Childhood Sexual Abuse and Its Effects On Childbirth

The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

If you missed the segment about Orgasmic Birth, aired on ABC"s 20-20 on Jan. 2,
you can still catch the mini-segments:

Birth Orgasms: Women Speak Out - Is it possible to have an orgasm during childbirth?

Women Who Prefer Home Birth - For some, delivering a healthy child doesn"t involve a trip to the hospital. [Note - the associated article says, "Modern medicine means not having to go through childbirth alone." It"s more accurate to say "Responsible modern medicine means reserving risky interventions for when the benefits outweigh the risks." I know lots of responsible women who give birth at home with the perfect birth team . . . their partner, their midwife and their doula. They are definitely not alone, and they have all the medical assistance they need, just like a woman giving birth with a midwife in a hospital! Savvy people know the difference between midwife-assisted homebirth and unassisted birth.]

The Orgasmic Birth web site also has a lot of great information about birth in general:
Birth by the Numbers
The Director"s Blog
Birth Stories

by Regine Spindler

INTRODUCTION

At the dawn of a new millennium, many caregivers are asking themselves and the healthcare system, why a high technological environment, surrounding such a natural event like childbirth, is not preventing a rising rate of cesarean sections, contrary to certain other European countries such as Holland, where homebirths are the rule and where the rate of cesarean sections is one of the lowest in the world. However, a certain number of medical interventions in childbirth are due to anatomical abnormalities or emergencies .

The caregiver should be aware that these abnormalities are rare. But this is not the topic of this study , and I will concentrate on childhood sexual abuse, which can be the cause of labor dystocia and its symptoms, such as failure to progress (FTP). I will also focus on the consequences of childhood sexual abuse on pregnancy, and on the relation with the caregiver.

In this paper, I used testimonies of sexual abuse survivors obtained on a support group maintained on Internet and researches having being completed already on the subject.

I will first try to define sexual abuse, its components, its background, and the signs and symptoms that a caregiver should recognize.
I will then proceed in quoting several excerpts of the testimonies I have obtained and will analyse their content to outline what happens to those survivors during pregnancy and childbirth.

In the next section, I will describe some symptoms which should help the caregiver in forecasting what could be expected from a survivor, and will suggest approaches to facilitate the relation between the caregiver and the survivor during pregnancy and childbirth, as well as describing other proposals of prevention and healing .

Even though this paper is primarily designated to be read by Gyn Doctors, Midwives, Doulas, and Childbirth Educators of my area (Catkill NY), I hope that facilities such as the family planning, rape crisis centers etc., will understand the necessity of reading this study, in order to start detecting the problem even before the onset of pregnancy, if possible, and start the healing process way before the survivor comes to the healthcare provider for the birth.

WHAT IS SEXUAL ABUSE?

Definition

In the USA, childhood sexual abuse is defined as having any kind of imposed sexual activity under the age of 18 years old. It is usually performed on a child, male or female, by an older person, male or female, having some power or authority on the child. It can happen in any family, regardless of its social-economical background. A member of the family or a neighbor can perform the abuse. It can be a rape, caresses, exhibitionism, sex talk etc. (Simkin, 1994).

Several researches show that 1 woman in 3 is a survivor of childhood sexual abuse, but it is very difficult to make a correct estimate, due to the fact that many women suffer from amnesia until they are much older, or they feel too traumatized to admit what happened. (Holtz, 1994).

Signs and symptoms

Some survivors can demonstrate behavioral symptoms such as: poor grooming, addictions of any kind, eating disorders, teen pregnancies, (Holtz, 1994; Frye, 1998) Psychosomatic symptoms such as pelvic pains, headaches, G I track disturbances are common. Women can experience over exaggerated gag reflexes, neck pains and endless nausea. Survivors who have not recovered any memory from the past abuse, usually experience at least some of these symptoms.

