The Impact of Childhood Sexual Abuse on Childbearing and Breastfeeding: The Role of Maternity Caregivers

Introduction

A breastfeeding caregiver can be therapeutic without being a therapist. By listening and acknowledging the mother's distress one can come up with ideas to resolve the situation or discomfort. (See Methods to Reduce Triggers of Abuse in Breastfeeding.)

Description and Definition of Childhood Sexual Abuse

Approximately one in four women has experienced early sexual abuse. ¹ Childhood sexual abuse is estimated to occur in approximately one in four girls and one in six boys. ² It takes place between a child (under 18 years) and an adult or even someone close in age, whom the child perceives as more powerful. It takes a variety of forms, verbal, psychological, and/or physical, with the goal of causing sexual arousal in the abuser or in someone else. Eighty percent of perpetrators are known to the child (parents, stepparents, other relatives, and respected elders). ³

Effect on the Child and Repression of Memories

Childhood sexual abuse leaves the child victim hurt, frightened, or confused. She feels that something is wrong, maybe she's to blame, and she is not sure how or whether to stop it. In addition, these feelings are worse when the abuser is someone she loves, can't avoid, and on whom she depends for shelter and food.

Children try to control their fear and terror either by repressing the memories such as believing that it didn't happen or by denial: “It's no big deal.” Some children dissociate. They actually close off the memory and experience so that it is separate from conscious memory. Some adult survivors remember “leaving their body.” ⁴

Adult Symptoms That May Indicate Abuse History

When women have a large file of medical or psychological complaints, often with no organic cause, or have undergone procedures that have not resolved the problem, this bears further investigation. Many abuse survivors somatize the abuse memories. The body expresses the pain. ⁵

For example, a number of adult disorders are known to be associated with childhood sexual abuse, such as eating disorders, substance abuse, chronic pelvic pain, sexual dysfunction, severe premenstrual syndrome, gastrointestinal and urological disorders, migraines, and various phobias, fear of medical and dental procedures, and discomfort with touch.^6,7

These and other physical and mental symptoms may be an attempt to cope with the underlying trauma of this early assault.^8,9

Studies indicate that 84–98% of people who have been abused never tell a physician about the abuse. ¹⁰

Perinatal Events Can Activate Memories

Although many symptoms or behaviors of distress psychologically or physiologically during pregnancy, birth, or postpartum period can have multiple meanings, when one sees a constellation of numerous symptoms, one can wonder if this woman has a trauma or abuse history.

Abuse memories can be activated at significant developmental periods or at stressful life events. Marriage, pregnancy, birth, breastfeeding, and becoming a parent are especially vulnerable times, due perhaps to uncontrollable factors such as rapid changes in the woman's body, uncertainty and pain of labor, stretching of the birth canal as the baby descends, the baby being placed on the breast, and in the end, for both parents, responsibility for a tiny, dependent infant.

There has been an increase in public awareness of this subject, but less recognized or discussed are the effects on childbearing. Maternity care providers may knowingly or more likely unknowingly care for women with such a history. Although some sexually abused women were helped by caring people at the time of the abuse during childhood, or through other circumstances were spared the aftermath of pain, others were not so fortunate. Many women have no memory or only a vague conscious memory of abuse and therefore may not disclose their history when asked about it. Other women who do remember feel shame, and by holding such negative beliefs about themselves choose to reveal nothing. As a medical caregiver it is legal and appropriate to ask about an abuse history. This type of inquiry can be done very sensitively, such as: “Many women have had unpleasant sexual experiences—being touched or forced into sex—or they have been physically abused. Have you ever experienced anything like that?” ⁵

If the woman answers in the affirmative, one does not need any “details” but can simply say, “I am so sorry; no one ever deserves to be treated that way. I'll try to be sensitive to your needs in this stressful situation. Will you let me know how I can help you feel more comfortable?” ¹¹

If there has been no disclosure, nevertheless, medical caregivers and others involved in direct care should be alert to particular characteristics that may indicate early sexual abuse, so that with understanding and sensitivity their care can lessen the chance of unintentionally activating abuse memories or bodily reactions or of re-traumatizing the survivor.

