 Okay so I now have the great pleasure of handing over control to Sarah who is going to, not only do a far better introduction of herself than I can, but also talk to us about trauma-informed maternity care, caring for women with a history of sexual abuse. And there you go, all yours. Thank you so much Liz. Good morning everybody and happy International Day of the Midwifery. I am feeling so honored to be able to have this opportunity to present information to you that I feel is very important. So enjoy my presentation. Firstly though, I would like to start by acknowledging the traditional custodians of the country on which I live and work. They were wandering people. I pay my respects to the rivers and lands, elders past, present and emerging. I acknowledge that sovereignty has never been ceded. So hello, I'm Sarah. I'm a midwife and lactation consultant and childbirth educator from Australia. So some of the information I'm talking about today is specific to Australian population groups and statistics, but the information is relevant to anyone across the world. So I've trained as a midwife in Australia and I have worked in rural and remote locations, including out back Queensland, working in areas with high concentrations of Indigenous First Nations Australian groups. I've also gained midwifery experience in Cambodia, Vanuatu and India. So in India specifically, I was working with pregnant teenagers, many of whom were pregnant due to sexual abuse. Throughout my career, I've worked with women who have been assaulted navigating pregnancy terminations, girls and women who have had the option of being forced to give up babies conceived through rape, and women who have gone on to mother those babies. So I've worked with these women in both the continuity and supported them along their journeys, and once off situations in hospital settings. So currently I'm working as a home birth midwife in private practice, and in true home birth midwife style, I have had a birth overnight. So if I make any mistakes, I'm a little bit tired. But I am currently working with a population group who are seen as less at risk of experiencing sexual abuse than previous roles. But these women certainly aren't immune to these experiences as well. I feel just from being a woman, having female friends and working in women's healthcare, coming across experiences of sexual abuse feels very prevalent. So some of the things I'm going to be talking about today are the definitions of sexual abuse, the prevalence, which population groups are most at risk, pregnancy with the history of sexual abuse, and the importance of ascertaining that history, withholding a history, and recognizings of an undisclosed history. Responding to a disclosure, traumatic maternity care and implications of that, as well as trauma informed care, what is it, and recommendations around it. I'm going to be sharing one woman's story with you and some resources. Firstly though, I'm also going to start with a poll. So I just want to engage with the information that you have at the moment. How do you answer this question? Numbers which are pretty consistent with when I have these conversations with people, but we'll be checking in again later and seeing if there's any change in your answers at all. I also wanted to find out how you felt when you looked after this woman as well, or these women. So I'm glad to see that you do have some knowledge, or you've received some training around this area of importance. Let's see how you feel after my presentation. Hopefully those numbers improve. So I want to start off first with the definitions of sexual abuse. So that can be ultimately whatever the person defines it as, but it can be seen as a lack of autonomy over reproductive health, threats and coercion, rape and violent acts, a lack of consent, violations of privacy and safety. So I just wanted to report on the prevalence as well and just recognize that these are numbers that are reported and include only women and girls in the number. So in Australia for women and girls under the age of 15, 15% report having experienced sexual abuse and that increase into 16% over the age of 15. Looking across all age groups globally, that number is sitting more at one in three or 35%. Usually the perpetrator is known to the woman and 30% of women report having experienced sexual violence from an intimate partner. So a lot of the information I share today is also relevant when looking after women in domestic violence situations, but most incidents are never reported. So these numbers are probably not representative of what those numbers really could be. And people might not report out of fear, out of being threatened, not being believed, being unsure of details or because of the nature of it likely being someone known to them or for social or cultural reasons. Also, abuses rarely are once-off situations, while women usually experience multiple incidences throughout their life. The population groups most at risk are those living rule and remotely, the LGBTQI plus community, people with a disability, lower socioeconomic status, Indigenous and First Nations Australians and unmarried and racially diverse women. So pregnancy can be a time when women are reminded of their sexual abuse and that can be due to power imbalances, the changes in their body, the intimate nature of exams or pregnancy and births being seen as a sexual experience. So incidents of domestic violence also increased during pregnancy and it can have poor implications on women's reproductive, sexual, physical and mental health. Trauma perpetuates trauma, meaning that if you have a