Pre and Perinatal Mental Health

by Marianne Littlejohn


In this article I wish to explore and describe the possible effects of womblife, birth and early postnatal life on the mental health of unborn/newborn baby and on the potential for human development and discuss a few interventions which may prevent pathology and/or facilitate healing.

If you can, try and imagine yourself as a tiny foetus inside a womb, bathed in fluid with the only source of nourishment entering your body through a pipe plugged into your stomach. You have no choice in deciding what foods you will eat or the kind of air you breathe, and may be flooded with feelings of terror or anxiety when oxygen levels in this source of nourishment diminish or fight or flight hormones are transfused.

Or try and imagine that the home you have lived in for nine months becomes small and tight, squeezing and shoving you through a small angular tunnel into an alien world, where you are left alone in a square box with see-through sides. Or imagine that you are preparing for this tunnel-journey and are suddenly and roughly pulled out of this home and thrust into a cacophony of voices, clanging instruments, hard surfaces, beeping machines and glaringly bright lights.

If you can imagine even one of these scenarios you may have a sense of what it feels like to be a baby in the womb or a baby being born. Pregnancy and birth are commonly viewed from the perspective of the mother but few of us are able to empathetically feel or identify with the experience of a baby in the womb or a baby being born. And if we could, what would we do to ameliorate the trauma that seems to be inherent in this journey to life for the baby?

The Evidence of Emotional Trauma to the Fetus

Mother and baby exist in unison and cannot be separated during pregnancy until after birth and the interactive effects of poor maternal care or exposure to teratogens have been shown to affect babies severely. South African research, for instance, documents that babies born to alcohol dependant mothers present with varying degrees of foetal-alcohol-syndrome, the most devastating symptom of which is mental retardation (Cape Times, Fri 7th Mar 04). This clinical syndrome is currently measurable in terms of physical/intellectual outcome, however emotional effects of distress on the baby during pregnancy and birth are more difficult to prove.

Several psychiatrists and psychologists, from the beginning of the 20th century, discovered and proposed that the first nine months of life in the womb and the birth of the baby are the most important events of human life. In 1923, Otto Rank wrote “The Trauma of Birth” in which he examines adult life and culture from a psychological viewpoint and suggests that birth anxiety is the prime source of adult neuroses and character disorders.1

Donald Winnicott, a British paediatrician and psychoanalyst, wrote in the 1960’s how he observed children re-enact what appeared to be their births, and that their anxiety and emotional problems resolved once they had been allowed to work through their birth anxiety.2 The late British theologian and psychiatrist, Frank Lake, who did research into regressive therapy with patients using LSD, was initially astounded by what he increasingly understood to be the reliving of birth trauma by his patients.3

Arthur Janov, an American psychoanalyst and proponent of primal therapy, a type of regressive psychotherapy, at first refused to believe that his patients were reliving their birth experiences. He later suggested the importance of the role of serotonin in mental illness before it was correlated by neurological research with types of mental illness and now believes that the ‘most important stage of childrearing occurs during the nine months of pregnancy.5

Medical professionals may accept that birth is traumatic for the baby and that there may be residual emotional effects, but may be sceptical that the nine months of pregnancy are neurologically or emotionally traumatic for the fetus. Frank Lake, after many years of psychiatric research, coined the term “Maternal-Fetal-Distress Syndrome”, when he became aware of the extent of foetal dependency on the mother’s state of wellbeing. Lake wrote that the first three months after conception “hold more ups and downs, more ecstasies and devastations than we ever imagined.4

A mother’s emotional state and level of stress may determine the child’s later behavioural and emotional state and may precipitate neurological changes in foetal brain structure and patterns of neurotransmission. Lake describes the basic ideas of Maternal-Foetal-Distress Syndrome as follows:

The catecholamines which convey the messages to do with the emotions round the mother’s circulation, (gearing all her organs and cells to feeling joy or sorrow, love or loathing, vitality or exhaustion), pass through the placental barrier (which to these substances is no barrier) into the foetal bloodstream via the umbilical vein. In this context the foetus does its own emotional homework and responds, either passively accepting the mother’s bad feelings as its own, as if true for itself, or by being protestingly overwhelmed by them.

