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Trauma-Informed Maternity Care

Yesterday I wrote a bit about maternal and child outcomes being pretty catastrophic here in the United States which I relate to the ongoing patriarchy. While it seems my readers don't often like to leave comments directly on my posts, I did get some private messages that applauded my narrative, but also added further to the discussion. They shared frustration with how race and gender impact diagnostic fairness, and growing resentment for the injustices nurses experience when they challenge a broken system and advocate for those in their care.

While I discussed social determinants of care in my post, two of my readers discussed their experience of physicians ordering unnecessary diagnostics or delaying discharge because their insurance coverage was exemplary, so essentially "using the patient to line their pockets at the cost of patient's mental health and autonomy." There also seems to be a growing concern for punishing women when they speak up about body autonomy because of a "fetus first" mentality and that the new pro-life laws really create an imbalance of power so physicians can better strong arm women when they are most vulnerable.

The reality is that women are often traumatized through their birth experiences, which is a psychological wound caused by their own perceived stress and pain. Midwives and doulas are well familiar with the stories of women feeling bullied, violated, and dehumanized, even detailing their birth experiences as stories of rape. These women many times subsequently fear any level of medical intervention, avoiding primary care and even more urgent or emergent care. These experiences impact the care the entire family because mommas are typically the ones who manage their family's healthcare, so her fear is projected onto her children and often empathetic spouse. This doesn't even speak to the plethora of women who have experienced sexual trauma or childhood maltreatment. As a nurse-midwife and primary care provider myself, I very much appreciate the need for trauma-informed healthcare; I am a momma with trauma too.

Trauma is complex. While it may be related to a single, easily identified experience, many times its about chronic stress, a history of being dismissed and dehumanized, having your autonomy stripped from you. We often recognize trauma within ourselves when events or scenarios evoke pain or stress in us, a trigger so to speak. For many this happens in the healthcare setting and so naturally, these individuals may avoid seeking care in effort to resist retraumatization.

Trauma exposure relates to substance abuse, depression and chronic dis-ease, and lifetime trauma has been linked to adverse outcomes in pregnancy. We seek to numb the pain of trauma and stored trauma, unprocessed and unhealed trauma, can be damaging to us like toxic chemicals stored in our body; it creates inflammation that may look like depression, chronic pain, or autoimmune disease.

It is likely to be true that most are unable to escape a life without some level of trauma. Many of us work through it well, but others can be fairly crippled by its impact. Maybe they live in a state of sympathetic dominance, chronically exhausted, overwhelmed, and ready for a fight. Maybe they feel frozen, and not living up to their potential. Some are real cognizant of this but most don't relate their current health and circumstances to past trauma; in fact, they may adamantly deny any relation, have anxiety or panic attacks, and fail to see the connection at all. Therapy, particularly EMDR, can be incredible for these individuals, but trauma-informed care is also an essential aspect of healing.

Trauma-Informed Care Providers

When care is provided in a trauma-informed way, whether with your primary care provider or even your yoga instructor, this care is extended in a manner that creates a safe and trusting environment that respects the lived reality and perception of each individual. Providing that space though means connecting with people, aligning with their energy, noticing and paying attention to the subtle ways people communicate with us, and to be quite frank, when conventional medicine offers fewer than ten minutes to conduct an entire consultation, this is much more like trying to avoid a pile up on a conveyor belt of endless patients, so connection can be challenging. Providing safe space, truly empathizing in a trauma-informed manner, may be near impossible.

A point that I feel many practitioners, including midwives, continue to be incredibly naive is that while they may recognize the impact of trauma on birth outcomes so ask so they can be aware, this comes with a sort of entitlement they can freely explore that trauma as a normal part of asking a woman's history. This can be a healing experience for some, but for others it is quite intrusive and furthers their trauma. When we engage those memories, "the timekeeper part of the brain that tells you that this was then and this is now, tends to go offline," as explained by trauma expert Bessel van der Kolk. We can quite literally re-traumatize our clients through this inquiry.

Better would be to ask if a woman would like to share any additional information with us that they feel might assist us in better providing them care. Our responsibility is to create that safe space so if our client wants to share, they feel supported, but inquiring about trauma just to complete the task within our charting is insensitive. Admittedly, a few years ago I was sitting in the waiting room at the emergency department with my son, and the nurse at the desk asked why were visiting. She wanted his medical details right there in the lobby and when I asked her, "Isn't this a violation of his privacy," she responded that it isn't if I am the one giving his information, but if she shared it that would be a violation. I was stunned, and over the next hour listened to countless people have to share their very detailed history before they were permitted care. This was traumatic for me because it was a power move, a violation of each of their privacy by someone who controlled the gate for their care, in emergency scenarios. This even happens in convenient care clinics and it's exceedingly unethical.