Common Reactions and Fears During Pregnancy

Common manifestations during pregnancy include: rejecting the bodily changes of pregnancy or, conversely, having exaggerated symptoms; perceiving the fetus as a parasite or invader, or being disturbed by the baby's gender (discomfort with the idea of a male inside her, if the baby is a boy; or worry about bringing a girl into the world and inability to protect her as she herself was not protected); and worry about being able to trust her partner. Numerous survivors avoid prenatal care. As a child her body boundaries were violated, so she may manifest inordinate fear of invasive procedures such as blood draws, vaginal exams, exposure, and nakedness.

As far as labor, she may fear being “ripped apart” during birth, fear not being a good mother, worry about reacting with strong negative feelings, such as anger, towards the provider, or worry that abuse memories will surface. One woman said that when the baby descended in the birth canal was the first time she could remember the feeling of her father's penis. She was 3 years old at the time of that abuse. It felt like an ice pick to her.

Issues of Control

Survivors go to great lengths to maintain control. As a child she had been vulnerable, had no control, was dependent on her caregivers (family), and was hurt; therefore the prospect of losing control, either over the care or interventions occurring during labor or over over her own responses to pain and other events, becomes extremely frightening. This need for control may appear as being demanding, as having long and inflexible birth plans, or as either mistrust or the reverse, overdependence on the care provider.

Choice of Caregiver

Many survivors choose female caregivers, expecting the midwife to be safer and gentler, and become unusually upset if the midwife doesn't respond as the survivor expected. The survivor may unconsciously be testing the care provider to see if she can trust her. On the other hand, the survivor may blame herself if she is not responded to as she had hoped, believing she is bad, unworthy, defective, and deserving of disregard. When caregivers understand that these reactions are not about them, but are reactions to the survivor's own pain of the past, they can see that they (the caregivers) are not the reason for this behavior and make every effort to not judge the woman unfairly and to work at providing good listening, acknowledging the woman's feelings, and offering sensitive care and joint problem-solving.

Potential Triggers During Labor

During labor the survivor may perceive the vaginal exams and instruments as rape and the baby in the vagina as recalling the abuse. The survivor may respond with dysfunctional labor, lack of cooperation, fighting the staff, fear and repugnance of blood and bodily secretions, hypervigilance, dissociation (appear to “leave,” “go away”), excessive pain and tension, and feeling mutilated with artificial rupture of the membranes, episiotomy, forceps, and other interventions. What may be occurring are flashbacks or re-triggered body memories of abuse. Dissociation is where a woman feels numb and separate from her body, which helped her as a child avoid the full experience of physical or emotional pain when being abused. This can become a method she uses during birth or in other adult situations to cope with pain or fear. Patricia described “being up on the ceiling during labor”; Karen worried about “going away.” The caregiver can softly ask the woman what she is experiencing, gently guide her back, and help ground her in the present by carefully touching her hand and reminding her where she is, focusing on the room, her partner, or some other safe image. One mother said she was in a dark place. I asked her to bring in light from the sun. She immediately felt safer and more present.

Other common events intrinsic to birth can activate memories, such as changed appearance, nakedness, and exposure of sexual parts, body positions, and baby emerging and even holding and suckling the infant.

Other interventions and procedures that trigger memories include: lines connecting the woman to machines, the intravenous line, restriction to bed, feeling drugged and numb (fear of being “trapped” and “unable to escape”), and dealing with strangers with authority and power, or even difficulty with trusting support people. For some women during labor the fear of loss of control may cause them to avoid labor altogether by requesting an early epidural or an elective cesarean section.

Care providers' language can be activating as well. Words used in labor to be encouraging, to have the woman imagine relaxing, trusting her body, such as “yield,” “surrender,” “just let go,” “just relax,” can have a double meaning to the survivor who as a child was told such words by an abuser. Sally remembers her father saying, “You just let go, honey, and it'll feel good.” ¹¹

Some Methods to Minimize Triggers

By becoming aware that recollections of abuse can come up unexpectedly and unconsciously during childbearing, caregivers can learn some methods to minimize triggers in some of the following ways. In advance, even if the woman has not disclosed her abuse history, by sensitive listening and discussing the typical events that will occur during prenatal care, labor, and postpartum, the caregiver can ask or discern what events might be distressing to the woman and explore with her some of her concerns or feelings related to them. Then together they plan some strategies to handle those events. ¹¹ Most of these concerns can be discussed beforehand, and then some of the ideas can be put in a Care Plan/Birth Plan in simple request form, such as “I would like,” or “I prefer,” or if the Clinical Nurse Specialist is helping the woman prepare: “She wishes or requests.” All women should be treated with this respect during this most vulnerable time, but it is especially important for survivors.

