The re-enactment of childhood sexual abuse in maternity care: a qualitative study

"I have to listen to them or they might harm me" and other narratives of why women endure obstetric violence in Bihar, India

BACKGROUND

Evidence suggests that obstetric violence has been prevalent globally and is finally getting some attention through research. This human rights violation takes several forms and is best understood through the narratives of embodied experiences of disrespect and abuse from women and other people who give birth, which is of utmost importance to make efforts in implementing respectful maternity care for a positive birthing experience. This study focused on the drivers of obstetric violence during labor and birth in Bihar, India.

METHODS

Participatory qualitative visual arts-based method of data collection-body mapping-assisted interviews (adapted as birth mapping)-was conducted to understand women's perception of why they are denied respectful maternity care and what makes them vulnerable to obstetric violence during labor and childbirth. This study is embedded in feminist and critical theories that ensure women's narratives are at the center, which was further ensured by the feminist relational discourse analysis. Eight women participated from urban slums and rural villages in Bihar, for 2-4 interactions each, within a week. The data included transcripts, audio files, body maps, birthing stories, and body key, which were analyzed with the help of NVivo 12.

FINDINGS

Women's narratives suggested drivers that determine how they will be treated during labor and birth, or any form of sexual, reproductive, and maternal healthcare seeking presented through the four themes: (1) "I am admitted under your care, so, I will have to do what you say"-Influence of power on care during childbirth; (2) "I was blindfolded … because there were men"-Influence of gender on care during childbirth; (3) "The more money we give the more convenience we get"-Influence of structure on care during childbirth; and (4) "How could I ask him, how it will come out?"-Influence of culture on care during childbirth. How women will be treated in the society and in the obstetric environment is determined by their identity at the intersections of age, class, caste, marital status, religion, education, and many other sociodemographic factors. The issues related to each of these are intertwined and cross-cutting, which made it difficult to draw clear categorizations because the four themes influenced and overlapped with each other. Son preference, for example, is a gender-based issue that is part of certain cultures in a patriarchal structure as a result of power-based imbalance, which makes the women vulnerable to disrespect and abuse when their baby is assigned female at birth.

DISCUSSION

Sensitive unique feminist methods are important to explore and understand women's embodied experiences of trauma and are essential to understand their perspectives of what drives obstetric violence during childbirth. Sensitive methods of research are crucial for the health systems to learn from and embed women's wants, to address this structural challenge with urgency, and to ensure a positive experience of care.

Evidence for the Impact of Stress and Trauma on Sexual Function in Women: Review and Clinical Recommendations

Stressors occur in a spectrum, ranging from daily hassles to life-threatening experiences, and can significantly impact sexual functioning. Thus, this review summarizes the intricate relationship between trauma spectrum experiences and women's sexual functioning. Biological mechanisms are described to elucidate the physiologic complexity that manifests because of trauma-related experiences. Additionally, both psychological and social implications are discussed. Treatment recommendations for practitioners working with women are discussed, underscoring the importance of adopting a trauma-informed care model.

Identifying, understanding and responding to domestic abuse in the perinatal period

Domestic abuse often begins or escalates during the perinatal period, increasing the risk of adverse pregnancy outcomes and death of the woman and infant. The hidden nature of domestic abuse, compounded by barriers to disclosure, means many clinicians are likely to have unknowingly encountered a patient who is being abused and missed a vital opportunity for intervention. This educational article presents the experience of a woman who was abused during pregnancy. It describes how to facilitate a disclosure and conduct an assessment and illustrates safeguarding duties alongside interventions.

The significance of paramedic communication during women's birth experiences: A scoping review

BACKGROUND

Internationally, over one-third of women experience birth trauma, leading to adverse mental health outcomes. Poor communication with healthcare professionals is a primary contributing factor. Paramedics attend various clinical presentations, including childbirth, yet their potential impact on women's birth experiences has been largely overlooked.

METHODS

A systematic literature search was conducted following the Joanna Briggs Institute methodological framework. The search identified 1015 potentially suitable articles, and 5 articles met the inclusion criteria. Data was analysed using reflexive thematic analysis from a feminist standpoint.

RESULTS

Three themes were generated: 1. First Impressions Count: paramedic demeanour impacted the woman's sense of safety and perception of paramedic clinical competence. 2. Choice as a Pathway to Control: when paramedics involved women in decision-making, it led to empowerment, while non-involvement led to women becoming passive participants. 3. Exposed, Violated and Disempowered: some paramedics disrespected and abused women, treating them solely as objects for the purpose of producing a baby.

CONCLUSIONS

This review highlights the influence of paramedic communication on women's birth experiences. While some paramedics communicated respectfully, other paramedics were the perpetrators of Obstetric Violence. Future research should inform paramedic education and improve outcomes for birthing women.

Trauma-informed care education for midwives: Does education improve attitudes towards trauma-informed care?

INTRODUCTION

Continuing education is important to improve midwives' attitudes to trauma-informed care in addressing the needs of women during the perinatal period. This study aimed to evaluate if there was a significant difference in attitudes towards trauma-informed care between midwives who participated in a 2-day trauma-informed care education program and those who did not.

METHOD

A static group comparison design was adopted with a convenience sample of midwives to analyse differences in attitudes towards trauma-informed care between midwives who received a 2-day TIC education (n = 19, intervention group) and their peers who did not receive the education (n = 18, comparison group).

RESULTS

The results suggest that midwives who participated in a 2-day trauma-informed care education program had significantly higher scores for positive attitudes towards trauma-informed care compared to those who did not take part in the program and that this effect was sustained at 6 months.

CONCLUSION

To minimise perinatal trauma for mothers and babies, midwives require specific trauma-informed care education. This study proposes that trauma-informed care education is a foundational pathway for implementing a trauma-informed care framework across a maternity service.

Intimate partner violence across pregnancy and the postpartum and the relationship to depression and perinatal wellbeing: findings from a pregnancy cohort study

PURPOSE

To compare the prevalence of emotional and physical intimate partner violence (IPV) across pregnancy and the first year postpartum in those with and without clinical depression and assess the association between maternal childhood trauma, current stressful life events and depression and IPV over the perinatal period.

METHODS

Data were obtained from 505 pregnant women from the Mercy Pregnancy and Emotional Wellbeing Study (MPEWS), a cohort study with data collected across pregnancy until 12 months postpartum. Maternal antenatal depression was measured using the Structured Clinical Interview for DSM-IV (SCID-IV) with repeat measurement of perinatal depressive symptoms using the Edinburgh Postnatal Depression Scale (EPDS). Trauma was measured using the Childhood Trauma Questionnaire, and experiences of physical and emotional intimate partner violence using items in the Stressful Life Events Scale.

RESULTS

Women experiencing IPV across the perinatal period were significantly more likely to score over 13 on the EPDS (p < .001) at each timepoint in pregnancy and the postpartum and physical IPV was associated with clinical depression. Further, a history of childhood trauma and current additional stressful life events were significantly associated with reporting current IPV in the perinatal period.

