Impact of Childhood Sexual Abuse on Pregnancy, Labor and Birth Essays

Impact of Childhood Sexual Abuse on Pregnancy, Labor and Birth Essays Impact of Childhood Sexual Abuse on Pregnancy, Labor and Birth Paper Impact of Childhood Sexual Abuse on Pregnancy, Labor and Birth Paper Child abuse is a common problem worldwide. The abuse can be in the form of physical, emotional, sexual or verbal offence. Both boys and girls can be victims of child abuse, a devastating trauma which can lead to long term negative outcomes in future life. In girls, child sexual abuse can contribute to many physical and health related problems, especially during vulnerable times like pregnancy. These problems can have adverse effects on the pregnancy and the newborn too. Research has shown that appropriate intervention at the right time by health professionals including midwives can prevent complications and enhance the outcome of pregnancy. Hence it becomes important to identify mothers with past history of sexual abuse so that appropriate care and support can be provided at the right time for the well-being of the mother and the child. This essay aims to research into the outcomes of childhood sexual abuse on pregnancy, delivery and postpartum and also into the role of midwife while dealing with mothers with previous history of sexual abuse. Introduction The definition of childhood sexual abuse or CSA varies greatly. While some definitions include only rape or attempt to rape, others include contact and non-contact abusive episodes also. According to the Royal Womens Hospital (2009), â€Å"sexual assault is any sexual behaviour that makes a person feel uncomfortable, frightened or threatened. † This includes touching, fondling, kissing, being made to look at, or pose for pornographic photos, voyeurism, exhibitionism and sexual harassment. According to the Australian Institute of Health and Welfare (1995; qtd. in Coles, 2006), child sexual abuse is â€Å"any act which exposes the child to, or involves a child in, sexual processes beyond his or her understanding or contrary to accepted community standards. † The cut off age for CSA varies with some surveys considering 16 years as the cutoff-age and other considering 18 years (Leeners et al, 2007). It is difficult to assess the prevalence and incidence of CSA because many cases go unreported. However, it has been estimated that 20% of all women experience CSA (Wijma et al, 2003). According to a recent Australian study by Gilson and Lancaster (2008), the prevalence of physical and or sexual abuse before the age of 16 years is 20. 5%. CSA is important not only because of the immediate devastating physical, mental and emotional consequences, but also because of the long term impact it exerts on the over-all health and also the psychological functioning of the affected woman (Leeners et al, 2007). Research has shown that about 96% of women suffer from long term consequences (Leeners et al, 2007). Impact of CSA on pregnancy CSA can lead to certain general health problems in the woman which can continue through pregnancy and delivery. They are abdominal pain, pelvic pain, irritable bowel syndrome, vaginal pain, dysuria, pelvic infammatory disease, headaches, breast pain, back pain and other musculoskeletal pains (Coles, 2006). These problems may be related either to actual infection, physical trauma, somatization, chronic stress, mental health issues or maladaptive behaviours. CSA can also contribute to the development of health-risk behaviours like alcohol abuse, smoking, physical inactivity, obesity, intercourse at an early age and multiple sexual partnership (Coles, 2006). Several studies have revealed that survivors of sexual abuse in childhood or adolescence are at risk for high-risk sexual activities when compared to those who have not suffered an abuse (Hulme, 2000 and Kendall-Tackett, 2003; qtd. in Kendall-Tackett, 2007). Such activities increase chances of unplanned pregnancies, teenage pregnancies, unwanted pregnancies and late prenatal care. There are some reports that abused women tend to smoke and have other health-related problems than non-abused women (Kendall-Tackett, 2007). Women who have suffered from physical and sexual abuse tend to relate negative feelings to pregnancy more frequently than women who are not abused (Jundt, 2009). Past history of abuse can cause depression and post-traumatic stress disorder which can again affect pregnancy. Other mental-health related problems include eating disorders, dissociation, somatisation, personality disorders, self-mutilation and suicidal attempts (Coles, 2006). Women who suffer from such mental conditions tend to suffer from more pregnancy-related complications and neonatal complications. They are also at increased risk for obstetric interventions like cesarean section, forceps application, epidural anesthesia, and vacuum extraction. Seng et al (2001; qtd. in Kendall-Tackett, 2007) reported that women with post-traumatic stress disorder had higher odds ratios for spontaneous abortion, ectopic pregnancy, hyperemesis, excessive fetal growth and preterm contractions. Dissociation due to CSA may lead to overseeing of certain early symptoms and signs of obstetric complications like prematue contractions, vaginal spotting and decreased fetal movements (Leeners et al, 2006). Research has shown that maternal history of sexual abuse in childhood can increase the risk of prenatal and postnatal