My cell phone rang as I sat eating lunch with friends. On the other end was a frazzled husband, speaking with barely restrained calm. In the background I could hear the accelerating waves of high-pitched wails reaching crescendo with each contraction peak. I didn’t wait for his desperate request. “I’ll be there in fifteen minutes,” I quickly reassured.
When I arrived, Katy was skittishly racing back and forth through the hallway as if she were running from a shadowy beast and its unearthly wailing. She was entangled in some nightmare from her past. Oblivious to my presence, she continued to beg in a childlike voice, “Daddy, I’m sorry. I’ll be good. I promise I’ll be good.”
My heart broke. I instinctually wanted to gather her up like a little child into my arms, rock her fear away and caress her with reassuring words, “It’s okay, honey. Don’t be afraid. You’re okay.” But I knew that approach wouldn’t reach through her panic and into her inner world. Feeling almost unkind I took charge, looking her straight in the eyes and, using my firm voice, guided her through each contraction, working to keep her grounded in the present and reminding her that she was now safe and protected. This was birth. It was strong, but she was okay.
She calmed and began to settle in and focus more on her labor, but still hung halfway between the present and the past. Eventually she began to completely slip away from her surroundings, just as she had done near the end of her previous birth with me. The few words she spoke were all said in French, her language of origin, and I was concerned that, once again, she would have absolutely no memory of her baby being born. So in between contractions I firmly took her hand and verbally led her, step by step, to follow the sensation of my touch out into her body from wherever she was hiding deep inside. I switched exclusively to French, inwardly grateful that I had rehearsed some key phrases beforehand since my French had gotten very rusty over the years. Before long the baby’s head gently slid out and I took the hand I was holding and placed it upon her baby’s head. “There’s your baby’s head. It’s out. Do you feel that? Just one more push and your baby will be in your arms.”
Suddenly everything changed. It was as though someone had switched off the background noise or turned on the lights. She snapped fully into her body and cast a doubtful eye on me. Immediately she sat up halfway and in a low-pitched voice demanded, “You promise? Just one more push? Because if you’re lying, I’m not pushing!” I almost laughed out loud at the absurdity of the moment. Her baby was right there, half born and she was negotiating the birth of the rest of his body!
“Yes,” I promised with a smile escaping the corners of my mouth. “Just one more push.”
“Okay,” she acquiesced suspiciously. “You promised.” Then she lay back down and pushed her baby into the world. The next moment was electric. To hear her exclaim those universal words, “Oh my baby, my baby,” was a midwife’s fulfillment. Tears ran down my face. It was in such contrast to her previous birth. Three years earlier, when I had placed that baby in her arms, she had simply looked up at me with confusion on her face and asked, “What is this?”
The first time Katy came to me I did not know that she was a survivor of abuse. She was a gifted, intelligent woman who left blank the intake form questions about abuse history. I think that there is a good chance she wasn’t even aware of the entirety of her past, although she was very guarded about discussing any history. The second time around, I was wiser based upon how events had unfolded at her previous birth. I knew that she must have suffered from childhood trauma of some kind and that her primary coping mechanism was dissociation. But she still either did not remember or was unwilling to disclose. I honored this nonverbal avoidance and, instead of digging up her history, we discussed what approach she thought would be the most helpful to her in labor. We planned methods that she thought would help her to stay present and I had invested in careful preparation by hitting my old French texts. It made all the difference. It was her fourth child, yet it was the first birth for which Katy had any memory. She was ecstatic! In the ensuing years she would call me occasionally and share how her life had begun to grow and change from that very magical moment of her baby’s birth.
Identifying Abuse History
More than one quarter of the women we attend as midwives will have some history of abuse. It is always helpful to know ahead of time and adapt to the unique needs of each individual. However, few women will disclose that fact at first intake, even when provided the opportunity to do so. They may share it later, when a trusting relationship has developed, or may not share it at all.
It is important to provide a minimum of two opportunities in the course of care for women to disclose: one in writing and one during a prenatal later, when trust is well-established. On the written intake history, ask if she feels unsafe, threatened or concerned in any way about her current living situation. Also ask whether she has any abuse in her past history, giving her the option of selecting from “none,” “yes” or “I am not sure.” Consider giving her the opportunity to check all that apply from a list that includes emotional, physical, sexual, and spiritual abuse, as well as “other.”
