Perinatal risk factors for neonaticide and infant homicide: can we identify those at risk?

J R Soc Med 2004;97:57-61
doi:10.1258/jrsm.97.2.57
© 2004 Royal Society of Medicine

J R Soc Med 2004;97:57-61
© 2004 The Royal Society of Medicine

Perinatal risk factors for neonaticide and infant homicide: can we identify those at risk?

Michael Craig MRCOG MRCPsych  

Room E209, PO 50, Department of Psychological Medicine, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK

E-mail: [email protected]

    INTRODUCTION

Infant homicide is a legal term that refers to killing of achild in the first year of life. Infanticide, as defined bythe Infanticide Act, is when a mother ‘causes death of her childunder the age of 12 months by wilful act or omission, but atthe time of the act or omission the balance of her mind wasdisturbed by reason of her not having fully recovered from the effectof her having given birth to the child or by reasons of theeffect of lactation consequent on the birth of the child‘. Neonaticideis not specifically defined by the Infanticide Act, but in medicalpublications usually refers to the killing of a child duringthe first 24 hours of life.2

It is very difficult to get accurate figures on the incidenceof neonaticide and infant homicide since many cases are neverdiscovered; official figures are likely to be an underestimate.2,3 Inaddition a controversial body of evidence suggests that somewherebetween 2% and 10% of cot deaths may ultimately be attributableto infant homicide.4 Resnick2 has suggested that ‘hundreds andpossibly thousands of neonaticides’ still occur in Britain eachyear. Official figures, however, estimate the incidence of infanthomicide in Britain to be between 30 and 45 per year5,6 withneonaticide accounting for 20-25% of the discovered victims7and almost 15% of the remaining infant homicides occurring inthe following 4 weeks.5 Even these conservative figures meanthat infants have a much greater risk of becoming the victimof homicide than any other age group.8

In view of the large number of homicides during the immediatepostnatal period, are there any antenatal risk factors thatmight be used to aid in the prevention of future deaths? Followinga review of world publications from 1751 to 1968 and from experiencein three of his own cases, Resnick2 suggested that the motivesbehind neonaticide and infant homicide are inherently different:whereas neonaticides are committed ‘simply because the child isnot wanted’, he argues that most infant homicides are motivatedby ‘altruistic’ reasons, which attempt ‘to relieve the victimof real or imagined suffering’. Subsequent studies have supportedthe proposal that the motivations differ, but suggest that mostinfant homicides are due to a sudden loss of temper with the child9and not altruism. If the motivation behind neonaticide and infanthomicide differs, the risk factors for committing these offencesmay also differ. This paper will therefore analyse these offencesindependently.

    NEONATICIDE

The practice of neonaticide seems to have been widespread inmany ancient civilizations. Evidence of ritual killing of babieswith structural or aesthetic abnormalities has been documentedamongst the Aztecs, ancient Chinese, the Mardudjara Aboriginesof Australia and some African cultures.10 In ancient Greeceand ancient Rome, neonaticide was in some instances actually enforcedby law. Weak or deformed babies were destroyed for eugenic reasons andbecause they would be a burden on the state.11 In the rest ofEurope, however, there is little reliable information untilthe medieval era. In medieval England neonaticide was common.12In addition, the census figures of this time ‘showed a verymarked predominance of male children over female children, stronglysuggesting deliberate female infant homicide’.11 These figuresmirror those currently found amongst certain Eskimo tribes in Canada,13in the states of Tamil Nadu, Rajastan and Bihar in India14 andin China.15 Various explanations have been offered, rangingfrom a simple ‘preference of sons’10 or the wish ‘to exert maledominance over the household’,16 to economics whereby in somecultures females are seen as liabilities rather than assets.In addition, female infant homicide has been seen by some asthe most effective method of population control.17

The historical evidence thus points to three risk factors for neonaticide—femalegender; economics; and congenital abnormality. What is the evidencethat these are relevant today? Analysing neonaticide rates in Englandand Wales from 1982 to 1988 Marks and Kumar5 found that thevictims were equally likely to be girls (n=20) as boys (n=25);thus, gender seems not a risk factor in contemporary clinicalpractice in Britain. Whether there was an ethnic bias amongstthe female infant homicides is not clear from the study, butthis seems unlikely.

