Dr. Blakely on Obstetrics, 1933
Binghamton's Famous Doctor
The Psychology of Pregnancy
By: Stuart B. Blakely, M.D.
16 Stratford Place
"Read at the meeting of the American Association of Obstetricians, Gynecologists and Abdominal Surgeons, Excelsior Springs, Mo. September 28, 1940"
The writer of this paper is an obstetrician, not a psychologist nor a psychiatrist. This is not a venture into the neuroses and psychoses, but a discussion of some common mental states some attitudes of the pregnant women. A reasonably adequate search of medical literature has discovered but on article with the same title on this interesting and important subject.
The difference in the working of the male and female mind constitute a complex and controversial problem. Personally, I believe that the differences are profound and that they profoundly influence the women's attitude toward pregnancy and all that it signifies. Indeed, it has been suggested that these differences represent the effects of pregnancy itself on the female mind, acting through countless eons of time. There has been much speculation on how the male would react to pregnancy were he ever in that condition. Many obstetric patients express the wish that their husbands might share their experiences. Parenthetically, it must be emphasized that the pregnant state does not exhibit any new psychological elements, peculiar to itself.
Obstetrics offers the best opportunity to study the "animal" nature of the female, using "animal" in the broad biologic sense. Pregnancy and childbirth are so elemental; they reduce the women so completely to the level of her brute sister. Of this sensitive woman are not infrequently dimly aware and vaguely resentful. "Christian lady and plain animal sometimes wage a terrible subconscious battle".
The desire for a baby is basic in every women's soul. Her biologic destiny is childbearing and child-rearing, however much this may be, on occasion, resented and denied. The psychoanalyst knows the penalties exacted when this destiny is flouted, it matters not the reason nor how much freedom the women thinks she has achieved by "democracy", education and birth control. Childlessness' acts as a psychic trauma, though probably less today than when kitchen, children and church formed women' man-made sphere. Tennyson summed it up "women's wisdom is to bear and train a child".
A woman will often go to any length, even to impregnation by a man, not her husband, to achieve or to feign pregnancy. She may be motivated by inherent desire, or an irresistible urge, or by other reasons, often selfish or obscure e.g. as an escape vehicle (often unsuccessful); to bind a man to her; to meet the wishes or demands of husband or family; to retain support or inheritance. Among the more bizarre motives consider the advances made by women to fathers of talented children in the hope that they may have begotten on themselves offspring of like precocity. Formerly, simulation of pregnancy. Labor and the lying-in period, with the presentation of a borrowed or stolen infant, were not rare. Today, the sophistication of the present age militates strongly against its successful accomplishment.
On the other hand, is the astounding fact that a woman will also go to any length even to court death itself, to avoid or terminate pregnancy, proceeding against all pleading and advice, and for reasons entirely inadequate or at least past all understanding by the male. In these cases, she is usually motivated by fear.
The causes that produce the mental state of pregnant women are not well understood but may be grouped as follows. An inherited nervous instability (not going so far as to say a "psychopathic makeup) without doubt an important factor.
Toxins, infection, exhaustion, hormones and fetal products. Intoxications and infections are potent in the production of central and peripheral nerve lesion's; in less amount or degree theme easily might affect the psych's. Trendies endocrine changes occur in pregnancy, and hormones undoubtedly influence mental attitudes and behavior. Of fetal products and their effects, we know little, but we do know that they may have a most beneficent, as well as a most malignant, effect on the women's whole organism.
Physical discomforts and pain; fear, anger and mental strain; new responsibilities, and re and maladjustments all potential elements of psychic disturbance.
The impact of the fact of pregnancy itself, with all its implications and ramifications biologic, racial, social, religious, economic, etc. On the female mind with its varying background of heredity, environment and education. Whether the pregnancy is desired or undesired often materially influences the mental response.
Every part of the maternal organism reacts in some degree to pregnancy. I. The influence on the mind varies from slight to profound. The stolid bovine type shows little response; some women do not feel or know that they are pregnant. In others it is recognized by mental changes, not infrequently progressive for a time, of which three are prominent in the early months.
A changed or changeable disposition, sometimes excited and sometimes depressed.