For labor, as an example, women have come up with even simple requests, such as: always ask permission before someone touches her, have new people introduce themselves, have caregivers explain procedures before they happen, give control to the woman as much as possible, give her choice, help her learn some individualized self-comforting techniques such as relaxation breathing or imagining being in a safe place, and managing panic attacks. ¹¹

One method to handle strong feelings is to imagine placing memories or distress into a container (until after the birth or until she is in a situation where she can process her memories in an emotionally safe environment, such as therapy). ¹¹

Protect her modesty and her boundaries, recognize tone of voice, avoid triggering words (help her plan in advance with support people some phrases, actions, or images that are helpful), and avoid events that could make her feel shame or judged. For Sally, phrases such as “the baby takes the pain away,” “Your baby and your body know just what to do to birth your baby,” and “Let the pain leave with the baby” shifted her mind away from the past, and she began to focus on the present. Conversely, one woman was subjected to numerous vaginal checks without any explanation from the caregivers. She felt like an object, invaded, shamed, and inadequate and then angry at herself for not asking.

Check with her on her comfort in having the baby right on her chest after the birth. Carrie was not sure she'd be ready to have the baby immediately on her chest even though she heard that was best. She needed to be able to say, “Can I decide later and see how I feel?” As it turned out she felt good after the delivery and welcomed the baby. Another woman wanted the baby next to her, but clothed.

For some women breastfeeding makes them feel that their body is doing something good; for others having the baby that close feels like an intrusion. They may need more time to gather themselves together or as stated to have the baby dressed rather than skin to skin.

Ellen's birth plan illustrates the choices she made that helped her emotionally handle the events of birth and the early postpartum time. It was only one page but covered the following issues—Introduction; Most important issues; Drugs, Vaginal exams; Procedures, Breastfeeding:

Dear Caregivers: I have a history of trauma in my life and I make the following requests with the understanding that if there is an emergency, I accept the necessary actions. If it is a difficult labor, I want to have an epidural available. I am chemically sensitive. If narcotics are used, strong reactions are possible. I would like to meet the anesthesiologist (hopefully female) on duty upon arrival, if possible.

Most important issues:

I prefer that no men are involved in my care, including male doctors, nurses, technicians.

I prefer that only my husband and mother be present for labor and birth.

I would like to know who is in the room and why. I'd appreciate the door closed for privacy.

I need warning and to be asked before being touched.

Please include me in all decisions.

Please explain what you are doing step by step for any procedure.

I prefer having as few vaginal exams as possible. Please keep me covered for all exams and procedures.

Please do not surprise me from behind.

I can feel claustrophobic—connection to lines. I need the option to move and stand when possible.

I prefer to not use narcotics.

I prefer not to have an episiotomy.

I appreciate gentleness and calm.

I might need help with breastfeeding, but please ask before touching me.

Ellen's birth was difficult, but she was able to have a very late and light epidural without narcotics. This helped her relax, rest a short time, and then, on her own, push her baby out.

Her request for only her husband and mother as support persons was significant because there was another unwelcome family member who tried to enter the room but was skillfully asked to leave by the nurse. During the throes of labor Ellen would not have been able to do that. Ellen did ask for help from a breastfeeding consultant and did have a good beginning for breastfeeding.

Indicators in the Postpartum Period

The postpartum period offers several challenges to caregivers who are helping the mother adjust to the infant and establish breastfeeding. The survivor may be disappointed over the birth experience. She may have felt unprotected, out of control. She may have experienced flashbacks and felt angry at the caregivers or at herself and her inability to birth as she had hoped. She may experience unusual fatigue and have more difficulty healing and recovering.^11–13

Survivors worry about trusting anyone with the baby, even concerned about their partner. If the abuser was a parent, the survivor may be unable to breastfeed in front of the grandparents or to trust them with the baby.