SEXUAL ABUSE AND CHILDBIRTH

Analysis of testimonies

One of the very first thing that I could gather after reading those “confessions”, was a general fear of losing control, expressed by all these women during their pregnancy and childbirth. It is not surprising, during an or several continuous episodes of abuse, the individual have no control whatsoever on what is happening to them, many of them being sometimes under physical threats such as weapons.
“The labor was progressing so fast that I felt out of control and scared, and my baby hurt a lot…. My body began pushing. The pain became so intense that I found myself retreating out of my body…. My mind was full of images of the rape I endured when I was 2 years old, when my mother’s older relative tore me open from the top of my clitoris down to my urethra.” (Rose, 1992)

“I hated pushing and that was a big let down, since I had hoped that it would be easier than the dilating stage. I have a hard time coping with anything that my body does that I cannot control, like pushing out a baby, vomiting, menstruating etc.” (E-mail).

“The less I am ‘messed up with’ during childbirth, the better I do. Any time the control is taken out of my hands and put in to the hand of a medical professional, it brings back the terror and the powerlessness of the abuse all over again.” (E-mail)

On the other hand, some women let others take control over them: “I managed to enter in an emotionally abusive relationship with doctor who attended the birth. I found that one physician who did home births, and went with him regardless of the fact he made me feel 3 inches tall every time I saw him.” (E mail)

They also feel that there is no place safe, so they slip away somewhere else. “In fact, I felt as if I were viewing the whole scene from outside my body, up near the ceiling and to my left, about 10 feet away from where I lay. (Rose, 1992). “But when the contractions came I lost it and just pushed and screamed that it hurt, I cried for my mommy…. I just went someplace else, someplace safe in my mind. I know it sound strange but I just could not handle it, and I was so tired of being touched. ” (E mail).

Being touched or examined by the caregiver can trigger traumatic flashbacks and therefore putting an obstacle in a healthy relationship between the mother and caregiver. “And I had talked about not even getting checked during labor before.” (E-mail). “Hospitals only mean pain, humiliation, and illness to me.” (E-mail). “If I could not endure this vaginal exam on my first prenatal visit, how was I ever going to birth a baby? But I did not trust my body, would not, could not let myself push without her permission {the Midwife}” (E-mail).

Not feeling safe, mistrusting oneself and the caregiver seem to be a constant element, and is demonstrated by refusing exams and especially vaginal exams. Dissociation and flashbacks are also very frequent and play a determinant influence not only in the relation with the caregiver but during the labor itself.

Understanding and recognizing the symptoms

Pregnant women do often reenact unconsciously the abuse or the rape during prenatal exams and birth. They feel, as seen in the precedent section, totally under the control (imaginary or not) of the caregiver and can react to careless interviews, or exams, during their pregnancy and birth. Triggered memories can surge in forms of flashbacks, difficult to handle during labor (Kitzinger, 1992). Women need to feel safe and not disturbed for a good and efficient labor. Mammals are always looking for a retired and dark place in order to give birth. If they feel threatened the survival reflex predominates, and labor stops or is slowed down due to the influx of catecholamines insuring the fight or flight response (Odent, 1999). This is also true for women and this is one of the reasons, in my opinion, why so many survivors experience labor dysfunction, especially in first stage (Tallman & Herring, 1998).

List of symptoms (Simkin in Frye, 1998)

Psycho-social problems - Mistrust towards the caregiver, Bonding failure, Post Traumatic Stress Disorder, Eating disorders, Obesity, Desire to change one’s name, Failure to remove one’s clothes when appropriate, nervousness about being watched.
Mental problems - Fear of pain, Phobias of needles, pelvic exams or other invasive procedures. Dreams and nightmares, Dissociation disorders, Anger issues, Rigid control of though process, Poor self image, Blocking all early childhood memories,
Physical problems - Infertility, Migraines, severe PMS, Swallowing and gagging sensitivity.
Sexual problems - Sexual addiction, Inability to achieve orgasm, Prostitution (most have been abused), pregnant teens (66% remember abuse)
Problems during pregnancy, childbirth and postpartum - Fear of being “ripped apart” during birth, Inability to breastfeed or having difficulties, Hyperemesis gravidarum, threatened premature labor, May hold the labor at a certain point to protect genitals area or the baby, Fear of losing control.

The author advises to avoid generalizations and being conscious of the fact that not every woman displaying several of those symptoms may have been abused.

WHAT CAN THE CAREGIVER DO?

