Child Abuse & Neglect, Vol. 21, No. 2, pp.

181-186, 1997
Copyright 1997 Elsevier Science Ltd
Printed in the USA. All rights reserved
0145-2134/97 $17.00 + .00

Pergamon

PII S0145-2134(96) 00143-3

FETAL ABUSE
LINDSEY

KENT

Department of Psychiatry, University of Birmingham, Queen Elizabeth Psychiatric Hospital,

Edgbaston, Birmingham, UK

JAMES D. D. LAIDLAW
Mother and Baby Unit, Queen Elizabeth Psychiatric Hospital, Edgbaston, Birmingham, UK

IAN F.

BROCKINGTON

Department of Psychiatry, University of Birmingham, Queen Elizabeth Psychiatric Hospital, Edgbaston,

Birmingham, UK

Abstract--The possible occurrence of fetal abuse in expectant mothers has received little attention in either clinical
practice or in research. Five cases with reported fetal abuse are presented. Each case suffered from depression and
four of the five women had unplanned pregnancies and had considered a termination of pregnancy. Other possible
factors associated with fetal abuse included: denial of the pregnancy, ambivalence towards the pregnancy, previous
postpartum depression, and relationship difficulties. Enquiry of possible fetal abuse in pregnant women should be
made, particularly if a depressive illness is demonstrated. The relationship between fetal abuse and subsequent child
abuse remains unclear. Copyright 1997 Elsevier Science Ltd
Key Words--Fetal abuse, Depression, Pregnancy, Child abuse.

INTRODUCTION
THE POSSIBILITY OF a mother abusing her fetus has received little attention in research or
clinical practice, partly due to the disbelief expressed by many that this behavior exists. The
concept of fetal abuse encompasses any deliberate behavior that is known by the abuser
potentially to damage the fetus. This generally implies direct physical assault, but could also
include other behaviors including drug and alcohol misuse.
In an attempt to estimate the frequency of fetal abuse, Condon (1987) interviewed 112
pregnant women. He discovered that 8% of women acknowledged the urge to hurt or punish
their unborn child. In addition, 4% of fathers also expressed this urge. He described two
teenage mothers who hit their abdomen. One, in response to her cohabitee's behavior, thumped
it once, as hard as she could, causing bruising to the abdominal wall. Another 15-year-old,
who had been refused a termination, regularly punched the fetus through the abdominal wall
in response to its movements (Condon, 1986).
Received for publication July 24, 1995; final revision received July 19, 1996; accepted August 2, 1996.
Reprint requests should be addressed to Dr. Lindsey Kent, Lecturer, Department of Psychiatry, Queen Elizabeth
Psychiatric Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2QZ, UK.
181

182

L. Kent, J. D.

D.

Laidlaw, and I. F. Brockington

In two of the five cases of fetal abuse he reported, abuse of the child continued after birth.
Condon felt it likely that an abused fetus was at high risk of becoming an abused child, and
hence the importance of detecting this form of behavior (Condon, 1987).
The current paper describes five cases of fetal abuse that were detected during routine
assessment of referrals to a specialized Mother and Baby Unit suspected of suffering from a
pregnancy related depressive illness. This assessment includes enquiry regarding thoughts of,
or actual physical harm to the fetus or subsequently born child. The paper attempts to identify
possible factors which may be associated with this behavior.

CASE REPORTS
Case 1

A 29-year-old married woman, who was 32 weeks pregnant, presented with a 7-week history
of depression. She had no previous psychiatric history, but suffered mild premenstrual tension.
She had previously had two terminations of pregnancy: at the age of 17 when 12 weeks
gestation, and at the age of 28 when 8 weeks gestation. Both were because she did not wish
for children at that time in her life. She had a family history of depression and her father had
suffered from alcoholism. Her childhood had been unsettled and her parents had separated
when she was 14 years old. She had lived with her mother until her mother died of a diabetic
coma 2 years later, and then returned to her father. She had a stable employment record and
was happily married, in her second marriage.
This pregnancy was unplanned and she had initially considered a termination. She remained
ambivalent and delayed arranging a termination, and then decided to continue with the pregnancy. She suffered from nausea for the first 18 weeks, which disappeared, to be replaced by
back and hip pain and general physical discomfort from the 22nd week onwards. She began
to feel depressed in the 25th week and became irritable, lost her appetite, and slept poorly.
She experienced poor concentration and anhedonia, and suffered diurnal variation of her mood,
feeling worse in the evening. She became worried and anxious about how she would cope
with labor and how she would feel towards the baby when it was born.
Since becoming depressed she had been "revolted" by the fetus moving, and felt it was
being "malicious" towards her when it moved. She spoke of it being like an " a l i e n " and
"eating away at m e . . . like a parasite." These beliefs were not of a delusional intensity. On
two occasions, she punched her abdomen when she felt fetal movements, but not hard enough
to leave any marks or bruises. She pleaded with her husband to have the fetus " r e m o v e d . "
At times she felt suicidal and had considered taking an overdose of tablets. She was delivered
by an elective Caesarean section at 36 weeks gestation. Since delivery she has cared for and
bonded to her child well, without any subsequent problems.
Case 2

