How does childhood sexual abuse impact women in the childbearing year?

In pregnancy, it can manifest in the following ways:

• Little or no prenatal care
• Multiple unplanned pregnancies, many ending in abortions or child apprehension
• History of multiple sexually transmitted infections
• Scars from self-mutilation and other self-harming, high-risk behaviour

Women in general react to the news that they are pregnant in lots of different ways and feel lots of different emotions at one time. Feelings such as: joy, relief, excitement and apprehension. Women with abuse histories may feel all of these emotions but also often experience high levels of anxiety, fear and vulnerability related to the news that they will be having a child. Some women may not be ready to become mothers and face their abusive pasts. Fear that they will not be able to protect their child or fear that they may hurt their child may be all too real for them. They must be supported in making the choices that are right for them. Other women look forward to the birth of a child and embrace this time as an opportunity to begin their path towards transcending their abuse.

Pregnant women survivors are often in need of supportive caregivers who understand the impact that abuse has had on their lives and strategize ways to cope with the abuse while looking out for the health and well-being of the growing baby. Coping mechanisms, including self-harming behaviours, which can have an impact on the developing fetus, need to be looked at without labelling or isolating women further.

Coping Mechanisms in the Childbearing Year

Women survivors of abuse may engage in behaviours that are difficult to empathize with and complex to understand, especially in the childbearing year. As a means to cope with their abuse/abuse histories, women may be using drugs or alcohol, may engage in high risk sexual behaviours, may have eating disorders or may practice other self-harming behaviours, such as cutting themselves. In order to fully support women who have experienced abuse, it is helpful to look at survivors who are engaging in these behaviours as women who are attempting to survive, instead of as women who are intentionally causing harm to themselves and their unborn babies.

As her care-provider it is useful to provide her with a balance of information on ways that she may be able to minimize her baby's exposure to the harmful by-products of her high risk behaviours, while respecting her autonomy and decision making power. For instance: does she have access to clean needles, condoms, could she use some strategies to reduce her alcohol or nicotine consumption. Remember to offer a variety of suggestions and validate her for any attempt she makes at reducing harm.

Judging or preaching at her is counterproductive as women are acutely aware of the stigma attached to these behaviours. Women who have survived childhood sexual abuse often have difficulty self-regulating their emotions so they turn to external ways of soothing the stress, compulsions and anxieties they suffer as a result of the abuse. A mentality of "just quit" for the sake of her baby is unrealistic and insensitive; however, offering appropriate, alternative ways for her to manage these symptoms may be useful for her to try out.

If we practice in a way that isolates and silences a woman from sharing with us, then we will not be in a position to provide optimum service to her or her child(ren). Remember that she may not be in a position to make changes now but in demonstrating genuine care for her, you establish yourself as an ally and resource for the future when she may be in a better place to adopt new coping skills.

Women who are survivors of childhood sexual abuse can find it challenging to meet their dietary needs. If her coping mechanisms include substance use, or food restriction (anorexia) or bingeing/purging (bulimia), it may be difficult for her to maintain or gain weight during her pregnancy. Conversely, women who have experienced abuse may overeat, or cycle through periods of overeating followed by restriction, which are also forms of disordered eating. Women often face comments from family, friends and even strangers about their eating habits and weight gain patterns. In our experience women often feel caught between, on the one hand, feeling guilty about not gaining enough weight and worried about the health of their babies, and on the other hand, thoughts that they are gaining too much weight and will not be able to lose it after the baby arrives. This internal dialogue around food is often exhausting and it is difficult for women to come to some resolution about it without the assistance of a skilled team of professionals, including her primary health care provider, a psychotherapist, a nutritionist and a support group.

It's important to recognize that there are many routine medical procedures in the childbearing year that may be reminiscent of past sexual abuse

Anxieties about this aspect of the upcoming labour and birth can be experienced during the whole pregnancy. Survivors are often concerned about "triggers" causing events from their past to resurface through labour, birth and postpartum. During labour women tend to be concerned about being exposed to strangers, having their genitals touched by caregivers and being confined to bed. They are frequently concerned that the birth of the baby through the vagina will bring up memories of pain from their abusers and are worried about crying out in fear.

Here are some suggestions on how to assist childhood sexual abuse survivors during pregnancy:

Help her establish what is normal

Women who did not have mothers who were able to provide protection from their abusers, may lack awareness about personal boundaries and the role of a mother. They may be afraid that they too will be unable to protect their baby or may not have good boundaries in place to help keep their child safe. Normalizing these fears and providing education around early attachment, boundaries and self-care can help reduce a woman's anxiety and provide her with some tools. A woman whose mother was an abusive person in her life can have an even greater sense of bewilderment or concerns that she may not know how to care for her baby, and can present as ambivalent or highly agitated about the idea of becoming a mother. Patience, understanding and a referral to a good early parenting program, therapist or counsellor can assist her in making important community connections before the baby's birth.

Always ask permission to touch, using non-threatening language

Remember that, as a survivor, there was a time in her life when her body was used against her will, without consent neither asked nor given. It is important that she be able to articulate her consent and decline touch when she is not feeling safe. As her care provider, it is your obligation to follow her lead and not pressure her into procedures that she is not absolutely comfortable with, or else you risk causing her further harm. She may feel safer if there is another person present during physical exams and be in a reclining position rather than lying down for pelvic/cervical assessments.

Refer when necessary and follow up as needed

If working with survivors of childhood sexual abuse is outside your scope of practice, you should have a list of community services you can refer her to. These resources should be listed among other services, such as well-baby clinics, play groups etc., so that she is not taking something home specific to abuse if it is not safe or comfortable for her to do so. She should also have an idea as to follow-up support. If she is put on a waiting list for services, what can she do in the meantime if she needs to talk? Can she connect with you; will you call in a few days, weeks? What are the local crisis line numbers? If she is in a remote area, provide a 1-800 number to a provincial or national support line.

Believe her and listen...

Believe her and listen... this may be the only thing she needs to begin a path towards healing.

 

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