1
Submission to the CRC for the call on the General Comment
On the Right to the Child to the enjoyment of the highest attainable standard of
health (art. 24)
Catherine Bonnet M.D.
Email: bonnec7@hotmail.com
Clinical observations at a prenatal stage in relation to the right of the child to health
and health care article (3,6 and 24 of the CRC)
The cycle of life in parenthood may escape to human consciousness even after the legalization of
contraception (1967) and abortion (1975) in France. They are still unintended pregnancies that are
acknowledged after the legal delay of termination. Childbirth is not always welcome with happiness
by women or men. Some women are facing alone the pregnancy and the birth of a child in very
difficult circumstances. These conditions may challenge the right of the child to health and to
access to health care services at a prenatal stage and at birth.
Clinical observations in these issues were first described in a clinical study conducted in 19871989 in France1 by the author on women who gave up their baby for adoption under the secret
delivery and with anonymity. These findings raised the facts that this legislation may reduce health
risks for the child at a prenatal stage and at birth.
The right to deliver under the secret delivery was first in the legislation in a decree on 28th June
1793 under the French Revolution. It was re-enacted in another decree on 2nd September 1941
during the War World II. Since 1990 the French parliament has introduced this right in the civil
Code on 8th January 1993 and managed the legislation on 5th July 1996 and 22 January 2002.
Women who deliver under secrecy have the choice between the right to give and the right not to
give their identity. The last allows anonymity. The cost of the labor and the delivery are paid with
state funds.
On 20-21st June 1994 in the Declaration of Amsterdam during the Conference on the Rights of
Children in Armed Conflicts, it has been recommended to avoid stigmatization of children born as
the results of war rape and the secret delivery.2 On 13th February 2003 (Odièvre C. France,
requête N°42326/98) and on 10thJanuary 2008 (Kairns C. France, requête N° 35991/04) the
European Court of Human Rights upheld the French legislation, ruling that it did not violate the
European Convention on Human Rights. The National Academy of Medicine (Pr R. Henrion3, Pr
JM Mantz 4opinion) The National Ethics Advisory Committee (Opinion N°90)5, UNAF6, Family
Bonnet C. Nés du silence. Rapport pour la MIRE (Juin 1989), publié sous le titre, « Geste d’amour ». Paris Odile Jacob.
Février 1990.
Bonnet C. Adoption at birth a prevention against neonaticide and abandonment on a public place. Child Abuse and
Neglect. The International Journal. July-August 1993; 17 (4): 501-513.
http://www.ncbi.nlm.nih.gov/pubmed/8402253?dopt=Abstract
2 « Alinea 3.4
A child who is pregnant as the result of rape or other sexual abuse should have the same rights as an adult woman to
decide free of pressure
a) whether or not to continue the pregnancy and
b) b) whether or not to give up the child to adoption after birth.
Alinea 3.4.1
Every effort shall be made to prevent the danger of stigmatization of children born out of rape. Due to considération
should be given to the possibility of secret delivery (accouchement secret) and the adoption of this child »
3 L’accouchement sous X, peut-il encore exister ? Tribune du Professeur Roger Henrion ? La Revue du Praticien,
septembre 2011, 61 : 896-897.
http://www.larevuedupraticien.fr/index.php/component/content/article/58-sommaire/2291-juillet-2011?directory=55
1
4
http://www.academie-medecine.fr/Upload/Mantz_rapp_22fevr_2011_definitif.pdf
5
http://www.ccne-ethique.fr/avis74ae.html?debut=20
6
http://www.unaf.fr/spip.php?article12000
2
Planning7 member of the IPPF, and most of French gynecologists have written documents, papers
in favor of the choice of anonymity in case of secret delivery. However a proposal law N°4043 has
been registered on 7th December 2011 at the National Assembly to suppress the right to deliver
under anonymity and to oblige any woman to give her identity in case of secret delivery. 8
What are the prenatal indicators, which may delay the right of the child to health?
Studies show indicators that need to be recognized to prevent health risks in relation to the right of
the child to health and to child health care (Art. 6, 19, 24).
Pregnancy denial and concealment of pregnancy and their risks on the health of the child
There is only one epidemiological study on pregnancy denial conducted in Berlin by Jens Wessel
in 1995-1996, which showed there is 1/475 denial in pregnancy.9 Studies in literature have shed
light on pregnancy denial but there are few studies on samples of women who ask for a
secret/anonymous delivery while giving up the baby for adoption.10 A recent study performed by
INED in 2010 on 835 women who delivered under the secret delivery in France has showed the
month in which 503 women acknowledged being pregnant.