Regarding economics, it has been suggested that most neonaticidalmothers are financially poor,18 but in recent studies5,11,19 thecontribution of economic circumstances has not been examineddirectly. Neonaticide has been shown to be more common amongstteenage mothers than older mothers11,19 and in those with lowlevels of education.20 Although these factors may be associatedwith poverty, the connection remains uncertain. Finally, thereare no data to suggest that congenital abnormalities are overrepresentedamong today’s victims of neonaticide. Thus, the historical workhas been unhelpful in providing risk factors for modern application.Of greater potential value are a series of factors that appearstrongly associated with neonaticide. In a study of 11 neonaticidesin Britain between 1970 and 1975 D’Orban9 found that 45% ofthe mothers were primiparous, and a larger study from the USAgave a higher figure: looking at 139 cases perpetrated between1983 and 1991, Overpeck and colleagues noted that 65% were primiparous.As already mentioned, mothers who commit neonaticide are alsomore likely to be young. In the study by Overpeck, half wereless than 19 years. Almost 90% of women in this age group wereprimiparous, so the excess of primiparity may largely reflecttheir youth. Overpeck and colleagues also recorded that about35% of neonaticide victims had been born before term. Teenagewomen are, however, at excess risk of preterm delivery,21 sothis again may not represent a true risk factor.

A further risk factor associated with age that is highlightedin many case report studies is the frequent observation thatwomen are single2 and still living at home with their parents.22,23 Inaddition there is often a suggestion of there being limited communicationbetween the young mother-to-be and her family.22 In some familiesthis is blamed on a ‘strict fundamentalist upbringing’22 ora ‘parent committed to his religious ideas’.24 Other studieshave, however, focused ‘blame’ on the personal characteristicsof the woman—for instance, being immature,25 timid,26below average intelligence or passive.27 Gummersbach27 proposedthat passivity is a factor determining whether a woman commits neonaticiderather than having a termination of pregnancy An alternative explanationis the coping strategy of denial employed by many adolescents.23,26 Thenormal signs of pregnancy may be ‘rationalized away’, complicationssuch as vaginal bleeding misinterpreted.2831 The capacity fordenial may be so powerful that labour pains have been interpretedas colic or menstrual pains, and the delivery as a bowel movement.3

A common characteristic of women who commit neonaticide involves concealmentof their pregnancy.26 Numerous instances have been reported,and these presumably deal only with cases in which concealmenthas ultimately failed. In D’Orban’s study,9 all the motherswent on to hide the body of their victim.

Others seeking explanations for why these women do not seekan abortion have proposed that neonaticide is a ‘terminal abortion’ procedure20and that the risk is greatest in societies with strict anti-abortion laws.2Jason and colleagues32 found that neonaticide was more commonin rural communities where abortion was suggested to be lesssocially acceptable. Lester33 noted a decrease in neonaticidefollowing a relaxation of abortion laws in the United States.A later study,34 however, looking at data from 39 nations, didnot find an association between the strictness of abortion lawsand the incidence of neonaticide. Moreover, in England and Walesthe incidence of infant homicide changed little after 19855despite passage of the Abortion Act 1967.

Resnick has stated that the stigma of having an illegitimatechild is ‘the primary reason for neonaticide in unmarried womentoday as it has been through the centuries’. This suggestionis backed up by D’Orban’s finding that, in 24 cases of neonaticide,all but one of the victims was born out of wedlock. Againsta causal connection is the unchanging incidence of infant homicideat a time when the stigma of having an illegitimate child hasgreatly lessened; some may say, however, that amongst youngteenage women living at home the stigma of an illegitimate childis as great as ever. Although neonaticide has been describedat the hands of married women, the most frequent reason is extramarital paternity.2

One of the common misconceptions about women who commit neonaticideis that there is an underlying psychiatric illness. This isembodied in the Infanticide Act, initially passed in 1922 andreformed in 1938. This Act reduced the offence of infanticidefrom murder to manslaughter. It fails, however, to distinguishbetween neonaticide and infanticide. In Resnick’s study2 only17% of the women who committed neonaticide were psychotic. D’Orban9found that just 3 out of 11 women who committed neonaticidehad a psychiatric abnormality at the time of their act; 2 weresaid to have a ‘personality disorder’ and the other was judged’subnormal’. Childbirth was almost certainly not causal in eitherof these conditions. Despite this, all but one woman (whosebaby survived) were dealt with under the Infanticide Act 1938.In practice, it would therefore appear that the severity ofabnormality needed to fulfil the criteria of ‘disturbance ofthe balance of mind’ as specified in the Act is much less thanthat required to warrant a psychiatric diagnosis. Instead, Silvermanand Kennedy35 suggest that the circular argument ‘if they killedtheir kids they must be crazy’ has probably led to a bias inthe judicial system. It is noteworthy that an Infanticide Actdoes 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 possiblythousands of neonaticides’ each year in Britain the official figureis in the region of 10. If this figure is anywhere near correct,the women at risk are very unlikely to be identified beforethe event. Furthermore, most of the risk factors for neonaticideconspire against prevention. A shy, timid, passive, adolescentliving with her parents who is concealing her pregnancy, orin a state of denial with few biological manifestations of hergravid state and the absence of any psychiatric symptoms, isunlikely to come into contact with the medical profession. The difficultyis compounded by the observation that 95% of women who commit neonaticidedeliver at home and only 15% receive any antenatal care.9

