focal symptomatic interactional sequence. No direct advice or instruction on how to interact is provided to
mothers. The second form of treatment is based on interaction guidance,
a parent-infant psychotherapy created by Susan McDonough for families
with severe social/environmental stressors who are difficult to engage in
treatment (McDonough 1993). Videotape technology is used to highlight and then reinforce maternal strengths, emphasizing the positive aspects of her interaction with her infant.
Cramer and his team hypothesized that the interpretive therapy would
have more influence on internal and unconscious representations, whereas
interaction guidance would tend to impact actual behavior. Results support the notion that behavior and representations are interconnected: differences in outcome for the two approaches were minimal. Both were
effective in improving behavior (increasing maternal sensitivity and responsiveness) and in changing maternal perceptions of herself and her
infant (mothers began to see their infants as more affectionate and themselves as calmer and more competent). Positive changes were still evident
6 months after termination. Overall, the results suggested that parentinfant psychotherapy has potential as a major agent of change (Cramer
et al. 1990).

Early Identification and Evaluation of High-Risk Dyads

The antenatal period is the ideal point for early intervention. Guided by
the transactional model, clinicians can evaluate level of risk on the basis
of a pregnant womans various social and emotional assets and vulnerabilities. For example, an adolescent with a history of conduct disorder,
living in deep conflict with her own parents, would be considered at risk
for forming an unhealthy relationship with her baby; should she also display hostile attitudes and unrealistic expectations toward her unborn
child, concern about future abuse and neglect would be raised. A modified
version of parent-infant psychotherapy, in which the pregnant woman and
the imagined and expected baby are the dyad, can then be provided.
Standard parent-infant psychotherapy can be initiated at birth, when the
mothers first reactions to the baby can be incorporated into the treatment.
Interviews and questionnaires developed by attachment theorists over
the last 20 years have been enormously helpful in guiding the identification
of high-risk dyads. Many infant specialists use a brief separation-reunion
paradigm to assess mother-infant attachment style; avoidant, ambivalent,
or disorganized styles are easily discerned. Additionally, it is now widely

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229

accepted practice to assess the mothers other relationships, both past

and present. History of trauma or relational instability suggest that she
may encounter difficulty establishing a secure attachment with her infant.

Conclusion
Both psychoanalytic and attachment theories have molded current thinking about mothers and infants, uniting in the view that early motherinfant interaction is formative for development. Moreover, mothers psychological functioning is seen as the key to dyadic success, although contributions from the infant, family, and the larger social milieu are critical.
Although typical mothers are seen as specially equipped to meet their
infants needs, the demands of motherhood are formidable: women must
discern the cues of preverbal infants; respond in a timely and empathic
manner, even when overwhelmed and exhausted; and rework those inevitable old fears and anxieties that arise in the day-to-day mother-infant
situation. Severe problems in attachment may result when mothers are
overburdened by history of trauma, psychiatric illness, distorted ideas, or
emotional constriction. It remains for future research to elaborate the
role of fathers and other caregivers who may have significant influence
on mother and child.
Parent-infant psychotherapy uses mother-infant interaction as the window to those unconscious maternal thoughts and feelings that ultimately
determine an infants attachment security. This promising new form of
treatment seeks to make the mothers ghosts in the nursery more accessible, resulting in improved interactions as well as in deeper change at the
level of mental representation. As mother-infant treatment becomes more
widely used and researched, its effectiveness for avoiding tragic outcomes
such as child abuse and infanticide can continue to be assessed.

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Chapter

13

The Promise of Saved Lives

Recognition, Prevention, and Rehabilitation
Margaret G. Spinelli, M.D.

Dear Dr. Spinelli,

I have read your report on neonaticide. . . . I believe my case fits with
the cases outlined in the report.
I have been charged with criminally negligent homicide and have
just begun my sentence of 13 years here at .
I am writing to you to ask if you have any programing recommendations. It has been suggested that I complete an anger management
program while I am here. I was hoping that you may have some suggestions as to the type of programing I may require for rehabilitation.
The anger management was suggested by programing because the
case charge is criminally negligent homicide. The case itself was not
looked into by anyone who programs inmates.
I have the ability to take other programs that I think may be helpful to me. There are programs for other crimes here[,] but I have yet
to find anything rehabilitating for myself.
I may have overlooked a program. Please respond[,] as I ask for
your help.
Thank you,
G
Letter from a woman in prison

As this chapter signals conclusion, I remind the reader of this books

original intent. Future research and education pertaining to infanticide
are paramount, particularly because early intervention, and thus prevention,
235

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may easily be achieved. I address this deficiency by returning to the typology and associated details of infanticide described by the distinguished
contributors to this book and repeat Oberman and Meyers warning (see
Chapter 1: A Brief History of Infanticide and the Law) that there is no
singular cause for infanticide. Because mothers who kill their infants are
not a homogenous group, prevention must be multifactorial.
Unlike other types of murder, infanticide has known and identifiable
precipitants, namely, pregnancy and childbirth. Women come to us in obstetricians offices, antenatal clinics, and well-baby centers. We meet their
families and children. They complete questionnaires and attend interviews
with physicians, nurses, and social workers. How do we miss the warning
signs of potential tragedy?
This chapter is about women and infants at riskabout recognizing
clues, hearing unspoken messages, and establishing communication with
vulnerable mothers. While I describe assessment tools to identify depression or assess potential for fetal abuse, child maltreatment, or infanticide, I
also emphasize our relationships with mothers as our most important tools
for identification, intervention, prevention, and treatment. I also describe
self-help organizations, associations for professional and lay members, a
pen pal network of women serving prison sentences for infanticide, and
other vehicles and opportunities for prevention and treatment.

Mother-Infant Attachment
The continuum of mother-infant interaction disorders ranges from delayed
attachment to infanticide (Robinson and Stewart 1993). Approximately
10% of new mothers will experience delayed attachment to their infants.
Another 1% will have negative or hostile thoughts about their newborns.
Although child abuse is also on the continuum of poor attachment, infanticide is the ultimate failure of bonding (see Chapter 12: The MotherInfant Relationship). Although mother-infant attachment disorders are
most often described in the postpartum period, they may be detected,
and therefore explored, during gestation to facilitate the resolution of
hostile feelings before delivery. In essence, the antenatal period is the
paramount time for prevention.
Selma Fraiberg (1980) coined the phrase ghosts in the nursery to describe the process through which unresolved conflicts in a parents childhood may resurface in the parent-infant relationship (Scott 1992). The
mothers preexisting conflicts, centered on unmet dependency needs or
on an ambivalent internalized image of herself as mother, may be exacerbated by the event of childbirth (see Chapter 12).

The Promise of Saved Lives

237

During pregnancy, a woman redefines her relationship with her own

parents. Depending on early relationships, some antepartum women may
develop ambivalent or even hostile feelings toward their pregnancy and
the fetus that they carry. The anticipated maternal role may cause the
woman to reevaluate her relationship with her own mother, and old conflicts may surface.

When Bonding Fails

The process of bonding between mother and infant begins during pregnancy and continues through infancy and beyond. Because the growing
relationship between mother and fetus has its roots in the mothers early
experiences, these experiences may predict the success or failure of this
relationship. If pregnancy is a developmental state, as Benedek (1959)
suggested, then it makes sense that difficulties like conflicts, traumas, or
psychological stumbling blocks encountered along earlier paths of development may cause a woman to experience pregnancy as a time of turmoil. If a mother is stuck at a particular phase of her own development,
the bonding process is interrupted.
The mothers awakened ghosts in the nursery may generate love or
hostility that shape her interaction with her infant (see Chapter 12). The
predictive nature of the bonding process provides a template for early
intervention, which has the potential to reverse pathological interaction
and prevent sequelae such as abuse or infanticide.
Throughout normal pregnancy, the emotional attachment between
mother and infant grows (Pollock and Percy 1999). The mother develops
an elaborate internalized image of the fetus, a process conceptualized by
Rubin (1984) as binding inthe fetus becoming part of the self.
This early antenatal attachment is predictive of the postnatal bond and
may, in fact, determine the potential for later child abuse or even infanticide. Most murdering mothers have histories shaped by chaos, abuse, violence, and dysfunction. A history of childhood maltreatment is the most
consistently reported characteristic of abusive parents (Korbin 1986)an
intergenerational cycle prevalent among women who are imprisoned for
killing their children.
Women with a history of childhood sexual or physical abuse or both are
more likely to experience suicidal ideation during pregnancy (Farber et
al. 1996). Childhood abuse is also associated with the likelihood of previous suicide attempts, and childhood sexual abuse often results in
reproductive conflicts (Friedman 1996). The trauma of abuse can become an organizer for future development and conflict, merge with
wishes and inhibitions, and affect adult behavior and neuroses.

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Pregnancy can reawaken a mothers memories of past sexual traumas

and shame about body image and changes, and feelings like grief and anger may be manifested as suicidal ideation or infanticidal ideation (Farber
et al. 1996). Her feelings of vulnerability, helplessness, and despair associated with the newborn may elicit unbridled rage toward the infant.
Dietz et al. (1999) discovered a dose-response relationship between
unintended pregnancies in adulthood and a history of abuse or family dysfunction. Because women with unintended pregnancies are more likely to
be young and lacking in adequate support systems, they possess all the risk
factors for child abuse and necessitate close monitoring, early assessment,
and intervention. Similarly, certain character traits (e.g., aggression, isolation, and suspicion), drug or alcohol abuse, and poor social supports are
also indicators of potential violence against children (Korbin 1989). In
sum, womens early histories are a most important predictor of outcomes
during their pregnancies.

