Self-injury in pregnancy

Midwives magazine: February/March 2009


By Dr. Gloria H Babiker, consultant clinical psychologist and psychotherapist, Elspeth Pontin, chartered health psychologist, Sally Cottrell consultant midwife North Bristol NHS Trust and the University of the West of England, Dr. Sarah Oke, consultant psychiatrist.


‘Pregnancy dissolves familiar connections between the woman and her body which have hitherto been taken for granted. She is no longer in sole possession of her own body. Its familiarity is altered in subtle and major ways’ (Raphael-Leff, 1993: 16).

‘More than perhaps any other human action, self-mutilation speaks of distress, torment and pain. The act of wounding oneself embodies – literally – an implicit connotation of something unbearable’ (Babiker and Arnold, 1997: 1).


Introduction

It is emotionally and clinically challenging to think of a pregnant woman inflicting injuries upon her own body. However, increasing our understanding of how this behaviour may come about can only be beneficial to the women concerned and their midwives. In this paper we hope to describe first, how self-injury or deliberate wounding of the body is both a means of expressing and a means of coping with the unbearable. Furthermore, we hope to show that it is important to attend to the possible existence and the functions of this behaviour during pregnancy, which can be described as a time when some women are literally having to bear a great deal.

Self-injury has been defined as ‘an act, which involves deliberately inflicting pain and/or injury to one’s own body, but without suicidal intent (Babiker and Arnold, 1997: 2). In the National Institute for Health and Clinical Excellence (NICE) guidelines (NICE, 2004) self-harm is defined as ‘an expression of personal distress usually made in private, by an individual who hurts her or himself’ (NICE, 2004: 16), The greatest majority of individuals who self-injure are females of childbearing age, with acts of self-injury tending to begin in adolescence and peak between 16 and 25, with a mean age in the early 30s. Cutting on the forearms predominates (Crouch and Wright, 2004) with burning, hitting, and interference with wound healing as less common (Shaw, 2002).

Clinicians may have been aware of the probable functions and meanings of self-injury during pregnancy, nevertheless, the issue remains a relatively neglected area of research and policy; one that is only just filtering into midwifery practice as highlighted at last year’s RCM midwifery week. 

At a general level, the identification of mental illnesses in pregnancy is becoming an increasingly important part of the midwife’s role (The Confidential Enquiry into Maternal And Child Health (CEMACH), Lewis, 2007; NICE, 2007). Indeed, the increase in the detection and appropriate management of mental illness in this context is highly likely to be a contributing factor in the decrease of suicide, as the overall leading cause of maternal death (Lewis, 2007).

Midwives and other health professionals have recently become better supported in this role through clinical guidelines, such as the NICE clinical guidance for antenatal and postnatal mental health (NICE, 2007). These guidelines go some way towards the detection of specific mental health issues, such as depression and anxiety, as well as relational problems in pregnancy. However, it should not be assumed that self-injury is detectable by these same methods. This is largely due to the fact that self-injury may be considered to be an indirect way of showing mental distress, and may not be considered as mental illness, but rather as a way of coping, by the woman herself. Indeed, self-injury is related to a wide spectrum of difficulties, and often serves many functions for the same individual. These are outlined in what follows as central to our understanding and handling of the issue.


Prevalence of self-injury

By its nature, self-injury is often secretive, therefore the prevalence of self-injury among women is hard to ascertain accurately. Its estimated prevalence is thought to be between 400 and 1000 per 100,000 population per year (Department Of Health, 2003a). It is suggested that at least 1 in 600 people injure themselves enough to need hospital treatment (Tantum and Whittaker, 1992) and self-injury is one of the top five reasons for acute admissions for women in the UK.