A 41-year-old woman presented with a 6-year history of low mood related to long standing
marital problems. She came from a stable, happy family background and was described as
"easy going." She was in her second marriage, having had a daughter in her first marriage,
which had ended 13 years earlier. She then met her current husband who was prone to verbal
aggressive outbursts.
This pregnancy was unplanned and she became depressed. She lost her appetite and motivation, becoming lethargic, and took no care of her appearance. She had suicidal ideas and
attempted to poison herself with carbon monoxide by a pipe from the exhaust of her car, but

Fetal abuse

183

was prevented from doing so by her husband. She wanted to have a termination, but her
husband would not allow her to do this. During the pregnancy she had chorionic villus sampling
because of her age and concerns about fetal abnormalities.
She denied the pregnancy, saying "in my mind I wasn't pregnant" and made no preparations
for the arrival of the baby, such as buying baby clothes or preparing a room for the child. She
felt guilty about bringing a child into the world with "such a dreadful (marital) relationship,"
but denied hating the fetus. At times she became very distressed and "hysterical" and on
three or four occasions punched her stomach, leaving no marks.
At 42 weeks she was induced and delivered by Caesarean section because of fetal distress
and meconium staining of the fluid. She did not want the baby to die, saying "even though
I didn't accept the pregnancy, I still loved the baby." After the birth, she immediately bonded
very well to her daughter, and says "she's the best thing that ever happened to me."
Case 3

A 29-year-old woman presented with depression starting at 3 weeks gestation. Her upbringing had been unremarkable and she was happily married. She had experienced a previous
postnatal depression with associated attachment disorder following the birth of her son 3 years
earlier. This had been severe, and had lasted 6 months. Her mother had ~uffered several
episodes of postnatal depression.
She felt depressed, lost her appetite, and became tearful and anxious, especially in the
mornings. She was commenced on amitriptyline. She did not want the baby and considered a
termination, saying "it's like having something bad looming over you." She did not talk to
the fetus, tried to deny the pregnancy, and hoped for a miscarriage. During the first trimester
she punched herself in the abdomen five or six times, which caused some bruising. She
responded to the amitriptyline and her symptoms improved.
Following the delivery, she initially bonded to her daughter but then relapsed, becoming
depressed, tearful, and irritable about 3 weeks after the delivery. She developed an associated
attachment disorder which persisted, despite treatment, for 18 months.
Case 4

A 29-year-old mother presented with "murderous thoughts" about her 2-year-old second
child, whom she saw as a constant source of torment. After an unhappy childhood, she had
been thrown out of the family home by her father, and wandering the streets, had been
exploited, resulting in the birth of her first child, after which she suffered postnatal depression.
She had met the father of her second child after joining a church, but this man deserted her
after conception. During the pregnancy she became depressed and described the fetus as " a
cancer growing within her." She became so "wound up with hatred and frustration" that on
four occasions she punched herself in the stomach for several minutes. She also jumped from
the top of a bunk bed attempting to cause injury.
After this child was born, she felt overwhelming guilt and later, after the delivery of her
third child, relinquished this middle child for fostering, visiting him regularly.
Case 5

A 22-year-old married woman presented with a long standing history of depression and
anxiety that had worsened during this, her second pregnancy. She had been adopted shortly
after her birth. At the age of 18, she attempted to contact her biological mother, but was
rejected by her. At this point she began to demonstrate self-mutilative behavior involving

184

L. Kent, J.

D. D.

Laidlaw, and I.

