Psychological Development During Pregnancy

The Work of Pregnancy
The nine months of pregnancy offer parents-to-be the opportunity for psychological as well as physical preparation. The psychological preparation, unconscious as well as conscious, is closely interlocked with the physical stages of a woman's pregnancy. After nine months, most parents feel a sense of completion and of readiness. When this time is cut short, as it is in premature labor, parents feel raw and incomplete. When there are physical complications, they endanger the psychological adjustment.

The psychological work of pregnancy may surface as turmoil or anxiety. Emotional withdrawal or regression to a more dependent role in other relationships within the family is common in this period. The prospect of responsibility for a new baby lends a sense of urgency. A parent-to-be needs to withdraw or regress in order to reorganize. The anxiety within both parents may carry them back to the struggles and ambivalent feelings of earlier adjustments. This mobilization of old and new feelings provides the energy necessary in the huge job of adjusting to a new baby.

Both expectant parents and those who care for them must understand the power and ambivalence of the feelings that accompany pregnancy. Prenatal visits, whether with obstetricians, nurses, pediatricians, or, in certain cases, psychiatrists, must allow for the expression of a wide range of positive and negative feelings. In the authors' experience, pregnancy - like many other critical phases of life - is perceived differently by psychiatrists and pediatricians. The former are consulted in cases of crisis and troubled outcome, and thus are alert to the potential for neurotic or psychotic problems in pregnancy. The latter are more likely to be impressed by a mother's amazing capacity to rearrange her whole life toward the welfare of her child. By looking at the stages of pregnancy from our dual point of view, we hope to illuminate this remarkable period and also to trace within it the birth of parental attachment.

The work of pregnancy can be seen as three separate tasks, each associated with a stage in the physical development of the fetus. In the first stage, the parents adjust to the "news" of pregnancy, which is accompanied by changes in the mother's body, but not yet by evidence of the actual existence of the fetus. In the second stage, the parents begin to recognize the fetus as a being who will eventually be separate from the mother. This recognition is confirmed at the moment of "quickening," when the fetus first announces its physical presence. Finally, in the third and final stage, the parents begin to experience the coming child as an individual, and the fetus contributes to its own individuation by distinctive motions, rhythms, and levels of activity.

Stage One: Accepting the News
"I'm having a baby!"

In the past, a mother waited after a missed period for further confirmation of pregnancy from her own body. Changes in the color and sensation of the nipple, "morning sickness," or weariness made the fact of conception gradually more certain. Nowadays, parents are likely to receive the "news" from a physician after a pregnancy test, or even from a chemical reaction in a home pregnancy test.

However and whenever the news comes, parents will know that they have stepped into a new phase of their lives. Their feelings of dependence on their own parents must give way to responsibility. Their one-to-one relationship with each other must evolve into a triangle.

Initially, both parents are often euphoric. But almost at once the euphoria is replaced with a dawning awareness of future responsibility. When conception is planned, this awareness may have been faced already to some extent, but the reality of pregnancy requires a new level of adjustment; soon there will be no turning back.

The "work" of pregnancy now begins in earnest. The prospect of parenthood throws adults back to their own childhood. No adult looks back on childhood as unmitigated pleasure. The struggles of growing up are mobilized each time an adolescent or young adult faces a crisis and, in pregnancy, these struggles are raw once again. The first fantasy of most parents-to-be is one of avoiding the struggles of their own childhood and of becoming perfect parents. "Not one like my mother." "My father tried, but he got everything wrong." "I certainly hope I can do better than they did!" What is it that parents wish to do better? Is it to protect their child from an imperfect world, or from the perceived negative sides of themselves? The latter is the more likely. As we mentioned earlier, all parents hope that they will be able to shield the new infant from their own feelings of inadequacy, or from the perceived failures of their own lives. With this magical wish that their own inadequacies can be conquered, parents-to-be see themselves as completely nurturant, completely positive - ready to create the perfect child.

Behind this fantasy is also ambivalence. At some point, all parents-to-be begin to wonder why they ever let themselves in for such an adjustment. "Do I really want to be a mother, a father? If I don't, have I hurt this baby already? Can I hurt an unborn baby with my fears, my negative feelings?" Especially for a pregnant woman, the depth of the caring involved in this adjustment makes her so vulnerable that her magical thinking about hurting her fetus becomes very real. All pregnant women dream about the possibility of having a defective child. Not only do they dream of all possible aberrations, but in waking, they rehearse what they would do if their child were born handicapped. Any danger to the fetus that they may have read or heard about will be called up at some time during pregnancy. The barrage of information now available about the effects of drugs, food, tobacco, alcohol, or pollution on the developing fetus only exacerbates the fears that universally haunt pregnant women.