In my experience, the most important part of a questionnaire is a simple two-part selection that actually encourages disclosure by some women who might not do so otherwise. Those two options are:
- I would like to discuss this matter more during one of our future visits; and
- I do not want to discuss this, but understand that I am free to initiate dialogue any time at my discretion.
If a woman leaves the entire abuse section blank, including the “none” box, the absence of data itself gives you vital information. It is likely that she is a survivor and is unable to disclose at this time.
Midwives must learn to look for indications of abuse history, remembering not to draw too many fixed conclusions about each woman in our care. Our observations serve as a guide to personalize the style of care we provide. A midwife should never use her observations as leverage to pressure for a disclosure nor should she attempt to inform a woman that she must be a survivor of abuse. To do so would reflect a lack of respect for the woman’s own internal awareness of when and where is the safe time in her life to do that type of work. It disrupts her reality at a time when she is already experiencing great life changes. The woman whose story I have told above never disclosed to me, yet I was able to serve as a vital part of her healing and growth. Let me put this into perspective for those readers who may be thinking, “I was never abused and I don’t think I would know it if I saw it. What if I missed it and did the wrong thing?” One very experienced midwife I worked with felt this way. She felt inadequate because sometimes after a birth I would point out clear indications to her that the woman she was caring for had symptoms of possible prior abuse. She had not interpreted the signs and put them together as I had. However, I could reassure her that it made little difference, because she was so attuned to each woman’s individual personality and needs that she inevitably brought tremendous healing just through her love and careful individualized attention. In the end, it is simply love that heals.
Below is a list (not inclusive) of behaviors that should nudge a midwife or doula to be alert to possible abuse history:
- Ambivalence about self or baby • unstable and dysfunctional relationships, including sexual, friendships and marriage • re-victimization— choosing abusive partners, unhealthy vulnerability • substance abuse • eating disorders • extreme feelings of fearfulness and anxiety about test results or the birth • chronic anger or the inability to express anger • previous suicide attempts • self destructiveness • cut marks on the arms or other parts of the body • low self-esteem • depression • dissociation (often seen when a mom spaces out and “leaves” during a blood draw or pelvic exam) • sleep disturbances prior to pregnancy • feelings of isolation • need for attention (multiple, long phone calls) • guilt and shame • flashbacks • nightmares • impaired memory (instructions repeated over and over) or attention • hyper-arousal • physical complaints • identity disturbance (self-image, goals, values) • chronic emptiness or boredom • frantic efforts to avoid real or imagined abandonment by others (being risked out) • fear of being alone in the dark or shut/cornered in a room (always sits to either see or access the door) • swallowing and gagging sensitivity (difficulty swallowing vitamins) • suffocation feelings in water or with blankets • does not feel at home in own body • inability to heed body signals (hunger, pain, often hypoglycemic without identifying why) • poor body image • bulky clothes or overly sexual attire • abdominal disorders • headaches or joint pain • compulsive behavior (preoccupation with cleanliness) • phobias (needles, etc.) • the need to be invisible • perfect or perfectly bad • going into shock/shutdown in crisis • nervousness when watched • trust issues (inability to trust or total trust) • inability to make own health care decisions • risk-taking or inability to take risks • boundary issues (fear of losing control or totally lacking boundaries) • high appreciation of small favors by others • instinctively knowing and doing what the other person needs or wants • blocking out childhood years (esp. ages 1–12) • feeling of carrying an awful secret or being generally secretive • feeling crazy or different • feeling oneself to be unreal or the world to be unreal • creating fantasy worlds • wishing to be another sex • huge fear of vaginal exams with writhing, crying and clenching knees • minimizing (“It wasn’t that bad,” “Maybe it’s just my imagination”) • aversion to being touched, including hugs • trouble integrating sexuality and emotions • having to pursue power in sexual arena to feel in control • compulsively seductive or compulsively asexual • promiscuous sex with strangers concurrent with inability to have sex in intimate relationships • sexual addiction or avoidance • shutdown • crying after sex • erotic response to abusive treatment or anger • avoidance of mirrors • desire to change one’s name • limited tolerance for happiness or humor • verbal hyper-vigilance • quiet-voiced • stealing • black and white thinking (no grey areas, all or nothing).