F.

Brockington

superficially cutting her arms and legs, with several incidents of self-harm occurring over the
subsequent years.
She admitted to having cut and punched her abdomen during her first pregnancy, as she
felt she did not deserve a baby. She had developed a mild postnatal depression after this
delivery.
This pregnancy was unplanned and she had suffered a threatened abortion at 9 weeks, but
the fetus survived. However, at 20 weeks she requested a termination, which she then declined
only hours prior to the procedure. Shortly afterwards she began to cut her abdomen and her
arms and repeatedly punched her abdomen, hoping to damage the fetus. These attacks were
often in response to fetal movements. She delivered a healthy girl at term, but throughout the
labor and shortly afterwards she had recurrent wishes of the baby dying. She developed a
moderate attachment disorder in addition to a worsening of her depressive symptoms. The
self-mutilative behavior clearly worsened during each pregnancy and then declined in frequency
following each delivery.

DISCUSSION
Clearly this report of a small number of women prevents any definite conclusions being
inferred regarding any etiological factors. It is suspected that fetal abuse is underreported, and
little is known regarding the prevalence of this form of abuse.
The commonest form of abuse encountered involved repeated punching or hitting of the
abdomen. In some women this was in response to fetal movements, also described by Condon
(1986). Although the fetus is cushioned from external violence by the amniotic fluid, potential
danger to the fetus is considerable not necessarily as a result of direct trauma, but due to
possible placental abruption and fetomaternal hemorrhage, which may result in fetal anemia,
or possibly fetal death. Adams Hilliard (1985) describes a woman who was kicked in the
stomach and went into premature labor, and another who suffered a 16-week miscarriage after
such an event. Morey, Begleiter, and Harris (1981) describe a woman who was struck in the
abdomen by her partner, and gave birth to an infant at 29 weeks gestation. Despite delivery
without trauma, the infant suffered an intraventricular hemorrhage, swelling of the left eye
and bruising of the arm, neck and shoulder, although this event could be explained by premature
delivery of a delicate infant. The infant died on the second day postpartum.
Motor vehicle accidents are a comparable cause of maternal abdominal trauma. Stafford,
Beddinger, and Zumwalt (1988) describe eight cases of lethal intrauterine trauma, all with
some degree of placental abruption and associated with only minor maternal injuries following
vehicle accidents. Similarly, Agran, Dunkle, Winn, and Kent (1987) describe nine cases of
fetal death following maternal impact with the steering wheel in motor accidents, and Chetcuti
and Levene (1987) report a case of fetal morbidity following seatbelt trauma. Williams,
McClain, Rosemurgy, and Colorado (1990) evaluated major blunt abdominal trauma in 84
third trimester pregnancies. Of these, two cases suffered placental abruption, but the commonest
complication was premature labor occurring in 28% of cases where the traumatic insult was
prior to 37 weeks gestation. No cases of direct fetal injury were noted.
Most of these adverse events in this study refer to single episodes of abdominal trauma,
while the majority of cases suffered repeated trauma. The children born to mothers in this
study did not cause any pediatric concern following delivery.
In all cases in this study, the women were suffering from depression and also had comorbid
anxiety. Cases 2 and 3 denied their pregnancies to some extent, but neither of these two women
or the others were psychotic. Psychotic denial of pregnancy in chronically mentally ill women