Many years ago when I was still working as a labor and delivery nurse, I applied for a new job at a small remote hospital. This would be my first employed position after having lost my newborn in a pretty traumatic birth experience. He would have been ten months old. During my employee physical, performed by a nurse practitioner in the emergency room, the clinician asked about my medical history, my obstetrical and gynecologic history, including number of pregnancies and living children. I shared one of my sons had passed away and she asked why without even looking up from her chart. I felt a bit bunched in the gut and asked what this had to do with my employment. It seemed especially insensitive, intrusive, and even dehumanizing. As clinicians we can become a bit entitled believing we have privilege to anything and everything about their lived experience, failing to remember this is in fact a relationship we are building. There are boundaries.

Maybe women don't want to relate their older trauma to their new experience, or haven't the mental space to invite that back into their life right now, but also, not everyone has privilege to that part of ourselves. Sharing trauma makes us vulnerable, which isn't a welcomed feeling for many. We have to earn this privilege as clinicians and stop assuming we must know so we can offer resources or flag their chart so we don't trigger them in anyway. Being trauma-informed is about recognizing the privilege of even stepping into that inner circle of knowing.

The most prominent desire of those with personal histories of trauma is to have a trusting relationship with their healthcare provider. Many share that they seek empathetic practitioners and this empathy might identify the moment in which the clinician could or should lean into asking these questions. Certainly there are clients who won't share these histories unless first asked, because otherwise they don't want to burden or overstep, but this discussion should be treated with great care. It certainly is not one entered into sitting between triage curtains in the emergency room, with a clinician screening your candidacy for employment, particularly when her interest is very clearly about curiosity and not because her knowing might help offer space for healing.

Consistency in Care

That safe space is critical and can only really be provided through relationship, so when women seek care with practices with a number of practitioners, and the client has to meet a new clinician for many of their prenatal visits, each new encounter feels like another potential for personal invasion or for enduring more bullying. Visits with unfamiliar staff also means there is potential that traumatic history may be explored yet again as the new practitioner attempts to establish rapport, so when consistency in care isn't offered, even if they are trauma-informed, women often approach their care with all their defensive resources fully engaged.

Gaining Consent before Touching

Potentially you've heard me share this before; it was impactful. When I returned for my FNP certificate, a post-graduate degree for me - I had already been a clinician for more than a decade, the school sent an instructor to review my skills in the clinic setting while I was working with a preceptor. I was visiting with a pediatric boy who I saw regularly because he was utilizing controlled substances. He had felt safe with me in future appointments enough that he shared some of his really vulnerable fears and traumatic experiences. This was a relationship I was cautiously and respectfully nurturing, as I do with all my clients. When I went to offer the very brief physical exam, not super integral to this visit, I asked him if he would be comfortable with my raising his shirt to listen to his belly. This is my routine with every visit, and I ask the client to lift their own shirt. It is not my role to remove someone else's clothing, unless they need my assistance. This young man agreed, lifted his shirt, and I completed my assessment without incident.

After my visit, the instructor shared that I seemed comfortable and competent, but not to ask children for consent for the examination. If you know me at all, you know this is a conversation I can't walk away from - Enneagram 8 after all. She responded, "What if he had said no?" Well, ha! Then I would have respected that, and he would have felt I honored him which is potentially the greatest thing I could have offered him. He visits at least four times a year so if I had to detour listening to his bowel sounds, that would not have changed my management what-so-ever. There is no need to intrude upon one's self agency in the primary care setting. In fact, I would argue that my greatest role is to empower my littles to understand this concept more than any role I may play in their health and wellness.

Resources for Coping

Women with trauma have shared a desire for resources that address coping with traumatic exposures. This may include referrals for therapy, support groups, even help in meeting basic life needs. Sometimes is is knowledge about somatic therapies, EMDR, and a gentle, yin-based yoga class. We have educational programs galore. Journaling, investing in self which may look like connecting with nature or even connecting with other women, can be very healing. Rituals can help women connect or just gathering in safe spaces. I have created a Women's Healing Circle as one approach to addressing deep wounds in women who want to courageously explore healing and truly living freely.

Every yoga class I teach is an opportunity to explore empowerment and empathy. Simply offering students rocks they can either turn up for touch or down for no touch helps them check self, and explore their desires, and then to speak their voice in a way that is fairly non-intimidating. Mindfulness of the words we use too, is exceedingly important. It can be easy for example for yoga instructors to say, spread your legs as wide as your shoulders, which can be triggering when what we want is for them to place their feet at about hip width, grounded into the mat. This can be the difference in a visual of submission and one of empowerment.

Patience. Awareness. Adjusting. Empathy. Compassion. Grounding. Connection. Safe space. Honoring self and others. Empowering. Equipping. All aspects of trauma-informed care. These are basic elements in how I approach all my healing practices, with each and every client.

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