Pregnancy denial and maternal attachment style: a prospective case-control study

Pregnancy denial and maternal attachment style: a prospective case-control study | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 10 June 2025 V1 Latest version Share on Pregnancy denial and maternal attachment style: a prospective case-control study Authors : F. Fohanno , Aurore Thierry , Hammami S , Julie Auer , Anne Laure Sutter , L. Vulliez , Violaine Gubler , … Show All … , Stéphanie Saad Saint-Gilles , C. Gentilleau , J. Le Foll , Sylvie Viaux-Savelon , X. Benarous , Gisèle Apter , J. Rolling , Julien Eutrope 0000-0001-7628-292X , and Anne-Catherine Rolland [email protected] Show Fewer Authors Info & Affiliations https://doi.org/10.22541/au.174952457.71677930/v1 364 views 206 downloads Contents Abstract Pregnancy denial and maternal attachment style: a prospective case-control study Introduction Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Objective : The psychopathology of pregnancy denial is under-researched. We hypothesized that mothers’ insecure attachment styles may increase vulnerability to pregnancy denial. Design : Prospective, multicentre case-control study. Setting : France. Population : 71 case dyads (D+) and 71 control dyads (D-) at inclusion; 70 dyads at 8 weeks postpartum (D+: 24, D-: 46). Methods : Data were collected 8 weeks postpartum through self-questionnaires and structured clinical assessment evaluating mothers’ attachment style representation (Attachment Script Assessment [ASA]), personality traits (International Personality Disorders Examination [IPDE]), psychiatric profiles (Beck Depression Inventory II [BDI-II], State-Trait Anxiety Inventory [STAI-Y], Edinburgh Postnatal Depression Scale [EPDS]), and socio-medical profiles. Main Outcome Measures: mothers’ attachment style representation between the two groups. Results : Based on the ASA, D+ mothers displayed significantly more insecure attachment style representation: median scores of 2.50 in the D+ group and 3.38 in the D- group. D+ dyads had more frequent indices of social disadvantage, especially in terms of house accommodations and marital status. Difference between the two groups were not statistically significant for EPDS postnatal depression score, BDI depression score, STAI anxiety score; while D+ women exhibited on average higher borderline and paranoid traits based on the IPDE screening. Conclusions : D+ mothers tend to exhibit more insecure attachment style representations, longstanding personality dysfunction, greater social vulnerability without differences in terms of associated emotional symptoms. Identifying mothers with insecure histories is crucial for psychosocial support. Pregnancy denial and maternal attachment style: a prospective case-control study F. Fohanno a , A. Thierry b , S. Hammami a , J. Auer a , A-L. Sutter-Dallay c , L. Vulliez d,e , V. Gubler f , S. Saad Saint-Gilles g , C. Gentilleau h,i , J. Le Foll j , S. Viaux k,l , X. Benarous m , G. Apter n , J. Rolling o , J. Eutrope a,p A-C. Rolland a,p a Service de Psychothérapie de l’enfant et de l’adolescent, Pôle Femme-Parents-Enfant, Centre Hospitalier Universitaire, Université Reims Champagne Ardenne (URCA), Reims Cedex, France bUniversité de Reims Champagne-Ardenne, VieFra, CHU Reims, Unité d’Aide Méthodologique, Reims, France c Filière de psychiatrie Périnatale, pôle universitaire de psychiatrie de l’enfant et de l’adolescent, Centre Hospitalier Charles Perrens, Bordeaux, France d Service de pédopsychiatrie, Centre Hospitalier Régional Universitaire, Besançon cedex, France e Laboratoire de Recherches Intégratives en Neurosciences et Psychologie Cognitive. UMR INSERM 1322, LINC, UFC, Besançon, France f 392 avenue Ernest Subilia 13600 La Ciotat, France g Pôle Universitaire de l’enfant et de l’adolescent, Centre psychothérapique de Nancy, Laxou, France h Service de Psychiatrie de l’Enfant et de l’Adolescent, Centre Hospitalier Universitaire de Toulouse, Toulouse, France i CERPOP, Université de Toulouse, Inserm, UPS, Toulouse, France j Polyclinique Ney, Hôpital Bichat, Paris, France k Unité de Psychiatrie Périnatale, Hôpital Croix Rousse, Hospices Civils de Lyon, France l Institut de Sciences Cognitives Marc Jeannerod, Université Lyon, Bron, France m Service de psychiatrie de l’enfant et de l’adolescent, Hôpital Pitié-Salpêtrière, AP-HP.Sorbonne Université, Paris, France n Service universitaire de Pédopsychiatrie du Groupe Hospitalier du Havre, Université Rouen Normandie, France o Service de Psychiatrie de l’Enfant et de l’Adolescent, Pôle de Psychiatrie, Sante Mentale et Addictologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France