Trauma-Informed Maternity Care – Study Notes (Chapter 8)

Introduction

• Trauma exposure is common worldwide and adversely affects women’s reproductive health. The chapter focuses on trauma-informed care (TIC) specifically for pregnant women in maternity (obstetric) care, noting that many principles from TIC in primary care apply to routine OB-GYN practice.
• Populations at very high risk for trauma include:
  • Homeless and incarcerated women
  • Those with substance use disorder
  • Refugees
  • Groups with high historical trauma burden (e.g., African and Native Americans)
• Types of interpersonal trauma include childhood maltreatment, intimate partner violence (IPV), sexual assault, and human trafficking; contraceptive coercion is a form of IPV that can lead to unintended pregnancy.
• Women may experience multiple forms of violence across the lifespan; care should be mindful of co-occurring traumas.
• Incarcerated women have faced suboptimal conditions in labor (e.g., shackling in some states); this practice has limited legislation against it in many places.
• Direct and indirect lifetime trauma exposure cumulatively impacts women’s health, including reproductive health and infant outcomes. Examples include:
  • Emotional and physical abuse linked to non-use of preferred contraception method
  • Higher rates of pelvic pain, sexually transmitted infections, infertility, and poorer perinatal/postpartum outcomes
  • Abuse histories and PTSD linked to higher risk of postpartum depression
  • Verbal or physical abuse during pregnancy associated with higher risk of low birth weight and neonatal death in offspring
  • Trauma histories can delay prenatal care seeking due to triggers during prenatal, perinatal, or peripartum care (e.g., exposure to restraint, monitoring wires, or other reminders of past abuse)
• Childbirth itself can be traumatic or trigger PTSD; PTSD prevalence in pregnancy ranges from 3rac{1}{3} ext{%} ext{ to } 14 ext{%} (approximately $3 ext{ extperthousand} ext{ to } 140 ext{ extperthousand}$ in different settings), with higher rates in low-resource settings; childhood abuse is a major risk factor for PTSD during pregnancy.
• Data suggest that sexual abuse in childhood is common among pregnant women, with estimates indicating that at least $frac{1}{4}$ of expectant women have such a history. CDC estimates suggest that about $frac{1}{5}$ of adult women experience lifetime completed or attempted rape.
• These data underscore TIC’s importance during pregnancy and childbirth and guide the trauma-informed approach in maternity care.

Goals of Trauma-Informed Maternity Care

Trauma-informed maternity care practice incorporates the following main principles:

• (1) Detection of new or ongoing abuse and/or violence to enable staff to offer support and referral.
• (2) Prevention of new trauma, acknowledging that childbirth itself can be traumatic.
• (3) Avoidance of re-traumatization for women with histories of interpersonal or other trauma, or prior “birth trauma.”
• (4) When appropriate, referral of women with trauma histories to trauma-focused treatment.
  • Note: Trauma-focused treatment may not be a priority or option for women who prefer to avoid triggers during pregnancy and birth.
• Routine application of TIC throughout maternity care is critical, as clinicians may not always know who has a trauma history; a trauma reaction can sometimes be the first sign of history.
• TIC in maternity care also aims to reduce intergenerational transmission of trauma (vertical transmission) much like preventing vertical transmission of infections during birth.

