What’s Going On In There? The Developmental Work of Pregnancy

By Michael Trout, MA

“The connection between the pregnant woman and her developing fetus is perhaps the most profound but enigmatic of all the human relationships.”  (DiPietro, 2010, p. 28).

INTRODUCTION: It’s a story we sometimes overlook entirely. Even when we do ask parents about it, sometimes we don’t catch the drama, the power, and the meaning of it.  The story is about the beginning of life, and what is happening inside the three people who are having this most profound and unsettling experience.Of course, we’ve long known that pregnancy is anything but innocuous for the one most visibly affected — the mother — but even then, we can fall short in our wondering.We know how to look backward (“What happened in there?”) when there is, later, a problem with the baby, or with one or more of the relationships.What if we had a chance to back up (long before there are symptoms of a problem), slow down, and just wonder what sort of mental activity is brewing in there, and why? What’s the point of it all? Is it really a developmental progression?  What variables impinge on the progression?  How do the parts — mom’s state of mind, dad’s dreams, baby’s sense of self, mom’s imagination about who this baby is, and the everyday things going on around this trio — all fit together, while influencing each other?That’s the sort of wondering we get to do, in this article, the first in a series on the developmental paths of early life.I wish we had room to ponder dad’s inner work.  We know it’s happening, and we know it’s important.  We’ll have to consider it another time. To be clear:  It is wondering that we’re doing herein.  We’re not establishing rules for pregnancy, or even proposing an orderly set of stages.  We’re just proposing a way to think about it all, and to imagine some implications.

EXAMPLE #1   A crisis in a little northern Michigan town is featured in the national news.  A Farm Bureau employee in the southern part of the state inadvertently mixes a fire-retardant chemical into cattle feed. The feed is shipped north and fed to unsuspecting cattle. Soon, I pass stacks of dead cows beside barns as I pull in for home visits.  Polybrominated biphenyls are discovered in the food chain.  Word in the nearby farming communities is that this little-understood chemical might wreak havoc in the brains of humans, including babies.  Soon it will appear in breast milk.  Mothers hear about it, although they are mostly terrified to talk about it.

If Reva Rubin was right, in an article published about this time (Rubin, 1975), that one of the key developmental/psychological tasks of the pregnant woman is her seeking safe passage for her unborn child, then what does the PBB crisis mean to a pregnant mom in rural northern Michigan?  Has she — irrationally, perhaps, but no less profoundly — come to believe she is failing to protect her baby?  Will this unspoken belief influence her capacity to move forward into other developmental tasks of pregnancy, including those needed to promote a profound sense of maternal self-confidence and authority?  Will she be able to attach to a child she fears she has harmed? When father asks her why she seems so blue, so detached, will she be able to put any of it into words?

EXAMPLE #2   A baby is born to a mom still silently grieving the death of a previous child. The second baby was conceived just days after the death of the first one. Neither mother nor father has ever spoken of their shared loss; as a result, it seems to not actually be shared by the two of them at all.  They press forward, in silence, as if nothing has happened. Can parents attach to an unborn baby when their hearts are broken — especially when they deny it is so?

In her brilliant description of the maturational crises of pregnancy, Grete Bibring drew our attention to the “…intense object relationship to the sexual partner [which] leads to the event of impregnation, by which a significant representation of the love object becomes part of the self” (Bibring, 1961, p. 15).  The above mom now has two pieces of unconscious psychological/developmental work to accomplish: In a state of estrangement from her husband, she must still manage to internalize the impregnation, in which the “love object becomes part of the self” (Bibring, 1961, p. 15); and she must achieve sufficient resolution of her grief over the child who has just died, in order to access needed libidinal energy for her connection to the next pregnancy, the next baby.

Perhaps it’s too much.  Perhaps something will stand in the way of mom connecting to the new baby — or even accepting that she’s pregnant. The mother to whom this happened fell mysteriously ill immediately after the birth of the second child. She moved far away for a “recuperation period,” leaving her new son in the care of a stranger. Mom seemed unfazed by the separation. She had, indeed, come to the end of the pregnancy without finishing essential internal work.  She could — quite literally — not “face” her newborn, who would live the rest of his life with the psychological residue of his mother’s detachment.

