Preparing for birth after sexual trauma can be a really challenging situation. I have tried writing this article in many different ways and in the end, I have ended up writing three articles. One is my personal birth stories, available here: My Births: Birth after sexual violence and birth trauma, which I needed to write to be able to extricate them from something that might help other people. This article, which talks about the context of birth and sexual violence and the shocking lack of resources to support this large minority. Thirdly, Birth Preparation for Survivors of Sexual Violence, an article which is a detailed set of questions and considerations aimed at helping survivors think about what they need in birth, so they can look at getting the support and care they need.
When I set out what I really wanted was to write something that would help survivors of sexual violence have a positive birth despite the additional issues they may have during pregnancy and birth. I wanted to write a positive approach to birth for survivors because any form of support for us as we approach birth is, at best, thin on the ground and mostly non-existent. The more I have researched, and written, the more I feel that widespread changes are needed that will change maternity care more widely, but in the meantime I think there is a strong case for services aimed at supporting surivivors of sexual violence in pregnancy, birth and the postnatal period.
Why society needs to talk about this.
The Lack of Support
A conservative estimate suggests that 1 in 5 women experience sexual violence of some kind, whether abuse, assault or rape, after the age of 16 (so that figure is not inclusive of violence towards children) (Rape Crisis website: statistics). 31% of young women aged 18-24 reported having experienced sexual abuse in childhood (NSPCC, 2011). The scope of sexual violence is huge. There are numerous studies showing that around 80% of survivors of sexual violence have at least one mental health condition, and more than half have more than one mental health condition, which can persist for years afterwards (National Institute for Health Research, July 2018). The 2018-2023 Strategic Direction for Sexual Assault and Abuse Services promises “Lifelong care for victims and survivors“, yet it makes no mention of services for pregnancy and birth, nor for supporting women to access cervical smears. The lifelong seamless care that is hailed in this strategic direction still feels like it is some way off. The impact of mental health conditions on physical health is also well documented, yet the focus of the Strategic Direction seems to focus solely on mental health, which ignores the holistic experience of survivors even when only considering healthcare. It ignores, for example, economic and social factors like difficulties working and remaining in employment or socialising, which are outside the remit of the NHS, but would certainly be a part of holistic and seamless support services.
Antenatal support for survivors of sexual violence
Up to 5% of women experience Gestational Diabetes which requires management during pregnancy. Pre-eclampsia affects up to 6% of pregnancies. The symptoms of these are mentioned to women, they are told what to look out for, what the tests involve and are often given leaflets on these conditions. Other information about what foetal screening tests are looking for and the more whimsical articles like what to pack in your hospital bag are also provided. Where is the leaflet about where to look for support if you are a survivor of sexual violence and have concerns about how pregnancy and birth will affect you? Pregnancy and birth are exciting times of massive change, and huge vulnerability. For survivors of sexual violence issues can arise from historical traumas that have seemed dormant for years.
This needs to be on more people’s radars. Midwives need training on dealing sensitively with disclosures, offering space for people to be open about their experiences. They also need to know where to signpost people who do disclose sexual violence, so that if they wish to seek support they can do so. These things are very difficult to do in time pressured appointments, especially when you may not see the same midwife twice throughout your pregnancy. Support needs to be readily available, there’s a crucial time window to support pregnant women. Pregnancies do not have a pause button whilst referrals are processed. As so many instances of sexual violence go unreported, and many survivors do not seek help at the time, it is important to make help as accessible and available as possible so that once people do decide to seek help it is readily available. At present there aren’t even Perinatal Mental Health Teams in all areas of the country, let alone any services specifically experienced in supporting survivors of sexual violence through any issues that pregnancy and birth may raise for them.
Birth is a huge life event
A traumatic birth affects more than just the perception of the event, it can affect the way that people view their body, the way they bond with their child, their likelihood of experiencing postnatal mental health issues. This is becoming increasingly recognised and acted upon, by independent support services, and more slowly by health services themselves. Preparation is key to a positive birth. It is not unusual for survivors of sexual violence to be extremely anxious about even thinking about birth, which is one of the reasons that specific opt-in support to help prepare for birth would be ideal, so that preparation could take place in a private and less time pressured environment than a course with a handful of other families, some of whom will be excitedly preparing for the birth of their baby, and some of whom may find their excitement is also complicated by the same issues, which are rarely discussed because of the stigma surrounding sexual violence.