It can aggressively fight them back, in resolute opposition to sharing the mother’s sickness. Others become ‘foetal therapists’, trying to bolster up a debilitated and debilitating mother from their own feelings of relative strength. Sensitivity to ‘poisonous feelings’ coming from a rejecting mother is very great ….to be the focus of mother’s love imprints a confidence that ‘sets you up for life’. (my emphases.6 In fact, Lake goes so far as to say that the first trimester of pregnancy is the most critical period for foetal growth and wellbeing.

The Effects of Prenatal Trauma

This tenet is borne out by animal research into the link between antenatal stress and impaired behavioural adjustment/ emotional reactivity in offspring, with the effects being carried into adulthood.7 Severe life events occurring in the first three months of pregnancy, such as the death of a child in the family, show increased incidence of congenital abnormalities. However, recent research suggests that antenatal stress and anxiety as early as 18 weeks pregnancy has a programming effect on the foetus, which lasts at least until middle childhood, and may show in behavioural problems such as dyslexia, hyperactivity and attention deficit.8

A mother’s depression during pregnancy is often associated with interpersonal difficulties leading to poor maternal-infant attachment, which may have a profound impact on cognitive and emotional child development.13

What is the significance of pre- and perinatal trauma for the long-term mental health of an individual or indeed, a whole community for that matter? Lynda Share, a psychoanalyst, has studied the dreams of her clients and reconstructed their infant traumas, and notes that very early foetal trauma seems to induce an overwhelming fear of progress in life. She posits that two conclusions emerge about infant trauma, namely:

  1. Memory of infant trauma can be stored indelibly in a primitive memory system such that it can be accessed through dream analysis and other psychoanalytic methods at a later point in time.

  2. Foetal Infant trauma-coming so early in life-also forms memory schemas through which future development and experience are filtered. These templates or schemas then become an "organizing principle" for the entire personality, colouring later ways of living, thinking, and seeing the world.9

Allesandra Piontelli, an Italian child psychoanalyst, became interested in prenatal memory when parents brought their 18-month-old to her for his inability to sleep and incessant restlessness. After observing and commenting that he seemed to be searching for something he had lost, his parents tearfully recounted that he had been one of a set of twins and that the twin and died in utero two weeks before birth.10

Piontelli tells the story of her analysis of a two-year-old psychotic girl who was born with the umbilical cord wrapped tightly around her neck and spent most of her early childhood wrapping ropes, strings and curtain cords around her neck.11

What About Mothers?

These clinical observations have far reaching implications if they are true and if we are to believe that maternal stress and anxiety is detrimental to the psychic development of our unborn babies, is this not just another way of assigning blame to women yet again? British Psychiatrist Margaret Oates states “it is a utopian fantasy to imagine there will ever be enough therapists or interventions to treat all anxious women during pregnancy.12 Let us remember that it was only in 1928 (less than a hundred years ago) that women were granted equal right to vote in United Kingdom and in many countries women are still not accorded equal status to men.

Is this research yet another avenue that may be used to control or victimise women by prescribing how they should be pregnant or give birth? Although anxiety may well rise during pregnancy, this could be due to social and environmental factors that women are unable to change, such as death in the family, poverty, housing problems, unemployment or lack of partner support. Such factors need to be addressed politically through mobilised community awareness and action and governmental policy changes and interventions.

Yet the increased incidence of postnatal depression in mothers who are anxious or depressed prenatally seems to be prevalent across all socio-economic levels of society.13

What Can Be Done?

It is my hope that public awareness and knowledge of the varying degrees of distress and emotional agony that both women and their unborn babies experience, will lead to the provision of socially supportive and protective structures for all women.

One such supportive structure, The Thula Sana Project, is a parent-infant interaction programme in Kayelitsha, Cape Town, and aims to facilitate the best possible early caregiver-infant relationships and so improve child developmental outcome. The programme is designed to provide emotional support and information to new parents, particularly mothers, in pregnancy and through the early weeks and months of adjustment after birth. By sensitising the parent to the baby’s individual and unique needs and communications it tries to increase the parent’s capacity to understand his or her baby and to make caring for that baby as satisfying and enjoyable as possible in a way that will best facilitate the baby’s healthy development.