history of traumatic events, things that might not seem traumatic to somebody else can add to held trauma that you already have. Women also can be quite submissive to their care provider's needs if they've never been in a situation where they've been able to articulate their own. So despite antenatal screening tools in many maternity settings across the world, to detect intimate partner violence and a history of abuse, the lack of continuity of care means women are unlikely to disclose such intimate information. It's commonly an avoided subject by both women and care providers. So avoiding the conversation around abuse implies an acceptance of an issue that is quite pandemic and it ignores the important associations that it has to the health and well-being of a woman particularly during pregnancy. So as care providers it results in missing information that can help provide appropriate care to the woman and it also affects the delivery of care. So however all care should be trauma informed and empathic to the possibility of a history of abuse. So how to take a history for a woman? So using a form with prompting questions can be explored in hopefully a compassionate, open and appropriate, time-appropriate manner obviously which can be difficult when working in busy hospitals. So these can be used to help guide health care providers on how to appropriately explore a history of abuse especially if they don't have any experience on it themselves. But incidents of disclosure do increase when women are asked about the history of abuse on more than just one occasion throughout their pregnancy care. So offering the opportunity to revisit these questions, as understandably women may not want to disclose this intimate information on the first antenatal meeting with a stranger. So you want to be responding calmly and sensitively. Don't overdramatize or pry for details and have the knowledge of support services and where to refer women if that is something that they are wanting. Provide examples of how this information might be able to provide appropriate care for them. For example how or if to perform vaginal examinations and some individuals may not want to reshare this information. So gaining consent to share that information among other providers involved in the woman's care. So some women are pretty open to sharing their experience of sexual abuse but why might some individuals choose not to? That might be out of fear of being stigmatized, misunderstood or not believed. The partner is unaware or is the perpetrator. They may not want to relive those painful memories or shock their care providers. They may have no memory of the abuse or be uncertain about details. They may feel that information isn't relevant or that it no longer affects them or caregivers avoiding the subject or not being given the opportunity to talk about it. Or lastly if the assault was ever performed by a health care provider. Therefore it's important to recognize signs when a woman has not disclosed her history to you. So how often in maternity care women labeled as difficult, non-compliant, demanding. So when there is a history of undisclosed sexual abuse an individual may appear angry or distrusting, inflexible, uncooperative, reserved, disconnected. They may be a late booking, they may lack engagement or seem disinterested in their care which can come across to providers that women don't care about their pregnancy well-being or they may have recurrent presentations especially if they're trying to escape the dangerous situation. They may request a female care provider. Their reactions to vaginal exams may be things like crying or laughing, tense going mute, shaking, shallow, rapid breathing. They may tense or flinch when being touched or dissociate completely or seem like they've checked out. They may have really overwhelming emotional reactions such as being inconsolable or screaming or crying or yelling. They may be overly dismissive or they may have discomfort with or not want to breastfeed. So after sharing this information I just wanted to check in again and ask if you feel like you've looked after a woman with a history of sexual abuse. Okay so a little bit of a shift there so thank you for sharing. So how do we respond if a woman has disclosed this information to us? You want to avoid responses that are overly emotive so filled with anger, shock, disgust, disbelief, shame, crying, minimising, avoidance, pity or making promises you can't fulfill because responses like this can discourage people from disclosing information for fear of upsetting their care providers or feeling a sense of shame. So respond by acknowledging that the woman has shared intimate information with you and thank her for having that trust in you and reassure her that the information shared can help to personalise her maternity care experience whilst reinforcing that they are the ones who are in control of what they disclose and to whom. So you want to respond calmly and with concern and by acknowledging her feelings without portraying that you can resolve her situation because for most maternity providers this is well outside your scope and it's important then to know where to refer women if they are wanting extra assistance. So it's important to establish if she's currently safe in her situation and also asking what their needs are and what it is they need to feel safe in their maternity care. So I think it's really important to touch on traumatic maternity care. Firstly it's important to establish what traumatic care is and that is defined by the woman because it's her perception of the care that she's