The Myth of Maternal Bliss

Historically, pregnancy has been freighted with a mythic social expectation
that it is a time of well-being, even bliss, for women. However, recent data
demonstrate a 10% prevalence of antepartum depression (Gotlib et al.
1989; OHara et al. 1990). The fact that postpartum depression is the
outcome for one-half of women who are depressed during pregnancy
(Graff et al. 1991) emphasizes the need for and benefit of early intervention (Evans et al. 2001). Although fetal abuse implies a direct assault
such as punching or hitting the abdomen (Kent et al. 1997), it also includes seemingly passive actions such as substance abuse. In addition to
poor appetite, weight loss, and poor compliance with prenatal care, the
depressed pregnant woman is at greater risk for using nicotine, drugs, and
alcohol (Scott 1992), further underscoring the potential for fetal abuse
in these women.

Women at Risk
Postpartum Risks
A dearth of information and education for new parents and families explains undiagnosed and untreated puerperal mental illness. In addition,
postpartum psychosis is abrupt and unexpected; it has a labile quality
that is misleading and confusing. A mother experiencing postpartum psychosis may appear well at one moment and quite psychotic at the next
(see Chapter 3: Postpartum Disorders).

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239

In contrast, postpartum depression has an insidious onset. If psychotic

symptoms arise, they may be subtle and invasive, lacking the manic quality of acute postpartum psychosis. The secret paranoid nature of delusion
may also inhibit self-disclosure.
Although childbirth itself is a signal for postpartum illness, societys
expectation that the transition from pregnancy to mothering will be smooth
and joyful can produce denial of any unpleasant events associated with
childbirth. Because the new mother is expected to be unfailingly happy,
the stigma of mental illness is even more pronounced at this time in a
womans life. Not surprisingly, she often keeps secret any thoughts and
feelings of guilt and failure she has experienced.
A mother with postpartum psychosis can be ashamed and confused
by her murderous thoughts, and thus her thinking is not easily detectable
to others. Her own observing ego attempts to keep hallucinations at bay.
Alternatively, a paranoid delusional system may prevent disclosure by
threat, as illustrated by the following case:
An obstetrician referred to me patient A, who had florid psychosis on
postpartum day 3. The psychiatrist recommended that A go to the university hospital emergency room. During As evaluation, she told the
emergency room psychiatric resident that she had no intention of harming herself, her infant, or anyone else. The psychiatric resident, planning
discharge, called the outpatient psychiatrist to arrange a visit for the next
day. The psychiatrist insisted that A be admitted because she was psychotic and had an infant at home. The attending psychiatrist equally
adamantly insisted on discharge. But just before A was discharged, she attacked her brother as he entered the emergency room, making the professional discussion moot and As admission mandatory.
A remained on the psychiatric unit for 2 weeks. She received neuroleptics but no mood stabilizer, despite her hyperreligiosity and manic
presentation. When A was discharged, she revealed to the treating psychiatrist a secret delusional system that she had not disclosed to anyone during
her 14-day hospitalization. She reported a delusional theme circumscribed
around the number 3: Her labor lasted for 3 hours, her infant was 3 days
old, and there were 3 delusional personae (or witches) demanding that she
kill herself, her mother, or her new infant. When A attempted to stab herself with scissors, her mother phoned As obstetrician.

No inquiries directed at uncovering a delusional scheme were made of

A before her discharge and resumption of care of her infant. The failure
to detect As delusional scheme could easily have led to tragedy, underscoring the need for medical and psychiatric professionals to query infanticidal ideation sensitively, yet persistently.
While doing so, the clinician should be aware that obsessional intrusive thoughts to harm the infant might also arise in the setting of post-

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partum depression (Wisner et al. 1999; see also Chapter 3). Unlike
psychotic symptoms, these obsessions are ego-dystonic thoughts of harming the infant that create tremendous stress for the mother; they must be
differentiated from those that pose a danger to the infant.
Wisner et al. (1994) described the biopsychosocial model of postpartum illness as a classification of symptoms with a common presentation.
Interestingly, their contemporary description and diagnostic classification
are in agreement with the work of the earliest researchers in the field, including Marc (1858) and Esquirol (1838). Wisners group identified the
phenomenology and organic presentation of postpartum psychosis through
clinical interviews and standardized objective mood and cognitive testing. They described the waxing and waning presentation, indicating the
need to evaluate infanticidal ideation very carefully, because a mother
may appear well then rapidly deteriorate (see Chapter 3).
A family or personal history of mood disorders is the most important
clue to early prophylaxis of postpartum depression. Psychopharmacological intervention before or after delivery is responsible for a large decrease
in the risk of recurrence and is described elsewhere in this book (see Chapter 3). Stewart et al. (1991), Cohen et al. (1995), and others have demonstrated this model of prevention in clinical trials.
The therapist or physician working with childbearing women faces
the unique challenge of treatment and prevention during a time of psychological and developmental transition. Such ports of entry as motherinfant interaction or family relationships may provide clues to the mothers
mood and well-being. It is imperative to evaluate her interaction with the
infant as well as any suicidal or infanticidal ideation. Concerns should be
addressed through couple and family intervention.
Treating mothers at risk also carries potential complications. Postpartum psychosis is a medical emergency. Hospitalization is imperative because of the unpredictable and labile quality of mood and likely paranoid
delusional system. Additional concerns include providing family education and addressing concerns for the infants well-being.

Early Trauma as Risk

Although infanticide and suicide are extreme outcomes of postpartum
depression and psychosis, mothers with postpartum mood disorders are
also at high risk for child maltreatment. Children of depressed mothers
are more withdrawn and irritable and have significant behavioral problems such as sleep and eating disorders, frequent temper tantrums, and,
when the effects of lower socioeconomic status exacerbate the situation,

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241

delayed language development (Murray 1992). Because the depressed

mother is unable to respond to infant cues or provide warmth and acceptance (Biringen and Robison 1991), early development is marked by insecure attachment behavior.
The depressed mother has several risk factors for consideration (Table
131). Her increasing frustration and her inability to soothe the infant
may cause her to view the infant as hostile. Infant behaviors such as those
mentioned above may in turn elicit hostile feelings from the mother towards the infant. Halpern (1993) suggests the presence of one or two difficult conditions, such as infant illness, poverty, or difficult personality,
intensifies hostile feelings in the mother. Certain social or environmental
factors, such as poverty, are particularly conducive to escalating hostile or
even murderous feelings on the part of the mother.
Table 131. Risk assessment for pregnant women
Family/personal history of depression of other psychiatric illness
Antepartum depression
Previous postpartum depression
Bipolar disorder
Childhood trauma
Home violence (past or present)
Substance abuse
Poverty, less education, young age
Increased number of children
Child illness
Poor or hostile antenatal attachment
Poor support system or unavailable partner
Edinburgh Postnatal Depression Scale > 10

In their case series of women who killed their children, Haapasalo and
Petj (1999) found that 63% of the women had a history of child abuse.
The mother with hostile or angry feelings or a history of abuse suffered
at the hand of her own mother will likely be overwhelmed by the stirrings
of hostile feelings aroused by her infants crying and neediness (see Chapter 12: The Mother-Infant Relationship).
For example, colic and intractable crying are common triggers for child
abuse. Levitsky and Cooper (2000) examined the impact of colic on emotional state of mothers in 25 mother-infant pairs. Explicit aggressive thoughts
and fantasies were reported by 16 (70%) of the mothers, while 6 (26%)
admitted to thoughts of infanticide during a colic period.

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Denial as a Risk for Neonaticide

A woman who denies her own pregnancy is at risk for a host of problems,
the most serious being neonaticide (see Chapter 6: Neonaticide). These
women, usually young, often fail to manifest symptoms of pregnancy and
fail to attend prenatal clinics, a situation frequently complicated by their
families collusion in denying the pregnancy.
The term denial of pregnancy implies the problem in identifying risk (see
Chapter 5: Denial of Pregnancy). However, when compiled, scattered
reports in the literature reveal a similar picture of precipitant signs, symptoms, and personal and family history. Therefore, early identification of
the described presentation provides signals for prevention.
In cases of neonaticide following denial of pregnancy, retrospective accounts hinting at trouble surface, almost without fail. Teachers report having
recognized a difference in the young womans mood and a drop in grades.
Family physicians may have actually diagnosed pregnancy but failed to
follow up. Professionals, relatives, and other people known to the young
woman invariably substantiate missed opportunities for intervention, as
demonstrated in the following case:
C appeared to her co-workers to be pregnant, although she denied this.
Staff from Cs employers Employee Assistance Program literally escorted
her to prenatal clinic visits. Although C went along with this, she continued to disavow her pregnancyeven in the face of evidence like the fetal
image on her sonogram. When one day C returned to work no longer pregnant, the staff became alarmed and alerted the police to their suspicions.
Regrettably, Cs infant was already dead.

If Cs denial of her pregnancy had been recognized earlier as a potential danger, a timely psychiatric referral may have saved her babys life.
By and large, things are not much better in the schools, because teachers are generally not well educated about adolescent mood disorders.
A depressed child is rarely bothersome and causes few problems in
the classroom. Usually quiet, withdrawn, and isolated, he or she attracts
notice only when the depression precipitates misconduct, truancy, or
tragedy.
Neonaticide is associated with denial of pregnancy (see Chapter 5), dissociative symptoms, dissociative hallucinations, depression, and suspicion
of early trauma in isolated, rigid family structures (Spinelli 2001). To ignore the existence of this prodrome is to abandon hope of reaching and
educating parents, teachers, and health professionals. If we identify the
precipitants associated with neonaticide, we can construct treatment
strategies and devise prevention and rehabilitation programs and meth-

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243

ods. Treatment strategies include individual and family psychotherapy,

prenatal care, mobilization of support systems, adoption alternatives, and
parenting programs. Prevention includes educating health providers,
teachers, and parents to identify early signs.

