 And now I would like to welcome to Geraldine Buncher from the Scotland and the Catherine Gotheridge from Birmingham. And you can take a look here and try to send yourself a book. Good afternoon. I'd like to introduce a project that Geraldine and myself have been working on. This presentation is called Maternity Care for Women, His Survived Special Abuse Healing Harm and Helping Healing and Avoiding Harm. This is an area of interest I've personally been working on now for more than 15 years and follows on from work that I started many, many years ago, early in my midwifery career, but has gathered a great deal of interest and support, particularly laterally or midwifery, but also the wider maternity agenda. I think one of the first things to establish in this presentation is the prevalence of this group of women that we're talking about. That of sexual abuse particularly is an issue that affects women and from a national, an international perspective, one could say that approximately one in four women are affected by issues around sexual abuse, particularly child sexual abuse. Many women never disclose their experiences of abuse, however it's not unusual for those women when they become pregnant and when they're giving birth to their babies to make some manner of disclosure and it's really a difficult scenario then for the woman, but also for those maternity staff who are trying to provide the best of care. So you could ask the question, what's the impact on how bearing women and what has this lifelong issue to do with maternity services? Well, we care for women across a range of times in their pregnancy and we could come into contact particularly with women early in their pregnancy who are afraid to use the service and at risk at any time really from vicarious harm, research particularly in the Swedish and Danish research areas have looked at this problem and have found that this group of women are more than likely to succumb to harm such as post-traumatic stress disorder, birth trauma, ongoing mental health problems and disartifaction particularly with their birth experience. It's a very intimate and intuitive time for women becoming pregnant and also giving birth. When you look at the type of care that midwives are wishing to deliver, the implication for harm is much more increased, the more intimate the clinical procedure is. Now one has to ask the question, is this procedure particularly necessary and is this procedure necessary at this time? And how can I best deliver this intervention with the woman consenting to it? I think another interesting and particularly useful issue is around how women present in maternity services. They may well delay presenting to us and that could be for a number of reasons. One could be that they're afraid that we may make treatment on their disclosures and one may be that they're afraid of how they might behave and be subjected to clinical interventions without their consent. So it's really important that women have confidence in us to allow their care to be given in a way that minimizes or avoids their distress. So what are the late implications for those women booking late or presenting late in their pregnancy and birth? Well, if you think about the issue of booking late, well these women will by nature be denied of the full range of screening opportunities that we like to offer to women and it's nothing else establishing that relationship that we sow value for these women. If women are avoiding our service altogether then they're being denied a very, very useful resource which is building up a body of knowledge for how she will cope with her pregnancy and how she can plan to be the parent that she desires. She could refuse those interventions and refuse screening and that's absolutely fine. It's really up to her to choose but what is not acceptable is that if we don't make every effort to engage with these women then we will by that very nature be allowing that woman to decline interventions without the full knowledge of their benefits. She may continue to choose birth care based on fear rather than education. Now all women have an element of anxiety which is normal during pregnancy that I would suggest that this group of women are much more fearful and much more likely to experience increasing levels of fear during pregnancy. Now that could then move into the domain where these women choose a method of birth based upon that fear. This might be a birth at home without a medical or a midwifery attendant. It may be to request even for a caesarean section when she's never had a caesarean section or at least a baby before. So fear based decisions are increasingly common in this group of women. I've mentioned that there is an increased anxiety during pregnancy and I think it's important to discern between pregnancy worry, pregnancy anxiety and pregnancy fear and then phobia. This is the nature of my doctorate research that I'm undertaking at the moment and this is increasingly evident to me in my engagement with women that many have had the history of child sexual abuse. One of the other areas that has a huge implication for maternity services and also for psychiatry is the prevalence of mental illness and is much more increased in this group of women. In a study around about eight years ago now in the UK undertaken by Hollis this was based on inpatient psychiatric female patients. They were screened and asked the question, have you at any point experienced unwanted sexual attention or childhood sexual abuse and that study revealed that 75% of women in the inpatient population of psychiatry at that time had a positive disclosure of sexual abuse. So one could argue that in screening women we are likely to find that there is a greater problem than we already suspect. Another element that hasn't gone and some evidence of research is dysfunctional labour. It's not uncommon when you put fear and you put birth into the same domain that a behaviour or a physiological response will be evident. There is a strong correlation with cervical dystocia at near to full dilatation and it's not unusual for this group of women to be unable to succumb to the second stage of labour with ease. There is much more prevalence with these women to have a cessation of labour at that point and encounter interventions again