CONCLUSIONS

This study confirmed the risk factors of childhood trauma and current stressful life events for reporting experiences of IPV in the perinatal period. Furthermore, women experiencing IPV reported higher depressive symptoms, providing evidence supporting the value of assessing those women who screen higher on the EPDS for IPV. Together these findings also support trauma informed care across pregnancy and the postpartum.

Childbirth experiences of women with a history of physical, sexual, and child abuse: a cross-sectional study of 2,575 Russian women

BACKGROUND

A substantial number of women who subsequently become pregnant and give birth have a history of physical, sexual, and/or child abuse. This study investigated the associations of these types of traumas and their cumulative effect with childbirth experiences, namely, mode of birth, maternal and child complications during pregnancy/childbirth, preterm birth, medical procedures, and obstetric violence during labour.

METHODS

A group of Russian women (n = 2,575) who gave birth within the previous 12 months, completed a web-based survey, where they provided demographic information, details about their childbirth experiences, and a history of trauma.

RESULTS

Women with any type of past abuse were at higher risk for maternal complications during pregnancy/childbirth (exp(β) < 0.73, p < 0.010 for all). More specific to the type of trauma were associations of physical abuse with caesarean birth, child abuse with complications during pregnancy/childbirth for the baby, and physical and child abuse with obstetric violence (exp(β) < 0.54, p < 0.022 for all). There was a cumulative effect of trauma for all the outcomes except for medical procedures during childbirth and preterm birth.

CONCLUSION

This study provides insights into potential different individual effects of physical, sexual, and/or child abuse as well as their cumulative impact on the childbirth experiences. The robust findings about maternal complications during pregnancy/childbirth and obstetric violence highlight the importance of trauma-informed care, supportive policies, and interventions to create safe and empowering birthing environments that prioritise patient autonomy, dignity, and respectful communication.

Continuing Education Intervention: Trauma-Informed Pain Management in Labor and Delivery

BACKGROUND

There is a gap in the availability of continuing education opportunities for labor and delivery nurses regarding trauma-informed perinatal care.

METHOD

A continuing education module on trauma-informed pain management in labor was created and distributed to 17 nurses in an intrapartum unit at a hospital in the Midwestern United States. Changes in knowledge, attitudes, skills, and intent to use trauma-informed principles were assessed using a pretest-posttest design and paired t test analyses.

RESULTS

Change in knowledge (p = .043) and skills (p = .011) was statistically significant. There were no statistically significant changes in attitudes.

CONCLUSION

Continuing education opportunities in trauma-informed perinatal care are needed for health care team members who provide care to trauma survivors in labor. Further research on the effectiveness of trauma-informed pain management in labor and birth is necessary to provide additional resources and recommendations for labor and delivery nurses. [J Contin Educ Nurs. 2024;55(1):21-25.].

Understanding the lived experience of pregnancy and birth for survivors of rape and sexual assault

BACKGROUND

One in five women in the UK are survivors of rape and sexual assault, and four in five women will give birth. This implies that a substantial number of women experience rape and sexual assault before pregnancy. We highlight and explore the voices and lived experiences of survivors during pregnancy and birth, to better understand the relationship between sexual violence, biomedicine, and pregnancy and to inform maternity care practice.

METHODS

This qualitative research took an intersectional feminist approach. We conducted in-depth individual interviews in England with fourteen women who self-identified as survivors of rape or sexual assault, and who had experienced pregnancy and birth after the assault. We conducted open line-by-line coding of the interview transcripts, and identified key themes and sub-themes inductively.

RESULTS

Three themes help summarise the narratives: control, safety and trauma. Maintaining a sense of control was important to survivors but they often reported objectification by healthcare staff and lack of consent or choice about healthcare decisions. Participants' preferences for giving birth were often motivated by their desire to feel in control and avoid triggering traumatic memories of the sexual assault. Survivors felt safer when they trusted staff. Many participants said it was important for staff to know they were survivors but none were asked about this. Pregnancy and birth experiences were triggering when they mirrored the assault, for instance if the woman was prevented from moving. Many of our participants reported having unmet mental health care needs before, during or after pregnancy.

CONCLUSIONS

Survivors of sexual violence have specific maternity care needs. For our participants, these needs were often not met, leading to negative or traumatic experiences of pregnancy and birth. Systemic biases and poor birth experience jeopardise both psychological and physical safety. Funding for maternity and mental health services must be improved, so that they meet minimum staffing and care standards. Maternity services should urgently introduce trauma-informed models of care.

'What do I do?' A study to inform development of an e-resource for maternity healthcare professionals and students caring for people with lived experience of childhood sexual abuse

BACKGROUND

The impact of childhood sexual abuse can last a lifetime. It is more prevalent than many common complexities that require additional care during the childbirth cycle but is rarely part of the education of healthcare professionals and students. This study informed the development of an e-resource to support maternity healthcare professionals and students caring for people with lived experience of childhood sexual abuse.

OBJECTIVES

To identify any previous learning of pre-registration students and healthcare professionals in relation to care of survivors of childhood sexual abuse, explore their clinical experience in caring for survivors, identify related learning needs, explore what survivors of childhood sexual abuse would like healthcare professionals to know about their maternity care needs.

DESIGN

A qualitative descriptive study using focus groups and interviews. Data derived qualitative content analysis was employed to address the objectives.

SETTING

The study was designed in consultation with The Survivors Trust and took place in South London, UK PARTICIPANTS: Thirty seven health care professionals and students participated, comprising 25 students of midwifery, health visiting and medicine; 9 midwives, health visitors and doctors with specialist obstetric training. Eight women with lived experience took part in focus groups.

FINDINGS

Care of women and birthing people who have experienced childhood sexual abuse had not been part of the undergraduate/pre-registration curricula, nor in specialist training for obstetricians. Many practitioners felt unprepared to care for those with lived experience of abuse and their learning needs were wide-ranging. The need for a learning resource was acknowledged and the outline plan that had been produced following the focus groups was endorsed by participants with lived experience.

CONCLUSION

Care for women and birthing people with lived experience of childhood sexual abuse can be challenging for both personal and professional reasons. This study confirmed the need for a resource that could facilitate the classroom teaching of students and be used for the Continuous Professional Development of qualified practitioners.

Experiences of maltreatment in childhood are associated with increasing anxiety and lower body acceptance over pregnancy

OBJECTIVE

Prior studies have established that childhood sexual abuse (CSA) survivors are at increased risk for anxiety during pregnancy. Less is known about the course of anxiety throughout pregnancy for CSA survivors as well as underlying mechanisms linking CSA and perinatal anxiety. We assessed change in anxiety over the course of pregnancy for CSA survivors and examined whether acceptance and awareness of pregnancy-related body changes mediated this change.

METHODS

299 pregnant participants from two larger longitudinal cohort studies were grouped into CSA (n = 67), "other Maltreatment" (OM; n = 111); and "no abuse" (NA; n = 121) based on responses to the Adverse Childhood Events scale. We used a general linear mixed model with repeated measures to examine change in anxiety (Hamilton Anxiety Scale) at two time points (MEGA = 26.2 weeks and 34.9) by abuse/maltreatment group and then examined whether group differences in anxiety were mediated by body awareness/acceptance (from Maternal Fetal Attachment Scale) using structural equation modeling.