Antipathies and aversions (possibly the expression of a rejection of the pregnancy); or, more often, curious inclinations and desires, especially in reference to foods. (5,9) This craving for strange articles of diet and the longing for unusual, possibly abnormal, things are called "pica", the Latin word for magpie. The greater the parity, the less the cravings. A common desire is for sour substances. One of the most bizarre was the case of the women who wanted a piece of her husband's arm and got it. While a completely satisfactory explanation of these curious anomalies of taste is not at hand, many are undoubtedly the expression of some unsatisfied body need. It is strange and interesting that these cravings of pregnancy are popularly believed to be the expression of a need on the part of the child; and that, if not satisfied, the child will be "marked", or will cry for the article till given it. Nausea, vomiting and rarer ptyalism of early pregnancy may have a toxic or endocrine basic but are most often largely psychic. Many patient's stats that they cannot be pregnant because they are not "sick". Coitus usually makes them worse. Numerous cases are recorded where the symptoms have been entirely relieved by an attempted but unsuccessful abortion, or where the patient was deliberately deceived therein. The lessened incidence of this symptom complex in recent years and the often speedy and spectacular relief by what is practically psychotherapy are strong arguments against a predominantly toxic or denial of the pregnancy an expression of fear, aversion or maladjustment. Occasionally it repression an effort to punish self or husband.
Most pregnant women are more impressionable and exhibit an increased sensibility to sensory stimuli and an increased suggestibility. They often complain in the early months of indolence or torpor, exhaustion and a tendency to sleepiness. What is sometimes regarded as dullness of intellect is probably the result of thought and feeling being concentrated on the pregnancy and approaching birth, with lessening of attention and indifference to environment. Pregnant women are also less solicitous for their souls, for they develop a strong egocentric attitude toward themselves and the child within them. This often changes their characters, occasionally for the worse. Such change, plus impulsive acts, is said to lead to increased criminality. It has been stated that shoplifters, for examples, usually do their stealing when menstruating or pregnant. Lombroso, however, says that pregnancy acts as a temporary moral antidote on the criminal women and that maternity is never the motive power of crime. Delee notes that in olden time pregnant women were considered mentally irresponsible, and the condition was advanced in extenuation of crime; they are not reliable as witnesses for their perception is less acute, their reasoning deficient and their interpretation false.
Changes in sexual personality during pregnancy vary. Libido, at least physical libido, is usually lessened. According to Kogerer, later in pregnancy the "psychosexual components" often appear in the active forms of Jealousy
2. Apparent lack of modesty, or exhibitionism due to their egocentric attitude and to the feeling that they have less sex appeal. They can see no reason to conceal what does no longer attract. This attitude is possibly more in evidence during the puerperium and the lactation period.
3. Tendency to employ substitutes, through the exhibition of simple neurotic or even hysterical reactions.
4. Erotic attitude toward the physician, often embarrassingly evident when coming out from the anesthetic.
Annoyance, resentment and anger are not uncommon mental states in pregnancy. One patient said that she was "mad" because she was pregnant and was just as "mad" when she miscarried. Women are frequently angered at the fact of their pregnancy because they are so impotent to avoid its consequences; and because they cannot transfer it to their condition. They resent being so forcibly reminded that they are animals, that their condition is their biologic destiny and that pregnancy and a child interfere with their "will to power". Many women never grow up, psychologically.
The pregnant women live in the midst of anxieties and fears. Many are dim and hazy, some of which have come down the "long road of women's memory" from the race's brute and pagan past. At the other extreme is actual terror. The degree of these fears may be altered or mitigated by heredity, environment and education. Let us name a few, remembering that we fear what we cannot control.
Fear of the expense involved, and of the financial strain of another mouth to feed with the attendant work and privation. So long as church and state, bolstered by medieval laws and medieval thinking, insist or imply that pregnancy shall not be prevented, at least so long should church and state aid and not penalize its members and its citizens for having children. Fear of the inadequacy or inability or unwillingness of the husband to bear the added burden of her pregnant self and the child to be, with the possibility of his desertion.
Fear of the loss of independence, and of social and economic freedom. Fear of the responsibility of bringing a new human being into a chaotic, sinful, warring world, and being unable to read it properly. Fear of the disgrace of having a baby, either because of the idea that pregnancy is dangerous in older women or because of the feeling that it is shameful to thus admit the continuation of sexual intercourse at that age. Fear of forfeiting the husband's love and affection by loss of figure or attractiveness, by the aging effect of childbearing and by enforced sexual abstinence. This fear may produce a feeling of animosity toward the unborn child, to be overcompensated for after its birth by an anxiety neurosis about it. The fear of loss of beauty and sex appeal may also be regarded as a Narcissist motive.