Fathers, Families, and Recovery

Rehabilitation for the mother recovering from postpartum psychosis includes psychopharmacology education and compliance, psychoeducation, engagement of support systems, and psychotherapy. Because the
shock and precipitous onset of postpartum disorder affect the entire family, the family must also be rehabilitated. Couple and family interventions are vital and should include psychotherapy and psychoeducation as
well as interventions for other children. The conjugal balance that has been
perturbed by postpartum mental illness can be restored by crisis treatment focused on the postpartum problem (Lalive and Manzano 1982).
If the balance is incompatible with integration of a child, long-term treatment is advised.
Childbirth is a developmental stage for the entire family. Couple therapy is effective for new parents as they adapt to new roles and replace fantasized parenthood with real life (Apfel and Handel 1999). In addition, it
provides the opportunity to identify paternal pathology, which may challenge the relationship.
Implications for family therapy are supported by OHaras (1985) report that depressive symptom severity decreased and marital satisfaction
improved when rated at intervals during pregnancy and the postpartum
period. In addition, Marks and colleagues (1996) demonstrated that women
with histories of postpartum illness with supportive husbands are less
likely to relapse.
Postpartum depression organizations can also offer a valuable experience for the new mother and father. Through group, individual, and family support, other mothers who have experienced puerperal psychiatric
illness can support the new mother through her recovery. These organizations have expanded to include fathers support networks and Web sites
for shared experience.

After the Tragedy

Little information exists about fathers who have experienced the tragedy
of infanticide. In my case sample of 17 neonaticides (see Chapter 6), only
two women identified the babys father. In all others, the relationship
was denied or described as a one-time experience. The theme of secrecy

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and denial remained through arrest, trial, and incarceration. The two
identified fathers remained supportive, although they colluded in the denial of pregnancy despite a continued sexual relationship. Both fathers
were approached by the prosecution to testify against the woman but refused. Generally, fathers were not expected to share responsibility for the
infants death. In one case that was not part of my series, the father had
an active role in the infants demise and received a sentence similar to the
mothers (Callaway 1999).
Women who have killed an infant during a psychotic episode are frequently married, some with small children. In cases familiar to me, husbands were strikingly supportive, often sharing responsibility and blame
for neglecting cries for help and failing to recognize signs of potential
tragedy. Life becomes fraught with court appearances, media exploitation, and years of incarceration. Sustaining a relationship in the face of
such tragedy remains an enormous challenge, as illustrated by the following case (Postpartum: Beyond the Blues 1989):
S killed her 4-week-old infant son during a postpartum psychotic episode.
S had suffered a severe depression after her 5-year-old daughters birth.
Her husband and family were unsympathetic and angry. They asked why
she had become pregnant if she was so unhappy with a child. When she
conceived a second time, her doctor assured her that the depression
would not recur.
During the second postpartum episode, S remained silent, thinking,
I will hang on a little longer. She could not.
S and her family were confronted with the unthinkable at her murder trial when she received an 8- to 20-year prison sentence. Ss husband
fought for his wifes release and worked to encourage a greater understanding of postpartum disorders through appearances on television and
before the State Board of Pardons. We must get Ks mother home, he
said. It is not right to punish S so severely for something that has grown
from family ignorance and denial. The disease itself is a monster. It comes
from nowhere, takes the things closest to you and does not look back.
Unfortunately, the parole board refused to moderate her sentence.

The Tragedy of the Yates Family:

What Can We Learn?
A series of errors paved the way to the tragic events of June 20, 2001, when
Andrea Yates drowned her five children (see Introduction, this volume).
I use these data not to add to the suffering of this family, but as a message
of caution and hope for the future.
The following factors represent precipitants or missed opportunities
for prevention.

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245

Personal or Family History of Psychiatric Illness

Prior to the episode at the time of the drownings, Mrs. Yates had at least
two previous postpartum episodes. She reported psychosis after her first
birth. After Johns (her fourth childs) birth in 1999, she was hospitalized
twice for psychosis, each admission precipitated by suicide attempts. A
family history of psychiatric illness was also reported.

Family Denial, Ignorance, or Fear of Stigma

Family members described Mrs. Yates as catatonic, noting that she stared
for hours and scratched bald spots into her head. Mr. Yates said his wife
was withdrawn because of her fathers death, and he often minimized her
illness despite her deterioration.

Poor Partner Support

A rigid belief system seemed to dominate the home and family. Man is
the breadwinner and woman is the homemaker, Rusty Yates told the prosecutor. His wife had 2 hours of personal time each week

Isolation
Andrea Yates home-schooled her children and had little interaction with
neighbors and friends.

Increased Number of Children

Mrs. Yates had five children from 1994 to 2000.

Family and Child Services Intervention

During a 1999 hospitalization, Mrs. Yates reported to the staff that she
was overwhelmed, living in a converted Greyhound bus with her growing
family of four children (Yardley 2001). Mr. Yates told a social worker
that he was training his sons, including the 3-year-old to use power drills.
The social worker filed the report with Childrens Protective Services, but
the state agency declined to pursue the case.

Inadequate Psychoeducation
The couple was warned about recurrence of her postpartum illness. Mr.
Yates explained that the couple would talk it over when she felt better and
decided to have more children; however, early medical intervention during
pregnancies would likely have prevented a recurrence of psychosis.

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Inadequate Medical Education About Postpartum Disorders

The psychiatrist must understand that postpartum psychosis is a psychiatric emergency. The waxing and waning quality of psychosis makes behavior unpredictable. Psychotic mothers must be separated from their
infants and children.

Poor Medical Management of Puerperal Psychosis

For unclear reasons, the treating psychiatrist discontinued Andrea Yates
from antipsychotic medication. In general, she failed to receive an acceptable standard of medical care.

Stigma and Lack of Public Education

Her friend wrote in a journal that Andrea smelled like she had not bathed
in days, paced like a caged animal, and warned Mr. Yates (CourtTV 2002).
A report to Child Services would have been warranted.
We as a society failed Andrea Yates. We share equal responsibility for
the tragedy. Friends, neighbors, and family watched as Mrs. Yates continued to decompensate. The medical community failed to provide appropriate protection, social work assistance, and child services to a severely
psychotic mother of five children. When the legal community and the
state failed to appreciate the severity of her illness, they eliminated her
last opportunity for appropriate treatment.
The Yates trial attracted national attention. The National Organization
for Women and the American Civil Liberties Union held vigils during the
trial. Advocates for the mentally ill blamed Texas laws narrow standards
for the insanity defense. Other troubling issuessuch as the quality of the
insanity defense and the troubling nature of expert psychiatric witnesses
whose opinions differed so remarkablycame to the forefront.
The case also aroused the attention of several mental health advocacy
groups such as the National Depressive and Manic-Depressive Association
and many organizations dedicated to postpartum disorders. They requested clarification of postpartum DSM-IV diagnostic criteria, improved
medical education and guidelines for treatment, a greater understanding of
a biopsychosocial model of postpartum disorders, education for families,
identification of women at risk, and consideration of infanticide legislation.
After sentencing, the American Psychiatric Association made a public
announcement on the insanity defense and mental illness (APA Statement on the Insanity Defense and Mental Illness 2002):

The Promise of Saved Lives

247

The American Psychiatric Association hopes that the Yates case will lead
to broad public discussion of how our society and its legal system deals
with defendants who are severely mentally ill. . . . reviews of insanity
cases show that the more heinous the act, the less likely that an insanity
plea will succeed, despite the disabling presence of severe mental illness.
Also, the standards for handling mentally ill defendants vary across jurisdictions. A mentally ill person tried for a capital offense in one state
may be found not guilty by reason of insanity, while another person with
similar severity of mental illness tried in another state may be convicted.
Advances in neuroscience have dramatically increased our understanding of how brain function is altered by mental illness, and how psychotic illness can distort reality. . . . Unfortunately, public understanding
has not kept pace with these advances.
A failure to appreciate the impact of mental illness on thought and
behavior often lies behind decisions to convict and punish persons with
mental disorders. . . . Prisons are overloaded with mentally ill prisoners,
most of whom do not receive adequate treatment.
Defendants whose crimes derive from their mental illness should be
sent to a hospital and treatednot cast into a prison, much less onto death
row.

The fact that the insanity defense is nonexistent in some states and
extremely limited in others speaks to our disregard for mental illness and
the rights of those who suffer. Until we treat mental illness with the same
dignity afforded to other illnesses, the course will remain unchanged. And
when the next tragedy occurs, we will gasp in horror.

Treatment After Tragedy

Treating a woman who has killed an infant presents a formidable task for
the therapist. A woman who has killed during a psychotic episode is remorseful and must work through her feelings of guilt and loss. It is imperative that the therapist work through his or her own countertransference
in order to assist the patient through this time (see Chapter 11: How
Could Anyone Do That?). Significant attention must be paid to suicidal
ideation while including the family in treatment, if possible.
Countertransference feelings are more complicated with the young
neonaticidal mother who denied her pregnancy. Their fragile, childlike
personalities place significant limitations on treatment. A detached style,
isolated affect, and la belle indiffrence in the face of infant death and a
murder trial can be a source of frustration for the therapist.
In all cases, the therapist must be mindful of potential legal involvement and seek guidance from appropriate sources. Documentation should
be factual and accurate.

