 I'm very glad to be at Virtual International Day of the Midwife this year, I'm a little bit nervous as I've never done this before so we'll just have to see how it goes. So as Halima said I am a third year student midwife at Robert Gordon University in Aberdeen in Scotland and this presentation is about supporting survivors of childhood sexual abuse and providing them with the best possible midwifery care. Okay so childhood sexual abuse also known as CSA is any act that involves a child for the sexual gratification of another person whether or not it is claimed that the child in question either consented or assented. Prevalence is very difficult to determine because many children will not report the abuse at the time either because they've been bullied or threatened into silence by their abuser or because they do not understand the situation and they do not know that there is anything wrong with the situation. However the NSPCC estimates that one in 20 children in the UK will be sexually abused. Statistics vary there are other studies that show that possibly as many as 20 percent of women will suffer sexual abuse before the age of 18 therefore it is safe to assume that many midwives throughout their career will look after women who are survivors of childhood sexual abuse and a lot of the time they will do so without knowing it. So childhood sexual abuse has long term or can have very often does have long term effects on survivors lives in particular when it comes to pregnancy in the perinatal period specific issues include a higher frequency of pre-term labour, a higher incidence of teenage pregnancy which is a lot more common in survivors of abuse both physical and sexual abuse than in the general population and of course perinatal mental health issues. These include anxiety and stress during pregnancy, exacerbation of PTSD of pre-existing PTSD, retraumatisation which can occur as a consequence of an association between pregnancy and the previous abuse and postnatal depression in the postnatal period. So there are some needs although of course all women are different there are some needs that are common to many survivors providing trauma informed care can help minimise adverse effects, it can help minimise retraumatisation and can also reduce the incidence of mental health issues during and after pregnancy. It's important for midwives to remember that many CSA survivors will have developed an aversion to being touched in any way and specifically in intimate ways such as during of a general examination. It's therefore very important for midwives to explain procedures to women and to give them multiple opportunities to give consent or to withdraw consent anytime. It's also important that midwives bear in mind that you can refer women to perinatal mental health services for support if women wish to attend. More specifically there are two themes that are very common when it comes to CSA survivors and pregnancy and those themes are feeling safe and feeling in control. Many CSA survivors link the concept of maintaining control over what is happening to them over what is happening to their body with feeling safe. Lack of control which can sometimes happen in a clinical setting when the clinical professional takes over control over the situation and the person or the woman feels that things are happening to her rather than her being an active participant in the situation. In a situation where there is lack of control this can trigger flashbacks as it can trigger an association with the abuse that the people have suffered because of course it mirrors the situation of abuse and which indeed they did not have control over what was happening to them. So as we said before someone will not disclose their abuse ever to their midwife or to anyone else therefore lots of midwives will look after CSA survivors without knowing that they are doing so and since there is no way of knowing if the person you have in front of you is a CSA survivor midwives are recommended to use universal precautions to mitigate trauma such as never seeming consent explaining procedures to women so that they can have a clear idea of what is going to happen and offering multiple opportunities to withdraw consent at any time if the situation is becoming too stressful for them. It is also important to give opportunities to disclose. Some women will wish to disclose, are happy to disclose their abuse to their midwife. Other women will choose not to do so. Other women it is important to note that they will not remember the abuse at the time and therefore they cannot disclose it because they have no memory of it. Other women will remember it but will either choose not to disclose it or will need to develop a trusting relationship with their midwife before they decide to disclose and this is where continuity of caterer comes in because of course if you build a close relationship between mothers and midwives if mothers see the same midwife all the time and they are able to throughout their pregnancy and birth and postnatal period and they are able to build a trusting relationship it is of course more likely that they will then feel safe enough to disclose their abuse. It is important that midwives listen to women because they will sometimes not disclose outright but they might give hints or cues or clues that might put the midwife that might make the midwife aware of the fact that there might have been abuse there. For example in some cases one midwife reported in a study that a woman she was looking after was very decided upon having an elective caesarean section and then of course that made the midwife aware that there might be something going on there and she gently probed and questioned the woman around this and then the woman decided to disclose her abuse so it can be something quite different from an outright disclosure but we all know as midwives how important it is to listen to what women say and hint to and especially what women don't say sometimes. It's very important for midwives to provide women with real choice when it comes to place and mode of birth. Some women who have survived childhood sexual abuse will want a home birth it is actually more likely for them to want a home birth than the general population and they're also more likely to give birth at home unassisted if they don't feel that they have the support that they