From MIDWIFERY MATTERS, Issue No.92, Spring 2002
Andrya Prescott, Independent Midwife
At the ARM meeting in Chichester I offered to run a workshop on how sexual abuse in childhood can impact on the experience of becoming a mother. I wanted to provide an insight into why acknowledging childhood sexual abuse is important to midwifery. I focused on ways of broaching the subject with women and offering empathetic and appropriate care. I believe that it is important that midwives should be able to identify good attitudes and behaviours in themselves as well as recognising where there is need for improvement.
Ideally midwives should be able to find ways of bringing the issue into the open, allowing women to discuss their experience if they choose. Midwives can thus empower women and minimise the potentially negative impact of previous abuse on childbearing and parenting. Definitions of abuse can range from, "any unwanted touching" (Finney, 1992) to considering the experience itself and not by physical acts alone (Bass and Davies 1988). Often the literature distinguishes between a victim - a person who is still in abusive relationship, and a survivor - a person who has physically survived and is no longer in the relationship.
I would like to add that some people find that they are not ready to be called a survivor even though they are out of the original abusive relationship. Classification belongs to the woman! Child abuse is divided into many different boxes - ritualistic, emotional, physical, sexual and so on, but women may not feel they fit into any category.
Different effects are experienced by different women, some may find it very emotionally traumatic, some may be in denial, where one woman tells everyone and anyone who will listen, another will cope by not talking about it. There are no hard and fast rules, many extremes are prevalent, exceptionally loud women or exceptionally meek, quiet women may be survivors. Women can be at radically different stages of the healing process if indeed they have found that pathway at all. Why ask?
Why should we ask women if they have experienced abuse? The fact that anything between one in ten and four in ten women have been abused is compelling enough for me. Parratt (1994) found that 65-70% of women who had been abused were "permanently damaged". All midwives will encounter abused women. By asking we can affirm that it is not OK to have been abused, the pain and anguish often caused by abuse is then validated. In the early days of awareness of abuse, people need to hear over and over again from many sources that abuse is not something they deserved or asked for. It is the manipulation by adults who were responsible for their actions. Not asking reinforces society´s attitude that abuse is not to be discussed and is not or should not be of any consequence. If an affirmative answer is given then the midwife can offer appropriate help or referral.
Even when women do not talk about abuse, or where they may not be aware of it, it is not uncommon for women to have memories triggered by the changes that occur to their body, certainly as they start to consider the birth or even during the birth itself. If they have been asked about abuse in some way then they have the opportunity to talk at any time. It implies a supportive and safe atmosphere.
Midwives should be aware that the pregnancy itself may be as a result of the abuse, in which case the woman may need support from the social services and, if she is young, then the help of the child protection service as well as emotional and psychological support from appropriate people.
I have listed some of the issues that arise during pregnancy and into motherhood and it is self-evident that we should ask in a sensitive and caring way. Not asking does not mean the issue will not arise.
Control
Control is essential. Abused women have learnt that losing control is dangerous physically and emotionally and they may structure their life to feel strong. Such a woman may be unable to risk anything that compromises her perception of control; she may need help to find a chink in her defences and take down the wall, must be sure of yourself and what you can offer, honesty is essential.
A woman’s perception of control is often maintained by extremes – aggression – submission – ritual – living in state of crisis.
Confidentiality.
If a woman discloses a history of abuse, document it only with her consent.
Midwifery care.
The woman’s body has been violated once already; she may experience midwifery care as further violation. Ask for consent for your actions! Remember your language, words like "relax" and "sweetie" may have been used before in very different circumstances.
Body image
Body memories can emerge as a woman’s body changes in pregnancy. Moreover, as the pregnancy becomes visible, taboos on body boundaries are lifted. The woman’s belly appears to become part of the public arena.
Screening and blood tests
Many women who have been abused have an overwhelming terror of needles. They need to know how appropriate blood screening is for them and must be able to make a truly informed choice. The midwife must be very sensitive in the way she takes any blood.
