COVID-19: Trauma-Informed Perinatal Care and Maternal Health

The experience of life during the pandemic and the impact of COVID-19 guidelines for perinatal care have changed the maternal-fetal experience of pregnancy and birth, as well as the maternal-infant experience during the postnatal period. The neuroception (1) of danger and the potential threat to one’s own life and that of loved ones has been sustained since the magnitude and lethalness of the pandemic was fully appreciated. Research assessing how pregnant women have been psychologically impacted by the pandemic is only beginning to be published.

In a study of pregnant women by Saccone et al. (2020), more than half the participants “rated the psychological impact of the COVID-19 outbreak as severe, and about two-thirds reported higher than normal anxiety” (p.295). Almost half of the women reported high anxiety regarding the possibility of transmitting the disease to their prenate. Women experienced the most severe psychological impacts and anxiety in the first trimester of pregnancy (2). For women who carry past experiences of trauma and suffer traumatic stress symptoms, consideration of how COVID-19 affects their and their developing babies’ health and mental health should also be explored.

Guidelines for prenatal and perinatal care have been issued by clinical and public health organizations (Choi et al., 2020) (3). These guidelines are based on the current limited research on the specific risk of COVID-19 in pregnant women and girls, and the rate of maternal-fetal/infant transmission in the perinatal period.

With the intention to protect mothers-to-be, developing babies, and the health care practitioners who care for them from COVID-19, trauma-informed care guidelines in perinatal care that were beginning to be implemented before the pandemic have been superseded by COVID-19 infection control and disease management approaches. As mentioned in my previous post, "Trauma-Informed Care Needed to Address Obstetric Violence" (March 31, 2019), six principles of trauma-informed care have been described by the Substance Abuse and Mental Health Services Administration (SAMHSA) including:

• Safety
• Trustworthiness
• Peer Support
• Collaboration and Mutuality
• Empowerment, Voice, and Choice
• Cultural and Historical Issues and Gender Awareness (4)

In the current hospital environment in which health care staff are highly stressed attempting to keep themselves and their patients from contracting COVID-19, the application of these principles to patient care may be overlooked. The question is, does anyone feel safe in the current environment?

There is a cost to the health and well-being of pregnant and birthing women and girls, many of whom are trauma survivors, and their offspring when they do not feel safe and do not receive trauma-informed care. Past and recent experiences of trauma, especially traumatic experiences that breached a woman or girl’s body boundaries, may shape her perception of internal safety, danger and life threat during pregnancy, the quality of her labor and birth experience, her experience of the care offered by health care providers, as well as the outcome of her pregnancy (5). We also know that conditions inside and outside women’s and girl’s bodies during the preconception, prenatal, and early postnatal periods profoundly impact their offsprings’ development, health, and behavior beginning at conception and over their life span (6).

The impact of pandemic infection control and disease management approaches on maternal-fetal and maternal-infant psychophysiology in the prenatal and perinatal period has yet to be studied. The trauma-sensitive care and resources intended to reduce the re-traumatization of trauma survivors in the prenatal and perinatal period have been set aside in service of COVID-19 infection control guidelines in hospital settings. Some of the very resources that trauma survivors rely on to manage traumatic stress symptoms and support them and their babies during labor and birth have been limited or prohibited.

Perhaps the most important resource trauma survivors have during labor and birth is the presence of chosen support people with whom they experience a felt-sense of safety. During COVID-19, pregnant and birthing women and girls have, at times, been limited to one support person who is only permitted to stay during the actual labor and birth and then must leave. Initially, some hospitals did not allow any support people.

Without these support resources, trauma survivors may experience the recurrence of previously abated traumatic stress symptoms or the exacerbation of existing traumatic stress symptoms. Maternal stress and traumatic stress symptoms have detrimental effects on the psychophysiology of the mother and fetus and negatively impact pregnancy, labor, and birth outcomes (5) (7).

Trauma Essential Reads

Talking It Out: Psychological Debriefing After Trauma

6 Reasons You May Struggle With the Term "Childhood Trauma"

For a trauma survivor, walking into a hospital alone in labor may be terrifying. Leaving your support person (people) at the door to the lobby of the hospital and walking into the environment you encounter inside those doors, an unfamiliar one now designed to prevent the transmission of COVID-19, may be even more so. Support people are also stressed as they are separated from the pregnant woman or girl at a time they were hoping to be a resource.