RESULTS

The CSA group demonstrated higher anxiety at both gestational time-points and significantly greater increase in anxiety over gestation compared to OM and NA groups (F(1, 280) p = .046). CSA and OM groups reported significantly lower body acceptance than those without abuse/maltreatment (F(2, 287) = 3.486, p = .032). A small proportion of the total effect of CSA on change in anxiety (0.5%) was attributable to body acceptance.

CONCLUSION

Pregnant CSA survivors experienced a greater increase in anxiety over pregnancy compared to other groups. Both abuse/maltreatment groups exhibited lower body acceptance, yet this contributed little to the association between CSA and anxiety.

Exploring women's experiences, views and understanding of vaginal examinations during intrapartum care: A meta-ethnographic synthesis

OBJECTIVE

To conduct a systematic review exploring women's experiences, views and understanding of any vaginal examinations during intrapartum care, in any care setting and by any healthcare professional. Intrapartum vaginal examination is deemed both an essential assessment tool and routine intervention during labour. It is an intervention that can cause significant distress, embarrassment, and pain for women, as well as reinforce outdated gender roles. In view of its widespread and frequently reported excessive use, it is important to understand women's views on vaginal examination to inform further research and current practice.

DESIGN

A systematic search and meta-ethnography synthesis informed by Noblit and Hare (1988) and the eMERGe guidance (France et al. 2019) was undertaken. Nine electronic databases were searched systematically using predefined search terms in August 2021, and again in March 2023. Studies meeting the following criteria: English language, qualitative and mixed-method studies, published from 2000 onwards, and relevant to the topic, were eligible for quality appraisal and inclusion.

FINDINGS

Six studies met the inclusion criteria. Three from Turkey, one from Palestine, one from Hong Kong and one from New Zealand. One disconfirming study was identified. Following both a reciprocal and refutational synthesis, four 3rd order constructs were formed, titled: Suffering the examination, Challenging the power dynamic, Cervical-centric labour culture embedded in societal expectations, and Context of care. Finally, a line of argument was arrived at, which brought together and summarised the 3rd order constructs.

KEY CONCLUSIONS AND IMPLICATIONS OF PRACTICE

The dominant biomedical discourse of vaginal examination and cervical dilatation as central to the birthing process does not align with midwifery philosophy or women's embodied experience. Women experience examinations as painful and distressing but tolerate them as they view them as necessary and unavoidable. Factors such as context of care setting, environment, privacy, midwifery care, particularly in a continuity of carer model, have considerable positive affect on women's experience of examinations. Further research into women's experiences of vaginal examination in different care models as well as research into less invasive intrapartum assessment tools that promote physiological processes is urgently required.

Adverse childhood experiences, the risk of pregnancy complications and adverse pregnancy outcomes: a systematic review and meta-analysis

BACKGROUND

Adverse childhood experiences (ACEs) have a profound negative impact on health. However, the strength of the association between ACEs and pregnancy complications and adverse pregnancy outcomes is not well quantified or understood.

OBJECTIVE

To conduct a systematic review and meta-analysis of the association between ACEs and risk of pregnancy complications and adverse pregnancy outcomes.

SEARCH STRATEGY

A comprehensive search was conducted using PubMed, Embase, CINAHL, PsycINFO, ClinicalTrials.gov and Google scholar up to July 2022.

DATA COLLECTION AND ANALYSIS

Two reviewers independently conducted the screening and quality appraisal using a validated tool. Meta-analysis using the quality-effects model on the reported odds ratio (OR) was conducted. Heterogeneity and inconsistency were examined using the I2 statistics.

RESULTS

32 studies from 1508 met a priori inclusion criteria for systematic review, with 21 included in the meta-analysis. Pooled analyses showed that exposure to ACEs increased the risk of pregnancy complications (OR 1.37, 95% CI 1.20 to 1.57) and adverse pregnancy outcomes (OR 1.31, 95% CI 1.17 to 1.47). In sub-group analysis, maternal ACEs were associated with gestational diabetes mellitus (OR 1.39, 95% CI 1.11 to 1.74), antenatal depression (OR 1.59, 95% CI 1.15 to 2.20), low offspring birth weight (OR 1.27, 95% CI 1.02 to 1.47), and preterm delivery (OR 1.41, 95% CI 1.16 to 1.71).

CONCLUSION

The results suggest that exposure to ACEs increases the risk of pregnancy complications and adverse pregnancy outcomes. Preventive strategies, screening and trauma-informed care need to be examined to improve maternal and child health.

Addressing Adverse Childhood and Adult Experiences During Prenatal Care

Adverse childhood and adult experiences can affect health outcomes throughout life and across generations. The perinatal period offers a critical opportunity for obstetric clinicians to partner with patients to provide support and improve outcomes. This article draws on stakeholder input, expert opinion, and available evidence to provide recommendations for obstetric clinicians' inquiry about and response to pregnant patients' past and present adversity and trauma during prenatal care encounters. Trauma-informed care is a universal intervention that can proactively address adversity and trauma and support healing, even if a patient does not explicitly disclose past or present adversity. Inquiry about past and present adversity and trauma provides an avenue to offer support and to create individualized care plans. Preparatory steps to adopting a trauma-informed approach to prenatal care include initiating education and training for practice staff, prioritizing addressing racism and health disparities, and establishing patient safety and trust. Inquiry about adversity and trauma, as well as resilience factors, can be implemented gradually over time through open-ended questions, structured survey measures, or a combination of both techniques. A range of evidence-based educational resources, prevention and intervention programs, and community-based initiatives can be included within individualized care plans to improve perinatal health outcomes. These practices will be further developed and improved by increased clinical training and research, as well as through broad adoption of a trauma-informed approach and collaboration across specialty areas.

Perinatal (Re)experiencing of Post-Traumatic Stress Disorder Symptoms for Survivors of Childhood Sexual Abuse: An Integrative Review

This integrative review aimed to synthesize both qualitative and quantitative research on the (re)experiencing of post-traumatic stress disorder (PTSD) symptoms during the perinatal period for childhood sexual abuse (CSA) survivors. Whittemore and Knafl's framework, which includes problem identification, literature review, data evaluation, data analysis, and results dissemination, was used. A search in four databases (i.e., PsycINFO, MEDLINE, Scopus, and ProQuest Dissertations and Thesis Global) yielded an initial sample of 3420 articles. After screening and deduplication, 16 articles met our inclusion criteria (i.e., history of CSA, minimum 8 weeks pregnant, reported quantitative statistics or qualitative findings, discussed PTSD symptoms) and were retained in the final sample. CSA survivors (re)experienced PTSD symptoms as a result of (1) aspects of their medical care (vaginal examinations, male medical providers, lack of control, and restraint), (2) physical sensations during pregnancy, childbirth, and breastfeeding, and (3) sex of the child (worries over child becoming an abuser/abused, male genitalia). CSA survivor's PTSD symptoms of intrusion, dissociation, avoidance, and hyperarousal were significantly greater throughout the perinatal period compared with individuals without CSA or with other traumas. CSA survivors are at increased risk of (re)experiencing PTSD symptoms throughout the perinatal period, which may be due to several internal and external triggers. Further research is needed to understand external triggers outside of medical care, and how the unique context of pregnancy may differ from other life contexts for survivors of CSA. Findings point to the relevance of adopting trauma-informed practices with CSA survivors during their perinatal period.