Routine examination
is routine only to maternity professionals! Palpation, especially of baby’s head, may be extremely uncomfortable. The need for extreme sensitivity in speculum examination or vaginal examination goes without saying.
Flashbacks
Vivid memories of abuse may be triggered by any aspect of treatment. An abused woman may experience an extremely vivid memory of something that has happened to her in the past, or she may panic while being totally unaware that her present experience mirrors the past in some way. Help her to feel safe – she may not know what happened. Flashbacks can be triggered by touch, language, and the position of woman or caregiver. Her reaction may be to go rigid, to tell you, or her breathing or facial expression may change, she may show signs of absolute panic. She may speak to someone who isn’t physically in the room with you or may appear suddenly terrified.
You may be able to help her by asking, "Can you tell me what was going through your mind during the last contraction?" You could also try asking her to reframe the current experience, differentiating it from her previous experience; if she says felt sharp like a knife, suggest smooth like a spoon.
Dissociation
Many survivors cope with the after effects of abuse by ‘dissociation’, a way of distancing themselves from their body and or mind, a numbness. A midwife may be impressed with how a woman is coping with the pain, by not feeling anything, but the woman may need to be helped back into the present. The midwife can use clear verbal directions to achieve this, asking the woman to focus herself into the room, to focus on the birth here and now. It may help to get her up and moving, reassuring her that this is safe environment, helping her to trust her body.
Physical sensations
During the birth other specific factors come into play. The pelvic area being stretched can simulate feelings of abuse – the midwife should help her to empower and reclaim her body. Talk her through the pain speak of the stretching as a 'coming out' not a 'going in'.
Procedures
Monitors and straps and VEs may be reminders of past abuse. Informed choice and honest discussion must play a large part in considering how appropriate each procedure is for an individual woman.
Positions
Lying on a bed really may not be OK for a woman who was abused every night when she tried to go to sleep!
Slow progress
It is often the unconscious mind that stalls labour. Fear of becoming a mother releases adrenalin thereby stopping progress. The midwife should work towards creating a feeling of safety using the power of imagery and visualisation and by her actions. Laughter is a great help in dissipating fear if you can find some humour.
Hands off the perineum
Practise helping women to birth their babies by themselves with no meddling. Consider the impact of an episiotomy, tearing and suturing. A woman may have scarring from the abuse so antenatal advice about caring for the skin using Vitamin E oil and or perineal massage might be appropriate.
Lithotomy
Does any woman like this position? If it becomes a necessity then try to work out what she needs to stay in control and in the present – if that is what she needs!
A general anaesthetic may provoke fear that a woman is totally out of control; other women may need a general anaesthetic in order to cope.
Elective caesarean
There is no guaranteed safe path to travel through childbirth. It takes a lot of courage to face natural childbirth in our society, particularly for abused women, but the rewards are great. For some women, however, an elective caesarean is the only means of retaining control over the birthing process.
Postnatal care
In the postnatal period many issues surrounding parenthood may arise. Constructive help from specialist groups could be appropriate to the needs of a woman who has been abused.
Overprotecting or underprotecting her children may be an issue that develops long after the midwife has discharged her.
Breastfeeding carries much emotional baggage for many women in our society which overemphasises the sexual appeal of the breasts at the expense of their physiological function. Midwives must be sensitive and aware that although, physically, a woman is likely to be able to breastfeed, emotionally it may not benefit her or her baby. The laudable desire to achieve 100% breastfeeding rates must not blind us to any emotional contra-indications. While I would be the first to advocate supporting all women as positively as possible about the benefits of breastfeeding, physically and emotionally this aspect must be considered.
Fear of their child being abused and the fear of abusing their own child is commonly something women will have come up for them. It would be sensible to encourage women to seek support if they feel that they may lose control and endanger their baby. Women can also be encouraged to develop openess with their children as they grow so the children will feel able to talk about anything uncomfortable happening to them.
Many articles about childhood sexual abuse contain lists of characteristics and ways of spotting women who have experienced abuse. These can be very useful if used appropriately. However, they should not be taken as positively indicative of past abuse. You may recognise some of these signs in yourself while knowing that they are not the result of trauma in your childhood! Use the list to aid your intuition.