Fear of abortion and fetal death. Fear that the child will inherit evil or other undesirable family traits often really a protest against the pregnancy (also often true of other expressed fears.). Fear of telegony. Fear that the child may have been harmed by unsuccessful attempts at abortion. Fear of the possible harmful effects of the mother's activities and experiences on the unborn, a consideration of which would lead into the fascinating field of maternal impressions. One of the commonest questions asked the obstetrician today is "will alcohol and tobacco hurt the baby".
The greatest fear of the pregnant women is of the dangers of pregnancy and labor and the pain of childbirth exaggerated or accentuated by ignorance, the influence of "old wives tales", and the publicity in the lay press and magazines of the morbidity and mortality associated with having a baby. In no other field of human thought and activity is superstition rifer and ignorance more profound, with most harmful results. It is notorious that intimate and informal gatherings of women tend, as the afternoon or evening wears along, to become obstetric clinics, usually of the abnormal. Why older women often seem to delight in frightening young women pregnant for the first time with obstetric tales of horror, or by solemn but often silly fantastic admonitions, is hard to say. Jealousy and envy have been suggested. Possibly it is their desire to impress the younger women with their superior knowledge and experience. It may be the outcropping of the alleged antipathy of women toward one another. At all events, it is remindful of the refined cruelty of the cat. There is grave question whether the usual magazine article. Often lurid or sensational, concerning pregnancy and labor and their dangers is not psychologically harmful. Of course, there is no reason why a patient should not be furnished proper prenatal and other literature about pregnancy, compatible with her mentality. A supremely satisfactory book or booklet o prenatal care for the expectant mother has yet to be written.
However, in spite of baneful influences, physical discomforts, anxieties and fears, pregnant women, especially after the first few months, are usually happy, even exalted. They register a mixture of pride, selfishness, and self-sacrifice, and often seem to "walk in radiance like a bride". The impatient euphoria of late pregnancy is frequently striking. They cheerfully rise death for the life within them. No one has greater love; few so great a courage. But to state that these things are so because the pregnant women are fulling her destiny very inadequately explains a physical and psychic read just meant of whose mechanism we are almost entirely ignorant.
Menial attitude toward Illegitimacy
Illegitimacy is of course, purely a social idea. In an era not long gone, an illegitimate pregnancy was considered a grievous sin and branded the women with the scarlet letter, setting her apart for life and not uncommonly driving her to suicide. I can member in a small town a woman who reminded unmarried a grew old, shunned, barely tolerated and covertly obscenely derided because she had made a so-called misstep and had been found out. Everyone, at least the women of the village, thought that she should be so punishments are isolation. I have often wondered what the women's own thoughts were on the subject. Without question the value gets on virginity has diminished in recent years, whether for good or bad I do not know. Probably the average young women of today are not sure that as illegitimacy is a sin, but the only evidence of poor technic or poor judgment. If it is a sin, she is quite sure that it cannot be atoned for by a loveless marriage. She rarely resorts to self-destruction. Indeed, the modern girl seems to fear parental anger or disappointment, or the family disgrace, more than her own shame. Were it not for the social retribution still exacted, especially by the female of the species, I am persuaded that illegitimacy would be much more common, or at least more commonly found out, with fewer abortions. I am occasionally taken aback by the courage, possibly better bravado, shown by some young women toward the opinion of the world on this question. If they acknowledge the baby as their own and take it unto themselves they rarely marry, for their admission proves that they are "damaged goods". Possibly the time will come when a woman will have the right to maternity by the man of her choice. I am not an apologist for illegitimacy, nor am I defending it, but it does not necessarily destroy society, as shown by Scandinavia where often one-half of the births are out of wedlock, and by Russia where there is no such thing as illegitimacy. Even in New York State, the word is banned from the birth certificates. It is hard to understand why the omission of a marriage ceremony should doom an innocent child to infamy.
Attitude of the Women pregnant out of wedlock toward the father of the child. If she really loves him, she may not even tell him what has happened; often forgives him all and cheerfully bear her burden along a cruel road to the better end. On the other hand, if she does not love him, she will often to any length of rid herself of the pregnancy and punish him regardless of consequences. But not always. It has been truthfully but cynically said that women have the strange capacity to love the unlovable, to cherish the unlovely and to defend the indefinable.