The influence of childhood abuse and prenatal intimate partner violence on childbirth experiences and breastfeeding outcomes

BACKGROUND

Despite the detrimental effects and life-course health consequences of violence exposure, relatively few studies have adequate capacity to investigate the evolution of violence from childhood to motherhood.

OBJECTIVE

This study aims to examine the cyclical nature of childhood abuse and prenatal inter-partner violent victimization (p-IPV) and its adverse impact on childbirth trauma and exclusive breastfeeding (EBF) practice in Vietnam.

METHOD

Using a prospective birth cohort, 150 pregnant women were recruited in the third trimester of pregnancy in Hue city in central Vietnam (Wave 1-Baseline) and re-interviewed approximately three months after delivery (Wave 2-Follow-up). The direct and indirect effects of violent victimization on subsequent childbirth experience (measured by Birth Memories and Recall Questionnaire) and EBF practice were estimated by using augmented-inverse-probability-weighted models, sensitivity analysis, and structural equation model.

RESULTS

Detrimental and prolonged effects of the inter-generational cycle of violence transverse childhood to motherhood. Women who experienced either childhood abuse or p-IPV violence were more likely to experience negative emotional childbirth memories [ARR 1.21, 95 % CI (1.04, 1.39)]. Evidence also suggested that not continuing to exclusively breastfeed at 3 months post-partum was strongly associated with prenatal depression, young age, and perceived low social status during pregnancy. Perceived strong connectedness among extended family members and social networks (i.e. nexus among family, friends, and neighborhood) provided a buffering effect by preventing EBF termination.

CONCLUSION

This research provides insights into the protective role of social connectedness in improving breastfeeding practice. It is vital to establish wholistic antenatal care and social service system to offer specialized support and response for victims of violence and mitigate the long-term sequelae of traumatic events.

Ensuring Trauma Informed Care in the Obstetric Setting: A vital role for the Psychiatrist

BACKGROUND

Trauma is highly prevalent, and women are twice as likely as men to develop post-traumatic stress disorder following a traumatic exposure. Consequently, many women entering the perinatal period have trauma histories. In the perinatal period, a trauma history, can negatively impact treatment engagement and adversely affect the experience of pregnancy, postpartum and parenting. A trauma informed care approach can mitigate these effects.

OBJECTIVES

This review aims to summarize literature that can aid psychiatrists in 1) identifying signs and symptoms of trauma in perinatal women 2) integrating elements of trauma informed care into perinatal mental health care, and 3) offering interventions that can minimize adverse outcomes for perinatal women and their children.

METHODS

A PubMed search was conducted with keywords including trauma, pregnancy, perinatal, post-traumatic stress disorder (PTSD), postpartum PTSD, trauma informed care.

RESULTS

Perinatal care, given its somewhat invasive nature, has the potential to traumatize or cause re-traumatization. Trauma related disorders are common and can present or worsen in the perinatal period. Trauma can manifest in multiple forms in this population, including exacerbation of pre-existing PTSD, new onset acute stress disorder in the perinatal period or postpartum PTSD secondary to traumatic childbirth. Unaddressed trauma can adversely affect the experience of pregnancy, postpartum and parenting. Psychiatrists caring for women in the perinatal period, are in an ideal position to screen for trauma and offer appropriate intervention. A trauma informed approach to obstetric care can help clinical teams respond to the unique trauma-related challenges that can arise during obstetric care. Trauma informed care, with its emphasis on establishing a culture of safety, transparency, trustworthiness, collaboration, and mutuality can empower health care providers and systems with powerful tools to respond to trauma and its myriad effects in a strengths-based manner. By applying a trauma-informed lens, psychiatrists can help their obstetric colleagues provide patient-centered compassionate care and treatment.

CONCLUSIONS

Applying a trauma informed approach to evaluation and treatment of perinatal populations could decrease the toll trauma has on affected women and their children.

Perinatal Care of Childhood Sexual Abuse Survivors: Scoping Review

BACKGROUND

An estimated one in nine women seeking perinatal care is a survivor of childhood sexual abuse (CSA), yet CSA may be unknown to nurses and other health care providers. Childhood sexual abuse can have adverse physical and psychological effects for survivors, and the intimacy of perinatal care can trigger distress like intrusive thoughts.

PURPOSE

To explore available literature about CSA survivors and perinatal care. Specific aims were to 1) identify nursing actions that ease undesirable feelings during perinatal care for CSA survivors and 2) identify gaps in the literature on perinatal care for CSA survivors.

STUDY DESIGN AND METHODS

Following the PRISMA-ScR Checklist, MEDLINE and CINAHL databases were searched using: "Child Abuse, Sexual," "Perinatal Care," and "Parturition." Initial yield was 109 records.

RESULTS

Applying inclusion and exclusion criteria produced 14 full-text articles. Findings suggest that obtaining consent, promoting safety, trust, and control, fostering a healthy nurse-patient relationship, and inquiring about abuse may improve how CSA survivors experience perinatal care. Gaps in literature include nursing assessments for history of CSA with nonverbal cues.

CLINICAL IMPLICATIONS

For all patients, nurses should foster security and trust. It is critical that CSA survivors be in control of their care. Procedures should be thoroughly explained, and most importantly, consent should be obtained prior to every physical touch. Nurses must ask about history of CSA because it is part of patient-centered care, which is central to nursing.

“I got to catch my own baby”: a qualitative study of out of hospital birth

Background

About 1.6% of planned births in the United States occur out of hospitals. Studies indicate that planned out-of-hospital birth (OOHB) is safe and satisfying for women; however, there is great variation among ethnic groups, and Black women are underrepresented. A recent phenomenon is the choice to have an unassisted birth (UAB) with no midwife or other professional maternity care attendant. The purpose of this study is to fill a gap in understanding reasons for choosing OOHB or UAB for two clinically important sub-groups of women: Black women, and women who have experienced childhood physical or sexual abuse.

Methods

This study recruited 18 women who had an OOHB or UAB and who identified as either Black or survivors of trauma to participate in in-depth qualitative interviews concerning their choice to give birth out of hospital. A grounded theory approach was utilized that involved a discursive process of data collection, coding textual passages to identify focused themes, memo writing to document analytic decision-making, and eventual conceptual modeling.

Results

All 18 participants endorsed a history of trauma. Focused coding to identify inherent concepts led to the emergence of a theoretical model of the arc of decision-making around choice of place of birth and birth attendant, or lack thereof. Women may choose OOHB or UAB because of a previous trauma, or because they feel discriminated against by healthcare professionals, either because of skin color, age, pregnancy, weight, or some other health condition. Women may choose OOHB or UAB because it affords more control during the process of giving birth.