One of the aspects of adverse childhood experiences, including physical, sexual, and emotional abuse for many children, includes the lack of adult protection and support. This is compounded when the adults upon whom the child depends are the perpetrators. One of the resources trauma survivors develop in the course of healing from traumatic experiences is the capacity to differentiate the past from the present. When facing stressors in the present that may remind them of past trauma or trigger flashbacks of these experiences, having trusted support people to connect with in the here and now can be a key resource that assists the trauma survivor in doing so. Without this support, differentiating the past from the present in a threatening environment may be more difficult or impossible and may trigger traumatic stress reactions.

Women and girls who experienced abuse and assault to the parts of their bodies now involved in pregnancy, birth, and breastfeeding may face additional challenges throughout prenatal and perinatal experiences, particularly during medical exams, procedures, and interactions with health care providers. Pregnant trauma survivors in the hospital without a chosen support person to help them feel safe and to advocate for them may be re-traumatized by the proximity to and physical contact with health care providers. Trauma survivors confined to bed may feel trapped between the guard rails and experience defense system reactions similar to the ones that were evoked during past trauma.

Experiences of dissociation and freeze may be triggered in a trauma survivor when a chosen trusted support person is not permitted to accompany them and help them to differentiate the past from the present. Dissociative and freeze states may prohibit patients from expressing their needs and requests for physical distance to health care providers. Health care providers often do not recognize signs of dissociation in traumatized patients and may not be trained to ask permission to touch patients or to check with patients about the distance from them that patients are comfortable with when they do not need to be touched.

COVID-19 precautions prevent patients from seeing the faces of health care practitioners and practitioners from seeing the faces of their patients. The facial expressions of others are part of how we perceive, beneath our conscious awareness, whether we are in a safe, dangerous, or a life-threatening environment, and whether we are being perceived as a safe, dangerous, or life-threatening person to others. This puts patients and providers at a disadvantage. Patients may misread the facial expressions of a provider, and providers may not perceive the impact of their actions on the patient without being able to see the lower part of their face. A trauma survivor’s silence is not an indication that they are feeling at ease or comfortable with how they are being treated.

The fear that every surface, every person-to-person encounter, has the potential to transmit the virus may trigger the stress response system of a pregnant woman or girl, as well as that of the health care practitioners and hospital staff who care for them. All the perceived dangers that women and girls have potentially faced before the pandemic when entering the hospital for maternity care are subsumed under the threat of being exposed and exposing their baby to COVID-19 in the hospital. Vigilant observation of how carefully (or not) hospital staff abide by COVID-19 precautions adds another level of psychophysiological stress for mothers-to-be. The perception of potential life threats to mothers and their babies, as well as hospital staff, activates everyone’s stress response systems, making a felt-sense of safety that would optimally support the labor and birth process very difficult to achieve.

As Thapa et al. (2020) remind us, “Maternal mental health problems are associated with short-term and long-term risks for the affected mothers’ overall health and functioning, as well as their children’s physical, cognitive and psychological development. Conditions such as extreme stress, emergency and conflict situations, and natural disasters can inflate the risks of perinatal mental health morbidity (p. 817)” (8).

Additional stressors of quarantine, physical distancing, home isolation, increased incidents of domestic violence, remote consultations with health care professionals, lack of privacy during remote consultations, the inability to access technology to have remote consultations with health care professionals, and loss of income and unemployment also increase the potential risk for undetected and unaddressed mental health problems. This list is far from complete. Mental health problems include depression, anxiety, and post-traumatic stress symptoms in pregnant women and girls.

The inability to receive pre-pandemic levels of in-person support and care in the prenatal and perinatal period during which screening, consultation, and counseling were more readily available leaves mothers, infants, and older children at increased risk for health and mental health problems. We do not know how long these changes in the delivery of prenatal and perinatal care will be necessary.

"Recommendations for the Promotion of Maternal and Infant Mental Health During the COVID-19 Pandemic" by Choi et al. (2020), offers guidelines for practice, research, and policy to support maternal and infant mental health in the perinatal period. These authors propose a “trauma-informed framework to promote social support and infant attachment, use of technology and telehealth, and assessment for mental health needs and experiences of violence”(p. 4) (3).

Now is the time to address the issues mothers-to-be face during the pandemic to prevent short and long-term impacts on all aspects of their health and that of their offspring.