p Université de Reims Champagne-Ardenne, C2S, Reims, France. Corresponding author : A-C Rolland, Service de Psychothérapie de l’enfant et de l’adolescent, Pôle Femme-Parents-Enfant, Av du Gl Koenig, Centre Hospitalier Universitaire, 51092 Reims Cedex, France. Email: [email protected] Short Title: Pregnancy denial and maternal attachment style Abstract Objective : The psychopathology of pregnancy denial is under-researched. We hypothesized that mothers’ insecure attachment styles may increase vulnerability to pregnancy denial. Design : Prospective, multicentre case-control study. Setting : France. Population : 71 case dyads (D+) and 71 control dyads (D-) at inclusion; 70 dyads at 8 weeks postpartum (D+: 24, D-: 46). Methods : Data were collected 8 weeks postpartum through self-questionnaires and structured clinical assessment evaluating mothers’ attachment style representation (Attachment Script Assessment [ASA]), personality traits (International Personality Disorders Examination [IPDE]), psychiatric profiles (Beck Depression Inventory II [BDI-II], State-Trait Anxiety Inventory [STAI-Y], Edinburgh Postnatal Depression Scale [EPDS]), and socio-medical profiles. Main Outcome Measures: mothers’ attachment style representation between the two groups. Results : Based on the ASA, D+ mothers displayed significantly more insecure attachment style representation: median scores of 2.50 in the D+ group and 3.38 in the D- group. D+ dyads had more frequent indices of social disadvantage, especially in terms of house accommodations and marital status. Difference between the two groups were not statistically significant for EPDS postnatal depression score, BDI depression score, STAI anxiety score; while D+ women exhibited on average higher borderline and paranoid traits based on the IPDE screening. Conclusions : D+ mothers tend to exhibit more insecure attachment style representations, longstanding personality dysfunction, greater social vulnerability without differences in terms of associated emotional symptoms. Identifying mothers with insecure histories is crucial for psychosocial support. Funding : Hospital Research Program of the French Ministry of Health (PHRC 2011). Keywords : Pregnancy denial, cryptic pregnancy, attachment, psychiatric background, social context, frailty. Funding This study was supported by grants from the Hospital Research Program of the French Ministry of Health (PHRC 2011). The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Introduction Pregnancy denial occurs when a pregnant woman and those around her are unaware of her pregnancy, often due to minimal or absent physical signs. 1,2 It differs from voluntary pregnancy concealment and psychotic pregnancy denial associated with maternal psychosis. 3 Although recognized as a clinical entity since the late 20th century, concepts of late pregnancy discovery date back to the 17th century. 4 There is no consensus on the definition of pregnancy denial; some define it as the discovery of pregnancy beyond the first trimester, 1 while others use the 22nd week of amenorrhea as a benchmark. 5,6 Epidemiological data on pregnancy denial are limited, with estimates ranging from 1 in 300 7 to 1 in 475 births, and rarer for total denial, which occurs in approximately 1 in 2,455 cases. 6 Research has attempted to identify risk factors for pregnancy denial, but no typical profile has emerged. Most affected women do not have underlying severe psychiatric disorders. 7,8 Some studies indicate a disadvantaged social background, with up to 40% of cases experiencing such conditions and 12% having a history of violence exposure. 8 However, an unperceived pregnancy can affect individuals across all ages and social classes. 1,4 Some findings suggest young, single women are at higher risk, 7 with no significant difference between primiparous and multiparous women. 8 The data remain nonspecific with contradictory findings, complicating the establishment of a risk profile. 9 Some researchers suggest that women with pregnancy denial may use denial as a defense mechanism to cope with anxiety or stress related to pregnancy, 10 particularly in cases of past exposure to psychotrauma or environmental stressors related to family, social or cultural factors . 