require from maternity services. Conversely other women might not want to have a vaginal birth at all and will request an elective caesarean section and of course it is important that midwives listen and advocate for the women in whichever situation. Women may benefit from referrals to perinatal mental health services as we said earlier but it is important not to assume that all women will want to talk about their abuse in counselling or therapy as they might have done this previously. They might have come to terms with their abuse and they might not require any more counselling or therapy or they might just not want to do it. So some legal aspects this of course is based on UK law and in particular Scottish law because it is based on what the Sexual Offences Scotland Act says so according to the Scotland the the Scottish Sexual Offences Act there are many forms of abuse that are criminal offenses and this is important to note because some women may not know that what they suffered was abuse and that it was a criminal offence. Some people will think that only rape constitutes abuse and is a criminal offence. In actual fact there are lots of forms of abuse that are indeed criminal offences and even when it is not physical abuse it is still a criminal offence such as showing sexual images to a child, indecent communication with a child, flashing, forcing a child to be present during sexual activity or forcing a child to masturbate. Even though the children in those particular situations have not been physically touched by the by their abuser those are still forms of abuse and are still criminal offences. The dangers of implied consent now normally legally there would be three ways of evidencing consent for a procedure which are inviting by word of mouth and implied consent. So implied consent is for example if you are going for a blood test and you hold out your arm for the person to put a tourniquet on your arm and take your blood. This is particularly dangerous and it can be particularly triggering for CSA survivors because studies report that CSA survivors might initially give consent and then find themselves in a situation where they cannot cope and are either become very distressed or are forced to disassociate in order to cope with the situation. So it is very important that consent is gained explicitly at all times and that women can always have the opportunity to withdraw consent at any time for whatever procedure. Again more legal aspects the right to a home birth. Now the Human Rights Act has article eight which is the right to private and family life and there was a European Court of Human Rights ruling that declared that this right extended to the right to a home birth. The right to request a caesarean section. Now this can be linked to article three of the Human Rights Act which states that nobody shall be subjected to torture or cruel and unusual punishments and while of course a vaginal birth might not be seen as torture by lots of people for women who have survived childhood sexual abuse the idea of a vaginal birth may well be viewed as an enjoyable torture and therefore they might request a caesarean section. Again this is specific to Scottish law again because it's the Patient Rights Scotland Act in 2011 that states that when providing healthcare that we don't like using the word patient in midwifery but it still applies to us patients individual in particular circumstances must be taken into account when providing healthcare and this very much applies to the particular set of circumstances that come with being a survivor of childhood sexual abuse. So in midwifery we we often talk about the four ethical principles of beneficence non-maleficence justice and respect for autonomy and these can all be linked to providing care for CSA survivors. So in the case of beneficence midwifery care appropriate sensitive midwifery care for CSA survivors can actually help them heal it can it can help women challenge unhealthy abuse-related behaviors and it can it can help them make peace with with their with their body with with what with positive things that their body can do. Some studies even report that breastfeeding which can be problematic it can be triggering but it can also be viewed as a means of healing because it is a very concrete way of showing women that their body can actually produce something good that their their body can do something good because it can it can feed another human being. So in this case midwives need to provide women with every opportunity to facilitate this to facilitate a journey of healing during the perinatal period and again of course this is more possible when when you have continuity of cater and you see this in midwife all the time. Non-maleficence so avoiding reenactment of abuse now we spoke about the potential for retraumatization so in some cases midwifery care can inadvertently be very triggering and provide provide triggers and occasions for women to actually relive their abuse and it is very important to to prevent this too so to be very mindful of what can can be a trigger for for CSA survivors. Justice now a lot of the time since it is very common for abusers in these situations to have been men. Women who have survived childhood sexual abuse will request only female staff to be present during the birth and this is often unfairly ignored because it you know it can be dismissed with oh you know the uncle registrar is a man she'll just have to put up with it she'll just have to make do. No this is not okay because it can be extremely extremely triggering for for survivors to have to to have to be in contact with with male staff. Respect for autonomy so it is important to consider survivors particular perception perception of pain because some women will find for example vaginal examinations extremely painful now for women who have not suffered sexual abuse this might not be the case it is quite usual for vaginal examinations to be uncomfortable but not downright painful. However for women who have suffered especially if the if the sexual abuse they suffered as children was penetration a vaginal examination can be excruciatingly painful and it is very important to respect this perception of their pain to not force through it and to listen to them to absolutely respect their autonomy in saying this is too painful for me please stop. So when it comes