248

Infanticide: Psychosocial and Legal Perspectives

Screening Tools and Mood Assessment

The earliest intervention for mothers at risk takes place in the antepartum period. With recognition that antepartum screening is the best intervention strategy for identifying women at risk, the prenatal clinic is the
optimum environment to use simple screening tools and objective mood
scales. A number of reliable diagnostic and assessment tools are available
to evaluate maternal mood and assess risks for neglect and abuse. Although these tools do not replace a diagnostic interview, they may facilitate collection of focused information. These measurements of maternal
risk factors can be easily administered in the antenatal clinic, where
women at risk can be identified in time for intervention.

Depression Rating Scales

The Edinburgh Postnatal Depression Scale (EPDS), designed to identify
postpartum depression (Harris et al. 1989), is a timely and simple screen
for antepartum changes. The EPDS includes only behavioral symptoms
without somatic symptoms, which may be confused with the discomforts
of pregnancy or the immediate postpartum state. The EPDS is a 10-point
patient-rated scale translated into several languages that takes approximately 3 minutes to complete.
Beck and Gable (2000) devised a scale, the Postpartum Depression
Screening Scale, that is a reliable and valid self-rated assessment of postpartum mood disorders. Items are exquisitely sensitive to what is experienced by mothers with postpartum depression. Additionally, the
Peripartum Events Scale, developed by OHara et al. (1986), measures
stressful life events that may precipitate peripartum mood disorders. The
Peripartum Events Scale significantly correlates with antepartum and
postpartum measures of depression and a womans self-rating of problems
with labor and delivery. The Antenatal Health Questionnaire queries
prepregnancy emotional disturbances and identifies women likely to experience a postpartum mood disorder (Nordstrm et al. 1988). Finally,
interventions such as interpersonal psychotherapy for antepartum depression have been used successfully to treat depression during pregnancy and
prevent subsequent postpartum mood disorders (Spinelli 1997).

Early Maternal Attachment Scales and Abuse Potential

It is critical to address the risk of abuse potential before parenthood. Fonagy
et al. (1991) found that the quality and style of maternal attachment can
be predicted when the Adult Interview Scale is administered before birth.

The Promise of Saved Lives

249

Condon (1993), using the Maternal Antenatal Emotional Attachment

Scale (MAEA), proposed a model of maternal antenatal attachment. The
MAEA predicts four different styles, each representing a particular combination of underlying attachment dimensions and aggressive potential
toward the fetus and the newborn (see Chapter 12: The Mother-Infant
Relationship).
The Child Abuse Potential Inventory (CAP) is designed to identify
acute or potential physical child abusers. A study by Todd and Gesten
(1999) demonstrated that the CAP was a useful and valid measure of personality characteristics common to abuse victims who have an increased
potential to commit future physical abuse. The CAP is an excellent tool for
identifying women at risk in order to treat underlying psychopathology.
Pregnant adolescents are more vulnerable to depression and child abuse
by virtue of their youth, inadequate support systems, greater likelihood
that the babys father is absent, and conflicts over education. Efforts to
include significant others in care are a priority, and parent-infant therapeutic care is a major foundation for prevention. Parent-infant psychotherapy and interventions such as Fields (1984) use of infant massage for
depressed mothers are early interventions to reshape the mother-infant
bond through early treatment (Erickson et al. 1992). A trusting relationship with a therapist may function as a protective factor and as a mechanism of developing parenting skills and attachment.

A Measure of Progress
Organizations dedicated to psychiatric disorders associated with childbirth and mother-infant health grew out of a fundamental need to recognize isolated and untreated women with depression and other psychiatric
illnesses and prevent consequences ranging from impaired early motherinfant interaction to mortality.
The Marc Society dates to the 1980s, when professionals in different
disciplines were working on postnatal disorders (Glangeaud-Freudenthal
2001) but lacked a forum for sharing knowledge and ideas. Responding
to this problem, Professors Channi Kumar and Ian Brockington of the United
Kingdom and Professor James Hamilton of the United States founded an
international society aimed at improving the understanding, prevention,
and treatment of mental disorders related to childbirth. They named the
society after the French physician Louis Victor Marc, whose early work
described the temporal relationship of mental disorders and childbirth
(Marc 1858).
The Marc Society was officially launched during the first academic
meeting on puerperal mental disorders, in Manchester, England, in 1980.

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Infanticide: Psychosocial and Legal Perspectives

Since then, experts from around the world gather at biennial meetings to
share state-of-the-art research and clinical knowledge. The societys focus
has grown to include antepartum and postpartum disorders, motherinfant attachment, child abuse, and infanticide.
In the United States, women initiated a grass-roots movement in the
1980s to remedy the failure to identify postpartum disorders. Nancy Berthold, for example, after her own isolating and confusing experience of
postpartum psychosis, organized women who had suffered from puerperal
mood disorders into a group called Depression after Delivery (DAD).
Today, DAD, a national group under the direction of Joyce Venis, R.N.C.,
provides individual and group support, professional referrals, and education for women and families with puerperal disorders (Venis 2000).
Under the umbrella of the Marc Society, Jane Honikman founded Postpartum Support International (PSI) in 1987 to meet womens need for
timely and relevant resources, information, and referral (Honickman 2000).
Today, PSI members include representatives of self-help organizations
and social support networks and individual professionals and experts in
this field. Other international organizations under the PSI roof include the
Postnatal Depression Support Association (South Africa), Meet a Mum
Association (United Kingdom), and the Prenatal Association of Canada
(PASSCAN). China, Denmark, Mexico, and 14 other countries have
organizations under the PSI umbrella, as do 31 U.S. states (in addition to
DAD, which is national).
In groups like DAD and PSI, members of diverse backgrounds and experience work together toward a shared goal of improved care for mothers and infants. Their membership rosters include laypeoplemothers,
fathers, children, other relatives of affected familiesand professionals
social workers, nurses, psychiatrists, obstetricians, pediatricians, and psychologists, to name a few. Such organizations function as a national and
international postpartum referral and networking system. For example,
PSIs Pen Pal Network Project, created in 1990, is an effort to connect
women serving sentences for infanticide in U.S. prisons with one another
and with PSI members. The network provides information and updates
on the women, their parole status, clemency petitions, and sentence modifications, as well as ongoing education and group efforts to influence
public policy and legislation.
In the realm of public policy advocacy, PSI claimed a victory with the
passage of U.S. House of Representatives Resolution 163 (H-RES 163,
October 10, 2000), The Postpartum Depression Resolution (U.S. Congress 2000). This resolution, co-sponsored by Representatives Jack Kingston (R-Ga.) and Lois Capps (D-Ca.), recommends that all hospitals and
clinics provide departing new mothers, fathers, and other family members

The Promise of Saved Lives

251

with information about postpartum psychiatric illness, including symptoms and treatment resources, and that the National Institutes of Health
promote additional research on postpartum psychiatric illness.
Another recently passed bill demonstrates increased social awareness
of the problem of abandoned infants. The Abandoned Infant Protection
Act (House Bill 1616) (2000) provides that no parent shall be prosecuted . . . for abandonment of an infant less than 15 days of age when that
parent voluntarily delivers the infant to one of the following individuals
and does not express an intent to return for the infant[:] . . . a health care
provider . . . [,] a law enforcement officer . . . [,] a social services worker
. . . [,] an emergency medical technician . . . [,] or any adult of suitable
discretion who willingly accepts the infant.
A bill was recently introduced in the House of Representatives by
Bobby Rush of the First District in Chicago, Illinois. Bill 2380, the Melanie Stokes Postpartum Depression Research and Care Act (June 28,
2001), has the goal of providing research on and services for individuals
with postpartum depression and psychosis (U.S. Congress 2001). The bill is
named for Melanie Stokes, a young mother who committed suicide while
in the throes of postpartum depression (Venis 2001).
Although postnatal women generally have a low rate of suicide, those
who develop severe postpartum illness are at high risk of suicide in the
first postpartum year (Appleby 1998). Uncharacteristically for females,
methods are violent and tend to peak in the first postnatal month.

