The Experience of Psychic Disorganization Following Premature Childbirth
The aim of this article is to study the experience of four first-time mothers that had psychic disorganization after having a premature birth. Qualitative clinical method was used to achieve this aim. Data were collected through semi-structured interviews carried out with the four first-time women who gave birth prematurely. Thematic content analysis was used to analyze the data. The results obtained show that the mothers’ expectations of the kind of children they wanted were ruptured, their imagination that premature birth was not a reality was wrong, the mothers did not expect to have premature or dead babies and thus were not prepared for it. Pregnant women are full of expectations before delivery. However, when they are told that they have premature babies, it can have a great impact on their entire psyche. They are usually invaded by many feelings which they cannot control or contain. Their psychic can be disorganized, which is reflected in too many repetitions and breaks in their speech as well as incomplete or unfinished sentences, as observed among the study participants. This accounts for their inability or difficulty to understand or describe in words this unexpected event. In addition to their inability to understand and explain premature birth, they tend to use the second personal pronoun (you) to express their feelings when hit with the bad news of having a premature birth.
Introduction
Majority of authors have described first birth as an important experience for people who are becoming parents for the first time because it causes a lot of changes in their psychic. This made Cicchelli, et al. [1] think that the birth of the first child leads to the creation of interdependencies and corresponds to a paroxysmal event that shows the tensions experienced by the primipara. This description of a paroxysmal event is quite clear as it shows that the psychic changes observed in first-time mothers are extremely intense. Along the same lines, Bydlowsky, et al. [2] sees the expectation of the first child as a parental crisis. To this end, she mentions that the first childbirth is thus the ultimate end of a slow psychic and sexual evolution, which begins in childhood.
The parturition of first-time mothers is associated with many complications, which make them to be at high risk. This made Munan et al. [3] claim that a woman carrying her first pregnancy begins a new life and it is a crucial time in her obstetric life; and also the subsequent obstetric performance of mothers depends on how their first pregnancy is handled.
Childbirth is an event that mothers anticipate and prepare for with joy and excitement throughout their pregnancy. The pregnancy might not be up to term that is the child might be born earlier before the actual date of delivery. This is known as premature birth. Premature birth is therefore a sudden and unforeseen situation and it is not a good representation of childbirth; it is not also good for the baby, whose parents have created in their minds during the gestation period. The arrival of premature babies causes anxiety among parents. The mother has to accept the sudden break-up with her child, which can be a source of frustration for her. Beyond this frustration, the parents are greatly disappointed for not having “a perfect baby” in “perfect conditions”. The disappointment thus generated is often mixed with a feeling of distress, helplessness when they see their child in the incubator. The sounds and atmosphere of care overwhelm parents in an unknown and disturbing world, which can increase their anxiety Vollenweider N, Nicastro N, et al. [4]. Many parents are confronted with this anxiety induced by the disturbing strangeness of having a premature birth. According to the World Health Organization (WHO), 15 million premature babies are born around the world each year.
Premature birth is a real disturbing and strange thing. It corresponds to what Freud [5] described as the fear which attaches to things that a person is familiar with and has known for long; a strange and unusual daily life. The conditions of preterm birth make the mother vulnerable because her psychic defenses diminish, and she does not have control over the physical and psychic aspects of birth Herzog A, Muller Nix C, Mejia C, Ansermet F, et al. [6]. The mother’s narcissism and body are attacked. According to Ravier and Pedinielli [7], this kind of birth is a real narcissistic wound.
From the viewpoint of the psychoanalytic approach, the conditions of premature birth generate an overflow drive characterized by an influx of excitations which make mothers unable to control their psychic apparatus [6]. Starting from the definition of psychic trauma, premature birth is traumatic; it is an unexpected, sudden and too early childbirth that affects the psyche of the unprepared and vulnerable mothers. It generates fear in mothers and modifies their temporality, making them unable to fit into a historical continuity where the present is woven from impressions left by the past and projections into the future [8].
Due to the sudden and unpredictable nature of the birth, mothers cannot mobilize their defenses to prepare for and cope with it Cognet A, Du Peuty C [9]. Premature birth is a sudden and unforeseen situation that upsets the representation of childbirth and the expectations of parents. Premature birth is traumatic. It makes mothers experience a sudden breakup, coupled with great frustration for Thompson et al. and Hynan, during pregnancy, parents construct idealized pictures or imaginations of childbirth. Like a disruptive element, premature birth turns all these representations upside down. The fear it generates marks a break between an inaccessible past and the impossibility of anticipation.
