Discovering a pregnancy after 30 weeks: a qualitative study on explanations for unperceived pregnancy

Abstract

“Unperceived pregnancy” names the phenomenon when a person becomes pregnant unintentionally and is not aware of being pregnant. Scientific explanations are roughly based on two hypotheses: psychological and physiological. We aim to gain a better understanding of unperceived pregnancy by studying the perspectives of people who experienced an unperceived pregnancy and obstetric professionals. Seventeen semi-structured interviews were conducted: eight with women who had experienced an unperceived pregnancy (≥30 weeks’ gestation), six with midwives, and three with gynecologists. Our findings show that women’s explanations for not noticing their pregnancy center around the absence of pregnancy symptoms. The failure to recognize more subtle signs of pregnancy was enforced by inattention, physical distractions, and psychological factors. In contrast, psychological explanations are dominant among obstetric professionals. Our study demonstrates a discrepancy in the explanations provided by women who had experienced an unperceived pregnancy and obstetric professionals. Potentially, this could result in people being unheard and misunderstood. We recommend that future research moves beyond a focus on “denial of pregnancy” to consider both psychological and physiological factors, and how these could potentially interrelate. This broadened approach will enhance our understanding of unperceived pregnancy and can contribute to improved counseling by obstetric professionals.

Keywords:

• Unperceived pregnancy
• denial of pregnancy
• cryptic pregnancy
• late discovery of pregnancy
• obstetric professionals

Introduction

“Unperceived pregnancy” names the phenomenon when a person becomes pregnant unintentionally and is not aware of being pregnant. This can be “partial”; when a pregnancy is recognized after 20 weeks of gestation, or “total”; when a pregnancy is noticed during delivery [1]. Late discovery of pregnancy occurs more frequently than is often expected. A population-based frequency study in Germany showed an average occurrence of 1 in 475 deliveries, and pregnancies that remained undiscovered until delivery occurred in 1 in 2455 cases [2]. During this period, the pregnant person¹ neither receives prenatal care nor makes lifestyle changes, placing them and the fetus at risk [3–6]. Furthermore, because the phenomenon is often not well understood, people who experience an unperceived pregnancy may encounter prejudice and stigmatization.

The scientific debate on this topic breaks down roughly into two hypotheses. Firstly, there is a broad scholarly consensus on the role of an “unconscious defence mechanism involving some kind of psychological processes” [7,p.2]. This phenomenon is referred to as “denial of pregnancy” and takes place when someone is not capable of making the necessary emotional adaptations that are required during a pregnancy. To avoid anxiety, a psychological defence mechanism causes a person to be genuinely unaware of the pregnancy [4,8–10]. Hence, denial of pregnancy is different from a concealed pregnancy in which someone is aware of the pregnancy but intentionally hides it [11]. In addition, there exists a differentiation between “psychotic denial,” which occurs in the context of a mental disorder involving psychotic symptoms, and “non-psychotic denial” [9,12,13]. This article will focus on the latter, non-psychotic variant, as psychotic denial of pregnancy requires appropriate psychiatric treatment that is beyond the scope of this paper.

A second hypothesis is suggested by Del Giudice [14], who attributes unperceived pregnancy to physiological processes, rather than psychological ones. Del Giudice [14] argues that pregnancy symptoms are often absent or minimal and, therefore, there is no “denial.” He argues that the focus on denial has resulted in a lack of research on potential physiological factors, such as low levels of the placenta hormone hCG [14]. In line with this argument, Sar et al. [1] state that the focus on denial could imply that someone had motive to hide the pregnancy. For these reasons, we use the neutral term “unperceived pregnancy” in this article, as coined by Sar et al. [1].

Explanations for unperceived pregnancy have not yet been determined [15]. Previous empirical research consists of prospective case control studies [16–18] and case samplings [2,3], retrospective record reviews [3,11,19], and case reports [1,9,20–23]. These studies do not include the perspectives of pregnant people and obstetric professionals. Therefore, we aim to gain a better understanding of unperceived pregnancy by studying the personal explanations of (1) people who have experienced an unperceived pregnancy, and (2) obstetric professionals who have assisted people with an unperceived pregnancy. This knowledge can be used to improve counseling and reduce stigmatization.

Methods

We used a qualitative research design with semi-structured interviews. We divided unperceived pregnancy into three categories, by week of gestational age at time of discovery: partial (weeks 20–29), whole (weeks ≥30 until delivery), and total (during delivery). In this study we focus on whole and total unperceived pregnancies, since these pregnancies are expected to be more visible.

Ethical approval

Ethical approval was granted by the Ethics Review Board of the Faculty of Social and Behavioral Sciences of the University of Utrecht, (20-682).