experienced. So it's not up to any outsider or care provider to define if an outcome or an experience was traumatic for the woman or not. So in Australia one in three women report their births as being traumatic and this incidence is higher for women who have a history of sexual abuse and it's actually interactions with health care providers which are reported as being more traumatic than medical interventions. It's reported that care providers actions can trigger distressing memories of abuse and this can be through physical triggers or from power imbalances using phrases like just relax stop moving trust your body can be quite triggering for some women. So physically restraining women pushing their legs open holding them down touching them without notice or consent or women having a lack of control so either that can be over the functions of their body during the labor and birth process what is happening to them or due to having a lack of information and therefore active involvement in their care or of course things happening to them without their consent. It can look like health care providers minimising or dismissing health concerns or concerns regarding their baby having a lack of control over health care decision making and this can be due to a lack of understanding of medical information and procedures not being properly explained or during emergency situations if they're not being updated and informed not having the authority or feeling like they're the lead decision makers in their care the physical just comfort and pain or sensations during labor and birth being in a supine position when being spoken to or especially if they're in lethonomy having their bodies exposed negative care provider interactions which is a significant risk factor for PTSD and that could be having had male care providers or feeling unsafe with the provider that they've been assigned shift changers and seeing different people throughout their care that could be care providers asserting dominance or yelling at women being told off women being undermined if they're being lied to or coerced to comply with the health care providers wishes and of course painful procedures particularly involving genitals and the use of instruments without the proper explanation and prior to gaining consent so what are some implications of traumatic maternity care so globally women with a history of abuse and trauma have higher rates of reproductive health issues and poor maternal health outcomes as it is so that's things like low birth weight lower breastfeeding rates and postnatal depression so with birth trauma that also relates to poor outcomes and it can have ongoing implications with parenting and bonding so emotionally these things might be feelings of blame or distrust towards themselves or their their care providers or their partners PTSD symptoms depression and not bonding with their babies which we know is to link to developmental delays in children so these implications can also affect partners and relationships so following traumatic births couples report a loss of intimacy having flat flashbacks of the birth experience and avoiding sex due to fears of falling pregnant um before I go on to some practice recommendations I just want to help define what trauma informed care is so gerba in their paper in 2019 on trauma informed maternity care determined four goals of trauma informed care so those were detection by staff which is critical and enables appropriate care during the pregnancy preventing more trauma caused by negative health care interactions and or traumatic birth experiences avoiding retraumatization through triggering language or actions so this could be insensitive questioning or probing when women don't want to disclose their histories and finally only where appropriate though referral to support so just keeping in mind that not all women will want to revisit or address these past experiences during their pregnancy which can already be a really emotional and challenging time for some women so many of the recommendations I'm going to be listing have come from research on what women have said that they want so what women want is control over who is present especially for invasive examinations and procedures avoiding triggering language and it's really important to note that that language is defined by the individual woman preference for a female care provider or a female present with male providers control over exposure of their body so being respected that not all women are comfortable having their bodies exposed and I feel like this is often isn't respected in in theater so making sure you're covering women up especially in lithotomy so clear communication so explaining all options and step by step through procedures prior to performing them they don't want to have to repeat their histories to new care providers so clearly documenting and drawing attention to important clinical notes and ensuring all providers looking after the woman have read them acknowledgement that cervical examinations can cause distress and approaching them sensitively respecting a no and not coercing or guilting women into procedures and checks they don't want respecting birth plans this could look like self-insertion of speculums or control over all invasive exams regarding being performed in the woman's own time when women are well informed they feel more in control so addressing the individual health literacy needs of the woman and not using medical jargon open-ended questions regarding the care needs of the woman so things like how can I help you if you're comfortable throughout your maternity care