After several weeks, a friend — horrified to discover that mother was making no moves to see her little boy — brought them together for a visit. Decades after that brief visit, in response to a request by this newborn as an adult and father-to-be, mother wrote to him of her memories of those moments of greeting: “I felt no inclination to sweep you into the embrace I’m sure all expected.  You looked very much as I expected you to look … and we examined one another with what I fancy was a quite neutral expression.”

Such breakdowns in the developmental work of pregnancy are often reparable. Parents play catch-up, and something allows many to “fix” the detachment or the depression that threaten life with baby. This particular mom never found her way back to her boy.  He stumbled into my office three decades later while awaiting the birth of his own firstborn son.

EXAMPLE #3  It’s not news when a mid-adolescent becomes pregnant.  We know something of the obvious risks — that she may go through the pregnancy alone and poor, that the normal narcissism of her own developmental status might deter her efforts to invest fully in the Other inside her — but what do we know about how this will all play out developmentally?

Pregnancy is never an “accident.”  Despite the pretense of many parents that they were uninvolved in the timing, it’s never true.  When and why it happens always has meaning.

For Becky, it was right after a family trip to see her grandmother in North Carolina. The trip immediately preceded not only the pregnancy, but a significant change in Becky’s school performance and mood.

Becky barely knew the boy-father, who was disinterested in her, and went on to impregnate another girl. While he evidently had no special meaning to her, the child growing inside her did. Sent to a home for unwed mothers, it was assumed Becky would give up her baby.  But she didn’t, even after discovering he was a boy. Her distance from him, throughout the pregnancy, was evident. At the delivery, one of the nurses took note of Becky sucking in her breath and mumbling, “Oh, no…” when she saw her newborn’s penis, even before she noticed his face. Nobody seemed to understand why she wanted to keep him when she felt so distanced from him.

I met her when she returned to our little town with her son in tow. She spoke often of her expectation that her son would leave her someday.  Males always did, or so her narrative maintained. Her father, I learned, had been a military man on the base near her grandmother’s house.  Becky’s mother had been a “townie.”  He showed little interest in the pregnancy for little Becky, and appeared to be relieved when he was shipped overseas right after Becky was born. Becky grew up in her grandmother’s house with her mom, but with no dad anywhere.It looked as if Becky might be repeating the pattern; another child would be born without a daddy nearby.

While I could not see it at the time, Becky began her interruption of the pattern by relinquishing custody of her son to her mother and stepfather before Jeremy was a year old. Her next step was to get pregnant again, this time with a military man. He was ordered to basic training at the base where her father had been 18 years earlier, so she moved back into grandma’s house.  She wrote me that her boyfriend had received orders to ship out, coincidentally to the same European country where her dad had been sent so long before.  She had pleaded with the base commander to change his orders. The father of her baby would stay.  They would marry.

In her very last letter, Becky said she had learned that her new baby would be a girl, and that it would “…all work out, this time.  I think you know what I mean.”

Sometimes the dynamics of pregnancy are awfully complicated, with the developmental work of pregnancy not completed for some years.


It would be unreasonable to assume that a living being as sophisticated and complex as an adult woman would treat the entrance of a human body into the insides of her innocuously, without noticing and responding.  “Noticing” and “responding” then become the work of pregnancy. In a flash, an expectant mother’s attention is riveted.  She is shaken. She does not just sit there.  She has work to do.  It will be sequential — developmental — but not perfectly so.


A key element of this early work is simply acceptance of the pregnancy.  This sounds easy enough, but it’s not automatic. It involves a developmental step.  It implies traversing a threshold into motherhood, which may be rife with worrisome meaning for some moms.  It implies an unfamiliar responsibility, the need to conserve emotional energy, and the acceptance of certain limits.

Something has come into mother’s body that did not use  to be there.  A certain resistance (not altogether unlike the natural rejection response of one’s body to a newly transplanted organ) must be overcome.  Mom must take note, her body must take note, and she must give permission.

For a young woman of rape, this may be a huge step. Already there was an intrusion of another kind.  Now she must somehow separate that intrusion (of the rapist’s body) from the part of himself he left behind.  She must find a way to reject the first while accepting the second.  This is a tall order.