Mothers thus experience, according to Crocq [10], a real upheaval which changes their personality, and temporality and makes them unable to explain preterm birth. This situation becomes nonsense to them and they experience a narcissistic shock. It constitutes a profound upheaval in their relations with the world and with themselves. According to Barrois [11], premature birth creates a hole in the signifier. Premature birth is experienced as a trauma that can disrupt the psychic functioning of parents [12]. Indeed, the distortion of reality caused by premature birth, according to Ansermet [13], leads to a trauma which “entails a symbolic abolition which leaves without representations. It is this hole that creates trauma”. This hole in the signifier is responsible for psychic disorganization. When confronted with premature birth, mothers experience psychic disorganization.
Thus, the present study aims to capture the experience of first-time women with psychic disorganization after giving birth prematurely.
Methodology
In this study, a clinical method and more specifically a case study was used, which aims to identify the uniqueness of each case. The study was carried out at the Obstetrics and Pediatric Gynecological Hospital in Yaoundé. Data were collected from 4 mothers who had given birth prematurely for less than a month. They showed signs of psychological trauma following their premature delivery. The purpose of the research was explained to them in order to obtain their consent.
Once their consent was obtained, they were told that their confidentiality and anonymity would be highly respected. They gave their consent for the interviews to be recorded. After this, the actual collection of the data was done. As it was difficult to obtain in-depth information of the psychic functioning of the participants, they were allowed to express themselves freely. We used semi-structured interviews. Each interview lasted for about 30 minutes.
The data collected were transcribed in order to facilitate their analysis. Thematic content analysis was used to analyze the data. The essential themes or meaningful units were identified and the essential passages were retained to empirically base the analysis.
Results
To account for the specificity of each case, the results are presented on a case-by-case basis.
Danielle’s Experience
From the outset, Danielle introduces herself as “mama magne”, the mother of twins, which shows she is a privileged and respectable mother. Indeed, among the Bamileke, the parents of twins are treated with respect, which she claims is accorded to her. Despite this, she says, “I had too many problems at first with this pregnancy; I underwent cesarean operation and lost one of the twins; the other one is lying there.” During pregnancy, with primary maternal concerns and maternal constellation, the expectant mother constructs a set of pictures of her child. At the same time, the maternal anticipation process is accentuated, especially in the seventh month of pregnancy. Indeed, during this period, the mother represents her child to herself (prenatal maternal representations) and the anxieties relating to childbirth are not yet present. This activity of representation gradually structures the mother-child relationship in the postnatal period. During the seventh month of her pregnancy, Danielle did not expect to have a premature delivery. About this, she says, “My expectation was that my pregnancy would come to term. It’s true that I was waiting for the twins, I was proud and ready to carry my two children, but I did not know that it will come to an end. Oh no! “.Still, in this maternal anticipation, Danielle sets aside negative thoughts in order to think positively. She says: “I imagined, just like all mothers who are expecting a baby, I would spoil my children. I must, I am going to give birth well; I am going to leave with my babies…. So, we think positive… oh no, you see, oh no. We think positively”. This positive thought or reflection thus makes them set aside anything negative that can happen during delivery. In this state of joy and pride, premature birth breaks in. It is sudden, comes too soon and gets to the psyche of the unprepared mother. Speaking of this delivery, she said, “It just happened, it started suddenly; no, contractions started on Friday August 30th. It was suddenly triggered just like that. I found myself here because I was not hospitalized.” The use of the expression “suddenly triggered” associated with the expression “just like that” shows the attack on her psyche caused by the premature birth and it indirectly indicates she could not anticipate this type of birth.
In her speech she emphasized that there were no problems, illnesses and discomfort during her pregnancy: “My pregnancy went without problem, without problem. I did not have any discomfort, I did not have malaria, I was not interned, nor hospitalized, none of that”. This reflects the appalling nature of premature labor for her. Faced with this disturbing strangeness, she did not have time to prepare.
This lack of preparation or anticipation makes this birth to resonate in her whole psyche. Indeed, when told she would have preterm birth, she was invaded by many feelings which she could not control or contain. This flooded into her existence and set her psyche in motion, as she says:
When the gynecologist told me I had to give birth, I was hot, I had tears in my eyes; I cried hot tears. I was lying on the stretcher in the hospital. He said there was nothing to do, that the membrane had ruptured. You know, I never imagined it would happen this way. We weren’t even expecting it because you know in such and such a month that you should give birth, and then you are suddenly told that today you have to give birth and on a short notice. I was beside myself. I was not I was in a state… I was completely overwhelmed by this surprised delivery. I could not imagine myself; this place became an unknown world for me. I didn’t know… I was absolutely not ready to give birth. I was overwhelmed.