complications in the mother and postnatal complications in the infant. However, it may not contribute to perinatal complications in the infant (Mohler at al, 2008). According to Grimstad and Schei (1999; qtd. in Coles, 2006), babies born to CSA mother are at increased risk of low-birth weight and prematurity. Other complications include preeclampsia and hypertension, intrauterine growth retardation, premature rupture of membranes, vaginal bleeding, postmaturity, drug abuse in pregnancy, gestational diabetes and trauma directed to pregnant uterus (Grimstad and Schei, 1999). Impact of CSA on delivery Research has shown that women who have experienced sexual abuse previously are at increased risk of extreme fear during delivery. Eberhard-Gran et al (2008) studied the occurrence of extreme fear in labour in the context of previous history of sexual abuse. Their study revealed that about 3% of women in the study group developed extreme fear during labour and one third of these women suffered from sexual abuse in the past suggesting a strong correlation between sexual abuse and extreme fear during labour. The pain during labour can trigger past memories of sexual abuse wherein the women suffered the trauma in a powerless and helpless situation and these memories can instigate severe feelings of fear. Impact of CSA on breast feeding and parenting in the post-partum period Childhood abuse increases the risk of postpartum mental health problems. Neonatal blues and postpartum depression, the most common mental conditions after delivery are exaggerated in those with past history of abuse. In a 3-year follow-up study of Australian mothers by Buist and Janson (2001; qtd. in Kendall-Tackett, 2007), it was found that 50% of mothers suffered from childhood sexual abuse and these women had higher scores for severe depression, anxiety and life stresses when compared to depressive women with no past history of abuse. It is evident from research that women who have experienced abuse in the past can have difficult relationships with partners and hence may not receive appropriate support from the partner in the crucial period which further contributes to depression, anger and frustration (Coles, 2006). Also, many abused women are single, divorced or have step parents and thus may not receive proper support from families too (Coles, 2006). All these factors, coupled with the stress of handling the newborn baby and also the physical exhaustion of delivery further contribute to worsening mental condition of the woman in the postpartum period. Breast feeding can trigger dissociation, panic attacks and flashbacks into sexual abuse in childhood (Beck, 2009). It can contribute to poststraumatic stress disorder, emotional distress, cognitive distortions, interpersonal difficulties, avoidance and other health-related problems (Kendall-Tackett, 1998). Becoming a mother is one of the major mile stone in the life of a woman. Pregnancy, delivery and breastfeeding are times when past memories of childhood abuse can surface. Normally, these are the times when the beautiful mother-child relationship and bonding occur and lifetime attachments are established (Main and Hesse, 1990; qtd. in Coles, 2006). Early family experiences have a huge impact on the development of parenting skills. Research has shown that abused women have greater difficulties with parenting in the context of poor mental health, deficiency in social support, and economic burden when compared to unabused women (Gilson and Lancaster, 2008). Powerful recall of previous abuse can lead to disruptions in the mother-child relationship and bonding (Coles, 2006). According to Gilson and Lancaster (2008), sexual assault can contribute to worsening anxiety and depression especially in the post partum period and thus compromise on the role of parenting. Lack of energy, inability to concentrate, irritability and difficulty in meeting the babys physical and emotional needs can affect the quality of parenting. Inadequate parenting can lead to emotional disturbance in children. Severe depression in the postpartum period can disturb the interaction between the mother and the child leading to insecure or avoidant attachment which can later lead to several emotional and behavioural problems in the long run like subtle behavioural abnormalities in the form of conduct disorders, oppositional- defiant disorder and post-traumatic stress disorder; and problems with object concept tasks (Murray, 1992). Models to explain the impact of CSA Many theorists have proposed various models to explain the reasons behind the impact of CSA on motherhood. According to post traumatic stress disorder model, abnormal stress hormones and increased sensitivity of the hormone receptors lead to ‘chronic hyperarousal’ which causes the impact (Kendall-Tackett, 2000; qtd. in Coles, 2006). However, the traumatogenic model puts forward that betrayal, stigmatization, powerlessness and traumatic sexualization during CSA is the cause behind diverse psycho-behavioural outcomes during pregnancy (Finkelhor and Browne, 1985; qtd. in Coles, 2006). Whereas, the somatization model proposes that CSA causes psychological distress which transforms into physical symptoms during motherhood (Coles, 2006). Cole and Putman (1992; qtd. in Coles, 2006) developed the ‘developing coping model’ according to which, CSA disrupts primary attachments because of psycho-physical trauma and leads to loss