Conclusion
Mothers characterized by certain socioeconomic factors, poor social supports, or mental illness are at significant risk of committing infanticide.
To date, however, effective strategies for identification, intervention, and
prevention are glaringly absent from the continuum of antenatal and
postnatal care and services. The ability to detect antenatal and postnatal
psychiatric illness more reliably and consistently than has been done historically holds the key to prevention.
Infanticide is not caused by a single factor (Haapasalo and Petj 1999).
The complexity of factors related to the origins of the impulse to kill,
whether individual, social, cultural, or developmental, must be acknowledged. Known precipitants include abuse, psychosocial complications, immaturity, isolation, marital problems, inadequate social supports, financial
constraints, domestic violence, early trauma, parental chaos, and adult
motherless motherhood (Simpson 2000). Because mothers are more likely
to commit child homicide in the first year after childbirth, the mothers own
identification with her child may be an important trigger for aggressive

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Infanticide: Psychosocial and Legal Perspectives

impulses. Other circumstances that increase vulnerability include social

isolation, early loss, immigrant status, abandonment by a partner, and domestic violence. A striking aspect of many infanticide casessuggesting,
perhaps, an area for future studyis that the infants father is rarely identified and rarely implicated in the act (Table 131).
As a major public health problem, postpartum psychiatric illness is
predictable, identifiable, treatable, and, most importantly, preventable.
Research methodology must be designed to substantiate a cluster of
identifiable symptoms and precipitants on the basis of contemporary
diagnostic criteria and the biopsychosocial model of psychiatry. Phenomenological studies will help identify symptoms in order to pave the
way for treatment strategies, prevention, and rehabilitation. This primary
method of prevention of postpartum psychiatric disorders and other sequelae of childbirth also provides secondary prevention by treating parents of children at risk. Adult psychiatric services should reach beyond
the mothers mental state to the family as the focus of intervention (Scott
1992).
As I indicated at the outset of this book, my own professional involvement in infanticide cases in the judicial system spurred my belief that we,
as a society, could do a far better job of preventing these tragedies. Just as
I began by enjoining the reader to share in the admittedly difficult task of
entering the minds of mothers who kill, I will close with a request.
I hope the reader who has journeyed through these chapters may now
share the belief that infanticide is preventable. Developing effective interventions and preventions will, of course, require further study of the
mental states of antepartum and postpartum women who are at risk to
commit or have committed infanticide. Those of us who pursue the goal
of prevention will be obliged to override any anger or revulsion we may
feel with the compassion and courage to seek a more in-depth understanding of infanticide. The collective knowledge and experience of the contributors to this book suggest that, while we need to know more, we already
know too much to look away any longer.
So I ask the reader who has come this far to take heart: the goal of saving
lives through the prevention of infanticide is attainable. We are acquainted
with mothers who may kill their babies, and perhaps some who have already committed child murder. We see them in hospitals and clinics and
other settings; we interview them and their families; we know their stories and circumstances. What is required of us is to not look away but to
communicate with and learn from these mothers. The great promise of
understanding them better will play out in incalculable saved lives.

The Promise of Saved Lives

253

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Field T: Early interactions between infants and their postpartum depressed mothers. Infant Behavior and Development 7:517522, 1984
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Fraiberg SH: Clinical Studies in Infant Mental Health: The First Year of Life. New
York, Basic Books, 1980
Friedman S: Reproductive conflicts in incest victims: an unnoticed consequence
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OHara M, Zekoski EM, Philipps LH, et al: Controlled prospective study of postpartum mood disorders: comparison of childbearing and nonchildbearing
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Index
Page numbers printed in boldface type refer to tables or figures.

Ainsworth, Mary, 213, 214, 215

Alto do Cruzeiro (Brazil), 120
child death in, 121125
Amazon, Brazilian, infanticide in, 126
American Academy of Pediatrics, 29
on SIDS, 27
American Academy of Psychiatry and
the Law (APPL), 175
American Civil Liberties Union, 246
American Psychiatric Association
recognition of postpartum
disorders by, 147
Yates case and, 246247
Amitriptyline, use during breastfeeding, 49
Amnesia, intermittent, in neonaticide,
107, 110
Amygdala, 66
Ancient cultures, infanticide in, 46
Anemia, vs. postpartum depression,
47
Antenatal Health Questionnaire, 248
Anthony, Susan B., 105
Antidepressants, use during breastfeeding, 4950
Anxious attachment, causes of, 227
APPL. See American Academy of
Psychiatry and the Law

Abandoned Infant Protection Act

(U.S.), 251
Abandonment, fears of, and
pregnancy denial, 8889
Abuse. See also Child abuse
emotional, and pregnancy denial/
neonaticide, 112
fetal, 238
sexual, and reproductive conflicts,
112, 114, 237
ACTH. See Adrenocorticotropic
hormone
Adam Bede (Eliot), 81
Addiction, and pregnancy denial, 83,
91
Adolescence, pregnancy in
denial of, 90
risks associated with, 249
Adrenocorticotropic hormone
(ACTH), 70
Affective denial of pregnancy, 8284,
91
Age
of infant, and risk of homicide, 195
of perpetrators of infanticide, 2425
of perpetrators of neonaticide, 90,
135, 189
of victims of infanticide, 23, 24

257

258

Infanticide: Psychosocial and Legal Perspectives

Arabia, female infanticide in, 5

Arson, infant deaths caused by, 22
Assault, infant deaths caused by, 21, 22
Assessment. See Evaluation
Assisted/coerced infanticide, 11, 12
Attachment
adult styles of, 214
mother-infant. See also Motherinfant relationship
antenatal assessment of, 249
assessment of, 228
categories of, 213
disorders of, 236238
early treatment of problems in,
249
importance of, 209
intergenerational transmission
of, 226
psychotherapy for improving,
210
sources of problems in, 229
Attachment theory, 212214
Automatism. See Involuntary act
defense
Autoscopy, in pregnancy denial/
neonaticide, 109
Avoidant attachment, 213
Baby blues, vs. postpartum depression, 41
Babylonian civilization, 4
Bariba (West African people), infanticide practiced by, 126
Bastardy infanticide, 7
Battering, and infant deaths, 21, 22
Befriending, of mothers at risk, 194
Benin, Peoples Republic of
(West Africa), infanticide in, 126
Berthold, Nancy, 250
Bion, W. R., 211
Bipolar disorder
acute-onset postpartum psychosis
as, 4243
postpartum admission for women
with, 39

risk of recurrence for, 54

thyroid dysfunction and, 68
use in legal defense, 148, 149150
Birth. See Labor and delivery
Birth defects, cultural responses to,
125127, 128
Birth order, as risk factor for infanticide, 24
Bowlby, John, 212
Brain
abnormalities of, early maternal
deprivation and, 215
basic structure of, 66
neurochemicals in, and depression,
6566
Brain stem, 66
Brazelton, T. Berry, 215
Brazil
infant death in, high expectancy of,
121, 124
mother love in, 121123
selective neglect in, 121, 123
tolerance of difference in, 127
Breast-feeding
during antidepressant therapy,
4950
during antipsychotic therapy, 5253
during estrogen therapy, 74
Brief psychotic disorder, use in legal
defense, 148
Britain
infanticide in, 191192
infanticide legislation in, xvi, 16,
137, 186188
history of, 78, 9
neonaticide in, 189191
prevention of infanticide, 192195
Brockington, Ian, 249
Bromocriptine, manic symptoms after
treatment with, 46
Calcium homeostasis, disorder of,
4647
Canada, infanticide legislation in, xvi,
137

Index
CAP. See Child Abuse Potential
Inventory
Capps, Lois, 250
Carbamazepine, use during breastfeeding, 52
Cassell, Elaine, 174, 175
Catechol O-methyltransferase
(COMT), 67
Catholic Church, and infanticide,
6
Chaldean civilization, 4
Chavez, Linda, 10
Child abuse
absence in traditional societies,
128, 129
by fathers, xxxxi
history of
and pregnancy outcomes, 112,
237238
and risk for mother-infant
relationship, 241
infant deaths caused by, 21, 22
infanticide related to, 11, 13, 195
risk of
assessment of, 216, 248249
postpartum disorders and, 240
in SIDS cases, 27
triggers for, 241
Child Abuse Potential Inventory
(CAP), 249
Child death. See Infant death
Childbearing. See also Labor and
delivery
and risk for psychiatric morbidity,
36, 186. See also Postpartum
psychiatric disorders
Childbirth Under X (France), 101
Children Act of 1989 (Britain), 195
China, female infanticide in, 56
Christian society, medieval, infanticide in, 67
Circadian rhythms, disruption in labor
and postbirth, 42
Civil cases, use of postpartum
syndromes in, 177180

259
Clomipramine, use during breastfeeding, 49
Cognition, with pregnancy denial/
neonaticide, 88, 112
Cognitive-behavioral counseling, for
postpartum depression, 4748
COMT. See Catechol O-methyltransferase
Condemned infant syndrome, 124125
Confucian doctrine, and female
infanticide, 5
Constantine (Roman emperor), 6
Contraceptives, oral, and postpartum
disorder symptoms, 63
Cortex, brain, 66
Corticotropin-releasing hormone
(CRH)
in fight or flight response, 70
during pregnancy, 45
Cortisol
levels of, in postpartum depression,
7071
as stress hormone, 70
Countertransference problem, 202,
247
Couple therapy, 243
CRH. See Corticotropin-releasing
hormone
Crime, infanticide as, xv
Criminal cases
infanticide, 140141
neonaticide, 138140
types of defense in, 141146, 142
use of DSM in, 146151
use of postpartum psychosis in,
problems of, 910, 140
use of postpartum syndromes in,
173177
Cultural conflict, and pregnancy
denial/neonaticide, 205206
Cultural norms, 12, 13
infanticide as rejection of, 4
Culture(s). See also Sociocultural
factors
ancient, infanticide in, 46