Recruitment

Criteria to participate in the study were: discovery of pregnancy at 30 weeks’ gestation or later in the past 10 years; currently not pregnant; and age ≥16 years. For obstetric professionals, the criteria were: professional experience with unperceived pregnancies (of ≥30 weeks gestation) in the past 10 years. In the Netherlands, pregnant people interact mostly with midwives, and gynecologists supervise the pregnancy if there is a medical indication or multiple pregnancy. We therefore interviewed both gynecologists and midwives. To recruit participants calls were made via social media and via the professional network of Fiom, the Dutch expertise center on unwanted pregnancy and questions about ancestry.

Data collection

All participants provided written informed consent and were assigned a pseudonym to protect their privacy. The researchers had no prior relationship with the participants. Interviews were conducted by the first, second, and last author via video call using Microsoft Teams due to Covid-19. All interviews were conducted in Dutch and lasted between 30 and 90 min. We used a topic list based on sensitizing concepts, to which new themes emerging from the interviews were added.

Data analysis

Interviews were audiotaped and either transcribed verbatim (interviews with people who had experienced an unperceived pregnancy) or processed into a report (interviews with professionals). The first and last author coded and analyzed the transcripts and reports in Nvivo using a grounded theory approach of open, axial, and selective coding [24]. The analysis process began with the authors independently (re)reading the interviews, dividing the texts into fragments and coding the content of the interviews (open coding). Discrepancies in coding were discussed and resolved through consensus. Subsequently, the authors developed categories and related them by constant comparison (axial coding). Finally, they systematically related the core category “explanations for unperceived pregnancy” to complementary categories in the data (selective coding).

Findings

Characteristics of participants

Table 1 presents characteristics of the 17 participants. Thirteen people who had experienced an unperceived pregnancy responded to our call, of which eight decided to participate in the study, all women. One participant had experienced two unperceived pregnancies. The mean age when the women discovered the pregnancy was 29 years (SD = 7.4; range 17–40 years). The mean age at the time of the interview was 32 years (SD = 9.8; range 18–44 years). Six midwives and three gynecologists participated, all women, with a mean age of 41 year (SD = 10.4; range 28–56 years).

Table 1. Characteristics of participants.

Women with an unperceived pregnancy (of ≥30 weeks) (N = 8)
Age (years)			Number of pregnancy (N = 9)*
<20		1	First		7
20–24		2	Second		1
25–29		0	Third		1
30–34		2	Takes care of child(ren)
35–39		1	Yes		8
40–44		2	No		0
Age at discovery (years) (N = 9)*			Contraceptive use during pregnancy (N = 9)*
<20		1	Yes		7
20–24		2	No		2
25–29		0	Level of education
30–34		4	Medium education level**		6
35–39		1	Higher education level***		2
40–44		1
Pregnancy discovered at (weeks) (N = 9)*
30–34		4
35–39		1
Delivery		4
Professional experience with unperceived pregnancies (of ≥30 weeks) (N = 9)
Gender			Occupation
Female		9	Gynaecologist	3
Male		0	Midwife	6
Age (years)			Years of experience
25–29		1	0–5	2
30–34		2	5–10	2
35–39		2	10–15	3
40–44		1	15–20	2
45–49		0
50–54		1
55–59		1

*One participant experienced two unperceived pregnancies.

**Corresponds to ISCED level 6 (bachelor’s degree or equivalent tertiary educational level) [25].

***Corresponds to ISCED level 3 (upper secondary education) [25].

Explanations for unperceived pregnancy

Our analysis demonstrates that women’s primary explanations for their unperceived pregnancy centered around the absence of pregnancy symptoms. Psychological explanations were dominant among obstetric professionals, who emphasized the contribution of psychological stress and anxiety in unperceived pregnancies. The women’s explanations for their failure to recognize subtler signs of pregnancy was linked to inattention, physical distractions, and psychological factors.

Absence of pregnancy symptoms

The women in our study primarily explained their unperceived pregnancies by the absence of pregnancy symptoms. They reported that they had not noticed significant changes in their bodies and that the pregnancy had come as a total surprise. Marieke recalled the first moment she held her child: “You have been inside me for nine months. Why have I never felt that, never noticed?”

Almost all women saw the absence of abdominal swelling as the main reason for the unperceived pregnancy. Only Marieke did not give this explanation: she had lost a lot of weight during the pregnancy, and her belly had been the only part of her body that had not flattened. All other women reported that they had not noticed any swelling, nor had the people around them. Many stated that they had still been able to fit their regular jean sizes, and some had even lost weight. Kaylee described the first moment her abdomen started to swell: “I’m a very petite little girl. And then at some point me and my parents noticed that I was starting to get a little bit of a tummy.” After a positive pregnancy test, her slightly swollen abdomen led her to believe that she was still in an early phase. Her first ultrasound, however, showed that she was an estimated 34 weeks pregnant.