1 to 3 month
76 women
15%
4 to 6 month
229 women
45%
7 to 9 month
158 women
31%
The day of birth
40 women
8%
332 women did not reply to this question and it is not explain why.
Most of women recognise their pregnancy soon after missing a period or when noticing other body
changes. They usually do a pregnancy test and then book their first antenatal appointment. Some
women/teenagers do not verify that they might be pregnant when they present physical symptoms
that could indicate a pregnancy. They rationalize their symptoms by attributing them to causes
other than pregnancy, whether or not they present with a mental disorder. Such condition
characterised by the non-recognition of the pregnancy is called a pregnancy denial.
Bonnet described how pressures from an intimate partner, family, society, religion, culture, etc on
the decision-making to keep or not the baby are often strong. High level of anxiety increases the
effects of cortisol level on the development/health of the child. It has not been described on
anonymous delivery study but in Glover studies.11 If women experience too much pressure they
may also decide to avoid the follow up and/or to post-pone the decision-making after birth in
placing the child in welfare institution or foster parent and progressively desert the child for long
time. This may affect its mental health.
7
http://www.planning-familial.org/actualites/dans-l’interet-de-l’enfant-preserver-l’accouchement-sous-x-002143
8
http://www.assemblee-nationale.fr/13/dossiers/levee_anonymat_accouchement_secret.asp
9 Wessel J. Endrikat J, Buscher U.
Frequency of denial of pregnancy: results and epidemiological significance of a 1-year prospective study in Berlin.
Acta Obstet Gynecol Scand. 2002 Nov;81(11):1021-7.
Wessel J, Endrikat J, Büscher U.
Elevated risk for neonatal outcome following denial of pregnancy: results of a one-year prospective study compared with
control groups.
J Perinat Med. 2003;31(1):29-35.
L’accouchement sous X, peut-il encore exister ? Tribune du Professeur Roger Henrion ? La Revue du Praticien,
septembre 2011, 61 : 896-897.
http://www.larevuedupraticien.fr/index.php/component/content/article/58-sommaire/2291-juillet-2011?directory=55
10
11
O'Connor TG, Heron J, Golding J, Beveridge M, Glover V.
Maternal antenatal anxiety and children's behavioural/emotional problems at 4 years. Report from the Avon Longitudinal
Study of Parents and Children.
Br J Psychiatry. 2002 Jun;180:502-8. http://www.ncbi.nlm.nih.gov/pubmed/12042228
3
If women are forced to give information about their identity, some may avoid the follow up or may
deny the child and its physical and mental health needs. They may not recognize the beginning of
the birth and become surprised alone by an unexpected delivery out of a hospital/health centre
without any health/obstetric support. This is a denial of the labor or the birth. Such conditions may
expose the child at a risk of morbidity/mortality according Wessel:12
 Intra-uterine growth retardation, low birth weight.
 Physical risks of harming the foetus during pregnancy with tobacco, alcohol and drugs
abuses.
 Precipitated labour, unexpected and dangerous deliveries.
 Spontaneous premature rupture of the membranes.
 Perinatal mortality.
 Neonaticide.
Neonaticide is the killing of a child the day of birth. The figures given by the data in the US
confirmed that children are more likely at risk of homicide or non-fatal child maltreatment the first
week/first year of their life.13 Since 1999 some children’s life has been saved by the “Safe Haven
Legislation”, which is recommended for preventing neonaticide by Spinelli and Miller14.
It has not been possible to demonstrate in France whether or not anonymous delivery was
decreasing the number of neonaticide and the children discarded and left to die because of the
lack of detailed data since infanticide qualification was suppressed from the penal Code in 1994.
From my knowledge there is only one study conducted in Austria by Klier and her colleagues,
which has demonstrated that anonymous childbirth decreases the number of neonaticide.15
Pregnancy denial has to be clearly distinguished from concealment of pregnancy, in which a
woman is aware to be pregnant. If some conceal their pregnancy and recognize it from the first
trimester of pregnancy, others very often conceal their pregnancy after having denied it. However
concealment of pregnancy may also lead to the denial of the health needs of the child and may
exposed the child to a birth denial with health morbidity/mortality.
If some women may become happy to give birth to a baby after recognizing lately being pregnant,
some may feel unable to care for the baby, unable to think about the baby, unable to name it as a
person as the results of hidden causes.16
Hidden causes: history of past sexual abuse/incest/recent rape
A baby is not only the emotional relationship with the man with whom a woman has conceived, but
the complex result of intergenerational relationships with parents, the family, the sequences of
events and childhood trauma, etc. Awareness of the reality of the baby after a pregnancy denial
may reactivate flashback of negative experiences of the past and may trigger ambivalent feelings
towards the child, thoughts of violent impulses, the fear of hurting its. Some women are afraid of
losing control of their thoughts and move on to the act, hitting the stomach. 17
12
Wessel J opus cité
13 MMWR Variations in homicide risk during infancy. Data in the US from 1989-1998
http://www.cdc.gov/mmwR/preview/mmwrhtml/mm5109a3.htmSpinelli MG.