such as assisted delivery and second stage for their infection. And then if one looks towards parenting there is a whole raft of issues that can arise. The main one that is evident in the first stages is around breastfeeding and in handling the baby. Many women talk about their experiences of putting their babies to the breast and feeling sensations and experiences that are not comfortable and almost take them back to the point when they were being abused as a child. So how practitioners have a whole range of issues to consider for this group of women. So if you were looking without knowing of a positive dysclosure you would need to have some background information in a number of areas. Behavioural signs of sexual abuse can be very subjective and one could argue that these might be attached to a whole range of personality or behavioural disorders. However, if you were to group them together these are just a few of those signs, symptoms or potential alerts to previous sexual abuse. So a history of post-traumatic stress disorder. Self-harming or self-injurious behaviours leading sometimes to suicide attempts. Certainly if you had discussions with these women they would talk about having the thought processes of wanting to be out of this world. You would also encounter discussions around dissociative identity disorders or for those more familiar with the phrase altered identity or fabricated identity. This is the human protective state that takes the individual into another person where they can behave as entirely different to the person that they are. Personality disorders whether they're borderline or full range disorders and psychosis are commoner particularly in those children who were abused at an early age and where the abuse is multiple in form. For instance, such as involving animal abuse, ritual abuse and some of those satanic or religious elements where the child has been subjected to brainwashing. These women will have a history of dependence on various substances which could be alcohol and could be drug related. The individuals can have a history of eating disorders and low self-esteem and low beliefs in themselves. The physical elements can be around signs of old trauma on the body. She can have a long and endearing feeling of malaise. Very often these women may have things associated with multiple physical complaints without a diagnosis. There is no doubt that these women were having a much more common disease profile such as asthma, irritable bowel disease, migraine and headaches. And then of course if you go into the gynecological spectrum these women will disclose long-standing pelvic pain, endometriosis, repeated sexually transmitted diseases, vaginismus and vulva trauma. And these are just a few of some of those physical and disease profiles that sexual abuse is likely to cause. So I would like now to just bring this into a more international and global context that sexual abuse is not just about one element, it's around a gender-based violence context. And that's where if we look at the United Nations definition that violence is directed against a woman simply because she is a woman and that violence can affect women disproportionately. It includes acts that inflict physical, mental, sexual harm or suffering, threats of such acts, coercion and other deprivations of liberty. I would also like to raise at this point elements around children where children are subjected to female genital mutilation, where children are used in war-based situations and rapes and where women and children witness physical, sexual and violent behaviour in front of them, usually where there are discords either in the family home or discords in the community where they're living. I'm going to hand over now to Geraldine who's going to talk through some of the issues that we've worked on together and we'll bring you into the project that we're talking about today. Thanks, Catherine. I suppose as a mad race we don't know everything. Nobody knows everything but sometimes we don't know what we don't know. I have certainly come across a few women in my career which is that year's long man, the term is to say this is one man and another. And he wasn't really or totally aware of how much of an impact sexual abuse had on his heart for women. Until one morning I was assessing her another mad race who was caring for someone who had just been beaten down to leave a lot and as soon as we went into the room we could see that she was in transgressing. He has been told at the report that there was something in a confidential envelope. We have an electronic system which requires you of course to go into the computer to get the electronic envelope open. But we didn't know what was here. So we went into the room. In the last thing that you're going to do is go and keep out the computer and go into the computer outside. We just don't want to miss looking after the lady. So what's coming now is her story which began at the beginning which we'll go into after that. We'll call her Lady Marvin. Obviously Marvin is not a man. She had her continuity of anti-increpancy, partly because she's moved past in the middle of her pregnancy, partly because of staff thickness absence and we know that if nobody spent these things do happen but in Portland we've now realized how crucial that can be especially to people who are vulnerable that they have to try to continue to live really focused on them and that now. She actually did make it to the school. She was very late in her pregnancy of the two weeks before she went into labor at the conclusion of what that's really been on the suboptimal. And by that I don't mean we don't need details or anything like that. We just need to know that there's something extra about this lady that we need to consider in this case. When we saw that the baby was coming we found that Marvin just didn't open her legs. She's a very new person but I'm like most women who are trying to birth she just could not open her legs. And we made the suggestion and we were able to help the baby come and she just couldn't do that. We saw what is holding this lady back. Why is she not working with us but wanting a bit of work to try and get a baby born because she was clearly getting more distressed and we saw we must be near how can we get her to help us. She