Conclusion

Previous trauma and experiences of discrimination were influential factors for women in the study sample in their choice of birthplace setting and choice of provider. These findings can inform clinical understanding for birth professionals, including doctors, midwives, doulas, nurses, social workers, and psychologists, and contributes more broadly to the national conversation about birth choices in the USA.

This study shares information from qualitative interviews with Black women and women who are survivors of abuse regarding their choice to have a planned out-of-hospital birth, or to choose an unassisted birth (UAB) with no midwife or other professional birth attendant. Black women are less well represented among those who choose OOHB, and little is known about the reasons that they may choose OOHB. Previous studies show that women who have experienced childhood physical or sexual abuse may prioritize having a sense of control and autonomy during their birthing experiences; however, little is known about their specific choice for OOHB. Our study recruited 18 women who had an OOHB or UAB and who identified as either Black and/or survivors of trauma to participate in in-depth interviews concerning their choice to give birth out of hospital. Through qualitative research methods, we analyzed transcripts of these interviews and developed a theoretical model about women’s decision making related to OOHB or UAB. We found that women may choose OOHB or UAB because of a previous trauma, or because they feel discriminated against by healthcare professionals, either because of skin color, age, pregnancy, weight, or some other health condition, and that choosing OOHB or UAB allowed them to have more control during the process of giving birth. Understanding the role that previous trauma and experiences of discrimination play in birthplace choice may help birth professionals to consider bodily autonomy, physical and emotional safety, anti-racism, and independence as important factors in their clinical interactions with birthing women.

Midwives Perceiving and Dealing With Violence Against Women: Is It Mostly About Midwives Actively Protecting Women? A Modified Grounded Theory Study

Violence against women (VAW) affects pregnancy, birthing, and puerperium. In this sense, domestic violence (DV) or intimate partner violence (IPV) may increase during pregnancy, sexual child abuse may affect the birthing process, and obstetric violence may occur during birthing. Thus, consideration of violence during pregnancy and puerperium is essential to providing optimal care for women. This implies that midwives should be able to identify women affected by VAW. Therefore, this study explored VAW as perceived by midwives in one region of Austria. Interviews with 15 midwives (mean age 38.7 years) were conducted in Tyrol, Austria, between December 2014 and December 2015. Data were analyzed with a modified version of Grounded Theory. The core category "protecting but walking on eggshells" showed the caution with which midwives approached VAW and in particular DV or IPV. Including VAW in midwifery was connected to midwives being active protectors of women in their care. This meant being an intuitive, sensible, guiding, and empowering midwife to the woman. Staying active was necessary to fulfill the protective role also with regard to DV. However, this was influenced by the visibility of the connection between VAW, pregnancy, childbirth, and puerperium. The key to including VAW and particularly DV was midwives' professional role of actively protecting women. Neglecting DV during pregnancy, labor, and puerperium meant further silencing DV, and keeping it hidden. Considering these aspects in planning and implementing actions to prevent VAW is expected to support sustainability and motivation to ask women about all forms of violence during and after pregnancy.

Trauma informed care education for midwives: An integrative review

BACKGROUND

Nearly half of new mothers describe their childbirth as traumatic. Perinatal trauma impacts both short and long-term biopsychosocial outcomes for mother and child. Midwife trauma-informed care education and practice is essential to mitigate this risk.

OBJECTIVE

This review aimed to identify and describe the nature and extent of trauma informed care education provided for midwives and midwifery students.

DESIGN

An integrative review.

METHODS

Five databases (Medline, Embase, CINAHL, Psycinfo, and Emcare) were searched to identify primary research regarding trauma informed care education for midwives and midwifery students. Quality appraisal was conducted using the Mixed Methods Appraisal Tool.

RESULTS

Three papers were identified. None of the papers were midwifery focused, with midwives representing a small proportion of the participants. Most midwives reported receiving no previous trauma informed care education and lacked confidence to provide quality care to women with lived trauma. Midwives reported trauma informed care education as essential and relevant for providing quality practice. Improvements in knowledge, skills and attitudes was demonstrated following trauma informed care education. More in-depth content and content delivered in multiple ways were recommended.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Midwives are well placed to deliver trauma informed care. Trauma informed care education for midwives is limited. Given the impact of perinatal trauma, further trauma informed care education and research is paramount.

Misoprostol for labour induction

Oral and vaginal misoprostol are effective induction methods, but there is a delicate balance between a quicker labour and avoiding side effects. In randomised comparisons with balloon catheters, oral misoprostol resulted in more vaginal births in the first 24 h as well as fewer caesarean sections without an increase in hyperstimulation events. Vaginal misoprostol was most effective when used concurrently with a balloon catheter. In comparison with dinoprostone, oral misoprostol had lower rates of caesarean section and uterine hyperstimulation with foetal heart rate changes, but fewer babies were born vaginally within 24 h. In contrast, vaginal misoprostol resulted in more vaginal births within 24 h, with no significant differences in caesarean section rates. There were no differences in perinatal adverse events with either route. When oral and vaginal misoprostol were compared, vaginal misoprostol resulted in more vaginal births in the first 24 h, but with more maternal and neonatal complications.

Co-production of an e-resource to help women who have experienced childhood sexual abuse prepare for pregnancy, birth, and parenthood

BACKGROUND

This paper reports the development of a co-produced e-resource to support those who have experienced childhood sexual abuse through pregnancy, birth, and parenthood. These are times of major transition for any woman but can present particular challenges for those who have experienced childhood sexual abuse. Re-traumatisation during the perinatal period is common and can occur in ways that may not be anticipated by those involved. Survivors often do not disclose their abuse and the childbearing journey can be lonely.

METHODS

The work was conducted in collaboration with The Survivors Trust and in keeping with the Survivor's Charter. A participatory approach was used. There were two phases: the generation of new qualitative data and development of the resource. To encourage participation from this hidden population, data were collected by a variety of means including focus groups, telephone interviews and an on-line survey. Survivors who had children and those who hoped to one day participated. Resource development was facilitated by two workshops and email feedback.

RESULTS

Overall, 37 women participated, all of whom were positive about development of the resource. Although many issues identified during data collection were specific to the participants' history of abuse other areas of concern would be relevant for any woman contemplating the journey to parenthood. Women often assumed that they were alone in their concerns and were reassured to discover that others shared their experiences. The final resource is hosted on The Survivors Trust Website and is accessible from all electronic devices. It follows the journey from deciding to have a baby, pregnancy, labour, birth, and the postnatal period through to parenthood. Links are provided to further information and sources of support. The process of developing the resource used trauma-informed principles and it speaks with women's words in a peer-to-peer voice.

CONCLUSIONS

This paper describes the development of an innovative and accessible e-resource that is based on the words and experiences of survivors of childhood sexual abuse. It recognises the importance of control and feeling safe and aims to empower those who use the resource as they embark on pregnancy, birth, and parenthood.

Disclosure of non-recent (historic) childhood sexual abuse: What should researchers do?