of trust in relationship and feelings of guilt. These in turn have detrimental effects on the self development of the woman. According to the attachment theory (Alexander, 1992; qtd. in Coles, 2006), survivors of CSA develop insecure attachment with other family members and this pattern may be passed on even to their children. Implications for practice Screening for ongoing and past sexual, interpersonal and childhood maltreatments must be incorporated into routine health care by all health care providers including midwives (Klerman et al, 2008). According to Rodgers et al (2003), more research needs to be done to examine the relationship between sexual trauma and poor pregnancy outcome in the context of determinants of this relation. It is essential to routinely screen women with history of sexual abuse so that these women can be identified and measures be taken to provide optimum care and support (Rodgers et al, 2003). Midwives, nurses and other health professionals dealing with pregnant women with past history of maternal abuse must incorporate certain aspects during prenatal care. All women must be asked about history of abuse in the past. Study by Klerman et al (2008) revealed that many women feel it is appropriate for health care providers to ask about childhood sexual violence and that they themselves would not volunteer the information if were not enquired into. Women identified with history of CSA must be told that this form of abuse is more prevalent than they think and it can lead to certain disturbances during pregnancy, delivery and breast feeding due to trigger of memories. Midwives have an important role in bringing up the issue of CSA into open and to allow women to discuss their tragic experiences if they wish to do so. By doing so, midwives can minimize the negative consequences of previous assault on the process of childbearing and parenting. Before performing any procedure, the woman must be informed as what will be done and the purpose of the procedure. The procedure must be started only after obtaining willful consent of the woman. This will help the woman differentiate between the present experience from past trauma in which she was helpless and powerless (Waymire, 1997). During labour, reassurance must be provided to the woman. She must be told that her body is working for her and that the pain she is going through is natural and good pain. This will enable the woman to distinguish the present pain of delivery from the past traumatic pain. While dealing with mothers with past history of sexual abuse, the prenatal programs must address not only basic health needs of the pregnant women, but also must target the abuse sequelae like psychological problems and detrimental health behaviours (Rodgers et al, 2003). This is because; improvement in mental health is associated with decrease in risky behavious and also improvements in physical health (Rodgers et al, 2003). The programs must also include education about risk of stress and other trauma-related problems. The woman must be monitored more frequently to pick up complications at early stages. In the post-partum period, in some women, breast feeding might need to be stopped in order to preserve proper mental health (Beck, 2009). Abused women must be treated with respect and care. These women must not be subjected to unnecessary intrusive interventions. They must be given an opportunity to choose the gender of the health care provider (Stojadinovic, 2003). For many patients, it may be useful to collaborate with mental health professionals to prevent retraumatisation and also to facilitate the process of healing. Support from partner or spouse must be encouraged because research has shown that partner support is a strong protective factor and it buffers depressive symptoms and enhances parenting competence (Wright et al, 2005). Conclusion CSA is a common physical, mental and psychological problem with long term impact on future life. Pregnancy, delivery and postpartum periods can trigger memories of the past trauma and impact the outcomes of the pregnancy. Early identification of mothers with history of sexual abuse is important to deliver proper interventions at the right time. The identification can be done by routine screening in the prenatal period by health professionals like midwives. Mothers with CSA must be handled specially with care and respect, and with minimal intrusive procedures. They must be offered support and counseling throughout pregnancy, delivery and breast feeding. The aim of prenatal programs in such mothers must be early identification of complications and provision of appropriate support so as to establish effective breast feeding and attachment, thus enabling proper and successful parenting. Although abuse against women, be it present or past has a devastating effect throughout the child-bearing cycle, research pertaining to this topic is still in preliminary stages. References Beck, C. T. (2009). An adult survivor of child sexual abuse and her breastfeeding experience: a case study. MCN Am J Matern Child Nurs. , 34(2), 91-7. Coles, J. Y. (2006). Breastfeeding and Maternal Touch after Childhood Sexual Assault. Submitted in total fulfilment of the requirements of the degree of Doctor of Philosophy. Centre for Health and Society, University of Melbourne. Eberhard-Gran, M. , Slinning, K. , and Eskild, A. (2008). 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