I remember her well: She was attractive, physically active and strong, with a vibrant personality. Along with her husband, she was the hardworking co-owner of a successful small business. She was bilingual and tri-cultural, and she was pregnant for the first time in her early forties after an IVF treatment. She wanted private childbirth education classes at home and a home waterbirth with midwives. She brought all her life experience to her commitment to have a safe, loving birth for her baby. She was also a survivor of childhood sexual abuse and she knew she was afraid of pushing.
To prepare for the birth, I met with her weekly. She did not talk in great detail about the abuse she had experienced in childhood. Instead, she focused on learning strategies to help her through labor and birth. As her due date drew closer she still felt fear, but she also felt prepared.
When she started labor, she called me and I came over. She labored actively and progressed well. At one point, when the baby got into a posterior position, she worked with me in a hands-and-knees position as I used a rebozo to help turn the baby. Shortly after the baby turned, the mother was complete and ready to push. She wanted to get in the birth tub, but she didn’t because it seemed likely the baby would come very quickly if she did. I called and asked the two other midwives to come over and help. When they arrived, one midwife did a quick vaginal exam to confirm that she was completely dilated, but after that check, progress stalled. For five hours.
I prayed. What could I do? The baby seemed to be so close and yet so far. In answer to my prayer, this is what I heard: Help her push.
I supported her to the bathroom to labor on the toilet. The other members of the birth team stayed in another room. As she was sitting there, I said maybe we could use visualization to help us. She agreed. So I said in an encouraging whisper, as she contracted, “Imagine you are pushing the sun into the sky!” As I said this in the darkened bathroom with just the two of us, she began to really push for the first time in hours. I repeated this mantra, she pushed with each contraction and the baby descended. Then she made one of those deeper, more guttural sounds that suggest to every midwife that the baby is getting close to emerging.
One of my sister midwives heard that sound and peeked her head in the door. With a small flashlight in hand, she crouched down beside me and looked between the mother’s legs. The baby’s head was visible! Immediately she reached out to support the baby’s head. The mother said she wanted to deliver in the birth tub, not on the toilet. So the three of us helped her move, gently supporting the baby’s head as we walked to the birth tub. Once there, she got in and pushed her baby out in the water. Within minutes, the 8 lb 5 oz baby girl was laid peacefully on her mother’s chest and the mother looked at her curiously.
Childhood Sexual Abuse:
Statistics, Symptoms, and Psychological Coping Strategies
Research suggests that one in three women in the US experience childhood sexual abuse before the age of 18 (Center for Family Justice; WHO). This can result in symptoms of post-traumatic stress disorder (PTSD), including fear, hypervigilance, the need for control, anger, depression, dissociation, nightmares, flashbacks, shaking, chronic pain, and being easily startled (APA DSM IV and DSM V). To endure the abuse in her childhood, the girl often uses one or more psychological coping strategies to survive:
- denial (“It didn’t happen”)
- repression (“I don’t remember it happening”)
- dissociation (“I wasn’t ‘there’ when it happened”)
- ignoring (“I won’t think about what happened”)
- minimizing (“It doesn’t matter that it happened”)
- deflection (“I’ll re-direct questions about what happened”)
- humor (“Isn’t it funny how that happened?”)
When a woman becomes pregnant, she may or may not have faced the truth about the abuse that happened to her in childhood. But cues or triggers that recall painful memories may increase in childbearing because pregnancy, birth, and breastfeeding are sexual experiences that have aspects to them that the woman cannot control, that may violate her will, and that may be painful in ways that sharply remind her of the abuse.
Midwifery Model of Care: Supporting Childhood Sexual Abuse Survivors
Midwives are well-equipped to support childhood sexual abuse survivors. That’s because the midwifery model of care affirms the pregnant woman’s rights to autonomy, self-determination, and informed consent or refusal. This is in contrast to what survivors experienced when they were abused. Sadly, it is often in contrast to the mainstream medical model of birth as well. Given the respect and empowerment fostered by the midwifery model of care, it should not be surprising that many sexual abuse survivors seek out midwives during pregnancy.
How can midwives most effectively support childhood sexual abuse survivors? First, it is important to learn about childhood sexual abuse and its effects on childbearing women. Two excellent books that can help with the learning process are Simkin and Klaus’s When Survivors Give Birth (2004) and Sperlich and Seng’s Survivor Moms: Women’s Stories of Birthing, Mothering and Healing after Sexual Abuse (2008).