Labor dysfunction will most frequently occur during the first stage, whether the abuse episode has been shared or not with the caregiver (Tallman & Hering, 1998), and is due to unconscious maneuvers from the woman in childbirth, who cannot control the pain anymore, as well as feelings of fear and the stress triggered by the fight for survival.

Establishing a basic bond between the caregiver and the patient during early pregnancy

Since one of the symptoms described previously is a basic mistrust in caregivers, it becomes obvious that step #1 is establishing a minimum level of trust with the client. It will enable the caregiver to recognize further down the road, possible problems and establish tentative of solutions. It is however challenging since symptoms of abuse may not be obvious at first sight.

Anne Frye suggests that disclosure of abuse is possible if the client is aware and remembers the episode(s). Questions such as: “Did you experience sexual abuse in your life”, is a direct and healthy way to start the issue. Some women will be comfortable enough to admit it if this is the case. However, some others do not because they cannot admit it due to feelings of guilt even if they remember, and some do not remember the events at all.

This is where the caregiver skills are challenged not only to recognize symptoms, but also to establish a relation where the client will feel safe. It is important to recognize them early in pregnancy, in order to allow sufficient time for the caregiver to assess data and organize a plan of care according to the highest possibilities of the client. (Fusco, 1998)

The room environment where both parties meet is essential : decoration, furniture, examination tables, clothes worn by the care giver etc…Permission should be asked before entering the client’s personal and intimate space and explanations should be given during pelvic exams, along with a constant preoccupation of letting the client know that it could be stopped at any time and resumed when the client feels safe enough (Holtz, 1994).

This is also the time where one will recognize non-verbal clues, such as rigidity of the body, grimacing or inappropriate behavior such as laughing or withdrawal.

Flashbacks can be experienced during exams and interviews and it is important to validate them whether the patient is verbalizing them or not (Frye, 1998).

Jennifer Burian (1995), labor nurse advises:

“Consider what your response would be if a woman disclosed a history of sexual abuse to you.
Provide an emotionally and physically safe environment for survivors.
Establish an atmosphere of openness and unhurried listening.
Be aware of your language. False intimacy in a soothing voice may trigger memories of perpetrator’s demeanor during the original abuse.
Be aware of the discomfort of body exposure
Remember that a vaginal exam can feel like a repeat of the abuse. Let the woman choose the timing and talk through it, stopping if she appears at all physically and emotionally unable to continue.
Assure her that she is safe, and affirm her strength through labor and birth.
Above all honor the emotions that she is feeling.”

During labor

It is crucially important that during the first stage of labor, continuity should be given to what may have been started during pregnancy, by the caregiver, the childbirth educator, and the doula. Ideally, the three parties should have remained in constant communication and interaction during the client pregnancy. Survivors in childbirth do need a maximum of compassion and understanding in order to allow themselves to express what they would feel during this time. The doula is essential to bring the extra support and care that will make the difference in the labor. She can advocate, interpret, and be the interface between the laboring woman and the nurses if they are not aware of the situation. We know that most of the caregivers do not stay during the whole duration of labor, which can be sometimes very long. The doula will be soothing, reinsuring, listening to the survivor as much as needed.

It is essential to remember that past the first stage, and when women get into transition, flash backs or dissociation are frequent, women may slip somewhere else refuse to push or dilate. They may even go back to an early stage of dilatation. The doula and the caregiver will have to continue to reinsure and keep eyes contact with the survivor to get the maximum of her strength and energy (Courtois & Courtois Riley, 1992). Its is also the moment to validate her feelings and emotions as well as her possible physical manifestations, screaming, closing her legs, refusing to be touched, etc. (Simkin, 1992).

Post Partum

Even though all of the above may have been provided, several problems may arise after the birth of the baby. Depression, difficulty in bonding with baby, problems in breastfeeding such as milk retention or repulsion to have the baby suck at the breast (Grant, 1992).

Seeking a solution

I borrowed the title of this section from an article from Nora Tallman and Cammie Hering, a midwife and a counselor, in which they explain that even after having done everything described above, they were still noting that survivors were having more medical interventions during childbirth than the regular patient. They concluded that it was already too late for the survivor at childbirth and that despite of all the measures they had taken, survivors were still experimenting labor dysfunction as early as the first stage, mostly FTP (failure to progress).

