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We now know that conditions inside and outside women's and girls' bodies during the preconception, prenatal and early postnatal periods profoundly impact their offspring's development, health and behavior beginning at conception and over their life span. "From the first weeks after conception through early infancy, the immature human organism 'reads' key characteristics of its environment and prepares to adapt to an external world that can vary dramatically in its level of safety, sufficiency and peril" (Shonkoff, Boyce, & McEwen, 2009, p. 2257) (1).
Creating Sanctuary to Support Experiences of Internal and External Safety
Human pregnancy is a species-specific growth process. The health and well-being of pregnant women and girls, and that of their developing babies over their life spans can be supported by the creation of sanctuary—a place or environment of refuge and protection in which they experience safety. The cultivation of safe environments for mothers-to-be, their developing babies and the individuals in their lives who support them during this critical period also benefits future generations.
There are different ways to describe the concept of safety. Awareness of our psychophysiological responses to our environment provides feedback on our experience of safety, danger or life threat in a given moment. The concept of neuroception introduced by Stephen Porges, describes how our nervous system rapidly evaluates our internal and external environment for safety, danger or life threat beneath our conscious awareness (2). Understanding this process helps us make sense of our body-mind reactions in different circumstances and interactions.
Internal safety during pregnancy is related to a woman's or girl's experience of, and feelings about her changing body and the sensations connected with her pregnancy over time. This includes feelings and sensations associated with the presence and movements of her prenate (embryo and fetus). Past and recent experiences of trauma, especially traumatic experiences that breached her body boundaries, may shape her perception of internal safety, danger and life threat during her pregnancy, the quality of her prenatal experience, and the outcome of her pregnancy (3).
Aspects of Safety
It is helpful to consider the aspects of safety that contribute to the creation of sanctuary for mothers-to-be and their developing babies. Sandra Bloom (2013) describes four types of safety: physical, moral, social and psychological (4). Experiences that are perceived as dangerous or life threatening, regardless of the type of safety challenge they pose, can impact the psychophysiology of the pregnant mother and her developing baby in similar ways.
- Physical safety is experienced in environments in which an individual's basic needs for food and shelter are met and ones that are free from threats of violence (from self or others) (4). During pregnancy, the physical safety of both the pregnant mother and her developing baby are, in part, dependent on the availability of adequate supplies of nutrient-dense food.
- Moral safety is experienced in environments that are free from cruelty, violence, dishonesty, injustice, hypocrisy, discrimination and ignorance. Moral safety permits and encourages nonviolence, honesty, justice, self-awareness, tolerance, knowledge, and compassion (4).
- Social safety is experienced in environments that are free from abuse, social isolation, social anxiety, poor boundaries, lack of empathy, gossip and rumors, bigotry and hatred, and constant conflicts. Social safety permits and encourages support, interaction, security, safe boundaries, compassion, assertive behavior, tolerance, and resolution (4).
- Psychological safety is experienced in environments where an individual is free from exposing oneself to unnecessary dangers, free from the inability to concentrate or focus, the loss of control over oneself, not being able to stay organized, being helpless in situations that are controllable, free from the inability to follow rules and structure, free from being shamed or humiliated, free from repeated failure, free from being bullied or bullying others. Psychological safety permits and encourages self-protection, humor, attention and focus, self-efficacy, self-esteem, self-empowerment, self-control, self-discipline, initiative, curiosity and creativity (4).
Some mothers-to-be experience a lack of one or multiple aspects of safety in their environment. Some experience a lack of safety in the settings in which they expect to find a caring and protective environment, one they hoped would provide sanctuary. While seeking and expecting sanctuary for themselves and their developing babies, they instead experience "sanctuary trauma" (Silver, 1986, p. 215) (5), which may result in increased levels of stress, and traumatic stress responses.
Traumatic Experiences and Boundary Violations Challenge A Pregnant Mother's Capacity to Feel Safe
Traumatic experiences are those in which an individual feels their life is threatened, the life of their child (inside their womb or already born), or another person close to them. They include experiences in which there is an element of loss. They involve dehumanization, degradation, humiliation, forced separation and relocation. Traumatic experiences evoke feelings of intense fear, helplessness and horror (6).
"Psychologically and biologically, the severity of traumatic events is related to their being intense, inescapable, uncontrollable and unexpected" (Foa, Rothbaum & Zinbarg, 1992, p. 218) (7). Traumatic experiences trigger spontaneous psychophysiological fight, flight and freeze reactions and may result in the development of post-traumatic stress disorder.