11 Clinical experiences led us to hypothesize that an insecure attachment style may be an important dimension to understand the pregnancy denial’s psychopathology, as secure attachment is crucial for personality development and interpersonal relationships throughout life. 12 This clinical impression informed our prospective comparative study, ‘Denial of Pregnancy and Attachment’, which contrasts denial mothers (D+) with non-denial mothers (D-). The study examines maternal representations of their attachment style, social contexts, and psychiatric dimensions (depression, anxiety, and personality traits), as well as children’s outcomes and attachment styles (exploitation of results in progress). This article is the third in a series stemming from our research, following the protocol presentation 13 and initial data collection from mothers and their children at birth. 7 It is based on data collected during the second visit, coinciding with the mandatory check-up at 6–8 weeks postpartum. Methods Study status This study was registered in the European registry (EudraCT 2011-A01498-33) and on clinicaltrials.gov (NCT02867579). Recruitment occurred from April 2013 to April 2019. Study design This multicentre, prospective case-control study involved 10 French centres: Antony (Ile-de-France), Besançon, Bordeaux, Nancy, Paris (Bichat), Paris (La Pitié-Salpêtrière), Reims, Strasbourg, Toulon, and Toulouse. 13 During the second visit (V2), which took place between 6 and 8 weeks postpartum, mothers were assessed for their attachment style representation, social context, and relevant clinical dimensions, including depression, anxiety, and personality disorders. Patient involvement Patients with pregnancy discovered after 22 weeks of amenorrhea, i.e., 20 weeks of gestation for group D+, were included. Exclusion criteria included age < 18 years, intellectual deficits, acute or chronic psychotic disorder, non-French speakers, patients in irregular situations, lack of pregnancy follow-up due to geographical, social or administrative reasons, high risk of premature delivery, anonymous delivery, medically assisted reproduction (for group D-), patients under protective measures, and new-borns with poor prognoses or organic and/or genetic malformations. Groups D+ and D- were matched based on maternal primiparity status and whether the infant was premature (born before 37 weeks’ gestation). Informed consent was collected in the first visit of our study. Study population At the first visit (V1), 71 dyads in group D+ and 71 dyads in group D- were included in the study for 24 months. 7 At the second visit, 24 dyads in group D+ and 46 dyads in group D- were studied. Lost contacts were followed up on between the first and second visits through several telephone calls. The second visit was conducted either at home or in a hospital. Assessment Assessments were conducted by professionals, including psychologists and child psychiatrists trained in perinatal care. Data were collected using several specific scales, as mentioned below. Maternal representation of their attachment style The Attachment Script Assessment (ASA) is a reference scale for the assessment of attachment in adults, developed by Harriet Waters. 15,16 The concept of measuring attachment through narrative scripts was introduced in 1991, 15 highlighting that our interactions are guided by scripts that reflect our attachment styles (secure or insecure) based on reactions in interpersonal situations. 16 The patient creates six stories—three related to adult-adult interactions and three to adult-child interactions—using boards with 12 imposed words arranged in columns. The stories consist of an initial situation, the emergence of a problem, and a resolution. One story in each category is designated as ‘neutral’ to facilitate adaptation at the start of the test. To mitigate ordering effects, the stories were presented in a different sequence for each mother. Each story is rated on a scale from 1 to 7 based on elaboration, emotional states described, relationship context, recognition of difficulties, and their resolution. Scores from 3 to 7 indicate increasingly elaborate secure content. The manner in which the stories are told reflects the individual’s attachment representations and their own attachment experiences. 12 Audio recordings of the stories were transcribed, and the documents were then scored blindly and double-scored by two trained professionals using a coding manual provided by Profs Manuella Verassimo, Susana Tereno, and Antoine Guedeney. Psychiatric profile The Beck Depression Inventory II (BDI-II) is a scale used to assess depression and its severity, based on DSM-IV diagnostic criteria. It comprises 21 items rated from 0 to 3, with four statements reflecting varying intensities. 17 The Edinburgh Postnatal Depression Scale (EPDS) is a self-administered screening questionnaire for postpartum depression, consisting of 10 short statements. Mothers select the response that most closely reflects their feelings over the past week. A score of 11 or higher is considered as clinically significant. 