continuity of care provider which enables individualized care and as we know improves many outcomes that lap over with this population of women and helps to avoid traumatic birth experiences so recognition and rectifying the power imbalance between women and care providers so this can be done through your body language not standing over women or talking to them when they're in vulnerable positions or during contractions so coming down to their level if they're on the bed or the floor utilizing support services like social workers mental health teams and indigenous health workers so women are able to feel more confident navigating their care maintaining modesty and this may look like performing exams clothed or covered if preferred explaining risks and benefits of procedures and gaining consent prior to performing them and anticipatory guidance and explanation during those procedures supportive language during labor entering the room with notice or not entering the room until being invited in focus on building trusted relationships and continuity of care provider as much as possible so obviously in health hospital settings this may just look like if the woman has been cared by one midwife before trying to allocate her again to that same midwife on that midwife's next shift so emotional support during labor from care providers and supportive language so things like you are safe if you take any observations or a fetal heart rate reassure her that it's within normal limits and that everything is well and avoiding negative and dispowering disempowering language so instead of saying you're only three centimeters rephrasing that and saying your cervix is done a lot of work it's really soft it's opening so I just want to share with you another poll okay so after I've shared this information with you how you're feeling now with caring for a woman who has a history of abuse and I'm really glad that this has prompted people to want to find out more about this and I will be sharing some resources with you as well so I'm going to be sharing one woman's story with you and I have such deep gratitude that this woman was willing to share her experience because I feel like um her experiences is not individual to herself many women have experiences like this and I'm very grateful that she's open to sharing with you so I've just posted a link hi I'm Cassie Burnett I'm the mom of two beautiful souls William who is three and Willow who is three and a half months at the age of four I was molested by my step brother until the age of seven at 16 I was raped by my best friend and at 20 I was assaulted by my previous husband and his friends I then went on to have more sexual encounters that were consensual but not enjoyable and that I wasn't really mentally present for so my husband and I felt pregnant with William it was very easy but the care and the pregnancy was anything but I was assigned a midwife at the beginning initially but due to the constant this could be wrong this could be wrong this isn't measuring right my heart my heart rate was too high or too low or my blood pressure was off I didn't really actually get to see her very often I just saw whatever OB was available since it was a public hospital whoever had the next appointment so I had absolutely no continuity of care I had a lot of anxiety surrounding that pregnancy in him since the beginning there was a constant is he going to make it is something wrong with my baby I was never reassured that he was okay and that that I was just told that it was going to be a hard delivery so when I went into labor I didn't know any of the midwives or the doctors that were going to deliver my baby they let anyone come in while I was fully naked without my consent I continual I was continually asked if I wanted an epidural so I wouldn't tire out and then the next day about 24 hours in labor I was told since I wasn't progressing I needed to have centosin which then led me to an epidural to ensure that William was okay and not distressed they performed a lactic acid test on his head at which point there were multiple students in the room which I already had my legs up in the stirrups and they could I was exposed to everybody they asked if it would be okay if they were already in there well they were already in there and they were already doing the test so I obliged and I remember two midwives and one of the attending obese said that he was fine the test came back within normal range and then within five minutes of being told I was allowed to continue laboring I had the surgeon come in and say that he was in distress and that the surgeon was taking him I remember thinking how could he make that decision without without talking to me but then if my baby was in danger I wasn't going to ask any questions so after my son was born I felt even more numb and disconnected from my own body when we tried for willow it took us over a year and that included a heartbreaking miscarriage and a dnc that left me feeling even more numb and disconnected from my broken and misshaked uterus and those were the words told to me by one of the obese doing the dnc before getting pregnant with her I met Sarah she held space for me while I learned how to step into my power I formed a connection with her based on respect and understanding of where I had been we had multiple conversations not only about my sexual history but my abuse and how it affected the level of the level I was able to feel safe at with every appointment conversation or question that I had she informed me of exactly what she was going to do and asked my permission to touch me every single time