Danielle found herself unable to contain this event, and throughout the interview, she repeatedly mentioned that she did not imagine herself facing this situation. She attests that:
I knew that, I did not even imagine going through this situation that I am going through now. I knew that the pregnancy was due to come to term and then I would be in possession of my two children. Now, I am not only deprived of being in possession of my two children, I also have no rest. I am still nailed to the hospital with this one. I never imagined being in such a situation. I only heard it. I did not know how it happened. We just wished that it did not happen.
This repetition of the words “I did not know”, “I did not imagine” reflects psychic disorganization. Indeed, by its frightening nature, the premature birth caught her by surprise, thus shaking all her expectations and capacity to control herself. This disorganization manifests throughout the interview, through the many repetitions when she talks about her childbirth and experiences. Indeed, it is expressed as follows:
The water broke at home at 8 o’clock. Then, I was even going out already I don’t know, I don’t know; I’m just giving you my reason. I do not know if it is something else but I believe it was because I felt very tired. We need to ask the doctors to give us the real causes of premature children so that we can avoid it in the long run, in the future. No. I do not know, I don’t know. I’m told it’s too much stress. This disorganization of the maternal psyche is also manifested through the breaks observed in Danielle’s speech throughout the interview. Indeed, these breaks and unfinished sentences show her inability or difficulty in putting words together to convey this unexpected event. On several occasions, there are many breaks or sentences that are started but not completed in Danielle’s speech: “I, I’m told the other one is a baby girl got out very tired and then she succumbed ah! It’s true anyway. I don’t know if that’s one of the causes, but I got really stressed out about it”.
In addition to her inability to represent and express this premature childbirth, there is a fantastical break in her speech through the use of the second person singular (you) to express the situation: “Because you know in such and such a month that you should give birth, so you weren’t expecting… and then you are suddenly told that today you have to give birth now”. Later in her speech, she uses the “you” to address the issue of constraints in connection with the hospitalization of the child: “There’s frustration there because you spend the whole-time walking, walking; sometimes it’s the examination you come in the morning only to find your child in bad shape”. The use of ‘you’ thus shows an attempt to set aside or to be at a distance from the experience and feelings surrounding premature birth.
In explaining the suffering she endured following the premature birth, Danielle does not talk about herself, but rather about the general mothers with similar experience: “The mothers of premature babies suffer a lot. I am not lying to you. “. This recourse to general mothers signifies an attempt to distance herself from her suffering in order to be able to say it and control it.
Ishmael’s Experience
The second trimester of pregnancy is a peaceful stage during which the anxieties experienced in the first trimester regress; the fantasy of the imaginary baby then emerges and the baby is pictured from within to be fused to its mother. The mother, therefore, invests in the future mother-child relationship. In other words, the virtual object relationship is initiated. During this period, one of the study participants, Ishmael expected that everything would go normally and that she would give birth to a child at term: “I expected the pregnancy to be fine!. I, I, dreamed of giving birth to a beautiful boy; I wanted my baby to develop well”. She relies on the expectations of her spouse to talk about her own dreams: “The father of this one has never had a child. You see…oh no!. His dream was that the pregnancy was developing well, that I would give birth in the right conditions. He wanted me to give birth to a boy. I also wanted to give birth to a boy”.
Due to the fact that she had a miscarriage sometime before becoming pregnant again, Ishmael began to go for antenatal care very early to prevent its re-occurrence. Thus, she followed all the recommendations and instructions to the letter. Because she started monitoring her pregnancy very early and was proceeding normally, the premature birth came as a real test of reality, surpassing all that she had done to make the pregnancy successful. She has this to say:
I could not even imagine that it could happen to me again because I went to the hospital for one month. I did all what I was asked to do normally. I did not have any problem. In my head, I was quiet. I knew that…no, I will give birth in the right conditions; unfortunately, it happened as it happened. But when it happened like that, it didn’t stress me too much. I always have the firm belief that if the baby cries, and is taken to the incubator, she will live. Why? Because my mother gave birth to me and my brother in the village at 6 months without an incubator, and we survived.
Although being stressed, she relies on her own experience to control the anxieties induced by the situation. Indeed, she was also born prematurely at 6 months; her older sister had premature children in the village without an incubator and they survived. These experiences allowed her to manage her emotions, especially since her child was born in the city, where it can be adequately taken care of unlike her nephews who survived without adequate care. Despite this experience, this childbirth shook her psyche at the beginning: “If I did not have this courage, I could not have being able to withstand it, because I panicked at the beginning. You need to have the courage; to even touch my child, it took a lot of courage ”.