It is obvious from the length and diversity of the list that women who have not been abused will also exhibit some of these characteristics. However, when these behaviors are quite marked or if you see clusters of behavior, then you can make a mental note that there exists a stronger possibility of an abusive history. This isn’t a straightforward science and the broad range of compensating behavior runs from aggression to extreme passivity, from uncontrolled fears and anxiety to careful analysis and control. A woman may be hungry for attention and monopolize your time or she may simply “leave” through self-induced hypnotic trance.
Some broad correlations among these widely varied presentations can give an indication of the type of abuse and age at which it occurred. Generally speaking, the survivor who experienced a single event or trauma at a later age will be the one clenching her knees together during a pelvic exam with panic in her eyes. The woman who blankly stares to the side and loses body tension more likely experienced ongoing abuse that began at an early age.
Listening to Her Story
How should we, as midwives and doulas, respond to a woman in our care when she seems to be moving into disclosure? Stop talking. Listen. Show acceptance, understanding and empathy no matter what is being said. Don’t assume she uses words the same way you do; they may have other experiential meaning for her. It is okay to ask simple questions when you don’t understand or need clarification. Her disclosure will often be vague, but don’t press her to answer if she seems reluctant.
It is also important not to give up too soon during silences. Give her time to say what she finds hard to say. Be ready to simply sit and be silent if that is what she needs. You may feel as if nothing is happening and your time is being wasted, but the abused individual is working very hard inside just to formulate and work past fears to say simple things. Get rid of distractions such as pens and papers. Don’t chart. If you must document, do so after the appointment. Get the main points. Look for the message, misconception or feeling that the abuse produced that is affecting her pregnancy, upcoming birth or feelings about caring for a child. Actively concentrate on what she is saying. Allow her to grieve when necessary.
Look at her. Observe her body cues, such as crossing legs or covering parts of her body.
Acknowledge that you hear her by nodding your head, repeating facts or asking a non-threatening question for clarification. “You said this happened when you were twelve?”
Listen for what is not said. Talking around something rather than directly about it often means it is significant. Listen to how it is said, including her emotions, attitudes, change in tone of voice and posture. These things may reveal more to you about how she is feeling than what is actually said.
You may cause your client to conceal her ideas, emotions or attitudes by disagreeing with her, taking notes or asking too many probing questions. Remember, she still has a huge fear about telling: fear because of threats; fear of rejection; fear of not being believed; and fear that the emotions will be overwhelming.
If you can, stay relatively emotionless. If appropriate, it is okay to say, “I feel sad that you were hurt.” However, if you do cry, be aware that some women may shut down to protect you from their pain. If she asks about your tears reply, “I am hearing about a little girl who was afraid and hurting. That makes me sad.” By referring to the past rather than present person, it is easier for her to absorb the idea that someone would feel sorrow for what happened to her.
Try not to react angrily to the abuser, especially if you know it was a family member and not a stranger. An angry facial expression risks that your client may think the anger is directed at her. She may also feel a need to protect an offender who is a parent or other important person in her life. Approach the abuse as a legitimate hurt without implying that a horrible person caused it. This will help her focus on accepting and processing her own needs without moving to defend the abuser.
Look for her basic personality traits and values and avoid making assumptions about erratic behavior. Don’t assume that she is avoiding looking at you in the eye because she is telling a lie. Conversely, don’t think that she is trying to embarrass you by looking you in the eye. Avoid hasty judgments before all the facts are in.
Building Trust and Relationship
Realize that trust is selective and progressive. Trust was taken away from her as a child and is only earned slowly. She will choose what she discloses and when. Don’t take it personally when she has difficulty genuinely trusting you.
Be a part of helping her with problems that come up, but don’t make judgments or overload her with advice. Help her take one step at a time. Expect that she may seem distant at times, especially after a major disclosure. This isn’t about you. Reassure her that it was very helpful that she talked about it and you feel honored that she would entrust you with the information.
