Moving Beyond the Pain: Women's Responses to the Perinatal Period After Childhood Sexual Abuse

Perinatal (Re)experiencing of Post-Traumatic Stress Disorder Symptoms for Survivors of Childhood Sexual Abuse: An Integrative Review

This integrative review aimed to synthesize both qualitative and quantitative research on the (re)experiencing of post-traumatic stress disorder (PTSD) symptoms during the perinatal period for childhood sexual abuse (CSA) survivors. Whittemore and Knafl's framework, which includes problem identification, literature review, data evaluation, data analysis, and results dissemination, was used. A search in four databases (i.e., PsycINFO, MEDLINE, Scopus, and ProQuest Dissertations and Thesis Global) yielded an initial sample of 3420 articles. After screening and deduplication, 16 articles met our inclusion criteria (i.e., history of CSA, minimum 8 weeks pregnant, reported quantitative statistics or qualitative findings, discussed PTSD symptoms) and were retained in the final sample. CSA survivors (re)experienced PTSD symptoms as a result of (1) aspects of their medical care (vaginal examinations, male medical providers, lack of control, and restraint), (2) physical sensations during pregnancy, childbirth, and breastfeeding, and (3) sex of the child (worries over child becoming an abuser/abused, male genitalia). CSA survivor's PTSD symptoms of intrusion, dissociation, avoidance, and hyperarousal were significantly greater throughout the perinatal period compared with individuals without CSA or with other traumas. CSA survivors are at increased risk of (re)experiencing PTSD symptoms throughout the perinatal period, which may be due to several internal and external triggers. Further research is needed to understand external triggers outside of medical care, and how the unique context of pregnancy may differ from other life contexts for survivors of CSA. Findings point to the relevance of adopting trauma-informed practices with CSA survivors during their perinatal period.

Perinatal Care of Childhood Sexual Abuse Survivors: Scoping Review

BACKGROUND

An estimated one in nine women seeking perinatal care is a survivor of childhood sexual abuse (CSA), yet CSA may be unknown to nurses and other health care providers. Childhood sexual abuse can have adverse physical and psychological effects for survivors, and the intimacy of perinatal care can trigger distress like intrusive thoughts.

PURPOSE

To explore available literature about CSA survivors and perinatal care. Specific aims were to 1) identify nursing actions that ease undesirable feelings during perinatal care for CSA survivors and 2) identify gaps in the literature on perinatal care for CSA survivors.

STUDY DESIGN AND METHODS

Following the PRISMA-ScR Checklist, MEDLINE and CINAHL databases were searched using: "Child Abuse, Sexual," "Perinatal Care," and "Parturition." Initial yield was 109 records.

RESULTS

Applying inclusion and exclusion criteria produced 14 full-text articles. Findings suggest that obtaining consent, promoting safety, trust, and control, fostering a healthy nurse-patient relationship, and inquiring about abuse may improve how CSA survivors experience perinatal care. Gaps in literature include nursing assessments for history of CSA with nonverbal cues.

CLINICAL IMPLICATIONS

For all patients, nurses should foster security and trust. It is critical that CSA survivors be in control of their care. Procedures should be thoroughly explained, and most importantly, consent should be obtained prior to every physical touch. Nurses must ask about history of CSA because it is part of patient-centered care, which is central to nursing.

A Narrative Analysis of the In Vitro Fertilization Experiences of Survivors of Sexual Abuse

OBJECTIVE

To explore the lived experience of in vitro fertilization (IVF) from the perspective of survivors of sexual abuse.

DESIGN

In this qualitative study, narrative analysis provided the framework to understand participants' IVF experiences.

SETTING

Participants were recruited through a regional support group for women with infertility.

PARTICIPANTS

Three women (mean age = 33.3 years) who self-identified as a survivor of sexual abuse and had at least one IVF experience participated in this study.

MEASUREMENTS

Each participant wrote a narrative text of her experience. Burke's method was followed for analysis of the narratives.

RESULTS

The most frequent imbalance was between what is happening (i.e., IVF procedures) and how the health care team provided the care. The repercussion was a negative experience for survivors, stemming from an insensitive manner in which their physical and verbal care was delivered by health care teams. These women were also deeply protective of their oocytes (eggs), embryos, and children.

