Trauma-informed perinatal healthcare for survivors of sexual violence.

Introduction

Pregnancy, childbirth, and the postpartum period are often filled with unexpected challenges for birthing parents. For survivors of sexual violence (SV), the perinatal period can be especially stressful due to the overlap between bodily sensations experienced in SV and pregnancy, childbirth, and perinatal care.^1,2 However, the perinatal period can also be a time of remarkable growth and resilience for those survivors who are able to experience childbirth as life-affirming, empowering, and healing. In some cases, the difference between a birthing experience that is re-traumatizing and one that is healing could be determined by the sensitivity and awareness of perinatal care providers.¹ Obstetric providers are uniquely situated to bolster the resilience of SV survivors by providing care that is trauma-informed and responsive to the needs of birthing survivors.

The most comprehensive trauma-informed care (TIC) framework was pioneered by the Substance Abuse and Mental Health Association (SAMHSA) and the National Center for Trauma-Informed Care.³ The goal of TIC is to create a healthcare environment that is safe and healing by integrating an understanding of trauma and trauma-related sequelae into routine practice. The TIC framework has been successfully implemented in primary care, pediatric, and mental health care settings;^4–6 however, there have been few studies to empirically study implementation of TIC in perinatal care settings. Long before the development of the TIC framework, midwives recognized the importance of providing sensitive care for survivors of SV; and clinical researchers have identified key aspects of perinatal care to address with trauma-informed practice.^1,2,7,8 Although more research is needed to establish best practices and perinatal-specific tools, the TIC approach offers a useful conceptual framework for a systemic integration of this clinical wisdom and empirical knowledge.

The Substance Abuse and Mental Health Association proposes four key assumptions for the provision of trauma-informed care, also known as the four “R”s: Realize the widespread nature of trauma and potential for recovery; Recognize the impact of trauma and how it manifests; Respond by integrating understanding into policy, practice, and procedures; and actively Resist re-traumatization³ as described in table 1:

Table 1.

Key ingredients of SAMHSA Trauma-Informed Care.

Key Assumptions	Key Principles
1. Realize the widespread nature of trauma and potential for recovery.	1. Safety (privacy, comfort)
2. Recognize the impact of trauma and how it manifests.	2. Trustworthiness and Transparency
3. Respond by integrating understanding into policy, practice, and procedures.	3. Peer support
4. actively Resist re-traumatization.	4. Collaboration and mutuality
	5. Empowerment, Voice, and Choice
	6. Cultural, Historical, and Gender considerations
	(Source: ref 3)

This column will outline the four “R”s by reviewing the most relevant literature on SV and perinatal health, presenting the conceptual basis for trauma-informed care in the perinatal period, and providing concrete suggestions for integrating trauma-informed care into clinical practice as an individual clinician or clinical team.

Perinatal Trauma-Informed Care: The four R’s

Recognize the widespread nature of sexual trauma

In the United States, one in three women and female-bodied individuals have experienced sexual violence involving physical contact during their lifetime, and one out of five will experience completed rape.⁹ Although SV affects people from all backgrounds, women who identify as multiracial (49.5%) and American Indian or Alaskan Native (45%) experience sexual violence at particularly high rates.⁹ Additionally, female-bodied Lesbian, Bisexual, transgender, and queer (LGTQ) individuals are at especially high risk for sexual violence (43%−47%),¹⁰ and rates are highest for members of the transgender community who identify as people of color (53%−65%).¹¹ It is common for women who have a history of SV in childhood to also experience SV or intimate partner violence later in life,¹² leading to further trauma exposure. Given the high rates of SV within the US population, and especially among female-bodied people of color, SV presents a formidable challenge to maternal health.

Recognize the impact of sexual trauma and how it manifests in the perinatal context

Researchers have demonstrated an increased risk for pregnancy-related health conditions such as pelvic pain, cervical insufficiency, pre-term birth, and low birthweight associated with childhood experiences of SV.^13,14 Sexual violence may exert effects on perinatal health by way of the hypothalamic-pituitary-adrenal (HPA) axis, which can be altered by early life stress.¹⁵ In line with this theory, studies have shown that pregnant adults with histories of childhood SV exhibit atypical cortisol trajectories¹⁶ and thyroid function.¹⁵ The adverse perinatal health effects of SV can be compounded by other forms of stress, such as exposure to community violence, discrimination, inter-generational trauma, poverty, and other adverse childhood experiences.¹⁴ In addition to SV, black female-bodied people are disproportionately exposed to all of the aforementioned stressors due to interpersonal, institutional, and inter-generational racism in the US, which contribute to the disparities observed in maternal mortality and infant outcomes.¹⁷

In addition to the adverse health effects associated with SV, many SV survivors experience trauma-related distress related to pregnancy, childbirth, and perinatal care. Some pregnant SV survivors report that pelvic pressure or pain, fetal movement, and body changes trigger stressful memories of SV. Perinatal care procedures such as endovaginal ultrasounds, frequent physical examinations of breasts and genitals, and other invasive procedures, coupled with a heightened sense of vulnerability, lack of privacy, and lack of control, can provoke painful memories of past trauma. During childbirth, survivors of SV are at risk for experiencing birth as re-traumatizing,^18,19 and are twice as likely as those without SV to experience postpartum post-traumatic stress disorder.²⁰ Black women who have experienced past SV are at especially high risk for perinatal posttraumatic stress disorder (PTSD), with rates of PTSD in pregnancy almost five times higher than White women with SV.²¹ The increased risk for perinatal mental health challenges and birth complications for survivors of SV indicates the importance of addressing SV in the perinatal period to improve health outcomes for all birthing individuals, and most importantly for people of color who face the highest risk for poor maternal outcomes.