Don’t argue with her when you bump into wrong thinking. Instead, try asking questions that help her to see the error. Try to do this in a way that she doesn’t perceive you as being in a battle of wits with her, because you will be out-maneuvered every time. Guide her through any necessary steps of replacing misconceptions with truth and help her discover healthier new ways of approaching her relationships, pregnancy and the birth of her baby. Encourage her to make her own health care decisions rather than making all the decisions for her. If you “fail” her because she expected something from you without communicating her need, remind her that you aren’t a mind reader. You are happy to help, but you must be told what she needs. Don’t promise her anything you can’t follow through with and don’t ever fail to do what you promise. Reassure her—over and over again, if necessary—that you will not abandon her.
Understand and assist her to modify her tendency to care for others when she needs to care for herself. Show your concern if you discover that she is not caring for herself physically, emotionally or spiritually, but don’t berate her. Always remember: Nothing is intrinsically wrong with her, but something wrong was done TO her. The abuse had consequences. If she has lapsed into self-harm, such as cutting, eating disorders, substance abuse or other compulsivity, recognize that these behaviors have served as effective survival tools in the past. Simply telling her to stop will not work and you can’t successfully take these tools away without replacing them with something equally effective. Uncover her personal motivations for quitting and mine those to give her hope. “I believe in you!”
At the time of intake, I like to ask a woman about her self-perceived strengths, hopes and aspirations; later I may connect them to her desired behavior change. For example, if she is artistically gifted, have her draw the feelings related to cutting or actually draw cuts on her body in place of actual cutting. If she hopes to become a nutritional counselor, I might have her write a diet plan for an imaginary patient, based on her personal food preferences and then “test” it. If one of her listed strengths is a good support community, I may help her create a list of three people she can call when tempted with substance abuse. Ultimately, there will be times we must accept that clients are autonomous and will not always make the choices we would like them to make.
Show that you accept and care about her by touch, such as a hug at the door or leaving your hand on her arm briefly as you talk. It is vitally important that she is comfortable and consents to physical contact, though. Avoid sudden movement or coming up behind her without verbal forewarning. Understand her fear of being around a lot of people at one time or the need to always sit where she can either see or quickly access the door.
Although an individual may come across as strong and stoic, remind yourself that she may actually be falling apart inside. That’s why it helps to pay more attention to what she actually says is going on inside rather than how she looks on the outside. Conversely, she may present with high anxiety or panic attacks. Help her create resources for self-calming. Teach her deep breathing exercises, progressive relaxation and internal imagery techniques that we use in our childbirth classes. Ask her how she might use her senses to self-soothe, whether it be art, going on a walk, lighting a scented candle, praying, applying scented lotions, hot tea, music, a favorite food, working with clay, taking a bath, cuddling with a pet, massage or reading.
Take care of yourself by setting boundaries. You might apply this to the length or frequency of phone calls, length of appointments, or personal involvement in her life outside of maternity care. Once she knows you will do this, she won’t have to worry about overburdening you. At the same time, be willing to invest time and energy in her. Routinely schedule extra time for her appointments. Don’t think of her as a difficulty. Think of her as a miracle waiting to happen.
If you are comfortable and knowledgeable with the topic, work with the partner relative to sexual difficulties. At the prenatal, discuss non-sexual intimacy with the partner so s/he can be comforting without her fearing it will lead to sex at an emotionally or physically hard time. Do the same with conflicts about the birth plan. It’s important for a survivor to have control of some things since control was something she didn’t have as a child. Recognize your own prejudice toward certain subjects such as disclosures about homosexual acts or particular sexual struggles resulting from the abuse. Refuse to project your prejudice on her while providing her care.
You will not be able to totally prevent yourself from evaluating the facts and evidence of her story, but don’t make her truth be dependent upon “proving” her abuse to you. There are usually no witnesses to abuse and the offender will deny it 99% of the time. Instead, help her to heal by your unconditional acceptance. You will often hear a survivor doubt her own memories even while she is displaying emotional distress because of them. Denial is a great defense mechanism and has helped her cope in the past. It can be discussed if she wishes, but always go back to the important issues that are affecting her life, her pregnancy and her relationship with you and others and don’t waste too much time analyzing the accuracy of her memory. Something happened to produce the distress and problems and they do need to be addressed.
Taking the Punch out of Emotional Triggers
Traumatic events get “stuck” in the mind and the body along with the images, thoughts, feelings and body sensations associated with the trauma. Abuse carries with it specific sounds, sensations, smells and verbal statements that are often reproduced in the birth setting. These traumatic memories can get “triggered” or activated by a reminder in labor, so the woman appears to be overreacting. Her response isn’t just to current events, but to all of the underlying trauma. The memories can kick a laboring woman into hyper-vigilance and an inability to cope with labor or to relax. Some triggers may include:
- The sounds of moaning, sighing or crying out.
