crying

        I have wanted to be around pregnancy, birth, and breastfeeding for as long as I can remember. I didn’t realize initially that midwifery was the word for the passion I had burning inside of me. My story into that world played out like a movie. (I am an avid reader, so I’m sure the book would be better!). Flashback to a little redheaded, curious creature with freckles sprinkled across her nose crawling into the doghouse. I recall being in kindergarten the first time I witnessed birth. My sweet and tender dog, Bingo, gave life to the tiniest and most perfect puppies I had ever seen. She was so instinctual. NO fear. NO concerns. NO meddling. She worked, and she birthed. It was beautiful. She was such a good mother and taught me a lot about motherhood. I remember trying to help her get each puppy to a nipple. I stroked Bingo, and I told her all the time what a wonderful momma she was. That’s the day I became a midwife—I simply didn’t recognize the magnitude of that time and the shift in my heart until I was an adult, but it was the catalyst.

             Fast-forward to a love-sick high school graduate, seventeen-years old, freckles faded—a youngster full of hopes and desires. I went pre-med with the goal of working in obstetrics and gynecology. My plans to follow that path changed. I found myself shocked by a pregnancy. I gave birth—that’s the only positive thing I can say about that.  My first birth was traumatic, and the memory still fills me with fear and anguish. The experience left me confused, deflated, and less than empowered. I am convinced that this trauma has followed me into every aspect of my life. It affects the way I mother. Occasionally I am frozen with fear. I still have not forgiven entirely. I never reported the doctor, and I never confronted him. I blame myself even when the logical parts of me know better. I hurt to this day. It has been twenty years. 

            Time marches on. The scene sets upon me, now a 38-year-old woman married to the man I was love-sick over (and still am just as crazy for him) and have since birthed five more children. We grow and evolve. We find our power, and I found mine. My experiences landed me in the middle of what I always loved—pregnancy, birth, and breastfeeding. I am a midwife.

            I always believed I would be content catching babies; instead, I have found I feel unsettled. I noticed a shocking and saddening trend in the women I serve—trauma. My personal experience with trauma was not exactly the same as what I was observing with these women, but it felt familiar. I knew I couldn’t leave it alone. I knew I couldn’t leave them alone. How could I help? What could I do? I decided to go back to school, work on my doctorate, and try to change the way we currently care for birthing women after sexual trauma.

            Sexual violence and trauma are a widespread human rights and public health problem. The Centers for Disease Control and Prevention (CDC) (2017) and the World Health Organization (WHO) (2016) show that one in four women are victims of sexual violence by an intimate partner and one in three are victims of sexual violence in their lives. Over 27% of women have childhood sexual abuse in their history, and almost 23 million women have been victims of rape or attempted rape (Heritage, 1998; CDC, 2017). RAINN (2016) notes that every 98 seconds another American woman is sexually assaulted.

A population heavily burdened by sexual violence is the armed forces. There were 18,900 reported unwanted sexual contacts last year, according to RAINN (2016) and many more go unreported. Military Sexual Trauma (MST) is a large source of traumatic stress among women seeking Department of Veterans Affairs (VA) disability for PTSD, where 71% of women have reported sexual violence during their service in the military (Hyun, Pavao, J., & Kimerling, R., 2009).

The short-term and long-term negative impacts of sexual violence are catastrophic. Sexual violence has an association with adverse physical, mental, and health effects (Gisladottir, et al., 2016; WHO, 2017). Victims report feelings of fear, concerns for their safety, and post-traumatic stress disorder (PTSD) in large numbers (CDC, 2017). Studies indicate links to illicit drug use, alcohol use, smoking, high body mass index, depression, and anxiety (Gisladottir, et al., 2016). Although there is limited data associated with sexual trauma and obstetrical outcomes, research shows that women who have been victims have adverse physical and psychological reactions during the prenatal, antenatal, and postpartum periods (Heritage, 1998). Those reactions include increased maternal distress in labor and delivery, prolonged first and second stages of labor, antepartum bleeding, emergency instrumental delivery, hospitalization during pregnancy for common pregnancy complaints, both elective and emergency cesarean section, and poor bonding and parenting (Gisladottir, et al., 2016; Henriksen, L., Schei, B., & Lukasse, M., 2016).             