The published work has paid scant attention to prevention, andwhere strategies have been proposed they have often taken noaccount of the above facts. For example, the suggestion that’increased social support should be provided for young pregnantwomen, young parents and isolated parents’36 reveals a lackof understanding of issues such as concealment, denial, andthe fact that the perpetrator is usually a single mother who,far from being isolated, is usually living at home with herparents and family.

Goldstein37 proposes that the place where physicians can bestintervene is through the provision of effective family planningmethods for these women. Studies to date have not analysed themethods of contraception used by mothers who have committedneonaticide. It is probable, however, that these methods havebeen suboptimal and that an improvement in both education andthe provision of family planning amongst young women would beof great benefit. Resnick2 has suggested liberalization of abortionlaws as the best way to reduce neonaticide but most studiesdo not support this strategy, as already discussed. Green and Manohar24point out the importance of diagnosing pregnancy in an unmarriedwoman and the need to explore the impact of pregnancy on herpsychosocial status; healthcare workers should be especiallyalert to danger to the child in cases where the mother absentsherself from antenatal care. In cases where denial of the pregnancy extendsinto the third trimester Slayton and Soloff38 recommend inpatientmanagement, ‘if necessary with assistance of involuntary commitmentproceedings’.

    INFANT HOMICIDE

The historical work makes little distinction between neonaticideand infant homicide, so risk factors for the two are implicitlysuggested to be identical. Marks and Kumar5 found that between1982 and 1988 in England and Wales there were more male (n=129)than female (n=84) victims. The gender bias applies to deathsin the first three months with no difference after four monthsof age. This finding is confirmed by studies in Scotland6 andthe United States39 and yet is opposite to what would be predictedfrom the historical work. Marks3 suggests that the gender biasmay be due to an increased physical vulnerability of male babies,pointing out a parallel in the higher number of deaths amongstmale infants from any cause. Alternatively, parents may thinkthat male babies are more robust and are consequently more aggressiveto them. Other suggestions include the possibility that maleinfants interact with the environment in a different way, perhapsby being more active, assertive or vocal and are hence morelikely to elicit a murderous response.

There have not been any direct studies on the association ofpoverty with infant homicide. Marks and Kumar6 suggest, however,that economic factors are unlikely to be important since therate of infant homicide in England and Wales has changed littlesince 1957 despite continuing economic improvements. There islikewise no evidence of there being an association between babiesborn with congenital abnormalities and infant homicide.

Unlike neonaticide, mothers who commit infant homicide are usuallymarried or living with their partner.5,6 Consistent with thisfinding is the observation that mothers who commit infant homicidetend to be older than those who commit neonaticide,9 most beingover 25 years old;2 in a later study40 the average was 34 years.

The data on race and infant homicide are inconsistent. Althoughsome studies suggest that the incidence of child homicide andinfant homicide is greater amongst the black population, othershave found a higher rate amongst whites.41 Centerwall42 indicatedthat, when socioeconomic status is taken into account, thereis no difference in the rate of child homicide amongst the variousethnic groups.

Psychiatric morbidity is believed to be more relevant to infanthomicide than to neonaticide.22 Psychiatric symptoms may bepartially attributable to physiological changes postpartum43:women are at 25 times excess risk of becoming psychotic in themonth following childbirth3 and 10-15% of mothers have an episodeof major depression in the year after giving birth44. Resnick2reported that 75% of parents who killed their children had psychiatricsymptoms 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 thesedata Marks and Kumar6 found that women who killed children lessthan six months old were not usually classified as mentallyill but as ‘battering mothers’; however, mental illness didseem to account for most infant homicides over six months. Amongstthose women in whom mental illness was implicated as the causeof their actions, infant homicide was often found to be an extensionof a suicidal act (on the grounds that there would be no oneleft to care for the child). Occasionally the primary motivewas altruistic, based on a delusional belief that a terriblefate awaited the infant. Although psychiatric morbidity is arisk factor, most women who are mentally ill do not harm theirchildren and many women who commit infant homicide are not mentallyill.