CONCLUSION

Health care providers may use these findings to better meet the physical and psychological needs of survivors of sexual abuse who are coping with infertility. Providers can have a more positive effect on the IVF experience of survivors by ensuring that the procedures they perform and the information they share are explained fully and delivered in a trauma-informed manner.

Variation in self-identified most stressful life event by outcome of previous pregnancy in a population-based sample interviewed 6-36 months following delivery

The majority of health research uses a deductive approach to measure stressful life events, despite evidence that perception of what is stressful varies. The goal of this project was to 1) describe the distribution of self-identified most stressful life events in a cohort of women who experienced a perinatal loss (stillbirth or neonatal death) or live birth in the previous three years and 2) test how childhood adversity influences participant selection of their most stressful life event. We used data from 987 women (282 with stillbirth, 657 without loss, and 48 with a neonatal death in the first 28 days) in the Stillbirth Collaborative Research Network - OASIS (Outcomes after Study Index Stillbirth) follow-up study, a population-based sample set in five U.S. states in 2009. We applied an inductive coding process to open-ended responses to a question about the most stressful event or major crisis that participants had ever experienced, resulting in a set of 15 categories. We compare psychologic wellbeing across self-identified most stressful life event, accounting for sampling and loss-to-follow-up weights. Overall, stillbirth was most commonly identified as the most stressful event (18.3% [95% CI: 15.6, 21.5]), followed by loss by death of someone other than a child (17.25% [95% CI: 13.9, 20.3]). For participants who experienced a perinatal loss, we fit multivariable logistic regression models to quantify the association between report of childhood maltreatment and identifying the perinatal loss as the most stressful life event, calculating risk ratios (RRs). Reporting any moderate or severe childhood maltreatment was associated with 24% lower risk of identifying the perinatal loss as the most stressful life event (adjusted RR: 0.76 [95% CI: 0.58, 1.01]), after adjusting for race/ethnicity, age, and education. These results demonstrate the value of combining standardized measures with open-ended, inductive approaches to measuring stress in large, population-based studies.

Co-production of an e-resource to help women who have experienced childhood sexual abuse prepare for pregnancy, birth, and parenthood

BACKGROUND

This paper reports the development of a co-produced e-resource to support those who have experienced childhood sexual abuse through pregnancy, birth, and parenthood. These are times of major transition for any woman but can present particular challenges for those who have experienced childhood sexual abuse. Re-traumatisation during the perinatal period is common and can occur in ways that may not be anticipated by those involved. Survivors often do not disclose their abuse and the childbearing journey can be lonely.

METHODS

The work was conducted in collaboration with The Survivors Trust and in keeping with the Survivor's Charter. A participatory approach was used. There were two phases: the generation of new qualitative data and development of the resource. To encourage participation from this hidden population, data were collected by a variety of means including focus groups, telephone interviews and an on-line survey. Survivors who had children and those who hoped to one day participated. Resource development was facilitated by two workshops and email feedback.

RESULTS

Overall, 37 women participated, all of whom were positive about development of the resource. Although many issues identified during data collection were specific to the participants' history of abuse other areas of concern would be relevant for any woman contemplating the journey to parenthood. Women often assumed that they were alone in their concerns and were reassured to discover that others shared their experiences. The final resource is hosted on The Survivors Trust Website and is accessible from all electronic devices. It follows the journey from deciding to have a baby, pregnancy, labour, birth, and the postnatal period through to parenthood. Links are provided to further information and sources of support. The process of developing the resource used trauma-informed principles and it speaks with women's words in a peer-to-peer voice.

CONCLUSIONS

This paper describes the development of an innovative and accessible e-resource that is based on the words and experiences of survivors of childhood sexual abuse. It recognises the importance of control and feeling safe and aims to empower those who use the resource as they embark on pregnancy, birth, and parenthood.

Parenting Among Mothers Who Experienced Child Sexual Abuse: A Qualitative Systematic Review

Child sexual abuse (CSA) represents a significant public health problem. While CSA is associated with several adverse outcomes, recent attention has been given to its effect on maternal parenting. Despite a growing literature on this topic, a comprehensive systematic review has not been conducted. Thus, this review aimed to fill this gap. Several search strategies were used, including searches in academic databases. Two reviewers completed screening, full-text review, data extraction, and quality determinations. Extracted qualitative data were synthesized for the 108 studies meeting inclusion criteria. The primary themes emerging from women's accounts of the effects of CSA on their current parenting included abuse of child, breastfeeding, child-rearing practices, coping related to parenting, mother-child relationship, perceptions of child, perceptions of motherhood, and protection of children from abuse. Given the current lack of interventions designed for these mothers, the results of this review may aid in the development of evidence-based interventions.