            Women who are victims of sexual violence often seek health care even if they are not willing to disclose the trauma. A health care provider is likely to be the initial contact for victims, and research shows the victim will identify them as the most trustworthy (WHO, 2013). This places providers in a distinctive position to screen and address the holistic needs of women. The healthcare system often regards sexual violence as a criminal justice or domestic issue versus a medical crisis (WHO, 2013). WHO (2016) declares, in order to reach change, policy and legislature that tackles discrimination against women, promotes gender equality, supports women, and moves towards peaceful cultural norms must be enacted. Because of this mainstream thinking, policy often involves guidelines for clinical care or reducing criminal and violent acts against women. Considering these facts, it is important to also reflect on the frequently overlooked, but equally vital policy of screening. Research has shown that screening for violence has increased the identification of such violence, but has not reduced the rate of that violence (WHO, 2013).

            WHO (2013) says antenatal care provides a prime opportunity for routine inquiry about sexual violence because of the vulnerability of pregnancy and the poor outcomes associated with sexual violence. They broaden that statement by acknowledging that this is possible because of follow-up care (WHO, 2013).  Many Swedish studies have shown proof that a singular screening does not result in many acknowledgments of sexual trauma. However, the trusting relationship built between healthcare providers and their patients after a few encounters and repetitive inquiries provide the safe environment necessary to bring trauma into the light. Midwives are fortunate to have the time to foster this type of relationship with their clients, and I believe, as a midwife, that it is our responsibility and it is our time to unshroud and dethrone the shame of trauma. 

            Birth after trauma is experienced with a certain thickness. The fog of hesitancy and fear cloud the experience. Labor can trigger feelings of our bodies being out of our control. At times women are taken back to that moment, their cruelest moment. The intersection of the best and the worst times we have ever journeyed through can be difficult to process. Preparations and simple steps can be taken to minimize triggers, alleviate anxieties, and empower the women, and that is where midwifery meets sexual trauma and birth. That is where my passion is leading me.

 

References

Centers for Disease Control and Prevention. (2017). The National Intimate Partner and Sexual Violence Survey.  NISVS Infographic. Retrieved from https://www.cdc.gov/violenceprevention/nisvs/infographic.html#share

Department of Veterans Affairs. (2015). The Center for Women Veterans. Counseling & medical treatment for the after effects of sexual trauma. Retrieved October 21, 2017, from https://www.womenshealth.va.gov/trauma.asp

Department of Veterans Affairs. (2010). Military Sexual Trauma Programming. Retrieved from https://www.google.com/search?client=safari&rls=en&q=vha+directive+2010-033&ie=UTF-8&oe=UTF-8

Gisladottir, A., Luque-Fernandez, M. A., Harlow, B. L., Gudmundsdottir, B., Jonsdottir, E., Bjarnadottir, R. I., & … Valdimarsdottir, U. A. (2016). Obstetric Outcomes of Mothers Previously Exposed to Sexual Violence. Plos ONE11(3), 1-12. doi:10.1371/journal.pone.0150726

Henriksen, L., Schei, B., & Lukasse, M. (2016). Lifetime sexual violence and childbirth expectations – A Norwegian population based cohort study. Midwifery3614-20. doi:10.1016/j.midw.2016.02.018

Heritage, C. (1998). Working with childhood sexual abuse survivors during pregnancy, labor, and birth. Journal of Obstetric, Gynecologic, And Neonatal Nursing: JOGNN27(6), 671-677.

Hyun, J., Pavao, J., Kimerling, R., (2009). Military sexual trauma. PTSD Research Quarterly, 20(2), 1-8. Retrieved from http://www.ncdsv.org/images/NCPTSD_MilitarySexualTrauma_Spring2009.pdf

Kimerling, R., Gima, K., Smith, M., Street, A., & Frayne, S. (2007). The Veterans Health Administration and military sexual trauma. American Journal Of Public Health97(12), 2160-2166. doi:10.2105/AJPH.2006.092999

RAINN. (2016). Scope of the Problem: Statistics. Retrieved from https://www.rainn.org/statistics/scope-problem

Stander, V. A., & Thomsen, C. J. (2016). Sexual Harassment and Assault in the U.S. Military: A Review of Policy and Research Trends. Military Medicine181(1 Suppl), 20-27. doi:10.7205/MILMED-D-15-00336

Suris, A., & Lind, L. (2008). Military sexual trauma: A review of prevalence and associated health consequences in veterans. Trauma, Violence, & Abuse9(4), 250-269. doi:10.1177/1524838008324419

World Health Organization. (2016). Media Centre. Violence Against Women. Retrieved from http://www.who.int/mediacentre/factsheets/fs239/en/

World Health Organization. (2017). Sexual and Reproductive Health. Sexual Violence. Retrieved from http://www.who.int/reproductivehealth/topics/violence/sexual_violence/en/

Responding to Intimate Partner Violence and Sexual Violence Against Women: WHO Clinical and Policy Guidelines. (2013).

Being a MOMMA Midwife