260

Infanticide: Psychosocial and Legal Perspectives

Culture(s) (continued)
medieval Judeo-Christian,
infanticide in, 67
traditional
absence of child abuse in, 128,
129
infanticide in, 125126
Custody cases, use of postpartum
syndromes in, 177178
Custody loss, previous, and pregnancy
denial, 89
Cuts/stabbing, infant deaths caused
by, 22
DAD. See Depression after Delivery
Daubert test, 157, 157
for neonaticide syndrome,
161162
Daubert v. Merrell Dow Pharmaceuticals, Inc., 158160
Death. See Infant death; Infanticide;
Neonaticide
Defense, criminal law
types of, 141146, 142
use of DSM in, 146151
use of postpartum syndromes in,
173177
Defense attorney, guidance for,
134135
Delivery. See Labor and delivery
Delusions
identification of, 239
in postpartum mental illness, 136,
173
Denial of pregnancy. See Pregnancy
denial
Depersonalization, in pregnancy
denial/neonaticide, 109
Depersonalization disorder, use in
legal defense, 148149
Depo-Provera, and postpartum
disorder symptoms, 63
Depression
antepartum, 238
brain-body relationships in, 6875

etiology of, theories of, 65

major
and obsessions, 4041
in postpartum period, 38,
3940
symptoms of, 3940, 40
use in legal defense, 148,
149150
minor, in postpartum period, 38
neurochemical factors for, 6566
postpartum
vs. baby blues, 41
cortisol levels and, 7071
evaluation for, 47
health visitors in treatment of,
194
hormonal contribution to,
4546, 7071
and infant development,
221222, 240241
insidious onset of, 239
lack of full recognition of, 147
obsessional thoughts in, 41,
4445, 240
prevalence of, 36
prevention of, 5051, 240
risk for recurrence of, 54
screening for, 54, 248
support organizations for, 243
thyroid illness and, 47, 6970
treatment of, 4751, 48
and pregnancy denial, 92
in women, 65
Depression after Delivery (DAD),
250
DES. See Dissociative Experiences
Scale
Desipramine
for postpartum depression, 48
use during breast-feeding, 49
Deterrence
harsh infanticide laws and lack of,
188
as rationale for punishment, 1415
Dexamethasone resistance, 71

Index
Diagnostic and Statistical Manual of
Mental Disorders, 4th Edition
(DSM-IV), 147
postpartum-onset specifier in, 38,
147148, 169
use in criminal defenses, 146151
Dietz, Park Elliott, 10
Diminished capacity defense, 143
depersonalization disorder and,
149
psychotic disorder and, 150
requirements for, 142
Disability requirement, for criminal
defense, 146
using DSM to satisfy, 146151
Dismissing attachment, 214
Disorganized attachment, 213
Dissociation
during birth experience, pregnancy
denial and, 85
in neonaticide, 107, 109110, 202
Dissociative disorder
in neonaticide perpetrators, 190,
191
and pregnancy denial, 113
use in legal defense, 148
Dissociative Experiences Scale
(DES), 107, 110111, 116
Dissociative psychosis, in neonaticide,
110
Dopamine
chemical precursor of, 66
estrogen and levels of, 72
neurotransmitters, 65
psychiatric symptoms associated
with, 66
receptors, and mental status
changes, 7475
Doss, Ms., 138139
Dowry system, and female
infanticide, 5
Doxepin, use during breast-feeding,
49
Drowning, infant deaths caused by,
21, 22

261
DSM-IV. See Diagnostic and Statistical
Manual of Mental Disorders, 4th
Edition
Early identification. See Identification
Eating disorders, and pregnancy
denial, 92
Edinburgh Postnatal Depression Scale
(EPDS), 54, 248
Education
and infanticide prevention, 171
maternal, and risk for infanticide,
25
Electroconvulsive therapy, for
postpartum psychosis, 51
Eliot, George, 81
Emotion regulation, maternal
psychopathology and, 221223
Emotional abuse, and pregnancy
denial/neonaticide, 112
England. See also Britain
poor law of 1576, 7
EPDS. See Edinburgh Postnatal
Depression Scale
Esquirol, Jean-Etienne, 8
Estradiol
in postpartum depression, 45
in postpartum psychosis, 51
Estrogen
postpartum effect of, 73
receptors in brain, 72
and regulation of neurotransmitter
activity, 66, 68
therapy, for postpartum disorders,
45, 51, 52, 55, 7374
withdrawal, psychosis after, 46
Ethnography, 120
Eugenics, and infanticide, 4, 5, 128
Europe. See also Britain; France
medieval, infanticide in, 67
Evaluation. See also Identification
of child abuse risk, 216, 248249
of infanticide risk, 195
of mother-infant attachment, 228,
249

262

Infanticide: Psychosocial and Legal Perspectives

Evaluation (continued)
of parenting behavior, 9899
for postpartum disorders, 47
of pregnant women, 216219,
228, 241
Evans-Pritchard, E. E., 125
Evidence
admissibility of, tests of, 157,
157160
novel scientific, 157
syndrome, 155, 156157
Expert testimony, vs. syndrome
evidence, 156
Exposure, and infanticide, 5
Family dynamics
with infanticide, 245
with pregnancy denial/neonaticide,
107, 111, 114, 189, 204206
Family planning, pregnancy denial
and, 99
Family therapy, 243
Fathers
child abuse by, xxxxi
infanticide and, 243244, 245, 252
infanticide by, xx, 191, 195
sentencing for, 192
and pregnancy denial, 244
role of, 225226
Federal Rule 702, 160
Federal Rules of Evidence, 158, 159
Fetal abuse, 238
Fetal death registrations, 2627
Fetus, violent fantasies toward, 8990,
94
Field, Tiffany, 221
Fight or flight response, 70
Filicide, xx
perpetrators of, 44
Fluoxetine
for postpartum depression, 4748,
48
use during breast-feeding, 50
Fonagy, Peter, 214
Fraiberg, Selma, 210, 226, 236

France, pregnancy laws in, 101

Freud, Sigmund, 115, 211
Frye test, 157, 157
for neonaticide syndrome,
161162
Frye v. United States, 158
Gamma-aminobutyric acid (GABA),
68
General deterrence, as rationale for
punishment, 14
Ghosts in the nursery (Fraiberg),
210, 236
Gingrich, Newt, 10
Gonadal hormones, alterations in, and
postpartum disorders, 46, 7273
Gonadotropin-releasing factor, 71
Greece, ancient, 4
Gregor, Thomas, 126
Grimm, Susan, 178179
Guilt
neonaticide and, 190191
in postpartum psychoses, 42
Hallucinations
dissociative, in neonaticide, 107,
109
vs. obsessions, 40
in postpartum mental illness, 136,
141
Hamilton, James, 73, 249
Harlow, Harry, 212
Health visitors, and treatment of
postpartum depression, 194
Hinckley, John W., Jr., 144145
Hippocampus, 66
Historical perspective
on infanticide, xvi, 49
on infanticide legislation, in
Britain, 78, 9
Holding environment, 211
Homicide, infanticide treated as, 134
Homicide Act of 1957 (Britain), 186,
187
Honikman, Jane, 250

Index
Hormones. See also specific hormones
and mood disorders in women, 64
in postpartum depression, 4546,
7071
in postpartum psychosis, 46
and regulation of brain chemicals,
68
in women, 64, 69
Hospitalization
involuntary, with pregnancy
denial, 100101
in mother-and-baby units,
194195
for postpartum psychosis, 240
House of Representatives Resolution
163 (H-RES 163), 250251
Hypercalcemia, vs. postpartum
psychosis, 47
Hypothalamic-pituitary-adrenal
(HPA) axis, 7071
Hypothalamic-pituitary-ovarian
(HPO) axis, 7175, 114
in pseudocyesis, 115
Hypothalamic-pituitary-thyroid
(HPT) axis, 6870
Hypothalamus, 66
Hysterical pregnancy (pseudocyesis),
114115
Hysterical psychosis, 115
ICD-10. See International Classification of Diseases, 10th Revision
Identification. See also Evaluation
missed opportunities for, 171172
of mother-infant disturbances,
228229
of postpartum depression, 54, 248
of postpartum psychosis, need for
training in, 43
of pregnancies at risk, 216219,
228, 237238
of pregnancy denial, 96, 242
screening tools for, 248249
of women at risk, 44, 213214,
238243

263
Illegitimacy, and infanticide, 67
Imipramine, for postpartum
depression, 48
India, female infanticide in, 5
Infant(s). See also Mother-infant
relationship
maternal projections on, 224225
psychoanalytic perspectives on,
210211
temperament of, 219
Infant death. See also Infanticide;
Neonaticide
causes of, 2123, 22
in Northeast Brazil
acceptance of, 124125
mother love and, 121122
Infanticide. See also Neonaticide
clinical considerations in, 136137
historical perspective on, xvi, 49
legal treatment of. See
Jurisprudence; Laws
perpetrator characteristics, 20,
2425, 195, 203
prevalence of, 19, 25, 2728
prevention of. See Prevention
rate of, social conditions and, 187,
188
reporting of, 2023
risk factors for, 23, 2425, 28,
251252
typology of, 1013, 11
as ultimate failure of bonding, 236
Infanticide Act of 1922/1938 (Britain),
xvi, 9, 137, 170, 186, 192
criticism of, 186187
support for, 188
Insanity, criteria for, 170
Insanity defense, 143146
American Psychiatric Association
on, 246247
concerns about, 175
depersonalization disorder and,
149
postpartum psychiatric disorders
and, 140141, 174

