Becoming a Trauma-sensitive Birthkeeper
Midwifery Today, Issue 138, Summer 2021.
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Traumatizing childhood experiences can affect a woman’s attitude toward pregnancy and birth. Trauma-informed care can build a link between the client’s trauma history and current concerns. Understanding how childhood sexual abuse or a history of childhood trauma affects pregnancy, labour, and birth can help the caregiver identify possible signs and triggers. This in turns facilitates an aligning of care with the individual needs and concerns of clients, in order to transfer them to the state of ability and competence. This perspective allows us to bridge the gap between clinical standards and the individual needs of pregnant women and women in labour who may have a history of trauma. Using these insights, we aim to create psychosocial perinatal care that has positive outcomes in all bio-psychological domains.
Working with women in a very difficult period as a doula and counsellor, I see it as integral to not neglect the unresolved effects of the past on the needs, behaviour, and emotions of my clients. While some of my clients are open, have a positive view of the future, and are filled with joy, others are tied to their old traumatic experiences and belief systems. As a result, the latter often consequentially struggle to open up to this new experience of pregnancy when faced with an impending birth.
Perhaps you can recall past clients who were stressed, restless, unwilling to “cooperate,” and lacking in trust of clinical staff or her partner. Or clients who did not want to be examined, desired detailed instructions for a birth plan, had a great need to be in control, had trust issues, and were on the path to reaching self-determination.
I was looking for a good method of care to address these issues, not only because I love challenges, but also because I recognized a need in my customers. So, I found myself in Seattle with Penny Simkin and Phyllis Klaus. Yes, Penny Simkin, a world-renowned childbirth educator, doula, and co-author of When Survivors Give Birth, together with Phyllis Klaus, psychotherapist and counsellor.
Maybe you are thinking right now: it’s not your subject. Even if sexual abuse is not as rare as previously thought in the past, you may never have heard from a client that she is a survivor. You may have thought or suspected several times that your client might have survived childhood sexual abuse, but she never told you that. Maybe you asked and she denied it.
In fact, just a small percentage of survivors disclose this information to another person—and often only after a long period of building trust. About 90% of childhood sexual abuse survivors knew their attacker and more than 30% of attackers were family members (Simkin and Klaus 2004; Sperlich and Seng 2008). That’s why many childhood sexual abuse survivors have difficulty establishing trusting relationships. “If we reluctantly accept that more than one-third of sexually abused children are abused by a family member, sometimes a family member they are being raised by and are dependent on for their basic needs, we can certainly understand why that child (and eventually that adolescent or adult) would have difficulty trusting people who are supposed to be trustworthy. And yes, that includes their doula …” and also their midwife (Shelley 2015).
Childhood sexual abuse is not the only contributor. Childhood trauma can cause similar triggers. Many of the clients I have advised have had a history of childhood trauma. Most of them were hospitalized as small babies or children in an intensive care unit, had a history of pain trauma, or had a major surgery. Sexual abuse is just one of many factors that shapes a child’s or adolescent’s development. Very often it is not possible to isolate its effects from all the other influences one encounters in her lifetime. Traumatizing childhood experiences, whether remembered or not, affect women’s attitudes toward pregnancy and birth (Bass and Davis 2008).
It can be especially challenging or retraumatizing when the body remembers the trauma. Survivors of childhood sexual abuse learn that the world, and their bodies, are not safe. This is completely different from children who are protected and nurtured, who learn to feel satisfaction and pleasure and simply to feel at home in their bodies. For abused and traumatized children, their body is a place where very painful and frightening things happen, so they are very often cut off from or learn to leave their bodies in order to avoid these feelings (Bass and Davis 2008; Rothschild 2017; Levine 1997).
Many childbearing classes, caregivers (midwives, doulas, obstetricians), and hypnobirthing coaches often use well-meaning guidance such as “trust your body,” “do what your body tells you to do,” “bring up your basic trust,” “open up,” “surrender,” or just “relax.” These suggestions may bring up old memories, reminding survivors of their sexual abuse. Because they were cut off from their bodies due to the trauma, survivors often feel physically inadequate. Even if the abuse happened in the past, the sensations and thoughts associated with the abuse are relived in the present (Levine 1997). This can often result in a strong desire to avoid becoming a victim again, leading to a fear of losing control. The abuse (as well the trauma) interrupts their process of developing positive self-esteem. Instructions like “open up” can therefore be detrimental to survivors because they are unable to do so. Alternatively, if one does indeed open up, she may lose control, which produces feelings of shame and inadequacy as a result of the abuse (Bass and Davis 2008). Or she is simply not in a position to feel safe enough to do so. When we build our techniques and methodology without identifying the concerns and needs of our clients, who may have experienced childhood sexual abuse or other childhood trauma, we may inadvertently bring up these feelings or sensations in a space that neither the caregiver nor the client can effectively deal with it. It also can cause discord in the caregiver-client relationship and you risk your client not being able to feel safe with you.
How can a midwife, doula, or educator on childbearing make a difference? With or without any knowledge about a client’s history of sexual abuse or other trauma? With or without disclosure?