Posttraumatic Stress Disorder in Maternity Settings

• Pregnancy is a life-changing event; in the US, nearly half of pregnancies are unintended: $frac{1}{2} ext{ (approximately)}$.
• The prenatal/peripartum care environment can trigger memories of past abuse beyond routine procedures (e.g., raised side rails, restraints, or delayed assistance).
• In the second stage of labor, the process of passage through the birth canal can evoke memories of past forced intercourse.
• PTSD prevalence in pregnancy ranges from 3 ext{%} to 14 ext{%}, with the highest rates in low-resource settings; childhood abuse is the biggest risk factor for PTSD during pregnancy.
• PTSD is linked to poorer perinatal health outcomes, including low birth weight, shorter gestation, maternal mental health issues, and impaired bonding.
• Pre-existing PTSD increases the risk of perceiving birth as traumatic and of experiencing PTSD symptoms postpartum, potentially affecting parenting and infant attachment.
• Acute stress disorder can occur after a traumatic birth before possible PTSD diagnosis; most cases do not progress to PTSD.
• The concept of birth trauma encompasses not only actual or threatened injury but also negative interactions with care providers that leave women feeling unsupported, disconnected, helpless, and isolated; such experiences can yield higher PTSD odds than obstetric complications alone.
• Childbirth experiences are influenced by health system factors (e.g., risk aversion, litigation concerns) that may shift focus away from patient-centered psychosocial outcomes toward physical risk mitigation.
• Being supportive and flexible, within safety limits, is essential for trauma histories in maternity care.
• The potential for intergenerational impact underscores the importance of TIC in obstetric settings.

Implementing Trauma-Informed Maternity Care

• Trauma-informed health settings design services around understanding trauma survivors’ vulnerabilities/triggers to be more supportive and avoid re-traumatization.
• Routine screening for trauma history, including childhood sexual abuse and IPV, is advocated in maternity care to tailor care and plan for childbirth.
• The American College of Obstetricians and Gynecologists (ACOG) advocates routine screening for child and adult sexual abuse as well as IPV.
• Screening for adverse childhood experiences (ACEs) during routine prenatal visits has been found feasible; most patients report that sharing ACEs is acceptable and helpful, especially when paired with referral resources like social work and mental health.
• Six TIC principles (Table 8.1) and their implications for prenatal/peripartum care:
  • Safety
  • Trustworthiness and transparency
  • Peer support
  • Collaboration and mutuality
  • Empowerment, voice, and choice
  • Awareness of cultural/historical and gender issues
• Practical implications include recognizing that birth is a family event shaped by community and cultural context; even routine childbirth education can be challenging for survivors and may require tailored approaches.
• Trauma-informed care can enable a positive birth experience and potentially act as a turning point in healing for survivors.
• Pathways to more woman-centered maternity care and shared decision-making (SDM) can act as conduits for TIC; SDM involves sharing information and evidence to arrive at consensus-based decisions with the patient.
• Challenges of SDM in perinatal care include the dynamic and time-constrained nature of labor and contractions, which can limit deliberation and decision time.
• Birth planning is important for trauma survivors to enable agency and trauma-informed preparation.
• Example testimonial: a survivor highlighted the impact of a clinician pausing to explain a cesarean and obtaining real consent, which provided a lasting sense of empowerment.
• Additional TIC interventions include Centering Pregnancy, co-constructed handheld or electronic maternity records, decision aids, and the use of doulas to support self-efficacy during labor and birth.
• Doulas and trauma-informed guidance in birth support are associated with improved birth outcomes, especially for underserved populations.
• Implementing TIC can be supported by dedicated staff knowledge about trauma, embedding TIC into standard workflows, and ensuring flexible, respectful communication.

Applying trauma-informed principles to maternity care: Table 8.1 highlights

• Safety
  • Obtain consent for even routine procedures; minimize vaginal exams; allow support persons; create advance trauma-trigger plans; provide a doula when possible; post door signs asking staff to announce themselves; keep the patient covered between exams; avoid triggering language; deliver care as a suggestion rather than directive when appropriate.
• Trustworthiness
  • Keep patients informed of all available options; engage in shared decision-making; offer “holding” during care.
• Transparency
  • Obtain informed consent for routine interventions; provide antenatal education about potential emergencies.
• Peer support
  • Use models like Centering Pregnancy; provide peer-to-peer support; designate trauma-aware staff per shift.
• Collaboration and mutuality
  • Use antenatal education, SDM, birth planning; co-construct maternity records; communicate in multiple ways; schedule flexibility; ensure eye-level interaction during care.
• Empowerment (voice and choice)
  • Provide survivor-focused materials; individualized trauma-informed birth plans; promote SDM; offer doula support; respect physical space and environmental preferences during labor; obtain consent consistently.
• Awareness of cultural, historical, and gender issues
  • Address social support disparities, use professional interpreters; be aware of racial disparities in maternal-fetal outcomes; consider a combined interpreter/doula approach where appropriate.