264

Infanticide: Psychosocial and Legal Perspectives

Insanity defense (continued)

psychotic disorder and, 150
requirements for, 142
successful use of, 140
Insecure attachment
causes of, 227
postpartum depression and, 241
types of, 213
Intellectual deficits, and pregnancy
denial, 91
Interaction guidance, for motherinfant disturbances, 228
International Classification of Diseases,
10th Revision (ICD-10), 38
Interpersonal abandonment, fears of,
and pregnancy denial, 8889
Interpersonal psychotherapy (IPT),
for postpartum depression, 47,
48
Interpretive psychotherapy, for
mother-infant disturbances, 228
Interventions. See Identification;
Prevention; Treatment
Interviews
in diagnosis of postpartum
disorders, 44, 6263
forensic psychiatric, 106
Involuntary act defense, 143
depersonalization disorder and,
148149
requirements for, 142
IPT. See Interpersonal psychotherapy
Irish of West Kerry, infanticide
practiced by, 125126
Isolation
and pregnancy denial, 93
and risk for child abuse, 216
and risk for infanticide, 245
Jurisprudence, infanticidal. See also
Criminal cases; Laws
in Britain, xvi, 78, 9, 16
international comparisons of, xvi
in United States, xvi, 9, 1416, 134
grave injustices in, 207208

infanticide court cases, 140141

neonaticide court cases,
138140
use of postpartum syndromes
in, 173177
Kingston, Jack, 250
Klein, Melanie, 211, 212
Knowledge deficits, and pregnancy
denial, 91
Kumar, Ramesh (Channi), 249
Labor and delivery
disruption of circadian rhythms in,
42
pregnancy denial and experience
of, 85, 110
Laws. See also Jurisprudence
infanticide
in Britain, xvi, 78, 9, 137,
186188
in Canada, xvi, 137
harsh, lack of deterrent effect
of, 188
in United States, xvi, 9, 137138
pregnancy, in France, 101
Lieberman, Alicia, 224
Limbic (reptilian) brain, 66
Lithium, for postpartum psychosis, 51
Loss of child, previous, and pregnancy
denial, 89
Luteinizing hormone, 72
MAEA. See Maternal Antenatal
Emotional Attachment Scale
Mahler, Margaret, 211, 212
Major depression
and obsessions, 4041
in postpartum period, 38, 3940
symptoms of, 3940, 40
use in legal defense, 148, 149150
Maltreatment. See Child abuse
Mania, in postpartum period, 38
Manic depression. See Bipolar
disorder

Index
MAO. See Monoamine oxidase
Marc, Victor Louis, 8, 249
Marc Society, 249250
Marital status, of neonaticide
perpetrators, 135, 189
Massip, Sheryl, 9, 10, 15, 141
Maternal Antenatal Emotional
Attachment Scale (MAEA), 249
McDonough, Susan, 228
Media, and infanticide cases, 14
Medical model, of infanticide, 810
Mehinaku Indians, infanticide
practiced by, 126
Melanie Stokes Postpartum
Depression Research and Care
Act (United States), 251
Mental illness, maternal. See also
specific illnesses
effects on offspring, 5354,
221222, 240241
and emotion regulation, 221223
infanticide related to, 11, 13,
172173
postpartum. See Postpartum
psychiatric disorders
and pregnancy denial, 9192
Middle Ages, infanticide in, 67
Midwifery services, for high-risk
women, 193194
MNaghten test, 145, 163, 174
defense based on psychotic
disorder and, 149150
postpartum psychosis and, 176
Model Penal Code (MPC)
defense based on psychotic
disorder and, 150, 151
and insanity defense, 145146
Monoamine oxidase (MAO), 67
estrogen and levels of, 72
Monoamines. See Neurotransmitters
Mood disorders. See also Bipolar
disorder; Depression
neurochemical factors for, 6566
in postpartum period, 3839
in women, 6364

265
Mother(s). See also Mother-infant
relationship; Motherhood
age of
and risk for infanticide, 2425
and risk for neonaticide, 90,
135, 189
education of, and risk for
infanticide, 25
high-risk
identification of, 213214,
238243
responses to infants
temperament, 220
infanticide/neonaticide committed
by. See Perpetrators
love for child. See Mother love
Mother-and-baby units, in Britain,
194195
Mother-infant relationship, 209229
attachment theory of, 212214
current views on, 214215
disorders in, 236238
early evaluation of, 228229
emotion regulation in, 221223
maternal perceptions and attitudes
and, 223225
psychoanalytic perspectives on,
210212
risks to, 209210
transactional model of,
215216
temperament and goodness of fit
in, 219221
Mother love
ambiguities of, 122123
child death and, 121122
perspectives on, 123124
Motherhood
demands of, 229
as developmental phase, 217
social norms governing, 12, 13
infanticide as rejection of, 4
MPC. See Model Penal Code
Mull, Dorothy and Dennis, 126
Murder, vs. infanticide, 170

266

Infanticide: Psychosocial and Legal Perspectives

National Depressive and ManicDepressive Association, 246

National Organization for Women,
246
Neglect
infant deaths caused by, 21, 22, 189
infanticide related to, 11, 1213
risk of, transactional model for
assessing, 216
selective
in Northeast Brazil, 121, 123
suppression of, 129
in SIDS cases, 27
Neonaticide, 12
ascertainment problems for, 2627
biopsychosocial model of, 113116
in Britain, 189191
clinical findings in, 107, 107112
court cases in United States,
138140
depersonalization in, 109
dissociation in, 107, 109110, 202
family dynamics with, 107, 111,
204206
incidence of, 23, 24
perpetrator characteristics, 20, 90,
135136, 189
pregnancy denial and, 12, 81, 93, 94,
105, 108109, 136, 152, 189
psychodynamic paradigm of,
115116
recurrence of, 95
risk for, pregnancy denial and,
242243
sociocultural factors for, 92, 101
systematic investigation of,
105117
in typology of infanticide, 11
Neonaticide syndrome
alternative diagnoses for use in
legal defense, 148
case illustration of, 151154
lack of recognition of, 147
legal acceptance of, determination
of, 161162

Neurotransmitters
deficiency of, and negative mood
states, 65
mechanism of action, 6667, 67
psychiatric symptoms associated
with, 66
Newborns
with birth defects, cultural
responses to, 125127, 128
maternal killing of. See Neonaticide
Norepinephrine
chemical precursor of, 66
estrogen and levels of, 72
in fight or flight response, 70
neurotransmitters, 65
Norms governing motherhood, 12, 13
infanticide as rejection of, 4
Nortriptyline
for postpartum depression, 48
use during breast-feeding, 49, 50
Novel scientific evidence,
admissibility of, 157160
Nuer (African people), infanticide
practiced by, 125
Obsessions
definition of, 40
in major depression, 4041
in postpartum depression, 41,
4445, 240
Obsessive-compulsive disorder, in
postpartum period, 38
Obstetric/gynecological factors, and
pregnancy denial, 92
Obstetric services. See also Prenatal
care
and identification of pregnancy
denial, 9798
and prevention of infanticide, 193,
239
Oral contraceptives, and postpartum
disorder symptoms, 63
Organizations, support, 243, 249
250
Osmond, Marie, 208

Index
Panic disorder, in postpartum period,
38
Para potens, end to, 6
Parent-infant psychotherapy, 210,
226229
effectiveness of, research on,
227229
groundwork for, 212
success of, 216, 219
Parenting
assessment and rehabilitation of,
9899
after denied pregnancy, 9495, 98
Paroxetine
for postpartum depression, 48
use during breast-feeding, 50
Participant observation, 120
Passive behavioral style, and
pregnancy denial, 91
Peer group support, 194
Peripartum Events Scale, 248
Perpetrators
of filicide, 44
of infanticide, 20, 195, 203
age of, 2425
therapy for, 247
as victims, xv
of neonaticide, 20, 135136
age of, 90, 135, 189
dissociative disorder in, 190,
191
therapy for, 190, 201208
Personality disorders, in postpartum
period, 39
Pervasive denial of pregnancy, 8485
Pfeifer v. Pfeifer, 177178
Pharmacological treatment
for postpartum depression, 4750,
48
for postpartum psychosis, 51,
5253
Population control, infanticide as
method of, 45
Postpartum Depression Resolution
(U.S. Congress), 250251

267
Postpartum Depression Screening
Scale, 248
Postpartum-onset specifier, in
DSM-IV, 38, 147148, 169
Postpartum psychiatric disorders,
3555, 134. See also Depression,
postpartum; Psychosis,
postpartum
acute, and infanticide, 170172
biological considerations in, 4547,
6176
clinical phenomenology of, 3945
definitions of, 37, 38
diagnosis of, 4445, 6263
effects on offspring, 5354
epidemiology of, 3738
evaluation and treatment of, 4753
insanity defense based on,
140141
missed opportunities for
identification of, 171172
nosology of, 3839
organizations dedicated to, 243,
249250
plasticity of, 136
pregnancy denial and, 94
prevalence of, 36
prevention of, 252
risk of recurrence for, 62, 63
undiagnosed and untreated, 61, 64
Postpartum Support International
(PSI), 250
Postpartum syndromes. See also
Neonaticide syndrome
insurance and disability claims for,
181
recognition of, medical and legal
dilemmas in, 180182
use in civil cases, 177180
use in criminal cases, 173177
Posttraumatic stress disorder (PTSD)
pregnancy denial and, 92, 94
rape and, 156, 205
Poverty, and risk for child abuse,
216

268

Infanticide: Psychosocial and Legal Perspectives

Pregnancy
adjustment to, psychological
requirements of, 216217
cognitive styles during, 87
denial of. See Pregnancy denial
as developmental state, 237
emotional reactions to, 8283
hormones during, 45, 72
hysterical (pseudocyesis), 114115
mother-infant bonding during, 237
risk assessment in, 216219, 228,
237238, 241
womans attitude toward, and
mother-infant attachment, 219
Pregnancy denial, 81102
biological model of, 114115
cognitive models of, 8788
consequences of, 9395, 102
dissociation/trauma paradigm of,
113114
emotional stressors related to,
8890
family dynamics with, 107, 111,
114, 204206
fathers and, 244
identification of, 96, 242
interventions for, 96101
medicolegal issues in, 100101
mothers accounts of, 203204,
218
and neonaticide, 12, 81, 93, 94,
105, 108109, 136, 152, 189
risk for, 242243
parenting after, 9495, 98
and postpartum psychiatric
problems, 94
psychotherapy for, 9697
reasons for, 8790
recurrence of, 95
risk factors for, 9093
sociocultural factors and, 83,
9293, 101
types of, 8286
Premenstrual period, postpartum
disorder symptoms in, 63