Non-recent (historic) childhood sexual abuse is an important issue to research, though often regarded as taboo and frequently met with caution, avoidance or even opposition from research ethics committees. Sensitive research, such as that which asks victim-survivors to recount experiences of abuse or harm, has the propensity to be emotionally challenging for both the participant and the researcher. However, most research suggests that any distress experienced is usually momentary and not of any clinical significance. Moreover, this type of research offers a platform for voices which have often been silenced, and many participants report the cathartic effect of recounting their experiences in a safe, non-judgemental space. With regard to the course of such research, lines of inquiry which ask adult participants to discuss their experiences of childhood sexual abuse may result in a first-time disclosure of that abuse by the victim-survivor to the researcher. Guidance about how researchers should respond to first-time disclosure is lacking. In this article, we discuss our response to one research ethics committee which had suggested that for a qualitative study for which we were seeking ethical approval (investigating experiences of pregnancy and childbirth having previously survived childhood sexual abuse), any disclosure of non-recent (historic) childhood sexual abuse which had not been previously reported would result in the researcher being obliged to report it to relevant authorities. We assess this to be inconsistent with both law and professional guidance in the United Kingdom; and provide information and recommendations for researchers and research ethics committees to consider.

Childhood abuse, pregnancy-related anxiety and the mediating role of resilience and social support

Physical, sexual and psychological abuse were examined as risk factors for pregnancy-related anxiety with resilience and social support as mediators. Pregnant women ( n = 638) completed measures of pregnancy-related anxiety, resilience, perceived social support and childhood abuse. Women with an abuse history had higher pregnancy-related anxiety scores ( m = 64.40) than other women ( m = 55.36). All abuse types independently predicted pregnancy-related anxiety; resilience and social support were mediators. Results highlight the value of antenatal screening for pregnancy-related anxiety including specific risk factors such as child abuse. Programs such as the Midwife Continuity of Care are useful in encouraging disclosure.

Breastfeeding Among Mothers Who Have Experienced Childhood Maltreatment: A Review

BACKGROUND

Current breastfeeding recommendations focus on the physical benefits of breastfeeding but do not take into account the influence of a history of childhood maltreatment on mothers' experiences breastfeeding. A better understanding of this relationship is important to be able to better support mothers during this critical time.

RESEARCH AIM

To review current research that examined how women's personal experiences of childhood maltreatment has affected their breastfeeding outcomes and experiences.

METHODS

A scoping review was conducted to evaluate current literature on breastfeeding and childhood maltreatment. We screened 275 articles, of which eight met the sample selection criteria and were included in this review. These articles were analyzed based on common themes that emerged: Breastfeeding intention, initiation, duration, and exclusivity; medical conditions associated with breastfeeding; and participants' experiences related to breastfeeding.

RESULTS

History of childhood maltreatment was associated with decreased and shorter duration of breastfeeding. Participants' experiences of breastfeeding varied: Some found it empowering, and others experienced great distress while breastfeeding. Challenges during this period included managing touch, struggling with the power differential between providers and participants, and coping with trauma symptoms (e.g., dissociation).

CONCLUSIONS

For some participants, it was possible to breastfeed successfully after childhood maltreatment, but others found the experience extremely difficult, even traumatizing. There is a need for a trauma-informed approach to lactation care for women with a childhood maltreatment history.

A “trigger”, a cause or obscured? How trauma and adversity are constructed in psychiatric stress-vulnerability accounts of “psychosis”

How do mental health professionals link adverse life experiences with the kinds of beliefs and experiences which attract a diagnosis of psychosis and what implications does this have for women with these diagnoses? Drawing on a broadly critical realist framework, we present data from two studies relevant to these questions. First, we analyse the discursive practices engaged in during a staff-only discussion of a female in-patient with a psychosis diagnosis who had been raped some years previously. Staff oriented to the irrationality and factuality of her ostensibly delusional statements about rape and pregnancy in the present and formulated adverse experience as a “stress factor” triggering a manic episode, thereby precluding alternative contextualising interpretations. In a second, interview-based, study, psychiatrists drew on a range of discursive resources which differentiated “psychosis” from other forms of distress, constructed trauma as a stressor which could trigger psychosis because of a genetic predisposition, and constructed medication as the primary intervention whilst trauma was de-emphasised. We discuss the implications of these findings for the kinds of explanations and forms of help offered and suggest ways in which distress might be contextualised as well as possible future directions for feminist research and practice.

Antenatal depression and its potential causal mechanisms among pregnant mothers in Gondar town: application of structural equation model

BACKGROUND

Various forms of life stressors have been implicated as causes of antenatal depression. However, there is a lack of understanding of which forms of stress lead to antenatal depression and through what mechanisms. Modeling stress processes within a theoretical model framework can enhance an understanding of the mechanisms underlying relationships between stressors and stress outcomes. This study used the stress process model framework to explore the causal mechanisms underlying antenatal depression in Gondar, Ethiopia.

METHODS

Questionnaires, using an Online Data collection Kit (ODK) tool were administered face-to-face in 916 pregnant women in their second and third trimesters. Pregnant women were included from six randomly selected urban districts in Gondar, Ethiopia during June and August 2018. The Edinburgh Postnatal Depression Scale (EPDS) was used to screen for antenatal depression. A Structural Equation Model (SEM) was employed to explore the direct, indirect, and total effect of stressors and mediators of antenatal depression.

RESULT

Sixty-three participants (6.9%) reported symptoms of depression. Of these, 16 (4.7%) and 47 (8.1%) were in their second and third trimesters, respectively. The SEM demonstrated several direct effects on antenatal depression scores including unplanned pregnancy (standardized β = 0.15), having a history of common mental health disorder (standardized β = 0.18) and fear of giving birth to the current pregnancy (standardized β = 0.29), all of which were associated with a higher depression score. Adequate food access for the last 3 months (standardized β = - 0.11) was associated with decreased depression score. Social support (β = - 0.21), marital agreement (β = - 0.28), and partner support (β = -.18) appeared to partially mediate the link between the identified stressors and the risk of antenatal depression.

CONCLUSION

Both direct and indirect effects contributed to higher antenatal depression score in Ethiopian women. The three psychosocial resources namely marital agreement, social and partner support, mediated reduced antenatal depression scores. Early screening of antenatal depression and enhancing the three psychosocial resources would help to improve maternal resilience.

Global burden of antenatal depression and its association with adverse birth outcomes: an umbrella review

Background

Women of childbearing age are at high risk of developing depression and antenatal depression is one of the most common mood disorders. Antenatal depression is also associated with a number of poor maternal and infant outcomes, however, there remains a lack of focus on mental issues in antenatal care, particularly in lower income countries. This systematic review of reviews provides useful evidence regarding the burden of antenatal depression which may provide guidance for health policy development and planning.

Methods

We searched CINAHL(EBSCO), MEDLINE (via Ovid), PsycINFO, Emcare, PubMed, Psychiatry Online, and Scopus databases for systematic reviews that based on observational studies that were published in between January 1st, 2007 and August 31st, 2018. We used the Assessment of Multiple Systematic Reviews (AMSTAR) checklist scores to assess the quality of the included reviews. We applied vote counting and narrative review to summarize the prevalence of antenatal depression and its associated factors, while statistical pooling was conducted for estimating the association of antenatal depression with low birth weight and preterm birth. This systematic review of reviews was registered on PROSPERO with protocol number CRD42018116267.