The absence of amenorrhea also played a key role in women’s explanations. Seven out of eight women had experienced monthly bleeding during the pregnancy. Gina reported that she did not have any bleeding, but also said that her menstrual cycle was typically irregular. Some women reported that their bleeding was the same as usual, while others found it more irregular or different.

Women who discovered their pregnancy prior to delivery all observed substantial changes to their bodies after discovery: they started to feel movement in their abdomen, their breasts started to swell, they became more fatigued, their joints became painful, or they gained weight. Moreover, several women stated that their abdomen had suddenly started to grow. According to Gina, her belly had grown drastically overnight: “The day after I discovered it, I woke up with such a belly. And the day before, I was flat.”

In contrast, most of the professionals did not consider the absence of pregnancy symptoms as an explanation for an unperceived pregnancy. Several of the professionals did mention that there can be significant differences in belly size between women, for instance because of the position of the fetus, the shape of the uterus, or the strength of the woman’s abdominal muscles. But most did not believe abdominal swelling could be absent for up to 30 weeks or more. Only midwives Ingrid and Esther recalled cases in which abdominal swelling had been absent, and both had observed a sudden growth of the abdomen after the pregnancy was discovered. Almost all professionals, on the other hand, recalled cases in which a woman’s body clearly showed that she was pregnant, but the woman claimed to not know. Because of this, they expressed that they sometimes found it difficult to distinguish between an unperceived pregnancy and a concealed pregnancy.

Inability to recognize signs of pregnancy

All women reported that the absence of key pregnancy symptoms resulted in them not recognizing more subtle changes in their bodies, such as fatigue, abdominal cramps, sensitivity to smells, weight gain, and mood swings. We divided women’s diverse explanations for their failure to recognize these signs of pregnancy into three categories: (1) inattention, (2) physical distractions, and (3) psychological factors.

Inattention

Some women acknowledged that they had not paid enough attention to the signs of their body. In hindsight, they said, there had been moments when they should have considered pregnancy. For instance, Yara recalled almost fainting in a clothing store: “I think that I could have paid more attention to my body. When something changed, I should’ve dealt with it more consciously.” A few women explained that they missed these signs because pregnancy had never occurred to them as a possibility, as they were using contraceptives or had fertility issues. Two women who did notice slight changes in their body did take a pregnancy test, but the result had come back negative.

Several professionals noted that women who experienced an unperceived pregnancy were often insufficiently able to recognize their bodies’ signals. They described many cases in which bodily changes were misinterpreted, such as thinking fetal movement was bowel cramps.

Physical factors

A few women reported noticing changes in their bodies but had ascribed them to other physical factors. For instance, Marieke said that her menstruation had changed after she had lost a lot of weight. When she informed her dietician and general practitioner, they both said it was a side effect of the weight loss. Leonie explained that she had been ill during the time of her unperceived pregnancy, and attributed her tiredness to her Pfeiffer disease, and her shortness of breath to the pneumonia from which she was still recovering.

Professionals gave some examples of how physical factors had masked pregnancies. For instance, one woman lost weight after a gastric bypass operation and attributed the rumbling in her stomach to recovery after surgery.

Psychological factors

Two women believed that their subconscious had played a role in blocking the pregnancy. They described it as a result of psychological stress and personal issues, reasoning that a self-defense mechanism of the brain had protected them from noticing the pregnancy. The women both recalled that prominent pregnancy symptoms had been absent but ascribed their failure to recognize subtle changes in their body, mood, or food preferences to psychological issues they were then dealing with.

Ana believed that the unperceived pregnancy was a result of her running away from childhood traumas. Consequently, she did not have the time nor peace to listen to the changes in her body. She explained: “I was in survival mode at the time. […] I was just running and flying, and not recording what was actually happening around me.” Similarly, Mariam believed that she had subconsciously blocked the pregnancy because she was not ready to have a child: “My life was not quite on track. I lived with my parents, I didn’t have a place of my own.”

The professionals all highlighted psychological issues, explaining that unperceived pregnancy often occurred to people who were already in a vulnerable position and could not cope with the pregnancy. From their perspective, most people were on some level aware that they were pregnant but subconsciously denied it. As midwife Rachel stated: “You fool yourself in such a way that in your own mind you aren’t pregnant, even though it’s clear that you are.”