Breastfeeding poses particular concerns. She may experience discomfort when placing the baby on the breast, have difficulty letting the baby be “in control,” lack confidence that her body will function correctly, or more quickly discontinue breastfeeding when challenges occur. ¹¹

Difficulties with the newborn include her fears about being able to protect the baby, worry about touching the baby's genitals, over- or underconcern about the baby, identifying with the baby's helplessness, being angry at the baby's needs, etc.

In the role of new mother, she may see herself as different from other women and believe that any problems that come up in child rearing are because of her past abuse. She may have difficulty setting limits or neglect her own needs by attempting to do everything perfectly.

Methods to Reduce Triggers of Abuse in Breastfeeding

Although many events around breastfeeding can trigger past abuse memories, there are several methods to have the mother feel in control and separate the past from the present.

Caregivers can be especially helpful in this period by providing the opportunity to discuss the mother's feelings about how the birth went and her thoughts and feelings about breastfeeding. In a similar manner as with preparing for labor, by listening carefully, validating her feelings in an accepting and nonjudgmental manner, one can help the mother explore what concerns she may have and then together explore potential solutions.

It is important to respect her privacy, to follow the mother's lead where the caregiver looks, to ask permission before any touching, and to be aware of the difference between appropriate and inappropriate touch.

One example could be her discomfort at nighttime feedings in bed. A possible solution could be that the father feeds the expressed breastmilk at night, or that the mother gets out of bed into a comfortable chair with music and fluids to drink. For a woman who suffered abuse in her bed late at night from a parent, being able to change the venue can relieve the fear and help the woman stay comfortable to breastfeed.

A number of other situations can trigger abuse memories. The important goal is to explore with the new mother her concerns or events that trouble her or interfere with her confidence to nurse her infant.

Some women are uncomfortable holding the baby skin to skin or letting the baby feed on demand. Change the typical language of “Feed on demand” to “Feed often, at least every 2 or 3 hours,” or “Feed on cue,” and make sure she can recognize the baby's cues. Information about infant development can be useful. Some women such as Janice are uncomfortable with the baby's roving hand as the infant reaches and massages the breast or nipple. The value of the infant's touch represents both physiological and psychological meaning. Give mothers information how our biology works, such as “every touch activates that wonderful hormone oxytocin (the cuddle hormone) and then prolactin for more production of milk. Neurologically, the baby's brain is developing synapses of recognition, of connection, of calmness; and psychologically the infant is activating feelings of comfort, closeness, exploration, consistency, and therefore security.”

Aside from understanding these types of meanings and purpose of the infant's behavior, the mother can learn ways to manage this. For example, she can hold the little hand; she can cover the breast that is not being used; she can wear big bauble beads to attract the baby's attention.

Some women are distressed with the sensual feelings produced by breastfeeding. It is helpful to reframe those sensations as that “cuddle hormone oxytocin doing its job of bringing moms and babies closer, and also helping the uterus contract. The sensations are activating the nourishment and immunological properties for the baby.”

Another area that is important for all new mothers and especially survivors are reminders to take care of themselves. Some women become exhausted trying so hard to be a good mother to counteract the negative self-image that past abuse creates. Help the mother learn some self-help relaxation methods to reduce anxiety such as calming breathing, mindfulness meditation, progressive relaxation, comforting visualizations, and plans for self-care activities, walks, music, support people, etc. Taking a moment to calm herself and check into her feelings and thoughts when she is tense can offset old fears and help her remain present as well as help her body relax enough for a good letdown. ¹¹

Acknowledge for the mother how well she is cuing into the infant's needs as she begins to see the baby for him- or herself and not as someone who is here to fulfill her unresolved needs for nurturing. Sometimes a sensitive reminder of how hard it must have been to be a child and not be seen or heard in times of need and how well she is picking up what her baby needs can be healing to a survivor. This can help her separate the past from the present.

For many women a good birth and breastfeeding experience gives them the confidence that their body did something right and can be a touchstone of validation that lasts a lifetime.^11–16

It is useful for caregivers to become familiar with community resources of psychotherapists or groups that specialize in childhood sexual abuse to offer appropriate referrals.

In sum, respectful, sensitive listening and validating the woman's feelings create a safe environment for the woman to express her needs, and providing choice and giving her control over what is done to her or helping her to feel in control over her own reactions and experience, all contribute to avoid re-traumatization and to create an empowering and possibly a healing experience for her.