Trauma-Informed Maternity Care and Shared Decision-Making (SDM)

• SDM is an interactive process where professional and patient information is exchanged; a consensus-based decision is reached collaboratively.
• In maternity care, SDM begins in prenatal care and extends through the postpartum period; it has the potential to improve birth experiences and overall satisfaction with care.
• Challenges to SDM in perinatal care include time pressure during labor and pain, which can hinder deliberation and decision-making processes.
• Birth plans are a form of advance planning to empower women, enabling them to be active agents during birth; this is especially valuable for trauma survivors.
• A survivor's anecdote illustrates the importance of real-time consent and clear communication during procedures.
• Interventions that align with TIC and SDM include Centering Pregnancy and shared decision aids; co-constructed records; and the inclusion of doulas as advocates and supports during birth.

Centering Pregnancy and Decision Aids

• Centering Pregnancy is a group prenatal care model that supports TIC by combining education with peer support, tailored to community and cultural contexts.
• Co-constructed handheld paper or electronic health records can support patient-centered care, though results have been mixed and require further study.
• Decision aids help women in the information component of SDM, improving informed choices during pregnancy and birth; studies show positive effects, though some mobile apps may have unintended effects on activation and require further evaluation.

Centering Pregnancy and Racial Disparities (CRADLE) studies and related programs

• Centering Pregnancy programs can address racial disparities and improve outcomes; examples include Centering and Race Disparities (CRADLE) and related group prenatal care research.
• Centering Pregnancy has practical tips for implementation in practice settings and can be adapted to different communities.
• Tools like co-constructed records and decision aids have been studied to measure impact on patient-centered outcomes and SDM processes.

Programmatic Examples

• Survivor Mom’s Companion (SMC)
  • A manualized 10-module self-study psychoeducational program designed for pregnant women with a history of childhood maltreatment to break cycles of abuse and psychiatric vulnerability in pregnancy and early motherhood.
  • Features include self-study modules with vignettes; an accompanying 30-minute session with a trained tutor (perinatal nurses, social workers, or health educators with standardized training).
  • SMC enables case finding for past/present trauma and can promote treatment engagement upon referral.
  • Demonstrated outcomes: improved interpersonal reactivity and reduction in PTSD symptoms among completers; available for individuals, healthcare organizations, and agencies via survivorMom.org.
• B’more Fit for Babies (Baltimore)
  • A trauma-informed community health project targeting obesity among trauma-exposed postpartum women, with broader goals to improve maternal health, reduce adverse pregnancy outcomes, and enhance parenting skills through TIC.
  • Context: Baltimore has high exposure to violence and historic trauma; obesity is a common issue among African American women and a contributor to infant mortality.
  • Development involved community input, a trauma-informed policy framework, and a peer-led model; aims to spread TIC across city institutions and inform community public health in other urban centers.

Conclusion

• Trauma is common among women and directly impacts reproductive health; survivors of sexual trauma and other violence face challenges during childbirth.
• TIC can make the birthing experience less frightening and less likely to be retraumatizing, and more empowering.
• Clinicians, agencies, and health systems can apply the guidance outlined to create a more trauma-sensitive environment during pregnancy, childbirth, and the postpartum period.

References (selected points)

• Foundational studies and reviews on ACEs, IPV, and trauma in pregnancy; key sources include analyses of trauma prevalence, screening feasibility, SDM, and TIC frameworks.
• Examples cited throughout include: Centering Pregnancy, SDM Delphi studies, Centering CRADLE studies, Survivor Mom’s Companion, and B’more Fit for Babies, among others.