The programme:

  1. Focuses on the interaction between the mother/parent/caregiver and the infant.
  2. Is delivered through a therapeutic counselling approach that allows space for the mother to share and explore her own personal struggles.
  3. Demonstrates to the mother the individual, communicative and interpersonal characteristics and capacities of the baby.
  4. Provides a space for the counsellor and mother, together, to think about the infant’s individual communications and needs.
  5. Provides information and useful strategies for managing common difficulties.
  6. Provides a model of positive, responsive and sensitive parenting.
The programme is delivered by trained and supervised family support workers from the community through a series of 19 home visits (4 antenatal and 15 postnatal) starting as early in the pregnancy as possible and terminating at six months after birth.

Another project, The Perinatal Mental Health Project at the Liesbeeck Midwife Obstetric Unit, Mowbray Maternity Hospital, Cape Town was started by Dr Simone Honikman in 2002. The aim of the project is to offer a woman-centred efficient mental health service to the women who attend the clinic. Women are screened for anxiety and depression during the pregnancy with informed consent and are referred to a psychologist or social worker for counselling if desired. Midwives are trained to use and score the screening tools, the Edinburgh Postnatal Depression Scale and A Risk Factor Questionnaire, which the women complete.

Sometimes all women need is someone to talk to, someone who will understand and listen. This is particularly relevant in cases of miscarriage, where a family member has died during the pregnancy, with marital or relationship difficulties and where a woman has suffered from depression previously, although there are many factors which may lead to emotional distress.14 This process of screening, referral and counselling helps staff and counsellors to support pregnant women who suffer emotional or interpersonal stress and refer women to appropriate services for further assistance with life problems or emotional difficulties.


These projects are not based on a utopian ideal, but have been developed in response to the needs of women and their unborn offspring. We may not be able to change the world in a lifetime, but we can make a difference to those women around us, our neighbours, sisters, colleagues, staff, and patients by really caring and putting compassion into practice.


1Rank, Otto. (1952). The Trauma of Birth. New York: Richard Brunner.

2Winnicott, D. (1958) In Collected Papers: Through Paediatrics to Psychoanalysis. New York: Basic Books, pp174-193.

3Winnicott, D. (1949), Birth memories, birth trauma, and anxiety. In: Through Paediatrics to psychoanalysis. New York: Basic Books, 1958, pp. 174-193.

4Lake, Frank. (1966). Clinical Theology: A Theological and Psychiatric Basis to Clinical Pastoral Care. London: Darton, Longman and Todd.

5Lake, F. (1981). Tight Corners in Pastoral Counselling. London: Dartman, Longman and Todd.

6Janov, A. (2000). The Biology of Love. Prometheus Books: New York.

7Lake, F. (1978) In a Report from the Research Department and Theological Issues in Mental Health in India. Nottingham: Clinical Theology Association, Lingdale.

8Weinstock in O’Connor, T. (2002). British Journal of Psychiatry 180:389-391.

9O’Connor, Thomas G., Heron, J., Golding, J., Glover, V., and the ALSPAC Study Team. (2003) Maternal antenatal anxiety and behavioural/emotional problems in children: a test of a programming hypothesis. Journal of Child Psychology and Psychiatry 44:7 pp 1025-1036.

10Share, L. (1994). If Someone Speaks, It Gets Lighter: Dreams and the Reconstruction of Infant Trauma. Hillsdale, N. J.: The Analytic Press.

11Piontelli, A. From Fetus to Child: An Observational and Psychoanalytic Study. London: Tavistock/Routledge, 1992, p 18.

12Piontelli, A. “ Prenatal Life and Birth as Reflected in the Analysis of a 2 Year Old Psychotic Girl.” International Review of Psycho-Analysis. 15(1998):73-81

13Oates, M.R. (2002) Adverse Effects of Maternal Anxiety on Children: causal effect or developmental continuum? The British Journal of Psychiatry (2002) 180: 478-479.

14Nonacs R. and Cohen L.S. (2002). Depression during Pregnancy: Diagnosis and Treatment Options. Journal of Clinical Psychiatry 2002:63 (suppl 7) p 25

15Dr Simone Honikman : Personal Communication 2004. The Liesbeeck Midwife Obstetric Unit, Mowbray Maternity Hospital, Cape Town.

Marianne Littlejohn is a long-term primaller from Cape Town, South Africa, who began primalling in the 1980s after reading "The Feelling Child" by Arthur Janov. She is a midwife involved in Kangaroo Mother Care research and also attends home and hospital births. Most importantly, she does "inner work" with parents-to-be, where they can explore their feelings about the coming baby, and hopefully resolve any unadressed issues before the baby is born. She has three sons, all born at home.

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