started screaming at the screams that I have never heard before and thankfully I have never heard since. The last couple and it's the night to meet the fat animal rather than a woman in labor. She's again dating a partner. She didn't push her baby out of class and say sometimes just a physical sensation but a feminine back up to another woman. She just could not help to get the baby pushed out of her. She did of course manage in the next few minutes it seemed like a long time to back up the baby. But I'm like most of us even where months have been quite upset and then you just run up to us. She was untanner with quiet. There was not a sound in the then. There was no smile, no welcoming beauty not all the things that you love about men and when there's a back and she said she was still unseemly. But she's gone from a screaming woman very vocal, very physical to very unharmed self non-communicable. Myself, some advice that was left out we were very sure so we didn't know what to do. We saw that wonderful we could have done to have moved that back better for her. We saw that. So I would like to saw one way and ask if there were any of the things who thought the subject's facial obvious and clear. Does it say there? There wasn't anything specific. There was no publications in relation to domestic violence but nothing about ethnicity clear and helping us clear was done in the subject's facial abuse. I would like to hear the sound to be in contact with someone about girls who is the lead midwife that call it an improvement school and that's not a good improvement school and that's what we measure. And to be able to talk a bit more than I normally do before that to talk about these case studies and to either way I'm going to see if there's something that was missed because possibly sometimes when you actually ask the question there are some things that are not here and there wasn't. However, we agreed that there needs to be the path of national vagueness and one of the midwifes, I think it was one of the midwifes who came through the north of school and had said that there's fairly recent that had cast an art school to them so everyone had raised cast an art school as some of the thing about it hadn't actually stepped into my head that point in time. So we got a call to do a work-in-party together at Health Care Inc. Scotland and we only had to, we were already focused on pricing about the topic and the realisation that something best that we needed to be done and we were lucky we did a professional work assistant who didn't have to go through all that and we got some of these of that and this is all posted on the Health Care Inc. website if anyone wants to look at it a bit further. We decided that there was some aspect there that we could have a huge tone of guidance and nobody would ever read it and that wasn't what was required. So we decided that we were to dense that into one page and four what to do and what not to do when we came to Scotland and now in this slide that we've discussed and it's probably very difficult to read you will see it if you go to the Health Care Inc. Portland website you will find that list of those and go on there. It doesn't tell you that disability or the flesh that you used to go on that but at least if you think about these things and more likely to be able to give individualised and sensitive care. In my old patch which is here from the family unit which is about 30 miles south of Glasgow we laminated the ghost of many of the Disney ones we laminated them, that's the base of them but we realized that a lot of them there wasn't anybody in the police who hadn't seen the ghost of we needed to do a little bit more and what the flesh on those bones were and what you could ask to reduce the need to see the woman better. One of our superfans of the mid-race and also an independent mid-race, Cassie McNamara she did me up and she said you know we see through the toughness that you didn't even see it in the ring and to talk it this way you can't be developed for a program involving passing and local volunteer agencies through cases initially and through silence most recently. I'll read that about what was just done there about the process around about getting the disease and going to organize and very luckily my head and the referee extended the study days and I've been back a few times and kept in hand looking for some more money and we've been extremely fortunate especially in some times they'll get funding for those study days. So we and Cassie McNamara have got around 200 mid-race teams, there are some mid-race who came from outside the area and they've had a couple of sessions along the way from masters and helpers of course too and their evaluations have been overwhelmingly excellent and the people who came from outside my board said you know what can we do, how can we get this education to where we are, everybody needs to know that there are people going away from the police what are the volunteers sometimes who said you know I've been in the mid-race for 20, 30 years and now I've cared for women who have been sexually abused and I can barely see some of the diseases that women are having that are quite difficult with the phone but actually it corresponds to something that has previously happened it won't be difficult at all it will just end in the death of a baby that's extremely difficult and Westwood had the information so much earlier but people sometimes wouldn't realize the value of the information because then back to what's the other way if you don't know what you don't know so what we can and do is we have to do something more universally this is important to everybody so again, fortunate to have a call we spoke from maybe last year at NHS Education Scotland and say that's their own national resource that we could maybe get out there to spread the word of extensive care for women who have been sexually abused we've got a series of this together and Catherine and I are part of that seeing that there are many other people involved there so that's what we think about when this one is involved in taxes, nurses, sexual health nurses anything in any potential way that would be intimate with any women sales involved in this we've just finished making a DVD of women stories and the volunteers from the