In a previous Blog, I wrote about escaping from the trauma of #sexualabuse and how #psychotherapy can help. I'm going to explore one of the possible long-term consequences of sexual abuse: #Birthtrauma. Its not inevitable, but if you have a history of rape or sexual abuse, then this can mean your risk of developing Birth Trauma should you become pregnant, does increase.
Fortunately, there is a lot you can do to reduce the risk and increase the likelihood of having the positive experience of birth and of your baby which you have every right to expect.
I first want to express how wrong this is: no-one should ever be raped or sexually abused: both are gross abuses of power, causing lasting emotional, psychological and physical harm. If you have been through such experiences, then you deserve all the support and treatment you need to recover and the authorities should do all they can to hold the perpetrator(s) to account. What really shouldn't happen, but sadly often does, is that you recover and move on from the awful experience, become pregnant and start preparing for giving birth, only to have the traumatic symptoms and memories return, just at what should be a joyous and wonderful moment. It can be as if you are still under the grip of the abuser and can't quite break free, maybe even years later.
So what is #BirthTrauma and why can a history of sexual abuse increase risk?
The Birth Trauma Association( https://birthtraumaassociation.org.uk/for-parents/what-is-birth-trauma) defines Birth Trauma as:
"a shorthand phrase for post-traumatic stress disorder (PTSD) after childbirth. We also use it for women who have some symptoms of #PTSD, but not enough for a full diagnosis.
(#PTSD - Post Traumatic Stress Disorder, is a condition often experienced by people who have survived highly traumatic events which have involved a threat to life or physical integrity. The symptoms are across three clusters: Re-experiencing (including flashbacks, nightmares, intrusive thoughts and physical symptoms such as pain, sweating, nausea and feinting; Avoidance - of reminders of the incident or of thinking or talking about what happened and Hyper-arousal - being anxious, finding it difficult to relax, constantly aware of potential threats. It has a highly debilitating impact on those who experience it.)
NICE (National Institute for Clinical Excellence) states it includes "Births, whether pre-term or full-term, which are physically traumatic...and births which are experienced as traumatic, even when the delivery is obstetrically straightforward."
In essence, Birth Trauma refers to having a frightening and perhaps painful experience of being pregnant, labour, birth and the post-partum period and the lasting impact of that frightening experience, which manifests as a trauma. It covers a wide range of experiences, including a long , painful labour, health issues in pregnancy and actual or risk of miscarriage. Partners can also be vicariously traumatised through witnessing their loved-ones'
pain and fear. Problems with IVF and getting pregnant can also be traumatising. Premature birth, complications and babies spending time in Neo-Natal Intensive Care can also leave their mark, as can insensitive treatment by clinicians.
Still-birth and fear of losing a baby can both have a traumatising impact.
Estimates of the prevalence of Birth Trauma are between 2% and 7%, meaning that between two and seven percent of women who become pregnant will experience some form of traumatic reaction.
Why does a history of rape or sexual abuse increase the risk of Birth Trauma?
Joseph & Bailham, cited in Thomas, K (2013), state that:
"The labour itself could awaken feelings and trigger associations with the original trauma, or possibly because the woman will feel vulnerable, out of control and experience pain."
So there could be elements of the experience of giving birth which remind you of earlier, traumatic experiences: even where the hospital staff are being friendly and supportive, you still might feel helpless and out of control and this will be worse if you felt out of control during the assault. Both a rape and childbirth can be extremely painful and sometimes pain can be felt in the same areas of the body.
This could be a particular problem if the original trauma hasn't been resolved yet: two other blog posts on this site ("Escaping Trauma: recovering from trauma when you have been deliberately targeted" and "Opening up about Sexual Abuse: the challenges, fears and how to heal"), explain in more detail what actually happens in the brain during and after a traumatic incident, but in brief, memories and traces of the incident can become lodged in the non-verbal part of the brain, which has no sense of time or place. If something happens which reminds the brain of the original incident, it will think its happening again and send out the same stress hormones as before, trying to get the body ready to fight, flee or freeze in response to the threat. This is particularly likely to happen if you were unable to get away: if your attacker was stronger than you, if they were known to you and in a position of power or if your brain's chosen response was to freeze (this will have been an automatic choice over which you will have had no control). Your brain and body won't just remember the original trauma, both will believe it is happening again, feeling the same pain and fear.
It doesn't require anyone to actually be aggressive towards you for this to happen: if you are traumatised, a perfectly well-intentioned gesture, smile or movement may contain something which reminds the brain of an earlier assault, especially if you are hyper-vigilant - on alert, waiting and watching for the next danger, a very common feature of #PTSD. It could even be just the experience of feeling out of control, of not feeling involved in decision making about what happens to you while giving birth.
The stress hormones released when a traumatic memory is triggered (such as cortisol and adrenaline), also have the effect of suppressing production by the brain of Oxytocin, a hormone responsible for relaxing the body so that the baby can be delivered. This can have the effect of prolonging the labour, adding to stress levels and pain, which makes the trauma worse and creating an unhelpful spiral.