The position regarding the occurrence of self-injury in pregnancy is not at all clear, with no research to date focusing exclusively on this area, and only a small selection of review studies including this aspect in their data collection (Lindahl et al, 2005). One or two studies in the US have examined hospital admissions and discharge notes of hospitalisations for pregnant women (Greenblatt et al, 1997; Weiss, 1999) and found the rates lower than for age-matched non-pregnant women. However, it is thought that the recording of rates of intentional injury was underestimated. The Avon Longitudinal Study of Parents and Children provides some evidence of self-harm ideation during pregnancy, with 10.2% of the sample endorsing item ten on the Edinburgh Postnatal Depression Scale (EPDS) (see box 1) at 18 weeks’ gestation and 6.8% at 32 weeks’ gestation (O’Connor, 2002; Evans et al, 2001). Likewise, Luoma et al (2001) studied first-time mothers in Finland and found 14.6% of women in their third trimester endorsing this item. However, it should be noted that the EPDS was never endorsed for pregnancy and that the routine use of it is not recommended in pregnancy.


Box 1 EPDS ITEM 10
* The thought of harming myself has occurred to me.
Yes, quite often
Sometimes
Hardly ever
Never



The beginnings of a way to cope/origins of self-injury

From infancy, the skin is very important as a fundamental means of communication between caregiver and child, and many signals are conveyed through its handling – or lack of handling. Self-injury is thought to develop as the result of difficult and distressing life experiences, most commonly those that occur in childhood, and some of which relate directly to the skin, such as with abuse and maltreatment. It is also related to a more general lack of verbal communication experienced in childhood, as well as trauma such as bereavement and loss (Babiker and Arnold,1997).

Lack of experiences of communication and soothing in childhood, as well as bereavement and loss, may lead to the experience of abandonment. In extreme cases, one can turn to the physical, the body, as a way of dealing with experiences of emotional distress later in life; such as cutting oneself as a means of turning psychic pain into physical pain and allowing the subsequent self-nurturing. Likewise, if another’s approval or disapproval is played out on a child’s skin, or with a child’s body, this can lead a child to continue to communicate via their skin or body as an adult (Babiker and Arnold, 1997).

While most commonly having its roots in childhood, adult experiences that have been related to self-injury have similar origins in that they relate to how we communicate with one another, such as being in abusive relationships, lacking support or communication from a partner, and the breakdown of a relationship (Babiker and Arnold, 1997).

Self-injury can therefore be seen to serve many functions for the individual, (see box 2). It is seen as representing a learned means of communicating emotions, such as shame and anger, perhaps to the abuser and society at large (Cook et al, 2004). It is seen as a way of punishing oneself (Babiker and Arnold, 1997).  It helps one gain control and ownership of a body that has felt out of control in the hands of others (Romans et al. 1997), and it helps regulate the affect of the individual who may not have been appropriately regulated themselves, through the externalisation of distress and shame, and allowance of subsequent self-nurture (Babiker and Arnold, 1997; Bonari, et al, 2004).

Self-injury could therefore be seen to be a highly adaptive behaviour, serving a variety of functions at different times, making it difficult to detect and even more difficult to overcome. It is important to remember that, for most women, self-injury is not about wanting to die, but wanting in some sense, to survive. For example, by allowing themselves to express emotions they would otherwise find intolerable (Suyemoto, 1998).


BOX 2
Self-injury develops as a way to cope by:
•    Affect regulating/coping with feelings e.g. shame, guilt, self blame
•    Communicating something to others – plea for help, punishment, defiance
•    Helping one feel more in control of their body/self



How might pregnancy exacerbate the problem of self-injurious behaviour?

Self-injury can be considered to perform functions for the individual in three areas: the body, the self and socially. Pregnancy can be seen to challenge women in the same three areas, which suggests that pregnancy could exacerbate self-injury. Some examples of this are discussed below.


The body

Many women are dissatisfied with their shape. A rapidly growing fetus can make the body feel out of control and frightening as it changes dramatically and rapidly. It can even feel to some as though an alien has taken over (Babiker and Arnold, 1997).