- The smells of sweat and fecal matter.
- Sensations of pain, pressure, burning and feeling as if you are being split open.
- Physical exposure and loss of personal privacy.
- Loss of control over what is happening and the inability to run away from it.
- Fluids running down legs and blood-stained underwear.
- Charged verbal statements such as “Relax; this won’t hurt; spread your legs; good girl; don’t move; you can do it.”
In the final month of pregnancy, I always go over these topics with self-identified survivors. I find out if they are particularly concerned about any of the triggers. I am explicit because many times it isn’t until our dialogue that she realizes that she may have some problems but hadn’t anticipated the possibility. I ask her if I should avoid any forms of touch, such as holding her wrist or arm when assisting her with movement. It is important for me to know if I should avoid any phrases during verbal labor coaching. We go over the smells, sounds, sensations and fears that she suspects might be problematic; then we explore solutions to each one that will help her regain a sense of control. I allow her to suggest what she thinks would be a good solution before I jump in with my ideas. Once we have a plan, I write it down and keep it with her birth chart.
Remember, up to 6% of all births result in symptoms of posttraumatic stress disorder (PTSD). Survivors are more vulnerable to this occurrence. Fortunately, aware providers can do a lot to help minimize and mitigate trauma, even when complications develop.
Women in Toxic Relationships
Unfortunately, some women find themselves in an emotionally abusive or controlling relationship for long periods of time before they begin to question what is happening. Pregnancy and childbirth may provide the perfect opportunity for her to re-examine the dynamics of her life. She now has a child to consider and she may legitimately find herself torn between saving the child from her own personal hell or having access to food, shelter and companionship in a vulnerable season of life. It is very hard for the controlled woman to reason out the dynamics of her choices because an abuser will choose someone who is already vulnerable due to her own lack of self-confidence, prior abuse, desire for a protector, or need for approval. The controlling partner purposely monopolizes the power to get what s/he wants by further undermining the woman’s sense of self-value. Common tactics used to achieve this goal are intimidation (through implied or veiled threats to withhold love or leave) and inducing guilt by implying the partner doesn’t care enough or, ironically, is self-centered. This technique works especially well with very conscientious women. The controlling partner may shame, put down, insult and use sarcasm to make the woman feel inadequate, thereby elevating his own power status. He may claim that he is the true victim and is being unfairly used and put-out in order to deflect blame and confrontation. This is an easy technique to leverage when the woman is pregnant and dependent. Truly good controllers are seductively charming, knowing how to flatter when they need to reel their partner back in tightly.
As a consequence of these covert methods of undermining confidence, the controlled woman may find herself confused about her own personal value, strengths and identity. She isn’t sure who she really is and begins to believe all the terrible things that are said about her. She lives in chronic fear for reasons she can’t always put her finger on and feels completely powerless. She may have private fantasies of escape, whether of fleeing the relationship or of her partner dying so that she can be free. The controlling person constantly challenges her reality, especially relative to what she sees him doing, by denying, rationalizing, lying and beating up on her so that she learns not to trust her own perceptions. She will be isolated, most often by the controlling partner. This keeps her from seeking help. He may do this in the prenatal course of care by never allowing her to attend a prenatal exam alone. Such partners are intensely jealous and eventually may isolate her from everyone but themselves. Look for breakdowns in relationships with her immediate family “because they misunderstand” her partner. Be cautious about directly challenging her relationship or coercing her to leave him or you may find she has suddenly transferred care to another provider. You may note that she appears to be lying to you in order to collude with him to give the appearance that nothing bad is happening. She will often defend him despite her own fear and panic. The woman in a toxic relationship believes she can get her partner to change. If he doesn’t seek change through outside resources himself, he will not change. Frankly, even that is a long shot.