Healing The Past By Nurturing The Future: A qualitative systematic review and meta-synthesis of pregnancy, birth and early postpartum experiences and views of parents with a history of childhood maltreatment

BACKGROUND

Child maltreatment can have serious effects on development and physical, social and emotional wellbeing. Any long-lasting relational effects can impede the capacity to nurture children, potentially leading to 'intergenerational trauma'. Conversely, the transition to parenthood during pregnancy, birth and the early postpartum period offers a unique life-course opportunity for healing. This systematic review aims to understand the pregnancy, birth and early postpartum experiences of parents who reported maltreatment in their own childhood.

METHODS

A protocol, based on the ENTREQ statement, was registered with PROSPERO. We searched Medline, PsycINFO, CINAHL, EMBASE, NHS Evidence and key Web of Science databases from date of inception to June 2018 to identify qualitative studies exploring perinatal experiences of parents who were maltreated in their own childhood. Two reviewers independently screened articles for inclusion and extracted data. Data were synthesised using grounded theory and thematic analysis approaches.

FINDINGS

The search yielded 18329 articles, 568 full text articles were reviewed, and 50 studies (60 articles) met inclusion criteria for this review. Due to the large number of studies across the whole perinatal period (pregnancy to two years postpartum), this paper reports findings for experiences during pregnancy, birth and early postpartum (27 studies). Parents described positive experiences and strategies to help them achieve their hopes and dreams of providing safe, loving and nurturing care for their children. However, many parents experienced serious challenges. Seven core analytic themes encapsulated these diverse and dynamic experiences: New beginnings; Changing roles and identities; Feeling connected; Compassionate care; Empowerment; Creating safety; and Reweaving a future.

CONCLUSIONS

Pregnancy birth and the early postpartum period is a unique life-course healing opportunity for parents with a history of maltreatment. Understanding parent's experiences and views of perinatal care and early parenting is critical for informing the development of acceptable and effective support strategies.

Measurement of Maternal Mindful Awareness of Fetal Movement

INTRODUCTION

Decreased fetal movement is a common concern late in pregnancy that may be associated with increased fetal morbidity and mortality. Limited research suggests a relationship between maternal psychological factors and perception of fetal movement. The goal of this study was to test the reliability and external validity of a novel self-report instrument for maternal mindful awareness of fetal movement.

METHODS

Pregnant women who were at 20 weeks' gestation or later and feeling regular fetal movement (N = 497) were recruited online through a commercial pregnancy website to complete an internet survey from April to May 2016. The online survey included demographic and pregnancy characteristics, psychological and mindfulness measures, and investigator-developed items on mindful awareness of fetal movement. Reliability and validity of the instrument were tested with exploratory factor analysis, correlations with psychological variables, and hierarchical linear regression.

RESULTS

Exploratory factor analysis of mindful awareness of fetal movement items using principal components analysis showed a 2-factor structure, noticing and distracted, with internal consistency of α equal to .69 and .57, respectively. Hierarchical multiple regression analysis showed that noticing was associated with increased gestational age, mindfulness (observing facet), and maternal-fetal attachment. Distracted was associated with increased education level and prenatal anxiety and with decreased mindfulness (nonjudging facet).

DISCUSSION

There was moderate internal consistency in the items measuring mindful awareness of fetal movement. Findings suggest relationships between mindful awareness of fetal movement and state mindfulness, maternal-fetal attachment, and prenatal anxiety. More research is needed to further develop items for a mindful awareness of fetal movement scale suitable for research and clinical practice.

