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Room E209, PO 50, Department of Psychological Medicine, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK
E-mail: m.craig{at}iop.kcl.ac.uk
 | INTRODUCTION |
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 TOP INTRODUCTION NEONATICIDEINFANT HOMICIDECONCLUSIONREFERENCES |
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It is very difficult to get accurate figures on the incidence of neonaticide and infant homicide since many cases are never discovered; official figures are likely to be an underestimate.2,3 In addition a controversial body of evidence suggests that somewhere between 2% and 10% of cot deaths may ultimately be attributable to infant homicide.4 Resnick2 has suggested that 'hundreds and possibly thousands of neonaticides' still occur in Britain each year. Official figures, however, estimate the incidence of infant homicide in Britain to be between 30 and 45 per year5,6 with neonaticide accounting for 20-25% of the discovered victims7 and almost 15% of the remaining infant homicides occurring in the following 4 weeks.5 Even these conservative figures mean that infants have a much greater risk of becoming the victim of homicide than any other age group.8
In view of the large number of homicides during the immediate postnatal period, are there any antenatal risk factors that might be used to aid in the prevention of future deaths? Following a review of world publications from 1751 to 1968 and from experience in three of his own cases, Resnick2 suggested that the motives behind neonaticide and infant homicide are inherently different: whereas neonaticides are committed 'simply because the child is not wanted', he argues that most infant homicides are motivated by 'altruistic' reasons, which attempt 'to relieve the victim of real or imagined suffering'. Subsequent studies have supported the proposal that the motivations differ, but suggest that most infant homicides are due to a sudden loss of temper with the child9 and not altruism. If the motivation behind neonaticide and infant homicide differs, the risk factors for committing these offences may also differ. This paper will therefore analyse these offences independently.
| NEONATICIDE |
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TOPINTRODUCTIONNEONATICIDEINFANT HOMICIDECONCLUSIONREFERENCES |
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The historical evidence thus points to three risk factors for neonaticide—female gender; economics; and congenital abnormality. What is the evidence that these are relevant today? Analysing neonaticide rates in England and Wales from 1982 to 1988 Marks and Kumar5 found that the victims were equally likely to be girls (n=20) as boys (n=25); thus, gender seems not a risk factor in contemporary clinical practice in Britain. Whether there was an ethnic bias amongst the female infant homicides is not clear from the study, but this seems unlikely.
Regarding economics, it has been suggested that most neonaticidal mothers are financially poor,18 but in recent studies5,11,19 the contribution of economic circumstances has not been examined directly. Neonaticide has been shown to be more common amongst teenage mothers than older mothers11,19 and in those with low levels of education.20 Although these factors may be associated with poverty, the connection remains uncertain. Finally, there are no data to suggest that congenital abnormalities are overrepresented among today's victims of neonaticide. Thus, the historical work has been unhelpful in providing risk factors for modern application. Of greater potential value are a series of factors that appear strongly associated with neonaticide. In a study of 11 neonaticides in Britain between 1970 and 1975 D'Orban9 found that 45% of the mothers were primiparous, and a larger study from the USA gave a higher figure: looking at 139 cases perpetrated between 1983 and 1991, Overpeck and colleagues noted that 65% were primiparous. As already mentioned, mothers who commit neonaticide are also more likely to be young. In the study by Overpeck, half were less than 19 years. Almost 90% of women in this age group were primiparous, so the excess of primiparity may largely reflect their youth. Overpeck and colleagues also recorded that about 35% of neonaticide victims had been born before term. Teenage women are, however, at excess risk of preterm delivery,21 so this again may not represent a true risk factor.
A further risk factor associated with age that is highlighted in many case report studies is the frequent observation that women are single2 and still living at home with their parents.22,23 In addition there is often a suggestion of there being limited communication between the young mother-to-be and her family.22 In some families this is blamed on a 'strict fundamentalist upbringing'22 or a 'parent committed to his religious ideas'.24 Other studies have, however, focused 'blame' on the personal characteristics of the woman—for instance, being immature,25 timid,26 below average intelligence or passive.27 Gummersbach27 proposed that passivity is a factor determining whether a woman commits neonaticide rather than having a termination of pregnancy An alternative explanation is the coping strategy of denial employed by many adolescents.23,26 The normal signs of pregnancy may be 'rationalized away', complications such as vaginal bleeding misinterpreted.28-31 The capacity for denial may be so powerful that labour pains have been interpreted as colic or menstrual pains, and the delivery as a bowel movement.3
A common characteristic of women who commit neonaticide involves concealment of their pregnancy.26 Numerous instances have been reported, and these presumably deal only with cases in which concealment has ultimately failed. In D'Orban's study,9 all the mothers went on to hide the body of their victim.