Women who have been in these relationships will have a damaged ability to be verbally intimate and trust their midwife. The midwife will more often identify these relationships before the woman self-discloses, but some midwives completely miss the dynamic that is presenting because the abuser charmingly engages them and keeps the prenatal focused around the topics he chooses. It is imperative to schedule a prenatal appointment at a time when it is impossible for the controlling partner to come. This may be difficult if he is the woman’s only means of transportation. In this case, consider a home visit scheduled when he is at work and take an apprentice with you. Always be polite to the abusive partner and do not directly challenge him or expose what you suspect. Never disclose any confidences that she may have shared with you in hopes of helping them work the relationship out. This could put her at serious risk.
In the case where a woman presents with unusual bruising and you suspect she is being battered, the dynamics become even more complex. You cannot forcibly remove the pregnant woman from her environment in the same way you can have a battered infant removed. Your only resource is to gain her trust—a challenging endeavor. If you suspect that you are not being told the true reason behind an injury, never indicate your suspicions when the controlling partner is present. Later, when her partner isn’t there, you can express your concern for her safety and the safety of her unborn baby. Never demean her partner or try to get her to see how evil he is. This tactic will move her into a defensive posture and you will get nowhere. Instead, talk with her about how scary it must be to live with someone you love when they haven’t learned how to manage anger. Normalize her situation by referring to “other women” who have had similar concerns about their partners. Tell her that many of them carry hidden fears that they or their baby might be hurt on a bad day. Ask her if her living situation ever causes her to worry about her safety or the baby’s safety now that she is pregnant. Acknowledge the painful conflict between love and fear. Suggest to her that there are resources for women who are learning how to maneuver through the decisions of life when they are partnered with someone who struggles with anger management. Tell her you know women who have been helped and are truly happy. Provide her with those phone numbers, tagging them with innocuous identifiers so that she will not get in trouble if they are discovered by her partner. Acknowledge that you realize the importance of not “embarrassing” him with the knowledge that you had discussed this, and let her know that you will keep her confidence. Inform her that she can call you at any time to talk.
In order to leave such a relationship, the woman will need to gather supporters who will help her feel safe and secure. The midwife can be an active part of this by calling friends and family and connecting the woman with domestic abuse support systems. She will need a safe haven outside of known relatives or friends because when she leaves, he may try very hard to find her and increase his threats. On occasion, some people do become truly violent, so a woman should take seriously any threat made to her or to her loved ones. If a threat is made, help her make a police report and seek a place the partner will not find. A clean break is the only kind that works in these circumstances.
Awareness of postpartum challenges begins in the antenatal period. Don’t dismiss statements she may make about fears of being a mother or discomfort with the idea of nurturing or nursing her baby. Pay close attention to expressed concerns about gender of the baby that may be related to unspoken fears. All of these topics should be explored ahead of time and plans made before they become a postpartum crisis. Make appropriate referrals if necessary. Find out what her support system will look like and assist her in drawing her community close for the postpartum season. Don’t hesitate to get permission to call her best friend personally and ask if she would be willing to set up a week’s schedule for donated meals and help with the housework.
Be aware that trauma survivors are statistically far more vulnerable to postpartum depression. Plan for additional visits and educate yourself about the difference between depression and postpartum psychosis.
Creating the Space
In Central America you can find small little dolls made from paper or corn shucks and dressed in bright scraps of native fabric, even down to their tiny hats. While these magical dolls are referred to as Guatemalan worry people or Guatemalan worry dolls, they are actually a Mayan Indian tradition. They may be stored not only in simple pine or straw boxes, but in colorful fabric pouches as well. You tell them your troubles and then place them under the pillow when you go to sleep. In the morning, when you rise, all of your worries are gone.
Midwives and doulas are like Guatemalan worry people. When we open our hearts and listen to the whispers of a woman who has gone through trauma we lift the burden from her. All the advice I’ve shared on how to help may seem complex; but in reality, it is all very simple. You are a sacred guardian, holding the space for each special woman as she approaches birth. You are creating paths of simplicity so that she doesn’t have a barrage of information, painful memory and complex decision-making coming at her all of the time. You create space for her to experience a whole new journey into acceptance, joy, delight and discovery: things she may have only barely tasted in life. Your careful work will give her room to be fully in her pregnancy and to fearlessly engage with her birth experience. You are the surrogate worrier who must anticipate, listen wholeheartedly and love her unconditionally. As a midwife, you are always seeking ways to provide good technical care; but of all the things you do, the things of the heart are the ones that will remain with her forever.