Language. Think about the language you use: spoken, body and especially written. Are you using shallow phrases? Are you showing her the respect she deserves? When discussing procedures available to her be aware of her response to different words – 'relax' is a favourite for causing tension before an internal examination!
Reclaiming one's body. Encouraging perineal massage can help a woman to reclaim that part of herself as well as all the physical benefits.
Informed consent. We should be asking all women for informed consent and we should respect their decisions. When a woman consents to any intervention it may be helpful to explain what you are doing as you do it. Ask what she is comfortable with.
Education. An abused woman may welcome information on what behaviour most people would consider normal and what behaviour is not generally acceptable within a relationship.
Listening and focusing. Some women will present you with an impossibly long list of problems and concerns; encourage them to take control and select the most important things to deal with.
Flashbacks. When a woman is experiencing a flashback – remind her that this is a memory not the abuse. Stay close to her, don't let her go away without support.
Reassurance. Reinforce the fact that the woman is not to blame, it is not her fault; incest is not an act of love, it is never OK. Physical arousal during abuse does not constitute consent, it is merely a reflex bodily response to stimulation and does not imply emotional acceptance of the abuse. Children need love and affection not abuse and sex. Emphasise the fact that she is allowed to say no if she needs to - it is her body.
Avoid internal examinations. Minimise or avoid internal examinations altogether – use other ways to assess progress, for example watch out for the red line, use your excellent observational skills.
Minimising harm. If a VE is necessary, consider asking the woman to take up a position which she finds less threatening and is likely to trigger fewer memories.
Informed choice.Epidural anaesthesia may make women feel invaded or it may remove them from pain.
Breastfeeding support should be hands off.
Avoid further abuse. Don't do anything you would find personally abusive.
Disclosure. Consider what your response would be if a woman disclosed abuse to you?
Provide a safe environment.
Listen to women in an unhurried environment.
Assure a woman that she is safe and affirm her strength.
Honour the emotion women are feeling.
Get some support for yourself. Ask your Supervisor or an ARM member.
Refer on. If you feel unable to help her directly then find an appropriate midwife, recommend counselling, homeopathy or therapy.
Provide a resource list of helpful books and organisations.
We are not always going to know which women have been abused. So how do we care for them? Why do we treat women who have been abused especially differently from women who have not? Don't all women deserve to be treated and cared for with respect, kindness, and tolerance? Don't all women need to be well informed and have autonomy and control of their bodies and babies? We do not always get the feedback; however, when you have helped to break the cycle of abuse for a woman, you may well have planted the seed for her to start her recovery and gain control over her body and life. Don't underestimate yourself or your actions. Next time you go to do something as a part of your routine consider how relevant it is and of what benefit it will be for the woman you are with.
Ainscough and Toon (1993). Breaking Free, Sheldon Press, London.
Bass and Davies (1988). The Courage to Heal, Cedar Press, London.
Burian J (1995). 'Helping survivors of sexual abuse through labor', American Journal of Maternal and Child Nursing, 20, 5, 252-256.
Coutois C and Courtois Riley C (1992). 'Pregnancy and childbirth as triggers for abuse memories: Implications for care', Birth,19, 4, 222-223.
Davies L (1991). Allies in Healing. A Support Book for Partners,Harper Row, USA.
Holz (1994). 'A practical approach to clients who are survivors of childhood sexual abuse', Journal of Nurse Midwifery, 39, 1, 13-18.
Parrat (1994). 'The experience of childbirth for survivors of incest', Midwifery, 10,1, 26-39.
Smith M (1998). 'Childbirth in women with a history of sexual abuse (1)', The Practising Midwife, 1,
5, 20-11 – Parts 2 and 3 follow in consecutive months.
Tilley J (2000). 'Sexual assault and flashbacks on the labour ward', The Practising Midwife, 3,4, 18-20.
Andrya Prescott may be contacted at: andrya@independentmidwife.com
This article was originally published in Midwifery Matters ISSUE 92 Spring 2002, p17-18
LW updated December 30, 2005