Dalia’s Experience
As in most cases, her delivery was sudden and ended everything she imagined for her baby. Talking about her expectations regarding her pregnancy, she spontaneously discusses the birth and its pains: “I imagined that I wanted to give birth in the right conditions. I wanted her to be a princess like others, like me too. I gave birth to her at 07 months and the pain (laughs)… the pain there, it made me strong but I gave birth. She didn’t… because she was very small. Now, she’s already a bit of a girl ”. The phrase ‘already a bit of a girl’ in her speech reflects a gradual recognition of human characteristics in her baby.
This childbirth thus came to put an end to a pregnancy which was going well without any problem as she emphasizes: “The pregnancy went well, so I didn’t have problems with it. I ate everything, anything. So, the child was… was…; it didn’t have too many complications (Sigh). During the pregnancy, I felt fatigued. The baby was in my belly; it moved, it moved well and did not disturb me’’.
Eleonore’s Experience
For this participant, when she discovered she was pregnant it was a source of joy for her, plus it being a twin pregnancy. This joy is thus accentuated by the treatment and consideration that the Bamileke culture grants to the parents of twins. With this joy, her pregnancy was going on smoothly: “When I even found out I was pregnant with twins, a girl and a boy, I was glad. The pregnancy went well, everything was going well; I would even say very well. I was expecting the twins; I was very proud and very happy because I am “magne”. At home in the West we are respected a lot. Oh no! I was happy with myself “.
Because of her new status of becoming a mother (magne) and the joy that this pregnancy gave her, she meticulously prepared for the arrival of her two babies: “As I said, I made trousers for two babies, which means that I bought everything in pairs, two, two I was proud and I prepared everything two, two. I got so ready that I bought everything in two pairs. I don’t even know what I’m going to do with the clothes. They are so many at home. Everything is huge. I was buying pair by pair, two by two During this period, due to the ongoing maternity processes, Éléonore spoke to her babies: “I was talking to my babies all the time, telling them stuff, see…oh no!”. During this period, her pregnancy was going on smoothly, but premature birth stopped all these investments, breaking the progress in all the processes and without any warning signs. She says, “Everything was going well, even a day before the delivery, the ultrasound scan showed nothing; everything was normal except that I was told I would give birth through caesarean operation. Everything was fine I went for the ultrasound scan on September 4th. Before that, before that I had two ultrasound scans; everything was normal “. But that same evening, she suffered a placental hematoma, which marked the imminence of childbirth: “I came home, the same evening, around two o’clock. I understand, I understand, I understand how it was. I get up; it’s blood. I bleed at two o’clock ”.
Due to the disruption of this childbirth which came too early without any warning signals, she finds herself in an unprecedented situation which leads to psychic disorganization. It manifests in the overflow drive: “I don’t know how to explain this. I’m so shocked. I’m only staying with the girl; she’s going to console me anyway”. In expressing this shock, she directly evokes the fact that she is only with the girl to whom she directly attributes a role of comforter, which already reflects the investment of her child.
This childbirth thus led to an overflowing of the instincts, signified by a ricochet and influx of excitement which overwhelmed her capacity to control herself: “It was a shock, eh! How did I give birth at thirty weeks? It’s weird, oh no!. When you’re not full, it’s weird. I felt a shock. Despite that, I’m still alive and my baby too”. In these remarks by Éléonore, the questioning associated with the oddity thus accounts for the feeling of strangeness in the face of preterm birth which upsets her psyche.
This is also manifested in Éléonore›s words through the succession of unfinished sentences. This reflects her inability to express her feeling with words: “It makes me, it never is, neither in, I don’t know how to explain this to you. I never.. for me it’s strange. I couldn’t imagine that one day my first pregnancy… I could go through it. So it’s already… almost a month out. So you can see, it’s a bit traumatic’’.
Associated with this psychic disorganization is a feeling of incapacity, which is why it is very necessary for the baby to reach maturity at the time of birth:
Yes, yes, when you see others carrying their pregnancies to term, others sometimes go beyond the term and you can’t see… oh no! It’s like you can’t like you can’t act like them oh no! I think it’s good to get to terms so that the child is well-formed. This childbirth, I would even say it is childbirth, I did not expect to give birth at 30 weeks. I never imagined it could happen that way.
This is responsible for her inability to identify with other mothers and, in turn, identifying with maternal figures and maternal roles. However, identifying with maternal figures throughout her development is important for her to play maternal roles, and construct the thought of becoming a mother.