Mental Attitude toward abortion, Abortifacients and Abortionists
I am sure that moral religious scruples against abortion are on the wane. Women are realists, less concerned with principles than with results. They are not much impressed with the illegality of something they may desire to do. Few hesitate to employ abortifacients, and the mechanical interruption of early pregnancy is very common. Abortion is today practically unpunished, even unpunishable, by the law. It is frequently made "big business". It has become almost an axiom, particularly relating to abortion, that it is not safe to believe the statements of any women about her sex life. This is something about which she is at times astonishingly unscrupulous and unreliable. Though in her heart the women despise the abortionist, I have yet to have a patient, dying as the result of a criminal abortion, volunteer the name of the person responsible for the crime. She often resists and successfully all attempts to persuade or compel her to divulge such information. The physician, who is led by motives of sympathy or gain to perform such abortions, sets his feet on the path that leads not only to professional ruin but also without exception to loss of the respect and confidence of his patients.
Even as in ancient Egypt the young women frequently go home and to her mother to have her first baby. The obstetrician who successfully conducts a women's first pregnancy and labor is often rewarded by loyalty and affection that is positively frightening. However, it is well to remember the story told by Dr. Frederick Loomis in his book "Consultation Room". He had planned to go to China. One of his patents, by her tearful pleadings, persuaded him to postpone his trip. After her delivery, he called her by name and said: "Now I suppose that I can go to China". She replied: "As far as I am concerned you can go to hell". Most obstetricians, sooner or later, become painfully familiar with this psychology also. Women often have curious reasons for choosing or changing accoucheur. I remember one who had just lost her only child of three years by meningitis. She announced that she was going to have another baby right away, but that she was going to have better luck next time with a different doctor, nurse and hospital for her delivery. One is tempted to ask, why not a different father also. Alexander Woolcott once asked the writer who was the obstetrician in attendance on Mrs. Oliver Wendell Holmes. He was interested in knowing the type of physician that the author of "The Contagiousness of Puerperal Fever" would choose to deliver his wife. The psychology of the attitude of the laity and the rest of the medical profession toward obstetrics and the obstetrician would make a chapter in itself.
Dream in Pregnancy
Pregnant women are supposed to dream predominantly of death, fire, and water. My own limited inquiry does not bear this out, though dreams about water do seem to occur rather frequently. The Aztecs called the sufferings of childbirth the tribute of death, and the death symbol is claimed to be the focal point of pregnancy psychology. Fire is a sex symbol, and in early creation myths, water was the feminine element from which live emanated. The interpretations of dream in pregnancy might well deserve the further attention of psychoanalysts'.
Esthetics and Pregnancy
While the women far advanced in pregnancy may be beautiful to the artist or the philosopher, the women herself is usually far from being in accord with that standard of esthetics for many reasons. When Shakespeare speaks of the "pride of pregnancy", he refers rather to the women's physical bearing than to her mental state.
Mental Hygiene of Pregnancy
From the obstetrician's standpoint, proper sex education and the psychological preparation for pregnancy are of vital importance in any discussion of mental hygiene. But there is time only for a brief consideration of mental problem of the actually pregnant, essentially normal women. Since the obstetric patient usually surrenders herself so completely to the physician of her choice, he bears a great responsibility. If the patient's mentality is not entirely hopeless, a great deal can be accomplished by thought and effort. As far as possible, physical discomforts are to be relieved; superstition and ignorance, combatted; emotional stress and strain, prevented; worry, anxiety and fear, eliminated. The tact, wisdom and cooperation of husband, family and friends must be enlisted. They, as well as the patient herself, usually sadly need education in physiology as well as psychology. The attitude of all should be that of envy, not sympathy; of cheerfulness, not gloom. The physician must take an active and intelligent interest, personal and professional, in the patient's pregnancy, listen patiently to her complaints and do all within his power toward the safety of her body, the serenity of her mind and the peace of her soul.
I hate the expression "only a confinement case", with all that it implies. Also, anathema to the writer is the doctor, who, for insufficient reasons or because he is a poor obstetrician, tells a woman that she should never have another baby or none within so many years, or that she must have a Caesarian in the future. Few realized how much mental harm can be done by such statement, or badly managed pregnancy and labor. Generally speaking, we are too much occupied with the mechanics of our profession, and too little interested in the minds of patients. In no other field of medicine is good psychology better rewarded and bad psychology more disastrous than in obstetrics.
There is no more remarkable phenomenon on this earth than the incarnation, development and birth of a human being. Pregnancy is the most important and momentous activity and experience of women's life. Often marvel why, how and that they go through with it, often under atrocious conditions, both physical and mental. The longer I practice obstetrics, while many of the processes of the female mind remain entirely incomprehensible to me, the more respect and admiration I have for pregnant womankind. Though their psychology is their own, they are the better half, these mothers of men. Men can never know the things that women keep and ponder in their hearts about the child to be.