18 The State-Trait Anxiety Inventory (STAI Y) includes scales for state anxiety (STAI Y-A) and trait anxiety (STAI Y-B). It focuses on the psychological, non-organic aspects of anxiety, excluding elements more related to depression. This self-questionnaire has responses ranging from 1 (no anxiety) to 4 (high anxiety). 19 In this research, only anxiety trait was assessed. The International Personality Disorders Examination (IPDE) scale is used to evaluate personality traits according to DSM-IV criteria. It includes a screening section (self-questionnaire) followed by a semi-structured interview for significant personality traits (score greater than or equal to 3) . The scale contains 99 items, with personality criteria grouped into six domains: work, personal relationships, interpersonal relationships, emotional responses, reality perception, and impulse control. 20 Outcome The main outcome was a statistically significant difference between D+ mothers and D- mothers regarding their attachment style representations. The secondary outcome was a statistically significant difference between D+ mothers and D- mothers regarding their social context and their psychiatric profiles. Statistical analysis Quantitative variables are expressed as medians and interquartile ranges, while qualitative variables are expressed as counts and percentages. We compared the two groups, D+ and D-, regarding attachment style representation (ASA score), medico-social context (type of housing accommodations, place of residence, marital status, drug treatment, support by professionals, etc.), postpartum depression (EPDS score), and anxiety (STAI score), using Wilcoxon tests for quantitative variables that did not follow a normal distribution and Chi-square or Fisher tests for qualitative variables as appropriate. We also examined the relationships between attachment style representation (i.e., ASA total score), postpartum depression (i.e., EPDS total score), depression (i.e., BDI total score), and anxiety (i.e., STAI total score) using Pearson correlations. Statistical analysis was performed using SAS software version 9.4. The significance threshold was set at p < 0.05. Results Description of the study population In V2, we analyzed 24 D+ dyads and 46 D- dyads. The test was administered at home for 31 dyads, in a hospital setting (including maternity ward, child psychiatry ward, and day hospital) for 36 dyads, and an unspecified setting for three dyads. There was no significant difference in the absence of the child during the interview (26% for D+ vs. 17% for D-; p = .527), nor in the absence of the father (87% for D+ vs. 70% for D-; p = .227). Maternal representation of their attachment style Mothers in group D+ had a statistically more insecure attachment style representation ( p = .001), with a median score of 2.50 in group D+ compared to 3.38 in group D- (Figure 1). This difference was observed for stories exploring both the adult-child relationship ( p = .006) and the adult-adult relationship ( p = .001). Each story confirmed the statistically more insecure attachment style representation of mothers in the case group: ‘Baby’s Morning’ ( p = .011), ‘Doctor’s Office’ ( p = 0.012), ‘Jane and Bob’s Camping Trip’ ( p = 0.005), and ‘The Accident’ ( p = 0.002). Medical and social context Mothers of D+ dyads are more likely to live away from home (Table 1), often residing with parents or in nonstable residency (e.g., hostels). D+ mothers are more frequently separated from the child’s father than D- mothers. No mother reported a change in marital status. There was no statistically significant difference between the two groups regarding maternal somatic problems, including wound healing, asthma, migraine, gastroenteritis, mastitis, gallstones, and joint pain. Similarly, there was no statistically significant difference between the two groups for newborn somatic pathologies (e.g., bronchiolitis, colic, conjunctivitis, gastroenteritis, umbilical hernia, mycosis, gastroesophageal reflux, horseshoe kidneys, respiratory distress, heart murmur, vomiting) (17% for D+ infants vs. 20% for D- infants; p = 0.999). Support from health and social professionals was provided in the majority of cases, but at a higher frequency in women in the D+ group compared to others (88% vs. 53% of D- mothers; p = 0.006). This difference was even more pronounced on the social level (Table 1). Psychiatric profile There was no statistically significant difference between groups in the EPDS postpartum depression score (7 [4-19] for D+ vs. 7 [3-16] for D-; p = .239), and the correlation score with the ASA score failed to reach statistical significance (p = 0.099). The BDI depression score showed no statistically significant difference between groups (6 [0-22] for D+ vs. 6 [0-32] for D-; p = .807), with no significant correlation with the ASA total score ( p = 0.115). There was no statistically significant difference in the STAI anxiety score between groups (33 [20-57] for D+ vs. 31 [22-63] for D-; p = .985). A negative correlation was found between the STAI score and the ASA total score ( r = -0.28, p = .0259). In the personality screening (IPDE), we identified significant differences between the case and control groups for borderline ( p = 0.007) and paranoid ( p = 0.036) personality traits (Table 2). During the 3rd visit (when the child is 6 months old), some centres did not conduct personality explorations as recommended (semi-structured interviews were performed only for personality traits significant for screening, i.e., a score of 3 or greater). For the 17 mothers whose borderline personality traits were significant on screening, 11 semi-structured interviews were conducted. Among these, the semi-structured interview was significant for group mothers in the D+ group and only one in the D- group. For the 25 mothers whose paranoid personality traits were significant on screening, 14 semi-structured interviews were conducted. Among these, the semi-structured interview was significant for three D+ mothers and four D- mothers. Discussion Main findings The results showed that D+ mothers had a more insecure attachment style representation than D- mothers (Figure 1). This insecure attachment style representation was seen in couple interactions stories as well as in adult-child interactions stories. D+ mothers had greater social vulnerability. There was no significant difference between D+ dyads and D- dyads regarding post-partum medical complications (Table 1). Additionally, we found no association between D+ mothers and internalized symptoms (depression, anxiety). D+ women appear to present more borderline and paranoid personalities traits than D- mothers (Table 2). Strengths and limitations To our knowledge, no study has yet explored the link between maternal attachment style and pregnancy denial. Our attachment assessment tool, the ASA, has several advantages over the reference tool, the Adult Attachment Interview (AAI). It is quicker to rate and is based on output structure rather than content. 34 The ASA includes both adult-adult and adult-child stories, while the AAI focuses solely on adult-child autobiography. 35 There is a strong correlation between ASA and AAI. 35-37 The ASA has been utilized in several studies, confirming its relevance and effectiveness, including among mothers from various ethnic backgrounds. 12 A limitation of this study is the number of individuals lost to follow-up between V1 and V2. As noted, it is challenging to follow a population with a precarious social background, 38, which applies to our D+ group. Additionally, trauma-exposed women or those with pathological personality traits may be more prone to experiencing mistrust or relational insecurity in their relationship with healthcare providers, which can complicate stable follow-up in the postpartum period. 39 We were also limited by the number of semi-structured interviews conducted after screening for personality traits using the IPDE, which did not allow comparative statistics. Analysis of lost to follow-up Several dyads were lost to follow-up calls, with a majority from D+ group (65% compared to 35% in control group). We assume that the mothers facing the most difficulties were those lost to follow-up, as D+ mothers tend to have more disadvantaged psychosocial background. Loss to follow-up may also be related to discontinuation of obstetrical care, unassigned telephone numbers, relocation, or no specific reason. Interpretation (in light of other evidence) Maternal attachment style In D+ dyads, the ASA significantly indicated a representation of insecure attachment style on the total score, as well as on the scores for each type of story (couple stories, parent-child stories) and each individual story. Mothers with an insecure attachment style representation appear to be at a higher risk for unperceived pregnancy. This finding aligns with vulnerability profiles associated with pregnancy denial found in the literature, including history of emotional, physical, or sexual abuse during childhood 21 and a fear of abandonment. 22 These vulnerability factors are often linked to an insecure attachment style. 