Prenatal care. See also Obstetric

services
delayed, and pregnancy denial, 93
lack of, and risk for infanticide, 25
Preoccupied attachment, 214
Prevalence
of infanticide
underestimation of, 25, 2728
in U.S., 19
of postpartum psychological
disorders, 36
Prevention. See also Identification
of infanticide, 54, 252
in Britain, 192195
education as method of, 171
missed opportunities for,
244246
need for training in, 43
psychotherapy for, 210
recommendations for, 28
of neonaticide, 242243
of postpartum depression, 5051,
240
estrogen therapy for, 7374
of postpartum psychosis, 5152
Probation, for infanticide, in Britain,
16, 192
Progesterone
effects on brain chemicals, 72
in postpartum psychosis, 46
in pregnancy, 72
and regulation of neurotransmitter
activity, 66, 68
Projections, maternal, 224225
Pseudocyesis (hysterical pregnancy),
114115
PSI. See Postpartum Support
International
Psychiatric disorders. See Mental
illness; Postpartum psychiatric
disorders
Psychoanalytic theories
of infancy, 210211
of mother-infant relationship,
211212

Index
Psychosis
dissociative, in neonaticide, 110
hysterical, 115
postpartum, 9, 169
acute onset as bipolar disorder,
4243
alternative diagnoses for use in
legal defense, 148
and criminal justice system,
910, 140
diagnosis of, 41, 4445
evaluation for, 47
hormonal factors in, 46
hospitalization for, 240
identification and initial
management of, need for
training in, 43
insufficient understanding of,
xvi, xvii
lack of full recognition of, 147
mood disorders and, 39
vs. non-childbearing-related
psychoses, 4142
plasticity of, 910, 238
pregnancy denial and, 94
prevention of, 5152
as psychiatric emergency, 246
recurrence rate for, 51, 54
rehabilitation of mothers
recovering from, 243
symptoms of, 41
treatment of, 5153
vulnerability to, 36
Psychotic denial of pregnancy, 8586,
88, 89
dissociation/trauma paradigm and,
113
interventions with, 99, 100
schizophrenia and, 9192
PTSD. See Posttraumatic stress disorder
Punishment. See also Sentencing
justifications for, 1416
for neonaticide/infanticide, 137
court vs. personal, 191
in seventeenth century, 170

269
Rape, neonaticide following, 202, 205
Rape trauma syndrome (RTS),
155156
Recognition. See Identification
Recurrence
of neonaticide, 95
of postpartum psychosis, 51
of pregnancy denial, 95
risk of, in postpartum disorders, 54,
62, 63
Reflective self-functioning, 214
Rehabilitation. See also Treatment
after postpartum psychosis, 243
as rationale for punishment, 1516
Reilly, Bernadette, 140
Reporting of infanticide, 2023
Repressive cognitive style, during
pregnancy, 87
Resistant attachment, 213
Retribution
fear of, in neonaticide perpetrators,
191
as rationale for punishment, 15,
208
Right and wrong test. See MNaghten
test
Risk(s)
for child abuse
assessment of, 216, 248249
postpartum disorders and, 240
for infanticide, assessment of, 195
to mother-infant relations,
209210
early identification of, 228
transactional model of,
215216
for neonaticide, pregnancy denial
and, 242243
in pregnancy, assessment of,
216219, 228, 237238,
241
of recurrence, in postpartum
disorders, 54, 62, 63
women at, identification of,
213214, 238243

270

Infanticide: Psychosocial and Legal Perspectives

Risk factors
for infanticide, 23, 2425, 28,
251252
identification of, 44
reduction of, 54
for pregnancy denial, 9093
Rome, ancient, 4
RTS. See Rape trauma syndrome
Ruddick, Sara, 123124
Rush, Bobby, 251
Sacrifice
child death as, 127
infant, 4
Sargent, Carolyn, 126
Satcher, David, 55
Schizophrenia
and infanticide, 172173
in postpartum period, 38
and pregnancy denial, 92
use in legal defense, 149150
SCID-D. See Structured Clinical
Interview for Dissociative
Disorders
Scotland
homicide rates and legislation in,
187188
infanticide legislation in, 192
Screening tools, 54, 248249
Secure attachment
adult, 214
mother-infant, 213
Sedatives, postpartum depression, 49
Sensitizing cognitive style, during
pregnancy, 87
Sentencing
of fathers vs. mothers, 192
inconsistencies in, in United States,
174, 179, 247
of infanticide perpetrators
in Britain, 16, 192
in United States, 140141
of neonaticide perpetrators
in Britain, 189, 190
in United States, 138140

Serotonin
chemical precursor of, 66
dysfunction, in postpartum period,
41
in fight or flight response, 70
neurotransmitters, 65
role in depression, 66
Serotonin selective reuptake
inhibitors (SSRIs)
for postpartum depression, 48, 48,
49
use during breast-feeding, 4950
Sertraline
for postpartum depression, 48, 48
use during breast-feeding, 4950
Sex-selective infanticide, 56
Sexual abuse
and pregnancy denial, 112, 114
and reproductive conflicts, 237
Sexuality, conflicts related to, and
pregnancy denial, 88
Skeoch, Dorothy, 140141
Sleep deprivation, and cognitive
disorganization, 42
Smith, Susan, 208
Social isolation
and pregnancy denial, 93
and risk for child abuse, 216
and risk for infanticide, 245
Social support, inadequate, and
pregnancy denial, 99
Sociocultural factors
for infanticide, 4, 125126, 187, 188
for neonaticide, 92, 101, 208
for pregnancy denial, 83, 9293,
101
Specific deterrence, as rationale for
punishment, 1415
Spitz, Renee, 212, 215
SSRIs. See Serotonin selective
reuptake inhibitors
Stern, Daniel, 214, 215, 217
Stigma
of birth defects, 125126
of mental illness, 239

Index
Stokes, Melanie, 251
Stress axis, 7071
Structured Clinical Interview for Dissociative Disorders (SCID-D), 116
Substance addiction, and pregnancy
denial, 83, 91
Sudden infant death syndrome (SIDS)
deaths caused by, 22
infanticides attributed to, 27
Suffocation/strangulation, infant
deaths caused by, 21, 22
Suicide, postpartum illness and, 251
Support organizations, 243, 249250
Synaptic space, events in, 67
Syndrome(s)
DSM-IV definition of, 155
postpartum. See also Neonaticide
syndrome
insurance and disability claims
for, 181
recognition of, medical and
legal dilemmas in,
180182
use in civil cases, 177180
use in criminal cases, 173177
rape trauma, 155156
Syndrome evidence, 155, 156157
Tarahumara Indians, infanticide
practiced by, 126
TCAs. See Tricyclic antidepressants
Temperament
dimensions of, 219
and mother-infant relationship,
219221
Therapy
in Britain, 190, 193
cognitive-behavioral, 4748
countertransference in, 202, 247
couple/family, 243
for infanticide perpetrators, 247
interpersonal, 47, 48
interpretive, 228
for neonaticide perpetrators, 190
case study of, 201208

271
parent-infant, 210, 226229
effectiveness of, research on,
227229
groundwork for, 212
success of, 216, 219
for postpartum depression, 4748
for pregnancy denial, 9697
as protective factor, 216
Thyroid disorders
and mood, 6869
and postpartum depression, 47,
6970
Traumatic deaths, 21
Treatment. See also Pharmacological
treatment; Therapy
of family units, 243
of mothers at risk, 240
of postpartum depression, 4751,
48
of postpartum psychosis, 5153
of pregnancy denial, 243
Trial. See also Civil cases; Criminal
cases
impending, and therapy, 206207
Tricyclic antidepressants (TCAs)
for postpartum depression, 47, 48
use during breast-feeding, 49
Tryptophan, 66
Typology
of infanticide, 1013, 11
of pregnancy denial, 8286
Tyrosine, 66
Ultrasound examinations, with
pregnancy denial, 98
Unintentional injury, infanticides
attributed to, 27
United States
contemporary responses to
infanticide in, 1013
legal treatment of infanticide in, xvi,
9, 1416, 134, 137138, 192
infanticide court cases, 140141
injustices in, 207208
neonaticide court cases, 138140

272

Infanticide: Psychosocial and Legal Perspectives

United States (continued)

legislative initiatives in, 250251
prevalence of infanticide in, 19
Unknown causes, infant deaths from,
2223
Valproate
for postpartum psychosis, 51
use during breast-feeding, 5253
Vaughan, Hester, 105
Venis, Joyce, 250
Victim, mother as, xv
Welfare policy, and infanticide, 10
Wernick, Stephanie, 151154
Winnicott, D. W., 209, 211

Witchcraft inquisition, infanticide

during, 7
Women. See also Mother(s)
depression in, 65
hormonal relationships in, 69
mood disorders in, 6364
at risk, identification of, 44,
213214, 238243
thyroid disorders in, 68
Yates, Andrea, case of, xvixvii,
174177
American Psychiatric Association
response to, 246247
missed opportunities for
prevention, 244246