Even without the violent or controlling intrusion of rape, merely the intrusion of the foreign body of the baby may be enormous for a woman who has never felt much control over her own body.

For a mom living in a war-torn part of the world, even allowing herself to consider that life is beginning inside may bring on anticipatory grief, as the likelihood is high that this new life will have a very short term indeed.

Under circumstances in which the safety of the fetus is more-or-less assured, however, mom will move forward (albeit unconsciously) toward acceptance of the intrusion of this “foreign body” (Bibring, 1961, p. 15), and incorporate it into her own. Mom and baby become one. (For this reason, death of the unborn baby in this early part of pregnancy may feel to mom like the death of part of herself.)

She will eventually reach through this haze of lack-of-identity and confusion and say, essentially, “Yes.” It’s an unconscious act, of course, this affirmation, this acceptance.  It’s not necessarily an act of acceptance of a person, yet, since little in the way of an identity is yet available.

This mostly-unconscious act of saying “Yes” may not be a one-time thing; the unconscious “decision” may be revisited several times.  As Lederman’s research showed us, acceptance of the pregnancy is not the same as acceptance of the baby, or of motherhood (Lederman, 1984, p. 17).  But accomplishing this first, delicate, unconscious act means her body can go on (instead of working to eliminate the intruder), and her mind can go on (tucking the fetus within so there is really no difference between that-which-is-mother, and that-which-is-baby — the safest possible place for baby to be, unless it isn’t).


We’ve always been eager to understand how a mother’s attitude toward her prenate affected his later development, and many of us entertained private theories, based on our clinical work, about such connections. But wantedness, per se, is not really the point of this description of mother’s developmental work of acceptance.  We’re not suggesting that the developmental work of pregnancy requires that all mothers reach a certain plateau of acceptance of the pregnancy, of the baby, and of motherhood.  There is reason to believe that these are separate kinds of acceptance, perhaps reached at different times, perhaps never equivalently in all mothers. Mothers are fully entitled to tons of ambivalence, mountains of giddiness and terror, and various acts of reliving the past and predicting the future through dreams and strange — but perfectly normal — flights of ideas.  Our purpose here is not to take the mystery out and find categories (much less diagnoses) for the normal work of getting ready.  Our purpose is to come to an appreciation of the nuance and complexity of what goes on inside. We’re not looking for pathology; we’re looking for an understanding of what this marvelous inner work usually is.


Having moved through acceptance of the intrusion of the foreign body, mom is now free to picture her baby; such imagining will constitute much of the work of the next developmental stage. Romantic notions aside, creating an identity for the being(s) growing inside may be tough, confusing, dismaying, complicated … and magical.

In this second developmental stage, the outlines of an identity begin to be formed in mother’s imagination. This may be an exhilarating time, as mother’s imagination infuses baby with the best-of-all-possible-characteristics from her own and her partner’s histories. For some moms, however, the door opens to worrisome thoughts:

  • “My mom demeaned me during my whole childhood for being fat. I think my baby is fat.  What will mom say when she looks at my baby?”
  • “I feel mad at him sometimes, even now. What if I just don’t like him?”
  • “What if he’s weird, like Uncle Joey?”

On and on it goes, this powerful developmental dance.  Thoughts are inconsistent and sometimes illogical.  Dreams are all over the place.  Ever so slowly, however, the notion of a person emerges.  It used to be that this developmental step — this emergence of an otherness —began sometime after quickening, after the baby announced herself suddenly and profoundly with a kick. But the near-universal use of routine ultrasound now pushes this second developmental step earlier in the pregnancy.  It can be joyful and affirming and real. Whatever else it is, it’s certainly far from innocuous.


Could it possibly be that mothers are obligated to say “good-bye” before they have fully said “hello”? In a sense, the answer is yes.