Fetal abuse

185

may place the women and their fetuses at high risk of fetal abuse (Miller, 19901). Condon
(1986), however, feels that psychosis is not a major factor in the etiology of fetal abuse.
Of the pregnancies, four of the five were known to be unplanned and these women had
considered a termination, two of them only deciding against it just prior to the procedure. They
all described varying degrees of ambivalence towards their babies. Relationship difficulties with
their partners prior to, and continuing throughout their pregnancies were described by three
of the five women. Of these, two eventually separated from their partners. Such difficulties
are likely to contribute to depressive symptoms.
In addition, three women had suffered from previous postpartum depression, which is more
than would be expected in the general population with a prevalence rate of around 10% to
15% of women (Cox, Murray & Chapman, 1993; Kumar & Robson, 1984). However, a
previous history of postpartum depression may have increased the likelihood of referral to a
specialized unit with a subsequent pregnancy therefore resulting in a more selected sample.
A positive family history of depression was also documented by two of the women. An
adverse social environment had been experienced by three of the five women during childhood,
including physical abuse of at least one woman.
None of these women gave a history of alcohol or drug abuse during their pregnancies.
Although these behaviors may be perceived as a form of fetal abuse, they are often present
prior to pregnancy and may not involve a direct attempt to harm the fetus.
Postpartum attachment disorder of varying severity occurred in three cases. As far as we
are aware, none of the children born to these women have suffered from subsequent child
abuse, but issues surrounding attachment and the subsequent well being of the child are
important. The majority of these cases have been collected relatively recently and the children
born to these mothers are still young infants.
Due to the apparent multifactorial etiology of this behavior, it is unlikely that a single
treatment approach will benefit all. It is likely that both psychological and social issues need
to be addressed. Disclosure of fetal abuse and the opportunity to discuss feelings in a secure
environment may be therapeutic, and may be one reason for the relatively good outcomes
we have documented. Antidepressant medication, when indicated, might also be expected to
contribute to a better prognosis. Further followup of these children and other cases of fetal
abuse is needed to clarify the important possible relationships with attachment difficulties and/
or subsequent child abuse and to identify beneficial therapeutic factors.
In summary, we would emphasize the importance and potential value of inquiring about
possible fetal abuse in any pregnancy, not necessarily only depressed women, as more information about this phenomenon is required.
Acknowledgement--The authors wish to thank the anonymous reviewers for their helpful comments and suggestions.

REFERENCES
Adams Hillard, P. J. (1985). Physical abuse in pregnancy. Obstetrics and Gynecology, 16, 185-190.
Agran, P.F., Dunkle, D. E., Winn, D.G., & Kent. D. (1987). Fetal death in motor vehicle accidents. Annals of
Emergency Medicine, 16, 1355-1358.
Chetcuti, P., & Levene, M. I. (1987). Seat belts: A potential hazard to the fetus. Journal of Perinatal Medicine, 15,
207-209.
Condon, J.T. (1986). The spectrum of fetal abuse in pregnant women. Journal of Nervous and Mental Disease,
174, 509-516.
Condon, J. T. (1987). The battered fetus syndrome. Journal of Nervous and Mental Disease, 175,722-725.
Cox, J. L., Murray, D., & Chapman, G. ( 1993). A controlled study of the onset, duration, and prevalenceof postnatal
depression. British Journal of Psychiatry, 163, 27-31.

186

L. Kent, J. D. D. Laidlaw, and I. F. Brockington

Kumar, R., & Robson, K. (1984). A prospective study of emotional disorders in child-bearing women. Brit&h Journal
of Psychiatry, 144, 35-47.
Miller, L. J. (1990). Psychotic denial of pregnancy: Phenomenology and clinical management. Hospital and Community Psychiatry, 41, 1233-1237.
Morey, M. A., Begleiter, M. L., & Harris, D. J. ( 1981 ). Profile of a battered fetus. The Lancet, 2, 1294-1295.
Stafford, P. A., Biddinger, P. W., & Zumwalt, R. E. (1988). Lethal intrauterine fetal trauma. American Journal of
Obstetrics & Gynecology, 159(2), 485-489.
Williams, J. K., McClain, L., Rosemurgy, A. S., & Colorado, N. M. (1990). Evaluation of blunt abdominal trauma
in the third trimester of pregnancy: Maternal and fetal considerations. Obstetrics & Gynecology, 75, 33-37.
R e s u m e n - - L a posible ocurrencia de maltrato fetal en madres embarazadas ha recibido escasa atenci6n tanto en la
pr~ictica clfnica como en la investigaci6n. Se presentan cinco casos con notificaci6n de abuso fetal. En todos los casos
las madres sufrfan depresi6n y e n cuatro de los cinco casos hubo un embarazo no planificado y la madre habia
considerado la posibilidad de interrumpir el embarazo. Otros posibles factores asociados con el maltrato fetal incluyeron: negaci6n del embarazo, ambivalencia hacia el embarazo, previa depresi6n postparto y dificultad en sus relaciones
personales. La investigaci6n de posible maltrato fetal en mujeres embarazadas debe ser llevada a cabo, de manera
especial si se ha demostrado la presencia de una enfermedad depresiva. La relaci6n entre maltrato fetal y posterior
maltrato infantil permanece poco clara.