23 Social context D+ dyads live less in their own accommodation than D- dyads. This data is consistent with social precariousness among mothers experiencing pregnancy denial. The precarious social environment identified in our study aligns with previous research, 6, 8, 10, 23, as well as with findings from our first article. 7 Couples in the D+ group are more frequently separated. The difference in marital status between the two groups may be attributed to their differing attachment styles, with secure attachment fostering more stable couple relationships in adulthood. 24 D+ dyads appear to have more social help offered. Literature indicates a correlation between non-supportive social environment and attachment disorders, 25 as well as increased offers of assistance when the social environment is in greater distress. 26 Medical context D+ mothers demonstrated a higher uptake of contraception. These women appear to be more fearful of experiencing another pregnancy during the postpartum period compared to D- mothers, which may be linked to their recent experience of pregnancy denial. There were no significant differences between the two groups concerning breastfeeding mode, sleep problems, or postpartum somatic problems in either the infant or the mother. Pregnancy denial does not appear to affect somatic pathologies or the physical development of children in the early weeks of life. Additionally, we found no proposals for medical support in the D+ group. The literature lacks consensus on the morbidity and mortality rates of children and mothers following pregnancy denial. It seems that there is no impact on the medium-term outcomes for infants, although pregnancy denial may lead to higher perinatal mortality and morbidity. 26,27 In women, there may also be an increase in perinatal morbidity, 28 but data on this subject are limited. Psychiatric profile There were no significant differences in self-reported questionnaires for depression, postpartum depression, or trait anxiety between the two groups. No psychiatric pathology was implicated in the risk factors. Existing studies also did not identify a specific psychiatric profile. 8,27,29 The IPDE screening for personality traits revealed a significant association with borderline and paranoid personalities in the D+ group. The relationship between borderline personality disorder and attachment disorder has been well-documented. 30-32 A link between attachment disorder and paranoid personality has also been described. 33 However, this screening does not diagnose and must be combined with a semi-structured interview to identify significant personality traits (score greater than or equal to 3). In our study, the methodology for this test was not consistently followed by certain centres, resulting in missing data and statistical limitations. Nevertheless, the tendency for personality traits to be over-represented in D+ mothers appears confirmed for borderline personalities, though not for paranoid personalities. This supports the strong association between attachment disorder and borderline personality disorder identified in the literature. 30-32 Conclusion This study enhances our understanding of the vulnerability factors associated with pregnancy denial. We found that D+ mothers had a more insecure attachment style representation compared to control mothers. Insecure attachment was associated with a more socially disadvantaged environment in the D+ group, consistent with existing literature 25 and our previous findings. 7 These mothers are more likely to exhibit borderline and paranoid personality traits. Further research on this subject would be valuable. In women who have experienced pregnancy denial, an insecure attachment style may contribute to early difficulties in self-construction, resulting in a greater frequency of immature defense mechanisms (e.g., idealization, denial, projection) such as those found in borderline or paranoid personality traits. Attachment patterns represent foundation upon which the individual develops their self-regulation abilities and the capacity to seek support in times of stress. Here, the onset of pregnancy can be interpreted as a major stressor for which the individual can neither rely on an external support (i.e., supportive and caring environment) nor their psychological resources for cognitive appraisal. The results of this study confirm this ”double jeopardy” of women with pregnancy denial. In this context marked by a lack of emotional insight, the absence of difference in the scores on the self-report anxiety and depressive questionnaires may raise questions about the ability to identify one’s emotional experiences, which is also observed in other studies conducted in adults with pathological personality traits. 