Birth trauma, sexual abuse and trauma-informed care.

I’m always deeply touched every time another woman* shares her story with me, often because the level of trust that this requires, but also that sharing what awful things a person has survived is difficult and painful.

I have just started to sit on a sexual abuse forum locally and this has been intensely powerful and also wonderful to see the amazing work being done to support those affected. Of course, I was there to raise awareness of the relationship between sexual abuse and the maternity experience and how this sadly is an area where women are often let down in their care.

I have also this week heard the stories of a few women around their experiences in birth from different perspectives including previous historical sexual abuse, recent rape and birth trauma. This led me to a place of many emotions but also self-reflection on my own experiences. It became apparent to me that as women we are so often expected to accept medical procedures as needed, even without consent. That women and our bodies are not given the respect they deserve, be it in close intimate relationships or in other settings such as healthcare.

I recalled examples of this personally that have troubled me before but I guess I had allowed to be excused due to what was deemed medical need.

After the birth of my first daughter I remember waking up in HDU and being thankful for being alive. I had no idea what had happened to me in theatre and the information wasn’t willingly shared by those over my care. I recall wondering why I wasn’t wearing any sanitary protection and asking the staff who also seemed perplexed. I remember being asked to open my legs for two staff to look, prod and poke. As it turned out I had been ‘packed’ due to the PPH and internal stitching from the surgical manual removal of my placenta. Without warning the nurses decided to remove the packing and the in situ catheter, no consent was sought, it was just done while I lay there in agony. I remember how matter-of-fact this was for the staff but how confused, vulnerable, battered and bruised I felt both physically and emotionally.

Several days later once I was on the postnatal ward, a knock on my door and in walked my consultant with a number of student doctors in tow. I remember lying there still unable to walk, black and blue from the attempts to keep me alive in theatre. I was discussed like I was invisible, that was until the consultant wished to share the marvel of my surgery and how they had ‘stitched me back together’. I was again asked to open my legs for the interested students to peer at my healing vagina. The only words addressed to me were, ‘to let them look at my wounds’ and ‘that at least I had survived and this was what mattered’.

This then led me to think about some years later when I needed to go into hospital for laparoscopic surgery. When I awoke from the surgery I was met with intense pain down below and was confused as to why. Upon asking the nurse I was informed that they had also carried out an internal vaginal examination and taken a biopsy. I hadn’t consented to this, no one had mentioned that a vaginal examination may be done and I left feeling uncomfortable and confused. It greatly set off my PTSD as it was reminiscent of my birth experience and it troubled me that things had been done to me without my knowledge and consent.

Sadly I hear this so often from the women I support. That they felt procedures done to them, forced on them, often without consent. How the explanation for this is that it was medically needed or was to help with the delivery of their baby.

It staggers me that we accept this as ok. The belief that women’s bodies can be treated this way and this is part of both pregnancy and birth but also other care they receive. I could honestly name more times that I felt this has happened to me, sometimes via dismissal of what I was suffering or that I was expected to undergo examinations and to just put up with it.

What echoes in my mind are the feelings that these experiences evoke. Fear, panic, loss of control. Feeling vulnerable, unable to prevent what was happening or not being able to consent. To being stripped of dignity, feeling intimidated and coerced. These are what lead to trauma. I’ve heard time and time again how women at birth have felt violated, manhandled, held down and had things done to them against their will. The same language is used when talking about sexual abuse.

What is even more disturbing is no one ever asked me about my previous life experiences, to see if I had a history of abuse or rape.

“I had midwives hold me down, one on each side as they pulled my baby out of me. As screams escaped my throat I was transported back to that dark night, to the pain and the violation. To a face before me of my rapist and I lost myself again.”

With 1 in 5 women suffering sexual assault, many women already carry the pain of trauma. Many of these will also carry the pain of childhood sexual abuse or exploitation. What does this mean for maternity care? That it needs to be trauma-informed. Both to prevent trauma and also to provide care that doesn’t re-traumatise or trigger previous trauma.

What does it mean to be trauma-informed?

It means an awareness;

That traumatic events are those in which a person is harmed, where there is a serious threat of harm, or where the person sees someone else being harmed.
Trauma is widespread, and many people in our society are exposed either to traumatic experiences themselves or will be in contact with people who have been affected by trauma.
That trauma can be a once event or repeatedly. That it can happen between people. (childhood sexual abuse, rape, domestic violence)
That it involves an overwhelming sense of threat and danger alongside a breach of trust, coercion, lack of control, powerlessness and domination.
The kinds of experiences that are traumatic and we can identify the types of situations that can trigger memories of the trauma and associated feelings.
That a person affected by trauma might understandably want to avoid people, places or situations that remind them of the trauma and associated feelings.
That trauma can affect a person’s mental health, physical health, capacity for learning and life chances.
That trauma can affect a person’s ability to access the care, support and treatment they require in a range of settings such as physical health, mental health, education, employment or housing. That this may be reflected in how they respond in certain situations.

It also shows the need for compassion and dignity in maternity care. In the need to gain consent. For not expecting or forcing women to undergo examinations or procedures. That there is clear communication and informed choice. That care is informed by that woman and her past experiences.

This applies too to all aspects of care. Be it breastfeeding support, postnatal checks or mental health support. Being trauma-informed means asking for a woman’s permission before supporting her to place her baby to her breast. It means awareness of her feeling vulnerable or uncomfortable with the removal of stitches or smear tests. I once had a woman tell me how her midwife had slapped her and told her to stop being a baby while removing her C-section stitches. Little did the midwife know that as a child this woman had been repeatedly slapped and told she was stupid. It also means that when offering mental health support we are conscious of how and where this is offered especially concerning birth trauma. That it does not re-traumatise or is dismissive of present or past experiences.

For women with a history of previous sexual abuse, their care should reflect what they individually need. What she has requested so as not to trigger her and that keeps her emotionally safe at such a vulnerable time.

Of course, we need to also remember that most women will not reveal that they have been victims of abuse. So trauma-informed care should be in everything we do. From scan rooms to delivery rooms, from receptionists to consultants.

I am humbled every day to support women after birth trauma, to hear their stories, and to see their strength in the most distressing of situations. They continue to inspire me to make sure their voice is heard, that support is trauma-informed and we continue to improve our maternity care keeping women and families physically and emotionally safe.