Banner by Aashka Sevak

Expecting a Ghost: Phantom Pregnancy and Societal Pressures Shaping Maternal Instincts 

by Ellie Stein

In 2008, “Ms. MN” waddled into a hospital in Nigeria, her stomach swollen with an enormous baby bump. She could feel her baby kicking, had been lactating, and noticed changes in her breasts, insisting that she was in labor. From all angles, and according to her partner who accompanied her, she was pregnant. However, upon an ultrasound exam, no fetus appeared - Ms. MN had been carrying a nonexistent baby for the past 8 months. 

Despite the fact that her body had completely transformed to accommodate a child, Ms. MN had not experienced pregnancy. Rather, she had undergone a phenomenon called pseudocyesis, commonly known as phantom pregnancy. Pseudocyesis is a complex mind–body condition where a woman exhibits objective signs and symptoms of pregnancy in the absence of a fetus. Many of these women present with perfectly normal mental stability; however, the presence of symptoms like amenorrhea, lactation, abdominal distension, and perceived fetal movements leave them indubitably convinced of their pregnancy, a state which persists until they are convinced otherwise. A pseudocyetic woman may even go into labor and deliver nothing, which can be a truly heartbreaking experience. 

The neuroendocrinological processes that cause and perpetuate pseudocyesis demonstrate the extensive physiological effects of the disease. This condition’s development can generally be explained in 3 stages: 

In stage 1, pseudocyetic women experience a “general feeling of apprehension” resulting from stress surrounding pregnancy. This may present as an immense desire to have a child, or extreme fear and anxiety around the prospect of pregnancy or motherhood . In the case of Ms. MN, reported abuse and threats of abandonment from her partner, as well as judgment from his family concerning her inability to conceive, drove her to desperation . 

In stage 2, a sensory perception results from this feeling of apprehension—stress-related weight gain or constipation can give the illusion of a developing baby bump, or consistent mental strain can cause amenorrhea. Though the symptoms may seem to be normal signs of stress, they take on extraordinary significance in a pseudocyetic woman’s mind . 

Stage 3 sees these objective signs of pregnancy compound on each other, as abnormal activity in the brain and endocrine system transform hormonal output. When a woman enters this final stage, pseudocyesis occurs due to impaired function of the hormonal reproductive axis—a complex network of interactions among the hypothalamus, pituitary gland, and ovaries that regulate reproductive function. The subsequent physiological changes are caused by defective neurotransmitters along this axis that control hormonal output. Specifically, the gonadotropin-releasing hormone (GnRH), luteinizing hormone (LH), and prolactin (all which stimulate the production of estrogen and progesterone, key players in conception) are released at unprecedented high levels. 

This atypical output stems from the fact that most pseudocyetic brains, much like those affected by major depressive disorder, have a deficit of dopamine. In women, dopamine is a potent inhibitor of pulsatile GnRH, LH, and prolactin, so its partial absence in the pseudocyetic brain leads to an increase in the release of all of these essential pregnancy hormones. This leads directly to the physiological symptoms that drive phantom pregnancy, such as those experienced by Mrs. MN. 

In the US, only about 1 in 22,000 pregnancies are cases of pseudocyesis. However, in developing countries such as Nigeria and Sudan, as many as 1 in 160 are known pseudopregnancies. These astronomical rates of pseudocyesis can be attributed to the cultural values retained by many of these nations, which place a high degree of social pressure on women to have children. Additionally, in these countries, poor access to fertility education and prenatal care prevents women from seeing doctors until labor, delaying treatment for pseudocyesis.  

The cultural premium placed on procreation in patrilineal, male-dominated societies creates an environment in which a woman’s socioeconomic value is closely linked to her fertility. Pregnancy and childbirth confirm womanhood, and those who struggle with infertility are often stigmatized. As a result, a woman’s fears of not achieving conception and the subsequent societal consequences may manifest in pseudocyesis. It is also worth noting that the polygamous practices of many traditional cultures allow men to abandon women who do not bear children, contributing to pressure to conceive. 

Legislation in these regions also reinforces the idea that having children is a woman’s sole source of social power. In Muslim cultures, a husband cannot lawfully divorce his wife while she is pregnant, and in Sub-Saharan Africa, a woman cannot share in her husband’s property until she has borne a child. Sadly, in developing countries, violence against infertile women is reported to occur in 10 to 60 percent of instances, exacerbating rates of pseudocyesis. 

Treating a woman for pseudocyesis requires holistic care for both physical and psychological symptoms, as well as a profound sensitivity to her mental state. The experience of delivering nothing during labor—real or not—can mimic pregnancy loss, and women who go through this are at increased risk for self-harm and suicide. 

There is perhaps no better illustrator of the pressing need for reform in these regions—of medical infrastructure, legislation, and sociocultural norms—than pseudocyesis. Interventions may be implemented on an individual, community, or public policy level, but progress will require a holistic approach that addresses all of these factors.  

Healthcare institutions should work to optimize treatment for each individual pseudocyesis patient. This may include recognizing concurrent mental health issues, such as depression or anxiety, and the unique situations that led to phantom pregnancy. Each patient’s causes and expression of pseudocyesis are deeply personal. Take Mrs. MN’s physical trauma, and her insecure and emotionally taxing relationship with her partner and his family. The multidisciplinary care required to resolve pseudocyesis can only be achieved through providers with the means and attitudes to specialize their approaches from case to case. 

This can be accomplished by improving the healthcare systems which remain sub-par in many developing countries. Adding more on-sight reproductive care providers in rural, isolated, or underprivileged communities would greatly improve access to prenatal care and treatment. In these institutions, increasing the quality and diversity of care offered — for example, employing both physicians and supportive psychotherapists — would not only result in more effective treatment of pseudocyesis, but would foster a more preventative approach to this condition and lower its incidence. In addition, all providers should be trained to recognize the signs of pseudocyesis. It’s especially important for such a complex and underresearched condition, in such high-frequency areas. 

Existing institutions such as schools and households can also work to decrease the prevalence of pseudocyesis. Increased and improved reproductive healthcare education and discussion on how to cultivate safe, secure relationships would likely prevent the factors that cause pseudocyesis from taking hold in future generations. 

Though it may be difficult, alleviating harmful sociocultural norms is essential in proactively managing the prominence of pseudocyesis. Community leaders can promote campaigns which aim to destigmatize infertility and promote gender equality in countries where these issues still adversely affect women. Public policy is perhaps the most powerful and concrete tool for this goal - the governments of these countries should abolish legislation that attaches the rights of women to their fertility, such as aforementioned sub-Saharan African property laws. These countries can also establish more rigid protection against violence and mistreatment toward infertile women, which may include instituting firmer legal consequences for these crimes. Lastly, public policy can intersect with reproductive healthcare reform. Governments can increase access to reliable pregnancy testing through mandates, or by supporting initiatives that provide these resources to communities in need. 

While pseudocyesis demonstrates the incredible capabilities of the mind-body connection, it also has real emotional implications for those who endure it and is a valuable window into the social struggles of far too many women like Ms. MN. With targeted reform to realize more accessible reproductive care and the means to gain social traction outside of motherhood, these women’s horrifying risk of pseudocyesis, as well as their status as second-class citizens, can be resolved for a more equitable future.