This doesn't mean will happen to you of course and there are lots of ways you can prepare to ensure you have a safe and rewarding experience:
Talk to Someone: If you are pregnant and have a history of rape, sexual abuse or #domesticviolence, then it can help to tell your GP or midwife as soon as possible. There can often be a whole team of health professionals involved in your maternity care and one of the worst things about being traumatised is having to repeat your story over and over again to lots of different professionals: most maternity units will have a Vulnerable Women Team who may be able to allocate you to a single midwife to work with through the whole process. The midwife will be able to liaise with the other health professionals for you so you don't have to keep repeating the story. They may also be able to help you think about what your triggers might be, going through the process and ensuring all other staff are aware of this to minimise the risk
Attend Ante-Natal Classes: these are run in all areas of the country by the NHS and #NCT: understanding exactly what is going to happen during labour can help take some of the anxiety out of the process.
Consider #therapy: In my two other blog posts about trauma (cited above), I talk about how #EMDR is a very effective treatment for resolving past traumas, reducing traumatic symptoms and freeing people from the grip of trauma. This approach, directly addressing memories of past trauma is certainly an option in early pregnancy. It can become less appropriate in the later stages due to changes in the body and nervous system. The cut-off point will vary for each person so its very important to consult your GP and / or Midwife before engaging in a treatment such as EMDR. Depending on your circumstances and with medical consent, processing of traumatic memories later on in a pregnancy may be possible, but you should always seek medical advice first.
This is another aspect of why this is all so unfair: you may find yourself trying to keep calm in the later stages of pregnancy for the sake of your health and that of your baby but find this difficult because of the trauma-related stress hormones which are still at an elevated level because the trauma is unresolved: there is a treatment which could resolve the trauma, reduce the level of stress hormones and help you feel a lot more relaxed but you may be advised against it, due to the stage of pregnancy.
Fortunately, there is an adaptation of #EMDR, The EMDR Therapy Protocol for the Prevention of Birth Trauma and Post Partum Depression in the Pregnant Woman (De Devitiis AM & Luber, M in Luber, M ed. 2016. EMDR Therapy: Scripted Protocols and Summary Sheets. Springer. New York. pp 325-355. The same authors have also published a group therapy version of the protocol in the same publication.)
This protocol is designed to be used towards the end of pregnancy and the authors recommend it is deployed after you have been to ante-natal classes, so you have a good understanding of what is going to happen while giving birth.
It aims to improve performance in the implementation of the complex process of childbirth, in order to reduce the risk of childbirth trauma (i.e. to help make it a bit easier to actually give birth, supporting techniques you may have learned in ante-natal classes) and strengthening resiliency while reducing the negative effects of stress suffered (previously) in childbirth. This enables women to feel more competent and secure, yet less anxious, by being more active and constructive. (ibid p 328).
The work starts with a series of exercises to help build up your inner resources, such as enhancing your concentration and body-focus, to help you feel more in tune with and in control of your body during labour and the Safe Space exercise: this helps you remain safe, self-contained and relaxed and gives you a place you can go to in your mind if you become stressed or frightened during labour. You can also develop the idea of an inner coach or supporter, someone who can support and soothe you if the process gets difficult.
The therapist will also help you identify the moments and aspects of giving birth which worry you most or which you think will be the most challenging and will use EMDR processing techniques to help reduce your fear of these challenges.
Finally, the therapist will lead you through a visualisation exercise to help you imagine yourself successfully and smoothly completing a calm and safe labour.
In the same publication, the authors discuss encouraging results from their own research showing reduced rates of PTSD and Post Natal Depression for women who have been through the protocol in comparison with a control group and researchers in Holland are also showing positive results through use of the protocol, but with a smaller number of subjects: (Stamrood CAI, in Fogashi et al, Journal of EMDR Practice & Research, Volume 7, No 1, 2013: Case Conceptualisation: Traumatised Pregnant Women.)
(This protocol was designed mainly for women who were pregnant again after a previous traumatic labour to help prevent any issues with the second delivery but it can also work for women on their first pregnancy, who have been traumatised in other ways.)
There are also many voluntary sector organisations, such as the Birth Trauma Association, who are also great sources of information, support and advice (Please see below).
If you do find yourself in this position, of preparing to give birth, against a background of experiencing rape, sexual abuse or domestic violence, remember that what was done to you was wrong and that there are many ways you can be helped. Please reach out.
Sources of advice, information and support:
The Birth Trauma Association: www.birthtraumassociation.org.uk
www.birthtraumaptsd.com
Baby Centre - Traumatic Birth Support Group:
http://community.babycentre.co.uk/groups/a3857275/traumatic_birth_support_group
The National Childbirth Trust: www.NCT.org.uk
Thomas, K. 2013. Birth Trauma: a guide for you, your friends and family to coping with post-traumatic stress disorder, following birth. Neal James. London.