In order to overpower such fears and her underlying ambivalence, a mother-to-be must mobilize more and more defenses. She must begin to idealize the infant, to visualize the baby as perfect and as completely wanted. The work of overpowering the negative forces escalates the positive wishes for the baby and for being the perfect parent.

As a pregnant woman struggles through this turmoil of ambivalent emotions, she will be especially available to the support of others. A physician or nurse or friend who is an experienced mother will be accepted readily. An expectant mother often develops a strong transference to any supportive professional at this time. She yearns for understanding of her powerful emotions, for mothering as she prepares to be a mother. Professionals or family members who can accept this temporary dependency on the part of a mother without being overwhelmed will be helping to launch a stronger family.

During this time, many women tend also to withdraw into themselves. The rebalancing of hormones and other physical processes is paralleled by emotional adjustments, and a great deal of time and energy is needed to achieve a new stability. Days may be spent in daydreaming, nights in sorting out strongly ambivalent dreams. When this inner work is successful, a mother can eventually look forward wholeheartedly to her new role. But she may spend a great deal of her own and her family's energy in the attempt. In the process, she will, in all likelihood, withdraw somewhat from her previous relationships. She may even unconsciously blame her husband and others for her condition, even while, simultaneously, feeling a sense of elation. Now and then, she is likely to feel that she has been forced into this role. Such feelings may represent her effort to share or displace responsibility for the overwhelming adjustment, and may also represent a realistic reaction under certain social and economic conditions.

A woman's most immediate task is to accept the "foreign body" now implanted within her. She may experience the embryo as an intrusion by her mate, and may temporarily want to withdraw from the man who has impregnated her. Just as her body lowers its defenses against this "foreign body" and comes to accept and shelter it, the mother, too, must come to experience the child-to-be as a benign part of herself.

Often, in an effort to accept her new condition, a woman will turn to her own mother or her mother-in-law. But here, too, she may feel ambivalent. Morning sickness and other physiological symptoms may serve to express the negative side of her ambivalence, while consciously she may be adapting with enthusiasm to her role. All pregnant women face this ambivalence, which surprises and disappoints them. Feelings of helplessness, of inadequacy, may even express themselves in the wish for a spontaneous abortion. While the disappointment and feelings of guilt that accompany either the bleeding of a threatened abortion or the reality of one belie this ambivalence, they are always there. Only gradually does the drive toward motherhood, with all the powerful components that we saw earlier, transform this ambivalence into fuel for the work of pregnancy, into the positive anticipation and energy of the later months.

Stage Two: First Stirrings of a Separate Being
At some point during the fifth month of pregnancy, a mother will feel the first butterfly motions of her baby-to-be. These delicate, stroking sensations will gradually turn into vigorous activity. After the confirmation of pregnancy, the moment of quickening is the next landmark event for expectant parents. This news, too, will be eagerly shared with husband, family, and friends.

Until this moment, mother and baby-to-be are one. Until this first fluttering of life, a mother can entertain the narcissistic image of total fusion with her child. Now, psychologically speaking, the baby has begun to "hatch." The earliest attachment may be said to begin here, for there is now a separate being, the possibility of a relationship. Quickening is the child-to-be's first contribution to the relationship.

When the mother begins to recognize the life of her fetus, she will unconsciously put herself in its place, identify with it. Her fantasies will be based on her infantile relationship to her own mother. Dinorah Pines reported a vivid instance of this two-layered fantasy. One of her patients had a series of dreams in which she became progressively younger as the pregnancy progressed; shortly before birth, she dreamt of herself as a baby sucking at the breast, "thus combining the representation of herself as the mother and as the newborn child" (Pines, 1981)¹. The new concreteness of the baby, supplemented by ultrasound images and the now visible body changes in the mother, brings both a new reality and new fantasies to the pregnancy. The mother can identify with the now evident fetus and also replay her own wishes of fusion and symbiosis with her mother. This fantasized "return to the womb" allows for yet another working through of unfulfilled dependency needs and symbiotic wishes. It is as if - through the mediation of her unborn child - the mother can "plug back into" the rewarding aspects of her early relationships with her mother, refueling and revitalizing herself. Curiously, this resembles the way toddlers dart back to their mothers, finding in that contact new energy to pursue their development toward individuation (Mahler et al., 1975)². Pines points out that pregnancy offers mothers a new opportunity for working through separation conflicts, promoting a new phase in their process of disengagement (individuation) from the original symbiotic relationships (Pines, 1981)¹.

This regressive trend can also activate conflict and pathological reactions. It may be experienced as a threat to identity, for it reawakens strong feelings of fusion between the mother and her own mother. If the mother's need for dependency is too great and unfulfilled (in some teenage mothers, for example), she will experience her fetus - and, later, her baby - as a rival, and may treat the infant as an envied sibling. In this case, mothering will seem a heavy burden and even a frustration of her own needs. When things go well, however, this regression to symbiotic identification with the baby will lead to renewed psychic energy and also a source of empathic knowledge of what a baby is all about.