For me it was essential to understand this wide range of concerns by taking into account the impact of childhood sexual abuse on pregnant women and women in labour. “Survivor stories” are a very good resource to understand and address, in a trauma-sensitive way, the issues that result from a history of abuse that arise in pregnancy or during the labour. Listening to the survivors and their concerns can provide you with an idea of what the underlying reasons are as to why your client is “untrusting” or “craving control.” Maybe it will completely change your mind about your clients and you’ll start to ask yourself: “How is something, which happened in your past, affecting you?” instead of “What is wrong with you?” or “What happened to you?” This shift can help you identify your client’s priority needs and provide her the optimal treatment (Seng and Taylor 2015).
“You should instead listen to the music behind the words” is Phyllis Klaus’s favourite piece of advice, and everybody who has taken a When Survivors Give Birth training course would agree. Now, after working with many women through this point of view, I acknowledge how wise it is and how much it helps me to look at the needs and concerns of my client in a different, trauma-sensitive way (Simkin and Klaus 2004).
“All suffering is bearable if it is seen as part of a story.” Isak Dinesen
The knowledge of possible signs and triggers that might indicate childhood sexual abuse in the woman’s history will allow you to improve your care with every client and help you to be a “trauma-sensitive” birth partner for everybody, without needing information or additional disclosure about her history. Penny Simkin and Phyllis Klaus teach their students to ask: “Would everything that I see, hear, and feel with this client seem more natural or understandable and make more sense if she were, in fact, a childhood sexual abuse survivor?” (Simkin and Klaus 2004).
To do this, you need to pay attention to the signs and identify potential triggers based on the concerns or fears the woman may express—no matter what’s behind it or what had happened in her past. By doing this, you will start to look differently at your client and her concerns. Furthermore, she will also become more comfortable with you, with this new openness and without your need for information about what she may be trying to hide. In case the triggers do arise, it is advisable to be prepared in order to reduce the risk of a traumatic birth experience.
An understanding of the impact of childhood sexual abuse on pregnant women has taught me a lot about the concerns and challenges pregnant women and women in labour face. As their doula I cannot treat these concerns or their sources. What I can do, however, is to support my clients in establishing individual coping strategies, comfort, and empowerment elements.
Trauma can have an overwhelming impact on a person’s integrity. It brings the nervous system into a “fight-or-flight” mode or, alternatively, leads one to just “freeze or skip out of the body” and “dissociate.” When behaviour, emotions, impressions, and meanings are linked to the stage of “I cannot” or “I must,” there is no other possibility or alternative to feel or to act (Levine 1997).
Medical birth support has fixed structures, standardized procedures, and guidelines for medical safety and security. These often cannot be reconciled with the personal and very individual needs of traumatized women. When I meet with a new client, she very often already has an idea about what she doesn’t want in her labour and what the setting should look like. Yet, this is often simply a dead end, a thought trap. It is important to know one’s own preferences, but with a clear list of “dos and don’ts” there is less space for the expertise of the midwife, for alternatives, and one’s own ability and flexibility. Working out alternative strategies to the “don’ts” was one of the most important issues I’ve learned with Penny Simkin and Phyllis Klaus and their When Survivors Give Birth methodology. Especially for women with a history of trauma, it is even more crucial to regard all options for action and as well to communicate these options and alternatives to standardized procedures to the midwife. Informing a woman about her own ability helps meet her needs, so that everyone can walk this path together.
I believe in post-traumatic growth and the impact of birth experience on it and on the self-esteem of every woman. My clients have taught me: They know best. They know best what they need right now. When I listen to their concerns, they tell me about their abilities and coping strategies, which often need to be discovered first. Increasing the capability of survivors and every single woman is a part of the renegotiation of trauma—away from “I cannot” or “I must” to “I can.”
I hope from the bottom of my heart that doulas, together with midwives, obstetricians, and gynaecologists, will together take part in building “trauma-sensitive” support systems that traumatized women and survivors of childhood sexual abuse need.
You can find more about the specific maternity triggers and signs for trauma in the book When Survivors Give Birth by Penny Simkin and Phyllis Klaus, or by attending their training, which is now also available in Europe.
- Bass, Ellen, and Laura Davis. 2008. The Courage to Heal: A Guide for Women Survivors of Child Sexual Abuse. New York: Collins.
- Levine, Peter. 1997. Waking the Tiger: Healing Trauma. Berkeley: North Atlantic Books.
- Rothschild, Babette. 2017. The Body Remembers, Volume 1 & 2. New York: W. W. Norton & Company.
- Seng, Julia, and Julie Taylor, eds. 2015. Trauma Informed Care in the Perinatal Period. Edinburgh: Dunedin Academic Press.
- Shelley, Selena. 2015. “Trauma to Triumph—Why You Shouldn’t Ask: Tools for working with Pregnant Childhood Sexual Abuse Survivors.” International Doula Magazine 23(3). Chicago: Dona International.
- Simkin, Penny, and Phyllis Klaus. 2004. When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse on Childbearing Women. Seattle: Classic Day Press.
- Sperlich, Mickey, and Julia Seng. 2008. Survivor Moms: Women’s Stories of Birthing, Mothering, and Healing after Sexual Abuse. Eugene, Oregon: Motherbaby Press.