Perinatal interventions for mothers and fathers who are survivors of childhood sexual abuse

Childhood sexual abuse (CSA) is a worldwide problem with severe long-term consequences. A history of CSA can impact the childbearing experience of mothers and fathers; affecting their mental health, parenting skills and compromising infant development. Nonetheless, the perinatal period offers huge opportunity for intervention and hope. This literature review collates evidence for perinatal psychosocial interventions targeting both mothers and fathers who are survivors of CSA. Publications dating from 1970 to June 2016 were searched using Medline, Maternity and Infant Health, PsychINFO, PsychArticles, PubMed and the International Bibliography of the Social Sciences (IBSS). There were no perinatal interventions that considered the needs of survivor fathers. Sixteen publications on 9 psychosocial perinatal interventions for CSA survivors were identified. However, no sub-analyses specific to CSA survivors were reported. Trauma-specific perinatal interventions drew from a range of theoretical models and varied widely in format. Generally interventions were associated with improvements in maternal mental health, parenting competence, infant attachment security and positive public health outcomes. They were safe and feasible to implement, acceptable to parents and therapist, and therapists were able to implement protocols with adequate fidelity. Yet current data is hampered by small sample size, inconsistent reporting of CSA rates and outcome measures, scarcity of observational data and longer-term follow-up. Intervention modifications are proposed for CSA survivors in view of their unique childbearing experiences.

A Systematic Literature Review of the Childbearing Cycle as Experienced by Survivors of Sexual Abuse

For women who have experienced sexual abuse, the physical changes associated with pregnancy and the lack of control during birth can be catalysts for trauma from past abuse to resurface. This systematic review offers women's health care providers a thorough evaluation of the state of the science on survivors' childbearing experiences. The literature shows that lack of control, dissociation, and flashbacks are common themes. Re-experiencing of the trauma occurred during various stages of childbirth and was traumatizing to women. Nurses and other clinicians providing care to childbearing women can provide control to survivors during health care encounters and can form therapeutic relationships to help them have more positive childbirth experiences.

"I Felt Like I Was Being Abused All Over Again": How Survivors of Child Sexual Abuse Make Sense of the Perinatal Period Through Their Narratives

Sequelae following child sexual abuse pervade the lives of adult survivors, significantly impacting on pregnancy and childbirth. Symptoms of this distress are recognized, but meanings for women are less understood. This research aimed to examine the meaning for women themselves of the impact of child sexual abuse on experiences of pregnancy, childbirth, and the postnatal period. Taking a critical feminist perspective, three open-ended interviews with three survivors enabled women's narratives of pregnancy and childbirth to be heard, explored the structure of these narratives, including how experiences were connected, and identified key themes and how selves and others were positioned. Women themselves contributed to the analysis of their own narratives. The different struggles of each woman occurred within three domains of experience: identity, embodiment, and parenting. They were underpinned by a fluctuation between empowerment and disempowerment. These findings, although based on detailed analysis of the experiences of only three women, dovetail with, integrate, and extend the existent literature, offering a framework for understanding the complexity of meaning making for women. Further research might develop this. The framework may facilitate clinicians' understandings of what it is like for some women having children who have experienced child sexual abuse.

Childhood Maltreatment and Perinatal Mood and Anxiety Disorders: A Systematic Review

Perinatal mood and anxiety disorders (PMADs) compromise maternal and child well-being and may be influenced by traumatic experiences across the life course. A potent and common form of trauma is childhood maltreatment, but its specific impact on PMADs is not well understood. A systematic review was undertaken to synthesize empirical literature on the relationship between maternal histories of childhood maltreatment and PMADs. Of the 876 citations retrieved, 35 reports from a total of 26,239 participants met inclusion criteria, documenting substantial rates of childhood maltreatment and PMADs. Robust trends of association were observed between childhood maltreatment and perinatal depression, as well as post-traumatic stress disorder, but findings for anxiety were less consistent. Examining multivariate results suggested that childhood maltreatment predicts PMADs above and beyond sociodemographic, psychiatric, perinatal, and psychosocial factors, but may also be partially mediated by variables such as later victimization and moderated by protective early relationships. Future research should test mediating and moderating pathways using prospective cohorts, expanding to cross-cultural settings and other disorder outcomes. Treatment and prevention of childhood maltreatment and its sequelae may help mitigate risk for perinatal psychopathology and its impact on maternal and child outcomes.

The Lived Experience of Childbearing From Survivors of Sexual Abuse: "It Was the Best of Times, It Was the Worst of Times"

INTRODUCTION

In the United States, one in every 5 women will experience sexual violence. Survivors are at risk for difficult pregnancies, substance abuse, stress, fear, and preterm births. A history of sexual abuse can impact several aspects of a woman's childbirth, thereby affecting her long-term physical and emotional well-being. The adverse pregnancy outcomes, combined with the prevalence of sexual abuse, underscore the need for research to understand survivors' experiences.