to psychological effects of childhood sexual abuse we know that there are a series of effects on everyday life so many CSA survivors will have medically unexplained medically unexplained symptoms such as chronic pain in particular chronic pelvic pain other physical symptoms such as headaches and bowel symptoms irritable bowel syndrome for example and this could be somatization so the physical expression of emotional pain. Other psychological issues that survivors may experience are anxiety depression and panic disorders which are common PTSD of course can be quite common and then there are other effects that are noted are phobias eating disorders and personality disorders dissociative disorders and self-harm and suicide attempts are also are also quite common. When it comes specifically to the perinatal period fear of childbirth was found to be very common in in one study and there are very various aspects of birth that survivors may fear they may fear staff or the clinical environment itself this can be either because they feel intimidated by people who are perceived to be in a position of authority or because they were subjected to forensic examinations as children at the time of their abuse and they associate the clinical environment with this and they can fear nakedness male staff pain needles used for taking blood samples and sometimes the birth itself dissociation is common during birth and this can involve the women reporting either the lower half of their body or sometimes the entire body as being somewhere else they can report sort of seeing themselves from the outside and their mind being somewhere else flashbacks are common some women may have flashbacks of their abuse for the first time during birth and this can be very very upsetting and disconcerting and when women disassociate you may see them with their gaze fixed in the ceiling talking in childlike voices or saying things that they would have said to their abuser at the time this can be very distressing for staff as well of course there is the potential that there can be a negative impact for on the whole pregnancy birth and breastfeeding and postnatal experience because again we were talking about control so women may feel that the baby inside of them is taking over control of their body and of course the pain that they may feel during labor can be associated with the pain that they felt during the abuse and there may be significant issues with breastfeeding because particularly if the abuse involved the breasts at the time women may feel that breastfeeding their baby is inappropriate sexual contact and may feel very guilty about this although as we said there is also a study that says that it can actually be a means of healing so breastfeeding can actually help of course again this is all very dependent on the support and the relationship between the mother and the midwife and of course as we said earlier postnatal depression is very common in CSA survivors. When it comes to the sociological side of things CSA survivors tend to self-isolate due to shame so women and people who have been sexually abused as children often feel very strong shame about what has happened to them and therefore they may decide not it interlinks with the reasons why they do not disclose the abuse because they're very ashamed of it they can be very ashamed of it and in one study there was a woman who was reported as saying that you just want to curl up and be part of the wallpaper this is an excellent example of of self-isolation due to shame you just want to blend in you just want to be normal you don't want such a fuss made you just want to be absolutely normal and for nobody to ever to ever know or suspect anything. The reasons why survivors do not disclose their abuse are vaded as we said before but there are also sociological reasons which include the fact that there can be a very strong sexuality taboo so a very strong taboo around everything relating to sex and some people find that this taboo is so strong in their social in their social circle that they that they feel that they cannot talk to it they feel that they have nobody to talk to and when this occurs in the family circle and this is coupled with lack of sexual education in schools this can mean that sexual abuse survivors have absolutely nobody that they feel that they can go to because sex is just not talked about. A further aspect is the continued stigma that exists around mental health and motherhood so some women will choose not to disclose or will try to hide the fact that they that they do have that they do indeed have mental health issues because they fear that they're going to be stigmatized and labeled as bad mothers for having mental health issues and therefore they try and and hide everything to do with everything to do with the abuse and the consequences of the abuse that they have suffered so what can we do sensitive midwifery care sensitive midwifery care we know of course is important in any situation and for everyone that we look after is midwives it is particularly important for people who feel that the overwhelming needs to feel safe and in control of what is happening to them in their birth experience so advocacy is extremely important we talked earlier about women's wishes to either have a home birth or to request an elective cesarean or to not have male staff present at the birth and again this links with continuity of cater so if women have a strong relationship with their midwife if they know their midwife and they trust their midwife it is important for them to know that the midwife can be an advocate for them and can and can provide care which is based on their particular needs and wishes of course we know that women-centered care is important for everyone but again in particular for CSA survivors the example Liz Garrett in her in her book about midwifery care for sexual for childhood sexual abuse survivors talks about the fact that some women report that the same procedure carried out by two different midwives can have radically different effects so for example a vaginal examination if the if the midwife is attentive to the women's needs and to her cues and to what is going on with the women that particular moment the vaginal examination which she found so traumatic performed by somebody else can actually be a lot less traumatic and maybe not traumatic at all