she gave me information on both sides of the coin that I was asking the question about I felt safe and I trusted her I do think that that is why I only had a three and a half hour labor from my water breaking to willow coming on the side I felt safe I had her on my bedroom floor and it was just the most magical experience that I could have ever imagined and I do believe that in part that's because she was holding space for me she she did make me feel safe and I did know her and I trusted her inspirational watching that video and I've watched it so many times and I obviously know that woman's story inside out um but I feel like Cassie's story really outlines the impact of continuity of care and the importance of women having trust and feeling safe with their care provider so on a physiological level birth flows smoothly when women feel safe and the necessary hormones of birth are released so it's undeniable that as mammals our labors stall when we don't feel like we're in a safe environment to birth our babies so I think that's just an incredible design of ours to keep our babies safe yeah instead women are told that their bodies are broken and that intervention is necessary to birth their babies when really I feel what women need is a safe environment and supportive care providers so I do want to share some resources with you so I'm so glad to hear that you are interested to learn more a lot of the information and recommendations that I've shared today in this presentation have come from an incredible book called When Survivors Give Birth by Penny Simpkins and Phyllis Claus um this book is appropriate for women and for care providers it's um they also run an online workshop called um under the same name and it can be found on the birth well birth right website and the next one is on the 19th of July and they're doing it online this year so it's available to everybody I think it's really important to um be aware of the effects that you can um have and the vicarious trauma that can occur from looking after women with a history of abuse particularly particularly for people who have experienced abuse themselves so utilizing um and like and consulting with your um colleagues senior staff members and hospital counseling services if they're available to you and being mindful of um workloads when looking after women with trauma for their increased needs but also for the increased emotional needs of yourself as well so yeah utilizing the elusive self-care so making sure that you're doing things that help you not carry that trauma and take it home with you and sometimes that can be as simple as eating well and trying to get enough sleep um so if any of the information I've spoken about today has been triggering or traumatizing for you in Australia you can utilize lifeline or beyond blue which are mental health support services and 1800 respect is specific to um sexual assault internationally though there is um a website called the calm zone which has a list of the mental health charities available in every country a list of resources and all my beautiful images are by Vita images if you want to check out her work so thank you so much for listening to my presentation I feel very honored to be able to share this information with you and to be speaking alongside so many beautiful presentations and other midwifery academics today so it gets a great honor thank you very much sir there's some powerful kind of points there and I keep thinking the back of my brain what would the world be like if that was our base level of care for all women regardless of their experiences oh absolutely I couldn't agree with you more so we had a couple of comments um Jeba actually has written something but she's gone offline but she'll be able to hear this in the the recording um if she worked with that she was just wondering about whether the hesitation to chest feed was a trauma response um well I guess it would be specific to every individual woman and what their history of abuse looks like so obviously a breast can be seen as quite a sexual part of our body so if that has been violated in one woman they may not feel comfortable feeding their babies but then I read also accounts from women as well that that was actually breastfeeding and chest feeding was something they actually were very empowered by because they were sort of taking back that body and they were impressed by the abilities of their body same as if they hadn't a positive birth experience as well that had really um positive outcomes for them and how they felt about their bodies and Susan has made a comment here that the whilst she was typing or I'm listening to Cassie's story that that was hard to hear that I'm piping one life that was volume or the story but the issue of higher risk and complex care options necessary to have the joined up relational continuity she was horrified by the term already in there and that Cassie's gift of her story to us is so revealing and brave and feeling safe in such a personal experience which you kind of like stated as well Chris is sitting that she dreads to think of just how many women we miss when we could be using labour and birthing as a time to heal yeah absolutely or for women like offer the opportunity for women to heal themselves through empowering experiences so I think care that promotes giving the power back to the woman can be really healing as well and yeah I just wanted to add on Susan's as well I think that's that statement as well can sort of be relevant to vaginal exams I feel like consent is not gained prior to entering a woman's body a lot of the time and it's sort of