Others seeking explanations for why these women do not seek an abortion have proposed that neonaticide is a 'terminal abortion' procedure20 and that the risk is greatest in societies with strict anti-abortion laws.2 Jason and colleagues32 found that neonaticide was more common in rural communities where abortion was suggested to be less socially acceptable. Lester33 noted a decrease in neonaticide following a relaxation of abortion laws in the United States. A later study,34 however, looking at data from 39 nations, did not find an association between the strictness of abortion laws and the incidence of neonaticide. Moreover, in England and Wales the incidence of infant homicide changed little after 19855 despite passage of the Abortion Act 1967.
Resnick has stated that the stigma of having an illegitimate child is 'the primary reason for neonaticide in unmarried women today as it has been through the centuries'. This suggestion is backed up by D'Orban's finding that, in 24 cases of neonaticide, all but one of the victims was born out of wedlock. Against a causal connection is the unchanging incidence of infant homicide at a time when the stigma of having an illegitimate child has greatly lessened; some may say, however, that amongst young teenage women living at home the stigma of an illegitimate child is as great as ever. Although neonaticide has been described at the hands of married women, the most frequent reason is extramarital paternity.2
One of the common misconceptions about women who commit neonaticide is that there is an underlying psychiatric illness. This is embodied in the Infanticide Act, initially passed in 1922 and reformed in 1938. This Act reduced the offence of infanticide from murder to manslaughter. It fails, however, to distinguish between neonaticide and infanticide. In Resnick's study2 only 17% of the women who committed neonaticide were psychotic. D'Orban9 found that just 3 out of 11 women who committed neonaticide had a psychiatric abnormality at the time of their act; 2 were said to have a 'personality disorder' and the other was judged 'subnormal'. Childbirth was almost certainly not causal in either of these conditions. Despite this, all but one woman (whose baby survived) were dealt with under the Infanticide Act 1938. In practice, it would therefore appear that the severity of abnormality needed to fulfil the criteria of 'disturbance of the balance of mind' as specified in the Act is much less than that required to warrant a psychiatric diagnosis. Instead, Silverman and Kennedy35 suggest that the circular argument 'if they killed their kids they must be crazy' has probably led to a bias in the judicial system. It is noteworthy that an Infanticide Act does not exist in either Scotland or the United States of America.
Management and prevention
Although it has been suggested that there may be 'hundreds and
possibly thousands of neonaticides' each year in Britain the official
figure is in the region of 10. If this figure is anywhere near correct, the
women at risk are very unlikely to be identified before the event.
Furthermore, most of the risk factors for neonaticide conspire against
prevention. A shy, timid, passive, adolescent living with her parents who is
concealing her pregnancy, or in a state of denial with few biological
manifestations of her gravid state and the absence of any psychiatric
symptoms, is unlikely to come into contact with the medical profession. The
difficulty is compounded by the observation that 95% of women who commit
neonaticide deliver at home and only 15% receive any antenatal
care.9
The published work has paid scant attention to prevention, and where strategies have been proposed they have often taken no account of the above facts. For example, the suggestion that 'increased social support should be provided for young pregnant women, young parents and isolated parents'36 reveals a lack of understanding of issues such as concealment, denial, and the fact that the perpetrator is usually a single mother who, far from being isolated, is usually living at home with her parents and family.
Goldstein37 proposes that the place where physicians can best intervene is through the provision of effective family planning methods for these women. Studies to date have not analysed the methods of contraception used by mothers who have committed neonaticide. It is probable, however, that these methods have been suboptimal and that an improvement in both education and the provision of family planning amongst young women would be of great benefit. Resnick2 has suggested liberalization of abortion laws as the best way to reduce neonaticide but most studies do not support this strategy, as already discussed. Green and Manohar24 point out the importance of diagnosing pregnancy in an unmarried woman and the need to explore the impact of pregnancy on her psychosocial status; healthcare workers should be especially alert to danger to the child in cases where the mother absents herself from antenatal care. In cases where denial of the pregnancy extends into the third trimester Slayton and Soloff38 recommend inpatient management, 'if necessary with assistance of involuntary commitment proceedings'.
| INFANT HOMICIDE |
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TOPINTRODUCTIONNEONATICIDEINFANT HOMICIDECONCLUSIONREFERENCES |
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There have not been any direct studies on the association of poverty with infant homicide. Marks and Kumar6 suggest, however, that economic factors are unlikely to be important since the rate of infant homicide in England and Wales has changed little since 1957 despite continuing economic improvements. There is likewise no evidence of there being an association between babies born with congenital abnormalities and infant homicide.
Unlike neonaticide, mothers who commit infant homicide are usually married or living with their partner.5,6 Consistent with this finding is the observation that mothers who commit infant homicide tend to be older than those who commit neonaticide,9 most being over 25 years old;2 in a later study40 the average was 34 years.