crisis actually were found related to their stories and we had hoped for the clock of that for you to do but unfortunately there are two different ones so rather than having the potential with the different ones to do we had to unfortunately decide to abandon that but I haven't seen the stories and seeing them getting found and seeing them finished is extremely terrible stuff but seeing the DVD doesn't really get the message of suicide you feel sad, you feel we could have been a better job in that moment but we need more to know what could have been that would have made that difference so we asked for more funding we hope that we'll get it one way or another we need everybody in the business in passing to look at every avenue to science that you can get not so that you can get a training resource only I know that the cause of the sensitivity of the subject might some remember if it's known for women who have been sexually abused that one is more mid-race than the other two so I pleased to try and get that out it's quite important to us that we can try and get some kind of speech-to-speech training incorporated within that well, I'll hand you back over to Tassel Thanks, Geraldine as Geraldine has said this one story has generated a great deal of interest and a huge amount of training I started these workshops some 10 years ago now and I really feel at the moment there's an energy and an appetite for listening to this material that hasn't been there before however, as you probably know Scotland whilst embracing this as a challenge is not necessarily the case in the other three countries of the British Isles although I have done workshops up and down the country that has not taken off in quite the same way that it has in Scotland Scotland has really coordinated its approach with a number of midwives who are training and willing to do a much more broader piece of work in education than just focusing on maternity if it's possible to do it in one country I really cannot see why it's impossible to do it elsewhere and I feel that women and their babies actually deserve it my argument is that there should be an undergraduate and a postgraduate training element around abuse and all the aspects of abuse and education for health practitioners I've done training for DPs I've done training for neonatologists and obstetricians I've also done training for anaesthetists but it's very, very sparse and I would say that this is more about people who have an interest who invite me to do it rather than a coordinated approach so you might ask why am I interested why is this a passion at mine well the passion is because I was one of those women I disclose very openly in the workshops that I do that I'm a survivor of child sexual abuse and I'd like to read to you a few lines of a poem that I wrote many, many years ago and the title of that poem is called Woman of Dirt and Woman of Dirt was the name that I held for myself my spirit has flown left me lonely in this shell of a body empty and sad walking through hell the burden and torment has crushed me with pain left me deceited and lost and crying with shame he creeps up behind me his eyes burning my back his smile is so nauseous his fingernails black he topples and shuffles inches from my side when I bravely turn round it's all in my mind I cringe and I shudder the memories still hurt of the baby, the child the woman of dirt I think I'm really going to leave this subject here because what there have been and I have tried to do is give you an overview of what essentially is a lifetimes work for me but certainly a whole day workshop in terms of the education that we introduce and also for the work that we're doing in Scotland in raising this as a huge public health issue but as a maternity issue that matters so much to women and matters so much to the clinicians who need to have education around the skills that would be useful when encountering sexual abuse during maternity care thank you for listening to us this afternoon thank you very much to Gialdin and Catherine for a very interesting presentation now you can ask questions in the chat box for Gialdin and Catherine there is a question coming up to Catherine what tools in life would you give for a woman who knows that she has had a sexual abuse as a child but don't remember it can you answer that question Catherine the question I'm going to answer is what tools advice would you give for a woman who knows that she has had sexual abuse as a child but doesn't remember it I work in a way that embraces universal precautions universal precautions means that I expect every woman to have a secret every woman to have an element of abuse in her lifetime and if you engage in this in a way that wishes to do no harm and ensures that you talk to the woman in a way that puts her in control at every opportunity then it shouldn't matter if you know or if she doesn't know but what you are doing is protecting her dignity and protecting her when she needs great advocacy and when she's really at her most vulnerable I have got skills and I have got lots of advice which is practical that I cover in the workshop I would say that it's easier to do it and to see it than it is to talk about it but it's a very simple list of do's and don'ts I think also somebody has said about sharing information that's an amazing thing to use it's being important that the information gets shared so that's not a problem at all the DVDs that we are talking about eventually will go on to the Knowledge Network in Scotland and possibly even onto YouTube or that in the future the learning tools the learning tool kits that we are trying to stop we are not quite sure about how that will be but definitely also lots of years if we can make it free and we can just share the videos and everybody should share it at some point in the other time as we talked about disclosure and I think Tassel and I are still in the workshop I have a friend of this who is around about 50% of women never ever disclose I think it's very clear that's quite the wrong way of Tassel that we are also advocating for universal support and obviously if a woman does share that information with you you can have it more individually to her needs and that's important it's about her needs but just to ensure the women potentially do not share