so the attitude of the midwife putting the woman in the center is can make all the difference in this case in all cases but in particular in this case the midwife mother relationship so we know we know there is a wealth of evidence about trust and and partnership in building the relationship between the mother and the midwife and of course again this is particularly important when it comes to labor and birth for for women who have survived childhood sexual abuse so in particularly in particular the second stage of labor when vaginal pain is present it is important that women who associate vaginal pain with their previous abuse feel safe enough in the care of their midwife to let go and just succumb to that because as we know that is when that is when the baby will actually be born so it is extremely important that women who associate vaginal pain with abuse are actually nurtured and feel safe enough in the care of their midwife to allow this to happen. Spiritual midwifery is the branch of midwifery that of course views birth and motherhood as a right of passage really and this can be as we touched upon earlier this can be particularly important for women who are survivors of childhood sexual abuse because birth can be indeed viewed as a right of passage and it can help women heal and as we said earlier this can happen with breastfeeding as well they can they can see that their body can actually do something good that something positive can come of such a physical such a physically demanding experience that it doesn't necessarily have to be something negative and associated with with previous abuse so it is important for for midwives to consider this angle as well so yes so this is basically the end so to recap main points as we know the prevalence of CSA is very difficult to estimate as it is substantially under reported for all the reasons we have spoken about. Again this is important to remember that survivors will often have long-term mental health consequences following their following the abuse that they have suffered but again it is important not to make assumptions and not to assume that all women will want or need a referral to mental health services. The theme of safety and control so the need to feel in control and safe during the perinatal period is paramount. Again it's important to remember that many survivors will not disclose so the midwife might not know that they are looking after someone who has suffered CSA and they may not disclose for years until adulthood or they sometimes will not disclose ever at all. Important to remember the potential for retraumatization during the perinatal period and again on a happier note it is important to remember that sensitive midwifery care will improve birth experiences and can improve outcomes for women and babies as well and that is the end. You can see I've done my homework there are a lot of references in there and that includes the presentation. Thank you very much Barbara for that fantastic presentation and such an all-important topic well done and thank you very much for sharing your experiences to all the midwife around the world. Thank you very much for having me. You're welcome. Yeah please if you have any question for Barbara don't forget you can send it in the chat box for how to throw some light in some areas you know Claire about. Yeah we are still waiting for the question if you have any question please feel free to join to send in the chat box we will gladly answer the question please thank you. I think I may have stunned everyone into silence. No it was an amazing presentation really. Thank you Helima. Thank you very much Helima for your support in preparing for this conference you've been you've been wonderful. You're welcome. Thank you so much also for sharing this experience to Ross we are so so happy everyone is yeah everyone is happy yeah thank you for sharing this experience to Ross and everyone yeah any more question any question please we are waiting Barbara I have a question here I was wondering that are you there please Barbara? Yes I'm here yeah what would a midwife do with the information if a woman discloses that she has suffered a child with sexual abuse what do you do first as soon as she tells you that? So in my experience the first thing that you would do is ask the woman what what she wants me to do with the information because again we said that the feeling of being in control of the situation is particularly important so I would ask her what she wants me to do with it does she want me to document it in her in her maternity notes so that staff is aware of the situation and if if she meets other staff they are they can be aware of her situation without her having to disclose all over again and does she want me to refer her to for example perinatal mental health services or it could be a case that for example her partner doesn't know anything about it and therefore she doesn't want any mention of this anywhere because she doesn't want her partner to know it is also important to note that childhood sexual abuse can lead to pregnancy so young girls can get pregnant from their abuse so that of course opens a whole different scenario where the partner might actually be the abuser so in that case there's a whole different alleyway that we have to pursue there with child protection for the unborn baby but for the woman herself if the woman is still a child there are situations where women as young as 13 and 14 years old get pregnant from their abuse and then the abuser is the person who is then noted as the partner so it is extremely important to ask the woman what she wants us to do and if she requires any help. Yeah thank you very much for that there's a question in the chat box that says do you have any thoughts about how to address survivors with severe taboos what are you taught about it? So it depends it depends on what kind of taboos are we talking about here I mean taboos regarding any form of sexuality or taboos regarding particular aspects of pregnancy and childbirth I suppose it kind of again we need the women in our care to lead us here because it is such a huge thing that we need guidance from the women because of course every woman every person is going to react differently to the situation so again it is a question of listening to the woman's needs and wishes and trying to work through things and