Respond and Resist re-traumatization: Policies, procedure, practice

Trauma-informed care practices integrate an understanding of the nature and effects of trauma into routine practice. Due to the nature of perinatal healthcare; the inherent vulnerability, lack of privacy, and lack of control; it can be particularly difficult to address trauma-related concerns in this context. However, this is precisely why it is critical to do so. With awareness, clinicians can modify procedures in order to promote safety, privacy, comfort and a sense of control while decreasing the risk of provoking trauma-related distress. All TIC practices aim to promote safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice, and choice; and recognize cultural, historical, and gender considerations.

There are two strata of TIC: 1) universal precautions, which are applied to all patient interactions; and 2) trauma-specific services which are tailored to individual patients with identified trauma histories. Due to the scope of this column, the discussion will focus on TIC universal precautions because it can be applied to every patient interaction.

Universal precautions focus on modifying procedures in order to increase patient’s sense of safety, trust, empowerment, and sense of control. TIC universal precautions do not deviate radically from standard care, and many clinicians already incorporate aspects of TIC into their practice. Trauma informed approaches to care include the elements as described in table one. These basic principles may be applied to any clinical interaction (see Table 2 for example recommendations of universal TIC practices). For example, in order to promote a sense of safety, which involves comfort, control, and privacy, clinicians can cover patients between procedures, limit the number of people in the room at any given time, and attend to and address signs of patient discomfort. In order to empower patients to use their voice in clinical encounters, the clinician can give the patient the power to give the “green light” and “red light” for all procedures. By doing this, the clinician makes it abundantly clear that the patient is in control and that their voice will be respected. This removes the hesitancy that many women have, especially women of color and SV survivors, to interrupt a clinician out of fear of disrespecting the clinician or being viewed as a “bad patient”. Whenever possible, clinicians can introduce themselves and discuss upcoming procedures while the patient is fully clothed, which communicates respect and collaboration.

Table 2.

Example Recommendations for Universal Perinatal TIC Practices.

• Give the patient control of the “green light” and “red light” to start and stop all procedures.

• Whenever possible provide an option of a female provider.

• When entering a patient room, introduce yourself and the upcoming procedure at eye-level.

• Invite patient to have support person in the room.

• Start with the least invasive methods of labor induction.

• Limit vaginal and breast exams.

• When possible, limit the number of people in a procedure room at any given time.

• Only ask the patient to remove clothing items necessary for a given procedure.

• Cover the patient between procedures.

• Avoid opening the patient’s legs, and instead invite the patient to open when they are ready.

• Provide a full description of any procedure in advance, including potential discomfort and any alternative procedures.

(Source: ref 2, 3, 7, 8, 18)

Approaching patients with awareness of gender and cultural considerations is a key aspect of providing TIC. Because the vast majority of SV offenders are male,⁹ many SV survivors may not feel safe with a male provider even if a female chaperone is present. Therefore, providing an option for patients whenever possible can strengthen patients’ sense of control and safety.⁸ It is also important to consider race and culture in order to provide TIC. For example, many women and female-bodied people of color have the experience of not having their voices heard, both out in the world, and in healthcare. Research has demonstrated that medical providers on average rate the pain of patients of color lower than that of White patients, and treat the pain of patients of color less aggressively,²² Additionally, people of color may find it difficult to trust healthcare providers due to a legacy of discrimination and maltreatment by the medical system.²³ Therefore, it is crucial to take into consideration one’s own identity as a clinician as well as the identity of the patient in clinical interactions in order to provide care that is informed and responsive to each patient’s needs. Intentionally inviting patients to voice concerns, actively assessing pain and discomfort, and responding with contextual understanding to patients’ lack of trust are essential components of a trauma-informed approach to care.

Conclusion

By observing TIC universal precautions, clinicians are able to provide care that resists re-traumatization and promotes resilience regardless of whether the patient has disclosed a history of trauma. For many clinicians, aspects of this TIC model are already part of routine practice, at the same time it may be helpful to consider ways in which current practices could be further improved using this framework. More research is needed to identify the most appropriate tools, strategies, training approaches, and resources for SV screening and trauma-informed perinatal care. It is likely that TIC is most effective when it is implemented on a practice-wide level, however each individual clinician can have a positive impact on patients’ experience of perinatal care and childbirth by practicing universal precautions. TIC would likely improve care for all patients with or without histories of trauma, but for patients with a history of SV, these practices can make the difference between experiencing childbirth as one of the most joyful life events or reliving the most horrifying moments of the past.