Recognition of a father's role helps a mother see the baby as separate from herself. If she remains aware that her pregnancy resulted from an act on the father's part as well as her own, and, ideally, of the father's wish for a child, she will avoid falling prey to the illusion that she alone produced the baby. When a woman chooses single parenthood, and especially when she chooses artificial insemination, these issues may be clouded. A woman who uses a man simply to fertilize her, or uses a sperm bank, is more likely to entertain the illusion that the baby is the result of her own omnipotent creativity. Her fears and doubts, as well as her hopes, will be heightened.

Acknowledging the father's role not only helps a mother-to-be with the job of separating from the fetus, and of differentiating it from her fantasies, but reassures her that she alone will not be responsible for any successes or failures. This can cushion her fears of inadequacy and her anxiety about her new role. If the relationship with the father has been fraught mainly with resentment and conflict, this may be projected onto the child-to-be. But if the relationship is sound, if the father endorses his responsibility as a co-creator and doesn't flee from his role, the mother will have a better chance of recognizing that the child is a separate being, with a separate potential for growth. As we will see later, the wish for a child also holds many promises for the father, thus bolstering his own attachment to his future offspring.

The beginning of fetal movement and the recognition that the baby is a reality heighten the mother's self-questioning. Periods of depression and elation may come over her unpredictably. Her fantasies about the baby become more specific. During this period, she may begin to dream about the perfect boy or the perfect girl. Her preference for one or the other may begin to surface, or she may repress her real wishes for fear of endangering the fetus. The traditional belief in the "evil eye" and the superstitious rituals surrounding pregnancy are expressions of the universal desire for a perfect baby and the associated fear that the mother will do something to endanger the fetus. So concerned are mothers-to-be with their own struggles, that intelligent women often express surprise and gratification when told that all women worry during pregnancy.

The rehearsal for an abnormal infant continues during this period. By the time the infant is born, a woman will have worried about every possible kind of problem her baby may present. She will have rehearsed in her dreams and fantasies what she must do if she is presented with a Down syndrome baby, or a cerebral palsied infant, or one who embodies any of the abnormalities that she has heard of in either her own or her husband's family. Hence, a premature or an impaired infant comes less as a surprise to a mother than as a disappointment for her lack of success in all the effort she has made during pregnancy. She will have rehearsed and even mobilized forces for helping her deal with the failure, but she must still face her grief at losing the "perfect" baby she dreamed of as a reward for her work.

The experiences of diagnostic amniocentesis and of ultrasound techniques for visualizing the fetus have a complex effect on this work of adjusting to a baby and a new role. Although mothers (and fathers) profess a hunger to know the sex of the baby (which can be determined by amniocentesis), a surprising number (about 40 percent) do not wish to be told. The pregnant woman's curiosity and amazement at seeing her baby visualized on a screen in the third month is accompanied both by awe and by a fear of looking too deeply below the surface. The work of adjusting to her ambivalent feelings and fears about the fetus has just begun. She is not ready to face the baby as a reality yet. Many first-time expectant mothers who watch the screen on which the fetal movements are being visualized express mixed emotions. They see the fetus as inadequate, fearsome, or incomplete. They turn away from the screen as if it were too frightening or overwhelming. "Is that a real baby?" "He looks so tiny and helpless." They find unbelievable the obstetrician's reassurance that the fetus is normal, and need to hear it over and over. Until they themselves feel the fetus's movement in the fifth month, this poorly visualized, shadowy creature is likely to be seen as unreal, vulnerable, fearsome. Such feelings are a reflection of the mother's struggle with her own ambivalence. She needs more time to get ready for the baby.

Elizabeth Keller, a Child Development Fellow at Boston Children's Hospital Medical Center, compared mothers and fathers who were told the sex of the baby after amniocentesis or ultrasound with parents-to-be who didn't know the sex of their baby until birth (Keller, 1981)³. One might expect attachment to, and early personification of, the newborn baby to be enhanced by foreknowledge of the baby's sex. Not at all. The parents who knew the baby's sex took longer to personify and recognize the individuality of the baby after birth. It seems there may be a protective system at work - protecting the parents and the baby from a too-early attachment. The work of attachment to an individual baby takes time, and early attempts to consolidate it may be rejected. Once again, this points up the problem of adjusting to a premature infant, for whom this work of attachment has been foreshortened.

¹Pines, D. "In the beginning: Contributions of a psychoanalytic developmental psychobiology." Int. J. of Psychoanalysis 8(1981):15-33.

²Mahler, M. S., F. Pine, and A. Bergman. The Psychological Birth of the Human Infant. New York: Basic Books, 1975.

³Keller, E. Personal communication, 1981.

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