trying to get to the root of things so for example if there is a very strong taboo regarding something then there must have been something strong that happened in relation to that and sometimes even just talking about it and asking the woman about it and trying to get to the bottom of where that comes from might be beneficial both for the midwife and for the woman herself she might realize that there is actually something she can do to overcome that taboo if she wants to but again it is extremely important to do what the woman wants us to do. Thank you for that there's another question here please my question the question says how can a woman with CSA be supported if she declines a vaginal examination and how can you assess the cervical dilatation if she declines VE those are two questions yeah well that's a good one I love that one and I love that one especially because I'm not a big fan of vaginal examination in the first place for anyone they have their place but I prefer to assess the progressive labour by other means so unless it is absolutely necessary I much prefer to observe women's behaviour during labour there are lots of other physical cues and clues that can that can make you suspect that labour is indeed progressing so I will quite often observe women's behaviour so how she behaves during the contractions and in between contractions we often do this in Scotland we do telephone triage a lot of the time so women do not actually come in to be assessed in labour straight away as the first stop will be telephone triage so if a woman phones in we listen to how she behaves during contractions we listen to how she's talking to us how she's breathing what she says and that will often give us an indication of whether we need to invite her in for an assessment because we think she's in labour so if a woman needs to stop what she's doing drop what she's doing and just concentrate on her contraction and this goes into a little bubble and is unable to hear us unable to hear what we're saying to her during a contraction that is a very strong indication that she is probably in active labour if a woman again this this is not universal because of course every every woman and every labour is different but it is very important to listen to what women say and to what women don't say I also use the purple line between the buttocks to to assess to assess progression of labour so this is particularly good to use for example if the woman is in all fours or if you're in in a water birth situation you can you can often see a purple line between the woman's buttocks that lengthens as dilatation progresses I remember Diane Garland who is here actually telling me something about the temperature of the legs Diane I will ask you to clarify this for me because I cannot absolutely cannot remember what it was but it was something about the temperature of the legs there's there's a line in the leg there's a some point in the leg that becomes cooler as labour progresses I believe I cannot remember and so sorry Diane but I remember you telling me about that and of course other cues such as red show which can be an indication that breath is imminent and the woman transition transition and transition stage between the end of the dilation stage and the beginning of second stage of labour can you know it can be very evident women can be become distressed or they can sometimes there is nausea and vomiting sometimes women will actually fall asleep for a few minutes and then wake up again with with stronger expulsive contractions it's important to listen as well because of course there can be involuntary pushing when when birth is imminent you can hear you can hear grunting a very strong indication that birth is imminent again is women saying I can't do this I can't do this or I want an epidural or I want a section I want pain relief I can't do this I want to go home and that is usually when a baby appears so there is absolutely a wealth of ways in which we can in which we can assess the progressive labour without having to research a vaginal examination sometimes I feel that when I do perform a vaginal examination it is merely confirmation of what I already thought so it absolutely can be done yes Barbara thank you very much at one last question please someone just someone just asks from your experience is there any language that one can use to ask a CSA woman about if she has been abused as a child from your experience any language one can use yeah okay so um in Scotland and in particular in in in my part of Scotland where I work I know it's not universal but here we have electronic maternity records which have a checklist when it comes to the booking appointments and one of the questions of the checklist is to ask about adverse childhood events now I never word it that way because I never just outright asked the closed question have you suffered adverse childhood events because that gets you absolutely nowhere and I tend to ask about their childhood I ask if they had a happy enough childhood or if anything unpleasant happened to them as a child and you know it's not universal but that works for me I have had people disclose when I when I word it that way because it it's an open ended question which gives them the opportunity to word things in their own way and you know adverse childhood events such sounds like such a horrible thing and it is not it is not a welcoming sort of language so I much prefer um I much prefer translating that into you know um was there anything not very nice that happened to you as a child and that that is you know also because you know they might not consider what has happened to them to be a child an adverse childhood event as such so they might not respond if you if you pose the question like that so I sort of rephrase it and that has worked for me I have had I have had um women disclose to me when I phrase the question like that so again um it is important to tailor the language of course to the person that that is that is sitting in front of you at the booking appointment this of course is in the checklist for the booking appointment but as we said earlier some women will not disclose at the booking appointment so it's it's important to give the opportunity further on in the pregnancy you know to sort of leave the opportunity open for for women to disclose further on thank you very much Barbara