As moms traverse the winding and complicated road from being alone in their bodies to becoming mothers, it appears there are two acts of differentiation that — while usually accomplished with little effort or even conscious attention — seem, nonetheless, developmentally important:

  • The “…growth of the pregnant woman from the role of the ‘daughter of the mother’ to the ‘mother of her baby’” (Schroth, 2010, p. 4). In other words, mother separates herself from her own mother as part of her preparation to become the mother of her baby. It seems a significant and meaningful step. In order to feel her power as a woman and to create a new view of herself as an efficacious, capable, intentional mom in her own right, she must assert that she is no longer merely her mother’s child. She is a mother, herself, perhaps resembling her mom in some ways, but wholly distinct in others.
  • The shift from the unconscious perception of the baby as part of the Self to the perception of the baby as an Other. In other words, mother separates herself from the baby who was fused with her as part of her preparation to encounter him as a unique and distinct human being.  Attachment, by definition, relies on accomplishment of this developmental task; otherwise, we’re left with mother everlastingly confusing the baby with herself, while the baby remains confused about the boundaries between self and other.

Psychoanalysts Jenoe Raffai in Hungary and Gerhard Schroth in Germany developed a systematic facilitation for this final developmental work (Raffai, 1995 and Schroth, 2010).  Offered during the last weeks of pregnancy, the facilitation supports moms conversing with their unborns in ways that acknowledge the differentiation while opening up lines of communication that may be helpful during delivery, and may feel familiar to both mom and baby as they later begin to attach during the first postpartum days.  Schroth suggests that a kind of empathic “mirroring” (Schroth, personal communication) by the mother may support the unborn baby’s sense of being seen and known before birth.

Practical results of this facilitation showed up in outcome studies on deliveries in Hungary and Germany. In the first Hungarian cohort of 1,200 mothers who participated in such facilitations, the rate of premature birth dropped to 0.1% (compared to the average of 8%); the cesarean section rate dropped to 6% (compared to the average of 30%); and the rate of postpartum depression dropped to nearly zero (from the average of 15%) (Raffai, 1995 and Schroth, 2010).

French child psychiatrist Miriam Szejer suggested, “By the end of the pregnancy… the fetus and the mother no longer live by the same rhythms” (Szejer, 2005, p. 69).  I’ve come to believe that this is as it should be.

What a glorious conclusion to the amazing developmental/psychological work of pregnancy: to be able, at the end, to say “Goodbye” in the very service of saying “Hello.”


No one would be surprised if a mom whose last baby died might delay the very first developmental step (acceptance of the intrusion of the foreign object), when such acceptance —or even acknowledgment — might cause so much pain.  She may barely have begun the
“…reorganization of the survivor’s sense of self to find a new normal” (O’Leary and Warland, 2016, p. 3). A strong sense of her capacity to protect her unborn may now elude mom (as well as dad, in ways often invisible to most observers), which may lead to a disinclination to imagine that they are pregnant again. One researcher, with decades of experience interviewing and supporting families after prenatal or infant loss, reports that “…most parents entering a new pregnancy believe … that grief for the deceased child will diminish” (O’Leary and Warland, 2016, p. 6), only to discover that grief is actually resurrected by the new pregnancy. Understand that we’re not implying that a baby conceived after loss cannot be accepted, but only that the developmental work of acceptance may, quite naturally, encounter a bit of resistance.

The developmental work of which we speak may be complicated by the loss of one baby — a “vanquished twin” — while the other one remains, lying inside.  Mom now has the work of grief and the work of acceptance all at the same time. Sometimes a mom simply cannot simultaneously do both.  So she may, without ever noticing what she is doing, turn over the work of grieving the lost twin to her partner, or delay it entirely. (The remaining/surviving baby is, of course, witness to it all.)

Sometimes interference comes from the outside world. What if mom is preoccupied with a sense that she is physically at risk (due to domestic violence, for example)?  She needs emotional energy to do the developmental work of pregnancy, but that energy is being drained away.  She cannot revel in a focus on self (already — and normally — a bit muddled, with unclear boundaries between that-which-is-fetus and that-which-is-mother), because the context of ease and safety is missing. Essential self-indulgence feels absurdly inaccessible in this state of uncertainty and unease.

And on it goes, through the entire pregnancy.  To notice these challenges is not to suggest psychopathology.  It is to acknowledge how complicated the work is, which makes it more than a little awe-inspiring that moms somehow navigate these unconscious waters so well.  The aim of such understanding need not be the elimination of all challenges.  Rather, the aim might be to support more of it becoming conscious, which then gives the family access to the narratives that naturally arise.  For example, dad might later be able to say to his son: “Your grandma got very sick while mom was carrying you inside.  Mom was sad about it.  She didn’t get to just think about herself, and about you. That’s why we’re making cupcakes for her, and for you, today.  Today is about nothing except the two of you being together, with no worries.”