Having a pre-existing trauma can mean that trauma being reawakened during a birth experience in which one feels that they are not in control. I don’t mean not in control of their body, although that itself can be a terrifying prospect. I mean that it is easy for survivors of sexual violence to feel triggered in an environment or situation where birth feels like a procedure that is performed upon them, in which assumptions are made that it is acceptable to touch them, to perform internal examinations, in which offers of support, which is what health care professionals are actually providing, are often stated as though they are going to happen, because consent is presumed.
It is essential, for all births, that consent is held as paramount, that interventions, tests, monitoring, and checks are offered as options with the reasoning behind them so that informed decisions can be made. Antenatal education about what can happen and what choices are available needs to be improved so that preferences can be considered in advanced when the time to think through options is available, free from the time pressure and the distractions of labour. This “planning” is an excellent tool for making strong decisions, and educating oneself to allow flexibility within one’s preferences, meaning that whatever twists and turns a labour takes, the mother can remain feeling empowered.
Healthy Mum, Healthy Baby
1) The first issue is that even the most complicated and intervention filled birth can be experienced as positive, not just as an experience in which the outcome was OK, and therefore the journey there is retrospectively justified. The factor that tends to affect this is how the care team interact with the mothers- are they communicating with them, are they talking them through their options, or are they responding to “issues” within the care team and presenting the next step as a decision that has already been made? Where women are consulted, are offered information, and feel that they are treated as a person, rather than a body and a vessel for a baby, the experiences tends to be positive, even where the birth, from an external perspective, looks traumatic.
This phrase is often used to dismiss many, many birth experiences, not least by the birthing women themselves. There is often a feeling that the end justifies the means in birth. There is no problem in wishing for a healthy mum and baby, however, there are two issues with this being our ultimate goal
The first issue is that even the most complicated and intervention filled birth can be experienced as positive, not just as an experience in which the outcome was OK, and therefore the journey there is retrospectively justified. The factor that tends to affect this is how the care team interact with the mothers. Are they communicating with them, are they talking them through their options, or are they responding to issues within the care team and then presenting the next step to the mother as a decision that has already been made? Where women are consulted, are offered information, and feel that they are treated as a person, rather than a body and a vessel for a baby, the experiences tends to be more positive, even where the birth, from an external perspective, looks traumatic.
The second issue is that mental health rarely seems to factor into the equation. Are women left terrified of childbirth? Are they anxious? Do they end up with postnatal depression? Do they have flashbacks to their birth? Do they feel scared, rather than supported, around medical professionals? These issues have lifelong effects and are rarely included in the healthy mum, healthy baby picture. For survivors of sexual violence, who are already more likely to experience mental health issues, the compounding of these issues through a negative birth experience can be huge.
The good news is that the best way to improve maternity care for survivors of sexual violence is largely the same as the best way to improve it for all women. Provide person-centred care, ideally with continuity of care throughout the pregnancy, birth and postnatal period. The bad news is that such improvement seems a long way off with the current budget constraints around all aspects of health care. In the meantime survivors of sexual violence, making up a significant group of those who give birth, are left without support for the specific concerns that they have, and signposting to, ideally specific support services, but in their absence, mental health teams who are able to deal sensitively with the concerns and feelings that preparing for birth may bring up could help this group have hugely more positive birth experiences that lead to increased mental wellbeing, better bonding with their babies, and even a healed perception of their own bodies.
A Positive Birth
Despite the many ways that sexual violence can negatively impact survivors, it is possible to have a positive birth as a survivor of sexual violence. For some survivors, birth can be a fantastically healing experience demonstrating the power of their bodies to do and create something beautiful. An empowered outlook on birth, and a team of Health Care Professionals and birth partners who have faith in the pregnant person and their body to give birth can help make this more likely. However, for some, birth can be a time of reliving trauma, and of pain and fear that brings otherwise buried experiences to the surface. This may confuse the potentially magical experience of meeting your baby, with horror and trauma.
I am not suggesting that their should be an aim for a perfect birth for all people. Perfection is rarely achievable. Positivity, actual positivity, not just a grudging acceptance, is achievable, and it should be achievable, with support for everyone, regardless of their medical history, their mental health and their experiences of sexual violence. A medical system that treats people as individuals, treats them with respect, and responds to their individual needs could make a huge difference in the births that all women expect and experience.
If this article has raised any issues for you, or you are looking for support in preparing for birth, then you may find this sister article
Birth Preparation for Survivors of Sexual Violence helpful.
Rape Crisis: England and Wales are a good place to start if you are looking for easily accessible support, and are able to signpost you to specific services in your local area.
The Positive Birth Movement is a fantastic place to start if you are looking for general information and support in working towards or promoting positive birth.