the number of schemes that we have in the labour war which are maybe more related to class tax, to previous abuse I think I'd like to say as well that healing is a process it's not necessarily a one moment event it can have years and years of hard work where you may work with a therapist you may work with a counsellor it's sometimes though just one thing that can make a huge difference and I've cared for women both as a midwife and as a psychotherapist where they agree that actually giving birth and having a good birth experience is one of the most healing events in their lifetime that takes them from feeling like a victim to feeling as if they're now beyond surviving but thriving so I think that's important that midwives understand this is a process of movement rather than just one element of care or one event We have had very good sort of a chapter to experience the women who did the very best with kids and first delivery however the families that we should have thought based on one of the factors should be this sexual abuse she recently was a dramatic baby and finally almost identical sex responses, identical complications leading to an identical career and the death and death time she had a midwife a midwife too or the bus and bus people who had been to class and study she came to the consultant the multi-disk remedy team the question that required us to be in the station the first time she was very shell-shocked out of mental health looking at the abundance of babies she was very concerned she felt more of a sense for it but she was so desk-shocked trying to tell the women to do it with her baby that she actually wanted to have her baby and in the end of the day she did not do this but was transformation of her There is a comment from Helen in the chat box about can you comment on her comment or do you want to comment on it you can see the comment which says I also think we have a responsibility not to negate birth trauma because a woman has been sexually abused these two can be very separate events I think that's a really important point as birth and abuse are individual experiences I think it's very common for us in maternity not to understand the psychology of birth and not to understand the psychology of life and trauma is trauma trauma can manifest itself in many ways under many different guises and I do think there is a vulnerability though around women who have been sexually abused that makes trauma more likely however I take that point as a very very good argument that the two events can be very separate and not have a unified conclusion absolutely and then would the survivors of abuse come in forward this night because it's been very much in the BDR women with us as well and bring the silence to help care for people who are sexually abused and have other branches in Scotland and we have a very significant increase in the fear I'd also like to come in at this point because one of the things that I said earlier on is around advocacy and about allowing the woman to choose what she wishes to undertake during her pregnancy and birth but also what she needs an advocate throughout the whole experience and I think in my experience I feel sometimes midwives get confused about their allegiances to women and they often take the stance of the trust or take the stance of her registration what I feel is really important is when you are caring for a woman is to engage totally in the element of advocacy if a woman feels safe with you whether she's been abused or not and that means that you are in some ways doing the job in the best way that you can if she is a survivor of abuse then she will know that she is safe with this midwife and having the confidence to advocate for a woman is one of the key elements I think of this program that we're talking about Lina is a very you know, no no we haven't talked about that or the case stuff more than she has transgressions that are all faculty unraveled and I want to see what after we have a brief discussion about you know what is it here what is it here what is it here and we say with the session it's been easier and she says that's because I can do that stuff and if I don't have the session when I think I have the normal bus then my users would help so very, very powerful students so very powerful women so we shouldn't assume any faculty that a woman has passed into is for other women you should find help I'm reading comments to one from Karen what about octogenarians who've been abused with children and still not dealt with it in my other life I've met probably one of the most fabbest discussions I had was with an elderly woman who have been abused as a five year old child and told me she was aged 83 told me for the very first time of that abuse I think it was one of the most moving moments in therapy for me because she said I thought I would have to die and take this to the grave with me she also went on to have four children and two of those children she gave birth unattended and I think these elements of being alone, feeling as though no one can help you, feeling as though you can't be reached was how she spoke in her account she used those births that has helped me understand my own experience of abuse in life but also in the care that I try to deliver for women and then in the training as Geraldine and I endeavour to deliver I call out your very good point about subquenches we were dealing with an abuse that actually abused in the little entail here is absolutely straight and up and down the land and doesn't exist in some places that's an even more important point I've said what's after all you do here in Melody there won't be quite a bit in the past she would have been abused in a female ring and that was one of the things that she said in the community that she was terrified that the cause had murdered the fellow who's just had abuse that the fellow had failed to be abused all that she was capable of abusing that child as well for a lot of worries about when you deal with that school and that doesn't end in a vice that obviously goes on for quite some time after that Thank you very much Geraldine and Catherine we can go on I'm short but we need to to intercession now thank you very much for an interesting presentation and also an interesting discussion with you afterwards Thank you