14
Miller LJ Denial of pregnancy in Spinelli MG. Infanticide: Psychosocial and Legal Perspectives on Mothers who kill
American Psychiatry Publishing. Washington DC 2003. pp 81-103.
Spinelli MG A systematic investigation of 16 cases of neonaticide.
Am J Psychiatry. 2001 May;158(5):811-3.
15 Klier C, Amon S, Nassan-Agha H, Friedrich MH, Fiala C, Benesch T, Bergemann N. Is prevention of neonaticide
possible –An Austrian experience? IAPAC congress 30 April- 3 May 2008 www.iacapap2008.org
16 Bonnet C. Accompagner le déni de grossesse. Paris, Perspectives Psychiatriques, Juin-Juillet 2002, Vol.41, 3 : 189-
194
17 Bonnet C. Geste d’amour, opus cité.
4
In Australia Condom conducted in 1986 a study in Australia on a sample of 112 pregnant women.
Of these 8% disclosed violent impulses to the fetus and 4% of fathers. Condom coined this
behavior "the battered fetus syndrome". Condom believes that such abuses made to the fetus are
not uncommon and are rarely detected because the professionals cannot believe it.18 Some
women do not express violent thoughts but reverse their anger against them with suicidal thoughts.
The risk of acting out is reduced as soon as they express their thoughts and feelings.
Asking then open questions on a history of past or recent sexual/physical abuse ((incest, sexual
exploitation, intimate partner violence, forced wedding, war rape, etc) before the birth decrease
their anger/anxiety and reduce such violence thoughts/acts. Then they feel able to think about the
future of the baby and to care for its health.19
Sexual abuse is far to be rare. An American epidemiologic study, the ACE Study, which explored
the adverse childhood experience with 17,000 adults between 1995 and 1997 showed that 20.7%
of them have been subjected to sexual assaults, 24.7% of women and 16% of men, 12% had
witnessed domestic violence against their mothers in childhood.20 The ACE Study also
demonstrated in 1999 a strong relationship between unintended pregnancies and traumatic
experiences of childhood.21 The International Association of Victims of Incest (AIVI) initiated with
IPSOS a survey in 2009. It indicated that 3% of the general population has been victims of incest:
2 millions of adults in France.22 A recent study of Devries and all describes in 2010 the prevalence
of intimate partner violence during pregnancy from 19 countries. Half of the surveys estimated the
prevalence to be between 3.9% and 8.7%. 23
In 2010 AIVI conducted a comparative survey with IPSOS in France to assess the effects of incest
on health and daily life between 341 members of AIVI and 946 individual from the general
population. The results show that the average delay of a spontaneous disclosure of incest is 16
years after the facts; 64% of survivors are experiencing or have experienced to be afraid to have
children because of fear one might become a bad parent against 7% in the general population.24 A
proposed questionnaire to 133 female survivors of incest members of AIVI found that 4% among
them discovered to be pregnant after the third month, 33% felt embarrassed with the fetus, 20%
expressed acts of violence against themselves and 4% to the fetus, 32% had an addictive behavior
risk during pregnancy for themselves and the baby health (10% alcohol, drugs 2% and 26%
tobacco). 25 Survivors of AIVI explained how denial of incest by their family, by society might result
in a denial of pregnancy, a fear to undergo examination and thus to follow the pregnancy, a fear of
18
Condom JT The battered fetus syndrome. Preliminary data on the incidence of the urge to physically abuse the unborn
child. J Ment Dis 1987 ; 76 : 722-725.
19 Bonnet C. Détecter l’inceste durant la grossesse, aurait-il un effet positif pour les futurs parents ? Syngof Mars 2010;
80: 25-28.
20
Dube SR, Anda RF, Whitfield, CL, Brown DW, Felitti VJ, Dong M, Giles WH. Long-term consequences of childhood
sexual abuse by gender of victim . Am J Prev Med 2005;28:430–438.
21
Dietz PM, Spitz AM, Anda RF, Williamson DF, McMahon PM, Santelli JS, Nordenberg DF, Felitti VJ, Kendrick JS.
Unintended pregnancy among adult women exposed to abuse or household dysfunction during their childhood. JAMA
1999;282:1359–1364.