Another area of psychiatric morbidity not directly related tothe physiological changes associated with pregnancy is substancemisuse. In a study of mothers who had committed infant homicide,most reported regular use of alcohol and/or cocaine antenatallyand postnatally.45 Substance misuse has been suggested to actin two ways: first, drug-exposed newborns and infants are oftendescribed as irritable, with poor feeding and irregular sleepingpatterns making them difficult to care for; secondly, substancemisuse can impede people’s ability to evaluate their own behaviourand is correlated with aggression.46 A rare psychiatric disorderthat can lead to infant homicide is Munchausen syndrome by proxy.47Its incidence is not known.

A recent article states that infant homicide is committed morefrequently by mothers than by fathers.40 The findings of Marksand Kumar5 suggest the opposite: in their study 84 fathers comparedwith 68 mothers were found to be responsible. Although the InfanticideAct does not recognize mental illness amongst fathers who commitinfant homicide, postnatal mental illness seems to occur inmen as well as women. Harvey and McGrath61 found that 40% offathers whose wives had suffered from postpartum psychosis experienceda classifiable psychiatric disorder— higher than the 30%prevalence rate in the partners of general psychiatry cases.48The men had seldom been abusive before the offence.7 Misinterpretationof the infant’s behaviour seemed to be the primary motive inmany of the cases studied.49 Any strategy aimed at reducingthe number of infant homicides therefore needs to take fathersinto account.

Management and prevention
The risk factors for infant homicide offer more potential forprevention than do those for neonaticide, and the antenatalclinic and postnatal follow-up provide opportunities for identifyinghigh-risk cases. The first line in identification is throughan awareness of the risk factors for postnatal depression andpsychosis, as well as risk factors and clinical signs of substanceabuse. This, for example, includes the knowledge that about40% of women with postpartum depression in a previous pregnancycan be expected to have another episode after a future delivery50and that women who have had both postpartum psychosis and apsychotic episode outside pregnancy will almost inevitably relapseafter any subsequent pregnancy.51

In Britain midwives are in a strong position to identify postpartummental illness, yet they fail to identify many cases.52 Thiscould be radically changed by implementation of an economicaland effective screening procedure such as the 10-item EdinburghPostnatal Depression Scale.53

For prevention of child abuse and neglect, home visits havemet with some success.54 Brenner and colleagues55 have suggestedextending this approach to those women at high risk of committinginfant homicide. Overpeck and colleagues19 have tentativelysuggested cross-training healthcare professionals to enablethem to deal with domestic violence; however, as they pointout, there are no data on the relation between infant abuseand infant homicide. In addition, as already discussed, menwho committed infant homicide had not usually been abusive beforethe offence. Southall et al.56 used covert videosurveillanceto investigate parents who had reported apparent life-threateningevents in their children and were suspected of having ‘induced’the illness (i.e. Munchausen’s syndrome by proxy). Abuse wasdetected in 33 of 39 cases, with recordings of intentional suffocationin 30. Although none of these parents had evidence of psychotic illnessmany had an underlying personality disorder. It is unclear howoften such behaviour leads on to infant homicide (or a misdiagnosisof sudden infant death syndrome) but Southall et al. argue stronglyfor formal videosurveillance in selected cases.

    CONCLUSION

In the perinatal period most women are under close medical surveillanceand in theory there is scope for identifying the mothers mostat risk of killing their babies. Unfortunately those most likelyto commit neonaticide tend to evade the healthcare system. Importantrisk factors that should be picked up in the antenatal historyare substance abuse and mental illness. With infant homicide,women at risk may be more amenable to detection, but the perpetrator isequally likely to be the father. The rarity of both events,coupled with the infrequent contact of perpetrators with healthprofessionals, will continue to hamper identification of thechildren at greatest risk. In many cases, however, infant homicideand neonaticide probably represent the extreme end of the abusespectrum. Detection of infants most at risk may consequently resultin a more widespread reduction of fatalities.

    Acknowledgments

I acknowledge the inspiration of the late Professor Channi Kumarand the help of Dr Maureen Marks.

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