Results

We have included ten reviews (306 studies with 877,246 participants) on antenatal depression prevalence and six reviews (39 studies with 75,451 participants) conducted to identify the effect of antenatal depression on preterm and low birth weight. Globally, we found that antenatal depression prevalence ranged from 15 to 65%. We identified the following prominent risk factors based on their degree of influence: Current or previous exposure to different forms of abuse and violence (six reviews and 73 studies); lack of social and/or partner support (four reviews and 47 studies); personal or family history of any common mental disorder (three reviews and 34 studies). The risk of low birth weight and preterm birth was 1.49 (95%CI: 1.32, 1.68; I² = 0.0%) and 1.40 (95%CI: 1.16, 1.69; I² = 35.2%) times higher among infants born from depressed mothers.

Conclusions

Globally, antenatal depression prevalence was high and could be considered a common mental disorder during pregnancy. Though the association between antenatal depression and adverse birth outcomes appeared to be modest, its absolute impact would be significant in lower-income countries with a high prevalence of antenatal depression and poor access to quality mental health services.

Healing The Past By Nurturing The Future: A qualitative systematic review and meta-synthesis of pregnancy, birth and early postpartum experiences and views of parents with a history of childhood maltreatment

BACKGROUND

Child maltreatment can have serious effects on development and physical, social and emotional wellbeing. Any long-lasting relational effects can impede the capacity to nurture children, potentially leading to 'intergenerational trauma'. Conversely, the transition to parenthood during pregnancy, birth and the early postpartum period offers a unique life-course opportunity for healing. This systematic review aims to understand the pregnancy, birth and early postpartum experiences of parents who reported maltreatment in their own childhood.

METHODS

A protocol, based on the ENTREQ statement, was registered with PROSPERO. We searched Medline, PsycINFO, CINAHL, EMBASE, NHS Evidence and key Web of Science databases from date of inception to June 2018 to identify qualitative studies exploring perinatal experiences of parents who were maltreated in their own childhood. Two reviewers independently screened articles for inclusion and extracted data. Data were synthesised using grounded theory and thematic analysis approaches.

FINDINGS

The search yielded 18329 articles, 568 full text articles were reviewed, and 50 studies (60 articles) met inclusion criteria for this review. Due to the large number of studies across the whole perinatal period (pregnancy to two years postpartum), this paper reports findings for experiences during pregnancy, birth and early postpartum (27 studies). Parents described positive experiences and strategies to help them achieve their hopes and dreams of providing safe, loving and nurturing care for their children. However, many parents experienced serious challenges. Seven core analytic themes encapsulated these diverse and dynamic experiences: New beginnings; Changing roles and identities; Feeling connected; Compassionate care; Empowerment; Creating safety; and Reweaving a future.

CONCLUSIONS

Pregnancy birth and the early postpartum period is a unique life-course healing opportunity for parents with a history of maltreatment. Understanding parent's experiences and views of perinatal care and early parenting is critical for informing the development of acceptable and effective support strategies.

Female genital mutilation: implications for clinical practice

Female genital mutilation (FGM) is an established cultural practice in over 30 countries. It has no health benefits, carries a high risk of physical and psychological harm, and is illegal in many countries including the UK. A sensitive approach is required, both in the management of complications and prevention of this practice. This article discusses the prevalence and classification of FGM, and offers practical advice to nurses and midwives involved in general and obstetric care. Legal aspects, including safeguarding responsibilities and the mandatory duty to report FGM in England and Wales, are outlined.

Determinants and underlying causes of frequent attendance in midwife-led care: an exploratory cross-sectional study

BACKGROUND

An adequate number of prenatal consultations is beneficial to the health of the mother and fetus. Guidelines recommend an average of 5-14 consultations. Daily practice, however, shows that some women attend the midwifery practice more frequently. This study examined factors associated with frequent attendance in midwifery-led care.

METHODS

We conducted a cross-sectional study in a large midwifery practice in the Netherlands among low-risk women who started prenatal care in 2015 and 2016. Based on Andersen's behavioral model, we collected data on potential determinants from the digital midwifery's practice database. Prenatal healthcare utilization was measured by a revised version of the Kotelchuck Index, which measures a combination of care entry and numbers of visits. Logistic regression models were fitted to estimate the likelihood of frequent attendance compared to the recommended number of visits, adjusted for all relevant factors. Separate models were fitted on the non-referred and the referred group of obstetric-led care, as referral was found to be an effect modifier.

RESULTS

The prevalence of frequent attendance was 23% (243/1053), mainly caused by worries and/or vague complaints (44%; 106/243). Among non-referred women, 53% (560/1053), frequent attendance was associated with consultation with an obstetrician (OR = 3.99 (2.35-6.77)) and exposure to sexual violence (OR = 2.17 (1.11-4.24)). Among the referred participants, 47% (493/1053), frequent attendance was associated with a consultation with an obstetrician (OR = 2.75 (1.66-4.57)), psychosocial problems in the past or present (OR = 1.85 (1.02-3.35) or OR = 2.99 (1.43-6.25)), overweight (OR = 1.88 (1.09-3.24)), and deprived area (OR = 0.50 (0.27-0.92)).

CONCLUSION

Our exploratory study indicates that the determinants of frequent attendance in midwifery-led care differs between non-referred and referred women. Underlying causes for frequent attendance was mainly because of non-medical reasons.

IMPLICATION FOR PRACTICE

A trustful midwife-client relationship is known to be needed for clients such as frequent attenders to share more detailed, personal stories in case of vague complaints or worries, which is necessary to identify their implicit needs.

Impacts of sexual abuse in childhood and adolescence: an integrative review

This article identifies the impacts of sexual abuse in childhood and adolescence. We conducted an integrative literature review in September 2018 using the Virtual Health Library. A search was conducted using the following descriptors: Sexual Abuse of Children and Adolescents and Sexual Abuse or Child Development. The inclusion criteria were open access full-text original articles published between 2013 and September 2018 in Portuguese, English or Spanish. Sixteen eligible articles were selected after reading the titles and abstracts. The full texts of these articles were read and organized into a table. The studies show that sexual abuse in childhood and adolescence has lifelong psychological, physical, sexual and social impacts. The findings of this study can help alert health care professionals to the importance of investigating the signs and symptoms of sexual abuse given the multiple impacts of abuse on victims' lives.

Assessing emotional aspects of midwives' intrapartum care: Development of the emotional availability and responsiveness in intrapartum care scale

BACKGROUND/PROBLEM

Emotional care underpins women's positive experiences during labour andbirth but is under-researched. Applying an attachment theory approach may inform the measurement of emotional aspects of maternity care.

OBJECTIVE

To develop and validate a self - report measure for midwives to assess their emotionally attuned intrapartum care.