Who are the vulnerable mothers-to-be whose past and recent experiences contribute to a felt-sense of danger and life-threat in their internal and external environment? Who are the vulnerable mothers-to-be who may be challenged to find safety and sanctuary during pregnancy? Margalit (1996) as cited in Kirkengen (2010) suggests, "We are all vulnerable, not just a few of us. Everyone has one characteristic in common, besides being mortal: we can all be humiliated" (p. 19) (8). Experiences of humiliation, and those in which an individual's personal integrity is violated, "that is having their boundaries transgressed without their consent or against their will" (p. 15), may affect their health (8). In the case of pregnant mothers, the lack of safety experienced in these situations may also affect the health of their developing baby and the outcome of their pregnancy (3).
Boundary violations occur during experiences of sexual, physical, mental and emotional abuse and neglect of children and adults, inside and outside of families. Kirkengen points out that boundary violations may also be "inherent in socially legitimized or rationalized violations of groups of people or strata of populations by means of racist, sexist or other discriminating structures that stigmatize, marginalize or humiliate" (p. 15), and some boundary violations are socially silenced (8). Some boundary violations are politically sanctioned.
The powerful emotions often associated with boundary violations (i.e. fear, rage and shame), and their physiological expression in mothers-to-be influence the environment within which their prenates are growing. The experience of maternal distress may be intensified in the face of boundary violations during pregnancy, as pregnant mothers react to threats to the safety of their developing baby, as well as themselves.
Parents-to-be are shaped by their past and recent experiences of humiliation and boundary violation. They carry these imprints into their psychophysiological experiences of pregnancy and parenting. The field of epigenetics explains how environment impacts the expression of genes and contributes to the intergenerational transmission of trauma. In this way, the boundary violations and humiliation experienced by our parents, grandparents and great grandparents (and those who came before them) may be passed down from generation to generation (9).
Individuals, families, communities, practitioners, service providers, governmental agencies and lawmakers all play direct and indirect roles in the creation of sanctuary and the four types of safety (or lack thereof) for parents-to-be and their developing babies.
For the sake of current and future generations, the long-term consequences of failing to cultivate safe environments in the critical prenatal developmental period must be recognized, acknowledged and addressed at all levels: individually, systemically, locally and globally.
References
(1) Shonkoff, J. P., Boyce, W. T., & McEwen, B. S. (2009). Neuroscience, molecular biology, and the childhood roots of health disparities: Building a new framework for health promotion and disease prevention. Journal of the American Medical Association, 301(21), 2252-2259.
(2) Porges, S. W. (2004). Neuroception: A subconscious system for detecting threats and safety. Zero to Three, 24(5), 19-24.
(3) Weinstein, A. D. (2016). Prenatal Development and Parents' Lived Experiences: How Early Events Shape our Psychophysiology and Relationships. New York: NY: W. W. Norton.
(4) Bloom, S., & Farragher, B. (2013). Restoring Sanctuary: A New Operating System for Trauma-Informed Systems of Care. New York: Oxford University Press.
(5) Silver, S. (1986). An inpatient program for post-traumatic stress disorder: Context as treatment. In C. Figley (Ed). Trauma and Its Wake, Volume II: Post-Traumatic Stress Disorder: Theory, Research and Treatment (pp. 213-231). New York: Brunner/Mazel.
(6) Yehuda, R. (Ed.). (2002). Treating Trauma Survivors with PTSD. Washington, D.C.: American Psychiatric Publishing.
(7) Foa, E. B., Rothbaum, B. D., & Zinbarg, R. (1992). Uncontrollability and unpredictability in post-traumatic stress disorder: An animal model. Psychological Bulletin, 112(2), 218-238.
(8) Kirkengen, A. L. (2010). The Lived Experience of Violation: How Abused Children Become Unhealthy Adults. Bucharest, Romania: Zeta Books.
(9) Yehuda, R., Daskalakis, N. P., Lehrner, A., Desarnaud, F., Boder, H. H., Makotkine, I. ...Meaney, M. J. (2014). Influences of maternal and paternal PTSD on epigenetic regulation of the glucocorticoid receptor gene in Holocaust survivor offspring. American Journal of Psychiatry, 171(8), 872-880.