Or mom might explain this narrative to her pre-teen daughter: “You’ve always had to work extra hard to get me to let you go.  I know.  I’m sorry.  Believe it or not, we’ve been fussing about this since you were inside me.  You were ready to separate from me before I was ready to let you be your own little person. I heard you, but I couldn’t get myself ready to let you go. That’s probably why you were several days late in being born, and why I sometimes act goofy and scared when you want to try something on your own.  I get it. Sorry.”


Recent research teaches us that the growth of maternal self-efficacy (MSE) during pregnancy is an important inoculant against perinatal depression, and is a predictor of satisfaction with both the childbirth experience and with later parenting (Fulton, et al, 2012). Achievement of high levels of MSE does not result merely from being surrounded by cheerleaders, of course.* The formula for one’s perception of self-efficacy may include self-evaluation of one’s abilities in specific domains, but it may also include a range of internal perceptions, including long-standing self-narratives about one’s personal power and agency, and one’s “remembered care from their own parents” (Fulton, et al, 2012, p. 331). One of the joys of the developmental work that rests on delicious and healthy self-absorption is that these perceptions can be made conscious, can be mused upon, and can even be revised.  During some parts of pregnancy, some moms find themselves dreaming about events that haven’t been thought of in many years; calling family members from whom they have been estranged; asking their own parents surprising questions; looking at yearbooks and photo albums and otherwise digging into old memories and narratives — all part of a noble effort to pull together an efficacious sense of self.

* It doesn’t hurt, of course, to have one’s attributes and capabilities highlighted during and after pregnancy. But one study of the relationship between social support and MSE turned up an interesting finding: “…partner support was unrelated to both maternal self-efficacy and depressive symptomatology” (Haslam, et al, 2006, p. 286), whereas higher levels of parental support were related to higher levels of MSE.

Perhaps planning for the delivery, itself, can constitute a piece of developmental work.  We have seen mothers wrap themselves protectively around their bellies as they declare how they want the upcoming process to unfold.  Does maternal self-efficacy increase when a mother asserts herself in ways not previously associated with her personality?  Must we take note of the potential loss of self-efficacy when it does not go according to plan? French obstetrician Michel Odent affirms a truth felt by many women: “In the age of industrialized childbirth, the mother has nothing to do.  She is a ‘patient’” (Odent, 2002, p. 29).  Perhaps less scoffing at assertive women who are looking not only for a better start for their babies but for a greater sense of their own authority in the world might be in order.  As a mother prepares the way for birthing her unborn, maybe she’s also doing yet more developmental work.


It can be seen that the developmental work of pregnancy is not a one-off and may not be tidily sequential.  It builds on itself (thus the descriptor we’ve been using: developmental).  It may be messy and clumsy, moving in fits and starts, and it may be unnerving to partners, employers and extended family members (if not the mother herself).  But it has purpose and meaning. Decks are cleared, issues revisited (if not resolved), hopes investigated, fears aroused anew (perhaps so they can be put to rest — or, at least, put into storage for a bit). Mom gets a chance to greet herself, to re-invent herself, to meet parts of herself she had forgotten.  She gets a chance to feel integrated, even as she may worry that she’s falling apart.  She gets a chance to feel powerful, even in the face of so much inner challenge, with more to come.

Guess who benefits from all of this?

One final reminder: This clumsy, dramatic, mostly unconscious work is not being done in private. There is a witness.  Certainly it’s clever for evolution to work this way, with baby and mom communicating throughout the pregnancy about who she is, about life outside, about what the baby can expect. It means that — irrespective of her conscious intentions — mom “talks” to baby; if it’s not her words, it’s her endocrine system, giving information about her heart, her state of being, her reactions to things she’s seeing or thinking about or feeling.  The baby, of course, is a perceptive listener, retaining the messages (while undoubtedly getting the meaning of some of them all wrong).

In the end, we see that there’s meaning in every last bit of this powerful, mostly unconscious developmental work of pregnancy.

List of References, Suggested Reading and Study Questions:

What’s Going On In There? The Developmental Work of Pregnancy – References and Study Questions