METHODS

A staged approach to tool development was followed. Item generation was informed by a critical review of the literature and expert review. Following a pilot test, the draft scale was psychometrically assessed. Principal component analysis with varimax rotation was used to establish construct validity. Cronbach's alpha determined internal reliability. Concurrent validity was tested with the 'empathic concern' and the 'personal distress' subscales on the Interpersonal Reactivity Index. The study was conducted with midwives (n = 705) who are members of the Australian College of Midwives.

FINDINGS

The Cronbach's alpha for the scale was 0.88. Principal component analysis revealed a one- factor solution. Significant but low correlations with Interpersonal Reactivity Index subscales of 'empathic concern' (rho = .256, p <.001) and 'personal distress' (rho = -.249, p<.001) confirmed concurrent validity.

CONCLUSION

The Emotional Availability and Responsiveness in Intrapartum Care Scale appears to be a valid and reliable measure of emotional aspects of midwives' caregiving. An Attachment Theory approach validates women's perspectives and elucidates our understanding of the importance of emotional labour support.

Parenting after a history of childhood maltreatment: A scoping review and map of evidence in the perinatal period

Background and aims

Child maltreatment is a global health priority affecting up to half of all children worldwide, with profound and ongoing impacts on physical, social and emotional wellbeing. The perinatal period (pregnancy to two years postpartum) is critical for parents with a history of childhood maltreatment. Parents may experience ‘triggering’ of trauma responses during perinatal care or caring for their distressed infant. The long-lasting relational effects may impede the capacity of parents to nurture their children and lead to intergenerational cycles of trauma. Conversely, the perinatal period offers a unique life-course opportunity for parental healing and prevention of child maltreatment. This scoping review aims to map perinatal evidence regarding theories, intergenerational pathways, parents’ views, interventions and measurement tools involving parents with a history of maltreatment in their own childhoods.

Methods and results

We searched Medline, Psychinfo, Cinahl and Embase to 30/11/2016. We screened 6701 articles and included 55 studies (74 articles) involving more than 20,000 parents. Most studies were conducted in the United States (42/55) and involved mothers only (43/55). Theoretical constructs include: attachment, social learning, relational-developmental systems, family-systems and anger theories; ‘hidden trauma’, resilience, post-traumatic growth; and ‘Child Sexual Assault Healing’ and socioecological models. Observational studies illustrate sociodemographic and mental health protective and risk factors that mediate/moderate intergenerational pathways to parental and child wellbeing. Qualitative studies provide rich descriptions of parental experiences and views about healing strategies and support. We found no specific perinatal interventions for parents with childhood maltreatment histories. However, several parenting interventions included elements which address parental history, and these reported positive effects on parent wellbeing. We found twenty-two assessment tools for identifying parental childhood maltreatment history or impact.

Conclusions

Perinatal evidence is available to inform development of strategies to support parents with a history of child maltreatment. However, there is a paucity of applied evidence and evidence involving fathers and Indigenous parents.

An exploratory study of whether pregnancy outcomes influence maternal self-reported history of child maltreatment

Childhood maltreatment is common and has been increasingly studied in relation to perinatal outcomes. While retrospective self-report is convenient to use in studies assessing the impact of maltreatment on perinatal outcomes, it may be vulnerable to bias. We assessed bias in reporting of maltreatment with respect to women's experiences of adverse perinatal outcomes in a cohort of 230 women enrolled in studies of maternal mental illness. Each woman provided a self-reported history of childhood maltreatment via the Childhood Trauma Questionnaire at two time points: 1) the preconception or prenatal period and 2) the postpartum period. While most women's reports of maltreatment agreed, there was less agreement for physical neglect among women experiencing adverse perinatal outcomes. Further, among women who discrepantly reported maltreatment, those experiencing adverse pregnancy outcomes tended to report physical neglect after delivery but not before, and associations between physical neglect measured after delivery and adverse pregnancy outcomes were larger than associations that assessed physical neglect before delivery. There were larger associations between post-delivery measured maltreatment and perinatal outcomes among women who had not previously been pregnant and in those with higher postpartum depressive symptoms. Although additional larger studies in the general population are necessary to replicate these findings, they suggest retrospective reporting of childhood maltreatment, namely physical neglect, may be prone to systematic differential recall bias with respect to perinatal outcomes. Measures of childhood maltreatment reported before delivery may be needed to validly estimate associations between maternal exposure to childhood physical neglect and perinatal outcomes.

"I Felt Like I Was Being Abused All Over Again": How Survivors of Child Sexual Abuse Make Sense of the Perinatal Period Through Their Narratives

Sequelae following child sexual abuse pervade the lives of adult survivors, significantly impacting on pregnancy and childbirth. Symptoms of this distress are recognized, but meanings for women are less understood. This research aimed to examine the meaning for women themselves of the impact of child sexual abuse on experiences of pregnancy, childbirth, and the postnatal period. Taking a critical feminist perspective, three open-ended interviews with three survivors enabled women's narratives of pregnancy and childbirth to be heard, explored the structure of these narratives, including how experiences were connected, and identified key themes and how selves and others were positioned. Women themselves contributed to the analysis of their own narratives. The different struggles of each woman occurred within three domains of experience: identity, embodiment, and parenting. They were underpinned by a fluctuation between empowerment and disempowerment. These findings, although based on detailed analysis of the experiences of only three women, dovetail with, integrate, and extend the existent literature, offering a framework for understanding the complexity of meaning making for women. Further research might develop this. The framework may facilitate clinicians' understandings of what it is like for some women having children who have experienced child sexual abuse.

Women's descriptions of childbirth trauma relating to care provider actions and interactions

Background

Many women experience psychological trauma during birth. A traumatic birth can impact on postnatal mental health and family relationships. It is important to understand how interpersonal factors influence women’s experience of trauma in order to inform the development of care that promotes optimal psychosocial outcomes.

Methods

As part of a large mixed methods study, 748 women completed an online survey and answered the question ‘describe the birth trauma experience, and what you found traumatising’. Data relating to care provider actions and interactions were analysed using a six-phase inductive thematic analysis process.

Results

Four themes were identified in the data: ‘prioritising the care provider’s agenda’; ‘disregarding embodied knowledge’; ‘lies and threats’; and ‘violation’. Women felt that care providers prioritised their own agendas over the needs of the woman. This could result in unnecessary intervention as care providers attempted to alter the birth process to meet their own preferences. In some cases, women became learning resources for hospital staff to observe or practice on. Women’s own embodied knowledge about labour progress and fetal wellbeing was disregarded in favour of care provider’s clinical assessments. Care providers used lies and threats to coerce women into complying with procedures. In particular, these lies and threats related to the wellbeing of the baby. Women also described actions that were abusive and violent. For some women these actions triggered memories of sexual assault.

Conclusion

Care provider actions and interactions can influence women’s experience of trauma during birth. It is necessary to address interpersonal birth trauma on both a macro and micro level. Maternity service development and provision needs to be underpinned by a paradigm and framework that prioritises both the physical and emotional needs of women. Care providers require training and support to minimise interpersonal birth trauma.