In a caregiving relationship, midwives are effective when they practice active, reflective listening and respond with empathy and emotional balance. It’s a good thing to know our own boundaries and take care of ourselves because our work is already demanding and abuse survivors often need more time, attention, and care. Sometimes it’s possible for a midwife to facilitate the survivor’s growing understanding and transformation by asking questions and offering her wisdom when the survivor can hear it. It’s always valuable to encourage a survivor to communicate her needs clearly to all of her caregivers and to help survivors feel loved, respected, and supported.
Support at Every Stage: Midwives and Survivors in Partnership
There are many ways to support survivors within the framework of the midwifery model of care. Here are a few suggestions:
Initial interview: Ask questions, listen actively, and establish trust
- Get permission to do any kind of bodywork (e.g., vaginal exams, pelvic exams, breast exams, etc.)
- Help with birth preferences planning
- Facilitate the woman’s understanding of cooperation with her body vs. control of her body in childbirth
- Foster a sense of safety
- Help the woman stay grounded in the present
- Non-directive pushing
Interventions, including cesarean:
- Be aware of the woman’s feelings (fear of pain, losing control, being exposed, being violated, being re-traumatized, having a flashback, etc.)
- Help ensure that her consent is fully informed and her decision-making is active by:
- asking clarifying questions of the woman and other caregivers (re: risks, benefits, alternatives, waiting, doing nothing)
- asking for more time
- reminding caregivers of the birth plan if the woman cannot speak
- interpreting the woman’s emotional state (if you’re sure of it) and communicating it to the caregivers (e.g., she’s having a flashback, a contraction, a “shut-down,” etc.)
Breastfeeding and postpartum care:
- Verbally explain how to help the baby latch
- Always ask permission before touching a woman’s breasts
- Always ask permission to hold the baby or do anything to or for the baby
- Actively listen and ask questions
- Respond with empathy and emotional balance
- Set time limits at the beginning of the call
- Give a 2–5 minute “heads up” warning toward the end of a call
Making Progress on the Healing Journey: Victim, Survivor, Overcomer
In criminal cases and law courts, by law enforcement officials and often by society, a woman who has experienced sexual abuse or assault is called a “victim.” Psychologists and therapists call such a woman a “survivor.” These are words that may accurately describe women who have experienced sexual abuse and assault. However, they are not the only words that apply to them. These women are also overcomers. As midwives, we can be part of the healing process for women by seeing them as strong people who have overcome many challenges in order to carry and give birth to a child.
The mother whose experience I shared at the beginning of this essay remains a dear friend of mine. After the birth of her daughter and struggles with breastfeeding, she went on at the age of 44 to have another safe, loving, home waterbirth with her son. Her life story encourages me as a woman and a midwife every time I remember it. She is an overcomer.
Not every woman can or will experience a birth that helps facilitate the healing of past abuse. But as midwives, we can do our best to listen to women’s stories, respect their free will, and share our wisdom. Healing can come from the care we provide even when things do not go the way that women hoped. It takes a lot of love and patience in the process and the work can be exhausting. But if the women are not giving up, then neither should we.
- American Psychiatric Association. “PTSD.” Diagnostic and Statistical Manual IV and V. Criteria also available online at: estss.org/learn-about-trauma/dsm-iv-definition or brainline.org/article/dsm-5-criteria-ptsd.
- Center for Family Justice. “Statistics.” Accessed May 15, 2018. centerforfamilyjustice.org/community-education/statistics.
- Simkin, Penny, and Phyllis Klaus. 2004. When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse on Childbearing Women. Seattle, WA: Classic Day Publishing.
- Sperlich, Mickey, and Julia Seng. 2008. Survivor Moms: Women’s Stories of Birthing, Mothering and Healing after Sexual Abuse. Eugene, OR: Motherbaby Press.
- WHO. “Violence against Women.” World Health Organization. who.int/en/news-room/fact-sheets/detail/violence-against-women.
Unhelpful vs. Helpful Responses in Conversations about Abuse
*Some of these are natural responses we can moderate and modify for the benefit of survivors when we are in conversation with them.