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Identifying existential concerns as an analytical tool: a response

Dear Editor I am writing in response to the article EPC 2020 31 no 2 180 ‘Identifying existential concerns as an analytical tool: an eye opener for the doctor.’ This was an excellent article, and I can speak from experience in UK General Practice, that using Yalom’s concepts of existential pressures can greatly inform all manner of consultations [1]. However, I would like to add pregnancy and childbirth as a fifth existential issue that is often overlooked, perhaps because Yalom, being male, was slightly removed from the implications. While death applies to all of us, the issues of pregnancy and childbirth create additional existential pressures that have powerful effects on women, while also having an impact on some men. No woman experiences pregnancy lightly. Whether pregnancy ends in therapeutic abortion, miscarriage, stillbirth or a healthy child, a woman has to face new existential challenges. How will she reconcile her own wishes and the requirements of pregnancy? How shall she deal with the idealisation of motherhood when contrasted with the relief she may feel after the termination of an unexpected and unwanted pregnancy? How will a woman balance her own needs with those of her child? If she suppresses or ignores her own needs is that a healthy message for her child to learn? When caring for young children women may face many losses; their previous work and career may take new forms or be lost altogether. Women may face new financial dependency or even domestic abuse, while their own options are constrained by the responsibilities of childcare and reduced earning power. A mother may feel trapped in a loveless or abusive relationship if she cannot be sure of supporting her children if she leaves. In addition, pregnancy and childbirth bring genuine fears of death (even in the prosperous west). Will mother and baby both survive? Childbirth creates permanent changes to the body, and ongoing health may be compromised after a difficult birth or by effects on mental health. A new mother may become isolated as previous work or social relationships become harder to maintain. Breastfeeding can create wonderful bonds, while some women also feel chained down, or fear they have failed if there are feeding problems. The male role in pregnancy and childbirth is also continuously changing and with changing social expectations many men also face existential challenges as they struggle to reconcile their caring, provider and partnership roles. The very definition of motherhood itself has been questioned when Transexual people have given birth, while selfidentifying as male or as fathers rather than mothers. Asking parents to be, or new parents, how they are experiencing their new roles, what tensions it has created for them and encouraging ventilation of the resulting emotions can be very helpful and more useful than labelling such concerns as ‘post-natal depression’. The consultation skills required to do this include being able to empathise, to pick up clues and cues about patients feelings and having some skills in therapeutic conversation. Allowing ventilation of difficult feelings can bring much relief, and as the authors correctly point out, allow the doctor to appreciate their own role as ‘Don’t fix it, just be there’. Thus, I would add ‘pregnancy and childbirth’ to ‘death, freedom, isolation and meaninglessness’ as one of the existential givens of existence. Primary Care clinicians who explore these issues can provide much relief for their patients.