Trauma-Informed Care Needed to Address Obstetric Violence

Maternal experiences of safety during pregnancy and childbirth support healthy psychophysiological processes in mothers-to-be and their developing babies and positive pregnancy outcomes (1). Trauma-informed care during the preconception, prenatal, and early parenting periods supports maternal-offspring experiences of safety.

Unfortunately, many pregnant women and girls from around the world, including the United States, receive disrespectful and abusive care during the perinatal period, as reported in a statement released by the World Health Organization in 2015 (2). This maltreatment, now referred to as “obstetric violence,” includes bullying and coercion by health-care personnel (3). These behaviors often evoke a felt sense of danger and/or life threat in mothers-to-be, which may activate defense system fight, flight, and freeze reactions and trigger traumatic stress symptoms.

Training health-care personnel who provide preconception and perinatal care in the trauma-informed care model would support awareness, prevention, and antidotes to disrespectful and abusive care during pregnancy, childbirth, and the postnatal period. The National Center for Trauma-Informed Care (NCTIC), part of the Substance Abuse and Mental Health Services Administration (SAMHSA), explains that a program, organization, or system that is trauma-informed “realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; responds by fully integrating knowledge about trauma into policies, procedures and practices; and seeks to actively resist re-traumatization” (as cited in Seng & Taylor, 2015)(4).

The six principles of trauma informed care as described by SAMHSA are:

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

In stark contrast, the World Health Organization’s description of disrespectful and abusive treatment during facility-based childbirth reported by mothers-to-be includes: “Outright physical abuse, profound humiliation and verbal abuse, coercive or unconsented medical procedures (including sterilization), lack of confidentiality, failure to get fully informed consent, refusal to give pain medication, gross violations of privacy, refusal of admission to health facilities, neglecting women during childbirth to suffer life-threatening, avoidable complications, and detention of women and their newborns in facilities after childbirth due to an inability to pay”(2).

The World Health Organization notes that the women and girls most likely to experience obstetric violence are “Among others, adolescents, unmarried women, women of low socio-economic status, women from ethnic minorities, migrant women and women living with HIV” (2). These women and girls may report experiences of racism in their interactions with health-care personnel.

Research demonstrates that women who report experiences of racism may have as much as a threefold increase in the incidence of adverse birth outcomes, including: low birth weight and very low birth weight babies and preterm birth (5). Experiences of racism may also contribute to disparities in maternal mortality rates in the U.S. As reported by the Pregnancy Mortality Surveillance System, black women in the U.S. are three to four times more likely to die from a pregnancy-related complication than non-Hispanic white women (16).

Landrine & Klonoff (1996) explain, "All definitions of racism include the notion of unequal treatment based on skin color or other physical characteristics. Because these characteristics are immutable and often central to one's identity, racism constitutes a profoundly personal and severe threat to well-being" (as cited in (6)). Racism in the context of perinatal care is a form of obstetric violence with very serious potential consequences for mothers and babies.

Perinatal care that is not based upon the trauma-informed care model may inadvertently trigger the physiology of traumatic stress in mothers-to-be, which affects her health and that of her developing baby over its lifespan, may impact the outcome of her pregnancy and negatively affect the developing attachment relationship between her and her infant. It is important to remember that both the pregnant woman or girl and her developing baby are experiencing the violence during these interactions with health-care personnel in the facilities within which they are receiving care.

Given the statistics on the prevalence of violence against women before and during the childbearing years, a significant number of women and girls carry experiences of past and recent abuse and assault into their experiences of pregnancy and childbirth. One in three women report a history of physical or sexual childhood abuse (7). Thirty-five percent of females worldwide over the age of 15 have experienced either physical and/or sexual intimate partner violence or non-partner sexual violence (8). It is important to note that this research did not evaluate the prevalence of emotional abuse, which is another form of violence experienced by women and girls. Seventy-eight percent of women who have been raped were first raped before 25 years of age, and 40 percent were raped before age 18 (9). For these trauma survivors, the experience of receiving disrespectful and abusive care from health-care practitioners may be re-traumatizing (10).

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An additional aspect of obstetric violence is the fact that women and girls often feel betrayed by health-care personnel and the facilities in which they receive care during and after disrespectful and abusive treatment. Betrayal has been defined by Kelly et al. (2012) as "feeling as though someone (or something) who should have supported you or protected you wound up being responsible in some way for the event. This could have happened because of something they actually did or something they failed to do" (p. 410). (11)

Betrayal trauma occurs when people or institutions on which a person depends for survival significantly violate that person’s trust or well-being (18). Pregnant and birthing women and girls who experience the violation of trust and maltreatment at this vulnerable time by health-care personnel — professionals on whom they feel dependent for their own and their babies’ safety, and potentially for their survival — may experience feelings that are associated with traumatic experiences. These include: feeling their life is threatened; feeling intense fear, helplessness, and horror; feeling dehumanized, degraded, and humiliated; and feeling threatened with forced separation (in this case from their baby and the individuals who support them) (17). As explained by Foa, Rothbaum & Zinbarg (1992), “Psychologically and biologically, the severity of traumatic events is related to their being intense, inescapable, uncontrollable, and unexpected (p. 218). (12). These qualities often apply to the disrespectful and abusive experiences suffered by mothers-to-be, which then trigger traumatic stress reactions. The experience of betrayal trauma has been associated with the development of PTSD and an increase in symptom severity (11).

An abundance of research now demonstrates how maternal prenatal stress and traumatic stress impact the health, development, and behavior of offspring over their lifespan (13), (14). Yehuda and Lehrner explain that “there is now converging evidence supporting the idea that offspring are affected by parental trauma exposures before birth, and possibly even prior to their conception” (15).

This evidence illuminates the crucial need for the evaluation of the impact of the quality of care provided to parents-to-be and their developing babies in the perinatal period. It is vital that health-care practitioners understand that the quality of care they provide in the preconception, prenatal, and postnatal periods impacts the psychophysiology of parents-to-be and their developing babies. Care that increases maternal stress and traumatic stress in this crucial period of offspring development significantly shapes the trajectory of the parent-child relationship.

The key question providers and facilities must answer is, “Are we seeking to actively resist the traumatization and re-traumatization of parents-to-be and their offspring?” Providing education and training in trauma-informed care in the perinatal period is one step towards preventing the harm inflicted by obstetric violence. One wonders how the commitment to “first do no harm” in the provision of health care has been overlooked in situations where health-care personnel and facilities have engaged in the disrespectful and abusive treatment of women and girls in the perinatal period.