Compounding this is the notion of a pregnant woman’s body feeling like it becomes other people’s property, and they have little say over it. Western society makes increasing demands to protect the interests of the unborn child, and the pregnant woman may find her needs taking second place (Clayton, 1991). This can occur in the context of midwives and doctors who take blood as well as performing abdominal palpations and other bodily intrusions, particularly vaginal examinations. There may also be the perception of invasion by the general public who feel they have a right to evade the norms of personal space and touch the pregnant stomach. Women may therefore feel that they lose their individual identity in the context of pregnancy and then birth (Stickland, 1996), and so self-injury performs the function of regaining this control and asserting oneself as separate to the fetus.


The self

Pregnancy may increase a woman’s vulnerabilities, meaning that past conflicts and anxieties are revived (Szigethy and Wisner, 2001) – sometimes ones that have been suppressed or unresolved, such as neglect or abuse (Austin, 2003) or rape (Hofberg and Ward, 2003).  In this way, self-injury may serve to continue abusive patterns, or act as punishment (Babiker and Arnold, 1997). Self-injury may also help to deal with confusion over sexual feelings – being pregnant is an overt sign of sexuality to the world and, as such, possibly shaming.

Drinking alcohol and smoking are strongly disapproved of in pregnancy in the UK as though social ownership and objectification of a person’s body and hostility towards her behaviour become acceptable because she is pregnant. In the USA, sanctions are increasing in severity to such an extent that criminal conviction can be the result of serving alcohol to a pregnant woman. Consequently some important coping strategies are less available to a pregnant woman or increase the woman’s guilt and low self-esteem. Hence, self-injury can increase in a pregnant woman who is usually reliant on alcohol or nicotine as a coping strategy.


Social functions

Today’s world is a complex and challenging place for women, many of whom have jobs outside the home yet still do the majority of housework and childcare. If self-injury is a way of regulating powerful feelings or coping with the demands and expectations of others, pregnancy may serve to add extra pressure by bringing on more powerful feelings and demands and expectations. For some women, this could result in feeling powerless and frustrated that they cannot conform to societal expectations, leading to feelings of shame and anger. Because they may not feel permitted to express this outwardly and be heard respectfully, the feelings are turned on the self, and the body may be spoilt, to either punish oneself or punish and defy the society whose rules overburden the woman (Babiker and Arnold, 1997).


The midwife’s position

The midwife’s position in relation to the pregnant woman needs to be one of concern for both the woman and the pregnancy. In some cases this may involve making a relationship not only with that aspect of the woman that is driven towards having a healthy body and a healthy pregnancy (NICE, 2007), but also with that part of the woman that punishes her body and expresses distress through her body. In this way, pregnancy becomes an opportune time to detect the problem of self-injury as almost all women will be provided with midwifery care and have their wellbeing monitored through routine antenatal appointments.

We know that women who self-injure will typically not disclose their behaviour. This may be particularly true during pregnancy when stigma and shame regarding the behaviour may be high (Shaw, 2002).  In addition, women may fear that they will be treated in a negative way by midwives or other health professionals (Cook et al, 2004) or even that disclosing their behaviour may trigger child protection concerns. Most importantly though, they may not be speaking of this to their midwife because they are not aware that their midwife would understand and want to help them.

As previously discussed, current guidelines, such as the NICE clinical guidance for antenatal and postnatal mental health (NICE, 2007), may still fall short of detecting self-injurious behaviour, even if they are appropriate for the detection of other mental illness (CEMACH, 2007). There is, therefore, a need for further guidelines detailing a specific, structured approach with universal application, regardless of a woman’s appearance.

Without such guidelines, appropriate training and support, making a relationship with that part of a woman that is distressed in this way is likely to be both stressful and difficult for the midwife who is having to relate to the whole person. If self-injury is disclosed, it may unwittingly alarm the midwife and indeed other health professionals and practitioners. Many non-mental health trained professionals may doubt their ability to provide effective care for those who self-injure beyond attending to the physical effects of the injuries. They may therefore avoid exploring an issue that makes them feel ill equipped and uncomfortable, or where they do not understand the treatment and support available. In addition, the behaviour may challenge beliefs about the inviolability of the body, particularly the mutilating of the pregnant body, and the health professional may find themselves treating the women with a lack of respect, even revulsion.