METHODS

This study's purpose was to understand the lived experience of pregnancy, labor, and birth from survivors. A qualitative, descriptive phenomenological research design was utilized. The purposeful sample included 8 female, self-identifying survivors of sexual abuse with at least one childbearing experience.

RESULTS

Analysis identified 302 significant statements that formed 7 overarching themes: 1) No one asked me. Just ask me!; 2) An emotional roller coaster: From excitement to grief for what could have been a better experience; 3) All of a sudden I was that little girl again and/or I compartmentalized it: The all-or-nothing experience; 4) Am I even here?: Nothing was explained and I had no voice; 5) All too familiar: No support, nowhere to turn; 6) Holding on to the choices I can make: Who my doctor is and how I feed my baby; and 7) Overprotection: Keeping my child safe.

DISCUSSION

The final result was the essence of childbearing for survivors in this study. They were not screened for a history of sexual abuse. Enjoyment and excitement were juxtaposed with guilt and fear. They had no voice, lacked support, and overwhelmingly desired control. They overprotected their children, from infancy into adulthood. The childbearing experience was a complex, emotional roller coaster permeated by the past. Women's health care providers can utilize the results to provide therapeutic care to survivors to prevent revictimization. The results elucidate the importance of screening for a history of sexual abuse and discussing the implications such a history can have on the childbearing experience.

Experiences of Mothers Who Are Child Sexual Abuse Survivors: A Qualitative Exploration

Child sexual abuse has been associated with a number of problems affecting women over their lifespan, including difficulties with parenting. However, there is a modest number of qualitative studies examining the impact of child sexual abuse on survivors who are mothers. There is a particular need for qualitative investigations that ask survivors who are mothers general questions about the impact of child sexual abuse on their lives rather than those that specifically ask about the impact of child sexual abuse on parenting. The former approach would allow survivors to describe effects that may impact parenting but that survivors do not consciously link to affecting their parenting. Such information may inform interventions to assist this population of survivors. This secondary data analysis examined themes revealed in interviews with 44 survivors of child sexual abuse who were mothers. Participants were seeking treatment for their child sexual abuse and completed an in-person interview in which they were asked open-ended questions about the sexual abuse they experienced as a child and how their abuse affects them now as adults. The interviews were recorded, transcribed, and coded using thematic analysis. The following six themes emerged from the narratives: (a) being a parent, (b) family of origin dysfunction, (c) the impact of abuse, (d) the abuse history and response to abuse, (e) coping, and (f) hopes and desires for the future. This study highlights several ways in which child sexual abuse impacts survivors who are mothers, areas for further study, and the need for interventions to assist this population in meeting the challenges they face as mothers.

Childhood maltreatment history, posttraumatic relational sequelae, and prenatal care utilization

OBJECTIVE

To test the hypothesis that childhood maltreatment history would be associated with inadequate prenatal care utilization.

DESIGN

A post-hoc analysis of a prospective cohort study of the effects of post traumatic stress disorder (PTSD) on pregnancy outcomes.

SETTING

Recruitment took place via prenatal clinics from three academic health systems in southeast Michigan.

PARTICIPANTS

This analysis included 467 diverse, nulliparous, English-speaking adult women expecting their first infants.

METHODS

Data were gathered from structured telephone interviews at two time points in pregnancy and from prenatal medical records.

RESULTS

Contrary to our hypothesis, history of childhood maltreatment was associated with better likelihood of using adequate prenatal care. Risk for inadequate prenatal care occurred in association with the posttraumatic stress and interpersonal sensitivity that can result from maltreatment, with low alliance with the maternity care provider, and with public insurance coverage. Prior mental health treatment was associated with using adequate prenatal care.

CONCLUSION

When childhood maltreatment survivors were resilient or had used mental health treatment, they were more likely to utilize adequate prenatal care. The maternity care relationship or service delivery model (e.g., no continuity of care) as well as structural factors may adversely affect utilization among PTSD-affected survivors. Since inadequate care was associated with adverse outcomes, further studies of these modifiable factors are warranted.