In contrast, four women stated that they did not believe that their subconscious had blocked the pregnancy, as they were ready to have a child. Leonie expressed feelings of regret because she had missed the possibility to enjoy the pregnancy and to prepare for the birth of her child: “I would have loved to be riding that pink cloud right away, and just have the normal ultrasounds and normal business.” Similarly, Marieke said she was ready to have a child: “My boyfriend and I used to say, “When a baby comes, it is very welcome.”

Discussion

This study was a qualitative exploration of explanations for unperceived pregnancy at 30 weeks’ gestation or later. We note that people who were in a vulnerable position or who did show clear pregnancy symptoms might have been less willing to participate in our study, resulting in self-selection bias. Women’s explanations for their unperceived pregnancy centered around the absence of pregnancy symptoms, in particular abdominal swelling and amenorrhea. These findings are in line with studies that report continued menstruation-like bleeding and reduced or absent abdominal swelling and weight gain [3,8,11,18,20,26]. The failure to recognize subtler signs of pregnancy, such as fatigue or mood swings, was linked to inattention, physical distractions, and psychological factors. In addition, two women who suspected a pregnancy had obtained a false-negative test result.

Psychological explanations were dominant among obstetric professionals, who emphasized the contribution of psychological stress and anxiety in unperceived pregnancies. For them the absence of pregnancy symptoms was a subordinate explanation for unperceived pregnancy. Some recalled cases in which the pregnancy was clearly visible, causing them to be unsure whether a pregnancy was unperceived or concealed [11].

Both women and professionals mentioned that factors such as mental health and socio-economic insecurity can contribute to a woman’s inability to recognize a pregnancy. These findings fit with research on the potential contribution of a psychological defence mechanism [4,8,9]. As in other studies [26], our participants reported drastic changes to their body quickly after discovery of the pregnancy. Sandoz [7] argues that this supports psychological explanations, since it demonstrates that a woman’s body is physically able to show the pregnancy.

We argue that physiological factors have to be considered alongside psychological ones when investigating unperceived pregnancy. Studies [3,4,9,11] that solely focus on psychological processes fail to explain how this could result in the absence of pregnancy symptoms. The potential contribution of absent or reduced bodily symptoms remains under-researched [14]. Hypotheses on physiological explanations include: the absence of nausea results from low hCG levels [14,27]; false-negative test results in advanced pregnancies are linked to an excess in hCG, referred to as “the hook effect” [28]; and the absence of abdominal swelling is associated with the vertical rather than horizontal positioning of the fetus [26]. Studies have also sought to explain the absence of amenorrhea in relation to hormone levels or continued contraceptive intake, but have not demonstrated causal relations [3,18].

Our study finds a discrepancy in the explanations provided by women who experienced unperceived pregnancy and obstetric professionals, and reveals that women did not experience major pregnancy symptoms. This discrepancy could result in people being unheard and misunderstood when they encounter obstetric professionals who do not acknowledge their personal explanations. Many women in our study received negative reactions from obstetric professionals and did not feel taken seriously. This shows that limited knowledge about unperceived pregnancy can affect the quality of care that a person receives.

It is important for obstetric professionals to recognize the experiences and perspectives of individuals who have experienced unperceived pregnancy. To raise awareness and understanding of this issue, Fiom has launched a campaign² emphasizing that unperceived pregnancy is more prevalent than commonly believed, that it can occur without typical pregnancy symptoms, and that it can be a distressing event for all involved. The campaign also highlights the need for support and understanding for those who have gone through this experience.

We recommend that future research moves beyond a focus on “denial of pregnancy” to consider both psychological and physiological factors, and how these could potentially interrelate. Researchers, as well as obstetric professionals, should acknowledge the potential contribution of absent or reduced bodily symptoms to unperceived pregnancy. Additionally, given the diversity of stories of our participants and the absence of clear risk factors or commonalities among individuals experiencing unperceived pregnancy [4,8,9], a single, definitive explanation for this phenomenon cannot be expected [3]. This broadened approach will enhance our understanding of unperceived pregnancy and can contribute to improved counseling by obstetric professionals.

Acknowledgements

We are thankful to all of the participants for sharing their stories.

Disclosure statement

The manuscript is comprised of original material that is not under review elsewhere. The authors have no competing interests – intellectual or financial – in the research detailed in the manuscript.

Additional information

Funding

Fiom is funded by the Dutch Ministry of Health, Welfare, and Sports. The ministry exerted no influence on the contents of this article.

Notes

1 We use “pregnant person” to include women and transgender and non-binary people who can become pregnant.

2 https://fiom.nl/ongewenst-zwanger/late-ontdekking-zwangerschap-komt-echt-voor