Discussion
Studies that have examined the experience of premature birth have highlighted its traumatic nature for both the mother and the baby, who is torn from the maternal envelope before the end of the “nine-month pregnancy contract”. For Cognet and Du Peuty, et al. [9], the mother is unable to put a “psychic end” to the pregnancy. According to Herzog, et al. [6], under these conditions, the mother is particularly vulnerable because her psychic defenses are weakened and she does not have mastery over the physical and psychic aspects of childbirth.
It is in this sense that Muller Nix, et al. [12] noted that premature childbirth causes an upheaval in parental expectations regarding the state of health of their child. For them, meeting this child born too early is an extraordinary encounter. This is because premature birth constitutes a narcissistic wound where the parents feel like the parents of an infant perceived as unfinished [7].
This feeling, as pointed out by Cognet and Du Peuty [9], is explained by the fact that the parent thinks the separation is distant and therefore could not mobilize the defenses to prepare for it. This lack of preparation associated with the conditions of birth generates an outburst of emotions which is comparable to a “traumatic upheaval”; this is because the “external excitations” which flow in will exceed the capacities of the parent to control her psychic [6]. In front of her baby, the mother, in the sense of Druon [14], experiences a “real test of reality”; “a shock” in front of her child who is so small and/or gives the impression of unease. Narcissistic moment experienced during pregnancy makes one to focus on oneself and makes the unborn child “an extension of oneself”. As much as pregnancy is a privileged moment of narcissistic restoration, it can cause a narcissistic withdrawal. Any break in this sense of continuity weakens narcissism. Therefore, instead of being rewarding, pregnancy runs the risk of being painful, even threatening, in which the expectant mother feels devalued, heavy, damaged and sometimes threatened in her physical integrity [15].
The traumatic repercussions of this childbirth make parents vulnerable and make them hardly available to discover their child. For Thompson et al., Hynan, et al. [16], with the processes of motherhood, parents construct idealized representations of pregnancy, childbirth and the child. Premature birth is therefore a disruptive element that turns all these representations upside down and pushes parents into multiple mourning work (perfect pregnancy, normal childbirth, the perfect child, etc.).
Crocq (1999) [15], speaking of psychotrauma, conceives of it as “a phenomenon of breaking into the psyche and overflowing of its defenses by the violent excitations associated with the occurrence of an attacking or life-threatening event ( physical or psychological) of an individual who is exposed to it as a victim, witness or actor ”. In talking about this situation, Freud (1920) [5] uses the concept of “breach of the excitation shield”. For him, the trauma is due to the intrusion of an agent external to the subject into his psychic and/or bodily intimacy. The breaking of the excitation shield which would normally repel excitations from the outside causes the economic disruption of the usual psychic investments. Because the psyche functions as a constantly changing energy system, the trauma relates to both the violence of the event and the state of the defensive barrier. Premature birth induces a break-in that surprises the mother. The fright felt and the astonishment freezes her in a way and her psyche is confronted with traumatic disorganization.
Premature birth creates a hole in the signifier [11].), which is responsible for the psychic disorganization which manifests in the words of the participants by the “ruptures” of the discourse, forgetfulness, illogical terms, slip, silences, the use of personal or impersonal pronouns, the influx of excitations which overflow their capacity or quite simply the phantasmal rupture.
This makes one think of psychic collapse, as described by Winnicott, et al. [17], as a state characterized by the presence of “primitive dissecting anxieties”. This state evokes the proximity of death; it is a death that one suffers from while still alive. In other words, it is the vivid experience of what could kill. Winnicott, therefore, sees collapse as an event that invades or impieties a person’s psychic space. It emphasizes the failure of the defensive organization of the ego in the face of the invasive event, this failure being due to the immaturity of the ego, which finds itself unable to integrate the event and signify it [18]. This childbirth thus strikes at the limits and induces a narcissistic and identity suffering, to the extent that maternal narcissism is hurt and maternal identity is blurred [19].
Conclusion
The objective of this article is to capture the experience of psychic disorganization following premature delivery in four first-time mothers. 4 mothers who gave birth prematurely and showed signs of psychological trauma were interviewed at the Obstetric and Pediatric Gynecological Hospital in Yaoundé. The results obtained highlight the fact that premature birth constitutes a disruption of maternal expectations and representations of their child. The inability of mothers to anticipate preterm birth and their lack of preparation for it affect their entire psyche. The psychic disorganization of the study mothers manifests through numerous repetitions in their speech, their use of incomplete sentences and the second person pronoun (you). This made them unable to describe and fully represent their traumatic experience caused by preterm birth.
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