22
http://aivi.org/
23
Devries et al. Intimate Partner Violence during Pregnancy : analysis of prévalence data in 19 countries. Reproductive
Health Matters 2010 ; 18 (36) 158-170.
http://www.ncbi.nlm.nih.gov/pubmed/21111360
24
http://aivi.org/
Lefèbvre M. Grossesse et accouchement chez les femmes victimes d’inceste. Mémoire. Ecole des Sages-Femmes
Jeanne Sentubéry. Poissy 2011.
http://aivi.org/
25
5
giving birth26 because: "The unborn child must pass through the genital tract raped in childhood"27.
How anonymous delivery increases the protection of the life of the child, improves
the right of the health of the child and the health care of the child in relation to the
article 2, 3, 6 and 24 of the CRC
Paul Hunt and Judith Bueno de Mesquita have observed: “It is often said that maternal mortality is
overwhelming due to a number of interrelated delays, which ultimately prevent pregnant women
accessing the health care she needs”. Among the three delays described in its relationship to the
right to health, Paul Hunt has indicated the “delay in seeking medical help for an obstetric
emergency for reasons of cost, lack of recognition of an emergency, poor education, lack of access
to information and gender inequality”.28
Women who are seeking for delivering under secrecy and anonymity may wish to hide the financial
costs of the delivery to their partner/family. Women who have experienced a pregnancy denial, a
concealment of pregnancy, hidden sexual abuses may avoid their health needs and the
recognition of the delivery. Professionals need to be informed that in protecting mother’s health,
they may protect the child health. Clinical observations has showed in France that the choice of
anonymity may:
1. Decrease the delay in seeking medical care for delivering
- Facilitate to plan the day/week of birth, which prevents from a delivery/birth denial alone without
health assistance.
- Understand the experience of pregnancy denial/concealment of pregnancy.
- Detect then hidden causes: a history of sexual/physical abuses in childhood/adulthood that was
never disclosed. To report to child protection may be needed if the mother is a minor.
- Prevent from obstetrical risks of morbidity for the child health during pregnancy.
- Prevent from the risks of child mortality by violence or severe neglect at birth.
2. Decrease the mother’s stress during pregnancy and its effect on child health outcome
because it decreases the amount of social/family pressures upon the decision-making.
3. Facilitate the decision-making at birth rather to avoid it and to choose placing the child in
welfare to post-pone the decision-making.
4. Protect the future mental health of the child against the stigmatization of rape
The stigmatization of the child born as the result of rape was raised in June 1994 in the Amsterdam
Declaration. The knowledge that a child was the result of rape may project negative thoughts upon
the child and affect its mental health. Some births may be the results from difficult circumstances or
even rape inside the biological family but this information is usually kept away. Anonymous birth
may preserve the facts surrounding the conception and may protect the child from health sufferings
of later disclosure. It allows the child a fresh start without the negative emotions provoked by the
knowledge of the circumstances of his conception. It does not discriminate the child born under
anonymity if the violent origin of its birth is not disclosed in the birth file.
26Aubry
I, Apers S. Etre parent après l’inceste. Paris. Editions JLyon 2009.
http://aivi.org/fr/nos-publications/livres-aivi
27
http://www.ordre-sagesfemmes.fr/NET/fr/document//2/menu/temoignages_de_sagesfemmes/la_sagefemme_la_parentalite_et_linceste/index.ht
m
28
Hunt P. Bueno de Mesquita J. Reducing Maternal Mortality. The contribution of the Right to the Highest attainable
standard of Health. Human Rights Centre. University of Essex. 2007
http://www.essex.ac.uk/human_rights_centre/research/rth/docs/ReducingMaternalMortality.pdf
Presentation of the author: Catherine Bonnet M.D.
Consultant in child and adolescent psychiatry, psychoanalyst for children and adolescents,
researcher and trainer in France and abroad, particularly on the issue of detection of violence
during pregnancy, denial of pregnancy and prevention of infanticide, abandonment of public
roads, the detection of incest or sexual abuse outside the family and child protection reporting.
She has conducted missions of consultancies in conflict armed countries to train professionals
that welcome children / pregnant women as a result of wartime rape. She is the author of Books:
Geste d’amour (1990), Les Enfants du Secret (1993), Enfance interrompue par la guerre (1994),
L’Enfant Cassé 1999, L’enfance muselée (2007) and publications on these issues. She has
received awards and honorary: 1991, Mustela Prize for the book Geste d’amour, 1996, “Marie
Paule Eiselé” Prize for the Rights of the Children from the Bureau International Catholique de
l’Enfance for the project of a Centre to prevent neglect and violence during pregnancy and at
birth, 2001 knighthood Chevalier de l’Ordre de la Légion d’honneur.
Declaration of interest:
The author is an adoptive mother, a member of Association International of Victims of Incest and
a member of Professionals Against Child Abuse.