The data on race and infant homicide are inconsistent. Although some studies suggest that the incidence of child homicide and infant homicide is greater amongst the black population, others have found a higher rate amongst whites.41 Centerwall42 indicated that, when socioeconomic status is taken into account, there is no difference in the rate of child homicide amongst the various ethnic groups.
Psychiatric morbidity is believed to be more relevant to infant homicide than to neonaticide.22 Psychiatric symptoms may be partially attributable to physiological changes postpartum43: women are at 25 times excess risk of becoming psychotic in the month following childbirth3 and 10-15% of mothers have an episode of major depression in the year after giving birth44. Resnick2 reported that 75% of parents who killed their children had psychiatric symptoms shortly before committing the act. D'Orban,9 however, judged that only 24 of the 89 women in his study had been mentally ill, of whom 14 had a psychotic illness. In a reanalysis of these data Marks and Kumar6 found that women who killed children less than six months old were not usually classified as mentally ill but as 'battering mothers'; however, mental illness did seem to account for most infant homicides over six months. Amongst those women in whom mental illness was implicated as the cause of their actions, infant homicide was often found to be an extension of a suicidal act (on the grounds that there would be no one left to care for the child). Occasionally the primary motive was altruistic, based on a delusional belief that a terrible fate awaited the infant. Although psychiatric morbidity is a risk factor, most women who are mentally ill do not harm their children and many women who commit infant homicide are not mentally ill.
Another area of psychiatric morbidity not directly related to the physiological changes associated with pregnancy is substance misuse. In a study of mothers who had committed infant homicide, most reported regular use of alcohol and/or cocaine antenatally and postnatally.45 Substance misuse has been suggested to act in two ways: first, drug-exposed newborns and infants are often described as irritable, with poor feeding and irregular sleeping patterns making them difficult to care for; secondly, substance misuse can impede people's ability to evaluate their own behaviour and is correlated with aggression.46 A rare psychiatric disorder that can lead to infant homicide is Munchausen syndrome by proxy.47 Its incidence is not known.
A recent article states that infant homicide is committed more frequently by mothers than by fathers.40 The findings of Marks and Kumar5 suggest the opposite: in their study 84 fathers compared with 68 mothers were found to be responsible. Although the Infanticide Act does not recognize mental illness amongst fathers who commit infant homicide, postnatal mental illness seems to occur in men as well as women. Harvey and McGrath61 found that 40% of fathers whose wives had suffered from postpartum psychosis experienced a classifiable psychiatric disorder— higher than the 30% prevalence rate in the partners of general psychiatry cases.48 The men had seldom been abusive before the offence.7 Misinterpretation of the infant's behaviour seemed to be the primary motive in many of the cases studied.49 Any strategy aimed at reducing the number of infant homicides therefore needs to take fathers into account.
Management and prevention
The risk factors for infant homicide offer more potential for prevention
than do those for neonaticide, and the antenatal clinic and postnatal
follow-up provide opportunities for identifying high-risk cases. The first
line in identification is through an awareness of the risk factors for
postnatal depression and psychosis, as well as risk factors and clinical signs
of substance abuse. This, for example, includes the knowledge that about 40%
of women with postpartum depression in a previous pregnancy can be expected to
have another episode after a future
delivery50 and that
women who have had both postpartum psychosis and a psychotic episode outside
pregnancy will almost inevitably relapse after any subsequent
pregnancy.51
In Britain midwives are in a strong position to identify postpartum mental illness, yet they fail to identify many cases.52 This could be radically changed by implementation of an economical and effective screening procedure such as the 10-item Edinburgh Postnatal Depression Scale.53
For prevention of child abuse and neglect, home visits have met with some success.54 Brenner and colleagues55 have suggested extending this approach to those women at high risk of committing infant homicide. Overpeck and colleagues19 have tentatively suggested cross-training healthcare professionals to enable them to deal with domestic violence; however, as they point out, there are no data on the relation between infant abuse and infant homicide. In addition, as already discussed, men who committed infant homicide had not usually been abusive before the offence. Southall et al.56 used covert videosurveillance to investigate parents who had reported apparent life-threatening events in their children and were suspected of having 'induced' the illness (i.e. Munchausen's syndrome by proxy). Abuse was detected in 33 of 39 cases, with recordings of intentional suffocation in 30. Although none of these parents had evidence of psychotic illness many had an underlying personality disorder. It is unclear how often such behaviour leads on to infant homicide (or a misdiagnosis of sudden infant death syndrome) but Southall et al. argue strongly for formal videosurveillance in selected cases.
| CONCLUSION |
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TOPINTRODUCTIONNEONATICIDEINFANT HOMICIDECONCLUSIONREFERENCES |
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| Acknowledgments |
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