like told to them while it's already happening and I feel like you know well that's too late then you've already you've already violated that woman again and Susan's actually put a question here that do you have any comments on how many midwives we may I think midwives Susan we may have been abused as in personally sexually abused Susan is that what you're asking for Susan's just clarified yes yeah I guess it would be potentially relative to the statistics that I've spoken to already and that would be an interesting research study to actually look at the the experiences of the carers and does that make them gravitate towards or away from caring for women with those type of experiences themselves yeah that absolutely does cost my mind as well um because we can always do more research that's the kind of we can always find more answers Celine's also reading what would you advise to midwives who are survivors themselves so there you go you've got someone who may be able to work with you to find the answers but what would you advice would you give to midwives yeah I think doing this research and looking into this topic more so and informing yourselves can be quite a healing experience and looking after your well-being as a midwife is so important as it is but doing things that kind of you know help you be able to not carry that emotional load with you as well finding your support people and you know maybe being honest if there's a situation where you're caring for a woman and that's really triggering and traumatizing for you maybe be like okay I'm not the best person to care for this woman and where possible maybe change that around so that's kind of something that for those of you who have had experience of working with women who disclose sexual assault or even knowing colleagues who have experienced it and worked with it what type of self-care do you do have you seen other kind of like midwives do because it's and it's not just with sexual assault as well we look at domestic violence we look at any form of abuse is what are some ways that you look after yourself because that's important too um and saline while people are kind of thinking and hopefully writing saline has actually got a comment saying time to revisit the language that we use without thinking yeah absolutely yeah I think there's a default of disempowering kind of language in maternity care as it is so I think you know if you have in your mind or the back of your mind that this woman potentially has you know everyone comes with their story as to care providers it's like if you keep in your mind that this woman has potentially had a traumatic experience in the past that's how we should be treating all women absolutely and if that was the gold standard it would be very much a different world so where to next for you in this area Sarah what do you want to explore more within this area I'm absolutely going to be doing the the course that's coming up online I've always sort of thought about that because I feel like an MG like a midwifery group practice or continuity of care model for women who have experienced abuse would be absolutely invaluable but I feel like there would be challenges to setting that up as well maybe from women not wanting to outwardly come forward and say yes I want to be part of this group practice because I've been abused before or maybe people because there's such a lack of access to continuity maybe people you know maybe playing up what they've experienced to be able to get into this care if they're aware of the services I don't I'm not sure I'm just thinking so how do we work with that how do we improve what we do no matter where we work then so that they don't have to find an individual service provider but they'll get that wherever they work I think just having awareness and being informed is obviously going to be something that's going to help guide your practice there's a lot of research available even if you're just looking into women who have experienced traumatic care in the past because like we know the such large numbers of women who have experienced traumatic birth experiences they're also carrying trauma and that can be seen as sexual trauma like where um you know there's big statements going around like obstetric rape and obstetric abuse that can be like a sexual violation to some women so you know these numbers actually might be a lot larger based on women's experiences than them or even what I've stated so I think compassionate care working on our ratios and workloads which we know I'd say around the world where midwives are overworked and we don't have enough time and space for these women for all women so how do we grow the midwifery workforce and therefore um you know implement more continuity of care we've been doing the research for a long time but how do we change it and make practice reform that's I guess the power to be to listen to our research um thank you very much I've just called for last comments because our time is um fast approaching you got many people saying thank you for sharing Ashley said thank you for sharing your wisdom and your insight into holding space caregiver caregiving with sensitivity and giving survivors power um and there was another comment that that book that you recommended was excellent um lots of thank yous for raising the issue um and once again I'd like to say thank you very much for your presentation it is information that we can never hear too often and until it becomes automatic everywhere we still need to keep sharing this information so thank you everyone thank you for now let me just thank you so much presenter and