They are suggesting setting up a special prenatal preparation, with a support group: “We designed a prenatal support group to help SOCAs (survivor of child abuse) heal their wounded sense of self. Its purpose is to develop psychological and emotional tolls for coping with the challenges of pregnancy, labor, and parenting. Although we do discuss past traumas, the group is primarily focused on the practical aspects of their upcoming birth experience and the challenges of parenting. Topics include dissociation and flashbacks, dealing with pain and fear, control, communication, and relationship issues. By limiting the group to SOCAs, a midwife and a counselor, participants feel safe to discuss painful subjects and to experience both giving and receiving support with others who have experienced similar traumas. Above all, we hope these women experience their empowerment and self-respect.”

Sheila Kitzinger (Midwife archives, 1990) encourages the educators counselors midwives to create a birth crisis network where women as women, “could support each other, question obstetrics policies and practices, and get involved in the politics of birth.”

Jan Stanton, director of Heart to Heart, headquartered in Chicago, is especially concerned with the rate of teen moms having been raped prior to their pregnancy and the average age of their first sexual abuse (9.7 – 12 years old), and the fact that 50% of these abuses were committed by family members. She also states that violence and weapons were involved in 75% of these cases.

She believes in teen parental education prevention in the form of workshops, such as knowing how to protect themselves and their children from sexual abuse, with an extensive support and information from community network (Sue LaLeike, midwife archives).

CONCLUSION AND DISCUSSION

Why concluding on such a note, after describing extensively what could have been done between the survivor and the caregiver? Many researches have been done already, and many things have been tried, therefore there must be something good in them, despite statistics showing bigger figures in labor dysfunction .

So should we solely turn and focus on prevention and forget the role of the caregiver in the story? It seems obvious, that as presented earlier in a previous section, prevention plus an extremely tight connection between all the parties involved, seems crucial in order to offer the survivor, the highest chances for empowerment, healing, and feelings of success and self realization during their birth, post-partum period, and parenting

I would like to mention that this paper will be offered to the Family Planning, the Reach Center, Columbia Memorial Hospital (Hudson NY), Domestic Violence Program, as well as to the local Midwives Gyn Doctors, in Columbia and Greene County NY and to any childbirth educator and doula interested in it.

Finally, I would like to address my very warm thanks to the survivors who were willing to share with me their stories, through the internet support group, and to Marsha Fusco who, very trustfully, offered her own paper on the subject.

REFERENCES

Burian J. (1995). Helping survivors of sexual abuse through labor. The American Journal of Maternal Child Nursing 20 (5): 252-256
Courtois C. & Courtois Riley C. (1992). Pregnancy and childbirth as triggers for abuse memories: Implications for Care Birth 19 (4): 22-223,
Frye A. (1998). Holistic Midwifery. Portland: Labrys press
Fusco M. (1998). The long term health effects of childhood sexual abuse, Issues and interventions. New York (SUNY Empire State College)
Grant L. (1992). Effects of childhood sexual abuse: Issues for obstetric caregivers.
Birth 19(4): 220-221
Holtz K. (1994). A practical approach to clients who are survivors of childhood sexual abuse. Journal of Nurse-Midwifery 39 (1): 13-18
Kitzinger J. (1992). Counteracting, not reenacting, the violation of women’s bodies: The challenge for perinatal caregivers. Birth 19(4): 219-221
Notes from Sheila Kitzinger Talk.1990). Crisis in the perinatal period. Midwife archives.
Laleike S. Many teen pregnancies caused by rape. Midwife Archives Http:
Odent M. (1999). Birth and sexuality. NY Open Center, The art of birthing, audio tape
Rose A. (1992). Effects of childhood sexual abuse on childbirth: one woman’s story. Birth 19(4): 214-218
Simkin P. (1992). Overcoming the legacy of sexual abuse: The role of caregivers and childbirth educators. Birth 19(4): 224-225
Simkin P. (1994). Memories that really matters. Childbirth Instructor Magazine. Winter: 20-24
Tallman N. & Hering C. (1998). Child abuse and its effects on birth. Midwifery Today.45: 19-21.