40 Identifying vulnerability factors is crucial for understanding this mechanism and for prevention, allowing for early identification of at-risk profiles pre-conceptionally, coupled with preventive measures and information dissemination. A better understanding of vulnerability factors can help tailor the follow-up offered to these mothers as they become aware of their pregnancies. Given the insecure profile of D+ mothers, we must consider the potential implications for their children’s future. Disclosure of Interests The authors report no conflicts of interest. Completed disclosure of interest forms are available to view online as supporting information. Contribution to Authorship Conceptualisation: JA and ACR. Acquisition of data: SH, JA, ALSD, LV, VG, SSSG, CG, JLF, SV, GA, JR, ACR. Data analysis: FF and AT. Data interpretation: FF, JE, XB and ACR. Writing: FF. Supervision: ACR. Details of Ethics Approval The study received specific approval from the independent ethics committee, the ‘Comité de Protection des Personnes’ of Nancy, under agreement no. 2011/56 on 7 May 2012. It was conducted in accordance with the ethical standards outlined in the appropriate version of the Declaration of Helsinki, originally established in 1975 and revised in 2000. All participants provided informed written consent prior to their inclusion in the study. Acknowledgements We would like to thank the mothers who agreed to participate and the PHRC national team ‘Denial of Pregnancy and Attachment’ : Dominique Dallay, Elisabeth Glatigny-Dallay, Camille Vancauwenberghe from Bordeaux; Didier Riethmuller from Besançon; Valérie Verlomme from Aubagne; Alain Miton, Sophie Rothenburger from Nancy; Olivier Parant, Ludivine Franchitto from Toulouse; Agnès Bourgeois-Moine, Marc Dommergues, Elisabeth Aidane from Paris; Joëlle Belaisch-Allart, Pauline Minjollet from Sèvres; Marie-Emmanuelle Meriot, Israël Nisand, from Strasbourg; Olivier Graesslin, Franziska Lempp, Emilie Vassaux, Coralie Barbe and Anne-Lise Varnier from Reims. We would also like to thank Professors Manuella Verassimo, Susana Tereno, and Antoine Guedeney for their training and support. Data Availability The datasets generated and analysed during this study are available from the corresponding author upon reasonable request. References 1. Bottemanne H, Joly L. 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Keywords maternal medicine medical sociology psychiatry Authors Affiliations F. Fohanno Universite de Reims Champagne Ardenne Bibliotheque Universitaire View all articles by this author Aurore Thierry Universite de Reims Champagne Ardenne Bibliotheque Universitaire View all articles by this author Hammami S Universite de Reims Champagne Ardenne Bibliotheque Universitaire View all articles by this author Julie Auer Universite de Reims Champagne Ardenne Bibliotheque Universitaire View all articles by this author Anne Laure Sutter Centre Hospitalier Charles Perrens View all articles by this author L. Vulliez Centre Hospitalier Universitaire de Besancon View all articles by this author Violaine Gubler 392 avenue Ernest Subilia 13600 La Ciotat France View all articles by this author Stéphanie Saad Saint-Gilles Centre Psychotherapique de Nancy View all articles by this author C. Gentilleau Centre Hospitalier Universitaire de Toulouse Psychiatrie de l'enfant et de l'adolescent View all articles by this author J. Le Foll Hopital Bichat - Claude-Bernard View all articles by this author Sylvie Viaux-Savelon Hopital de la Croix-Rousse View all articles by this author X. Benarous Hopital Universitaire Pitie-Salpetriere View all articles by this author Gisèle Apter Groupe Hospitalier du Havre View all articles by this author J. Rolling Les Hopitaux Universitaires de Strasbourg Service de Psychiatrie de l'Enfant et l'Adolescent View all articles by this author Julien Eutrope 0000-0001-7628-292X Universite de Reims Champagne Ardenne Bibliotheque Universitaire View all articles by this author Anne-Catherine Rolland [email protected] Universite de Reims Champagne Ardenne Bibliotheque Universitaire View all articles by this author Metrics & Citations Metrics Article Usage 364 views 206 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation F. Fohanno, Aurore Thierry, Hammami S, et al. Pregnancy denial and maternal attachment style: a prospective case-control study. Authorea . 10 June 2025. DOI: https://doi.org/10.22541/au.174952457.71677930/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . 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