Lack of understanding and training in the roots, functions and meanings of self-injury may manifest itself as poor communication, such as being rude or curt, avoiding the woman, seeming disinterested, or keeping her waiting. The woman is likely to be embarrassed, regretful, or have low self-esteem, and experiencing this disrespect may enhance her feelings of shame or guilt. This in turn makes the health professional’s task of engaging with the woman much harder, and they are both likely to encounter further feelings of negativity. The disconnecting behaviour and cycle of blame and shame may serve to reinforce motivation for the self-injuring behaviour through its mirroring of the very thing that led to self-injury in the first place. This is the very thing that the health professional should be attempting to alleviate.


Implications for future practice

It is vital that all those working in the perinatal health services, including midwives, increase their knowledge of what might compound self-injury while pregnant (as outlined in this review), confidence in its detection, and resources for intervention. In doing so, they are likely to also examine their attitudes and beliefs about self-injury so as to offer unbiased care (Price 2007). All these aspects are critical if the midwife and other healthcare professionals are to minimise rather than inadvertently exacerbate this problem.

One way for midwives to explore feelings and extend knowledge about these difficult issues is to become familiar with the content of important policy documents and practice guidelines; for example, Women's Mental Health: Into the Mainstream (Department Of Health, 2002), Mainstreaming Gender and Women’s Mental Health (Department Of Health, 2003a), the NICE Self Harm Guidance (NICE, 2004), and the Harm Minimisation Approach (Department Of Health, 2003b).

However, this alone is insufficient. If practice is to be effective, then theoretical knowledge, such as that outlined within this article, must be applied in the every day working lives of healthcare professionals. One way to cross the theory practice gap is to work alongside those who have already integrated theory with their practice and learn from their experience. 

Developing the skills to provide effective care should not be overwhelming. Indeed, many of the skills required will already be well developed in experienced healthcare workers such as empathy, listening, observation and evaluation.

Effective communication is at the core of any interaction between a caring professional and her patient. When asking a pregnant woman about self-injury it becomes absolutely essential. From openness, honesty and the sharing of all information relating to the woman’s care, trust can develop, empowering the woman to identify her needs and participate in the planning of her care.

It is important to:
•    Ask about self-injury in a non-threatening way
•    Listen to the woman’s feelings
•    Explore the antecedents of the injuring and find out the extent of her needs
•    Give as much control as possible to the patient
•    Seek other community-based practitioners with the woman’s consent such as GPs, health visitors and other social contacts
•    Determine whether full risk assessment is needed or a referral to the mental health services


Summary of recommendations for future midwifery practice

It is our hope that this review will go some way towards opening up a discourse about the meanings, functions and prevalence of self-injury in pregnancy. It also offers the beginnings of guidance for midwives and other health professionals involved in the antenatal care of women and the detection of self-injury. Clearly, there is much more to be done and official guidelines need to be developed or added to existing guidelines to ensure that this aspect becomes part of every midwife and perinatal health professional’s training and practice.

The following is a summary of recommendations for future midwifery practice:

1. It should be acknowledged that midwives might find caring for self-injuring women difficult.

2. In order to address this, there should be appropriate training and education to promote professional development of midwives in relation to aspects of psychological distress that involve self-injury.

3. There should also be support and supervision for midwives from their managers and clinical supervisors. This needs to include validation of the midwife’s concerns in this area, and respect for her need to express and come to terms with her negative feelings towards the woman’s actions.

4. There should be explicit guidance for midwives on how to ask women about self-injury during the completion of the booking history and at a later stage in the pregnancy. The inquiry should be aimed at reducing stigma, and understanding the functions behind such behaviours.

5. There should also be appropriate guidance on care plans that may help to prevent self-injury becoming more problematic at a later stage of pregnancy.

6. There should be information about non-statutory work in the area and guidance on where to direct women who need further services and support.


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