Trauma-Informed Midwifery Care

Chapter 1: The Reality of Trauma in the Perinatal Period You went into midwifery because you wanted to make a difference. You wanted to support people during one of the most vulnerable times in their lives. You pictured partnership, respect, and healthy births. Then you started practicing. You met the client who wouldn't let you touch her, even for a simple blood pressure check. You saw the person in labor who seemed to just disappear behind their eyes-completely unreachable-while the monitors beeped steadily. You dealt with the postpartum client who seemed angry, hostile, and resistant to every piece of advice you offered. It's frustrating, right? You might have thought, "Why are they acting like this? If they would just listen, this would be so much easier." Here's the hard truth: The problem often isn't them. The problem is that the standard model of maternity care is built on a faulty assumption. It assumes the birthing person feels safe in medical environments. It assumes their bodies and minds haven't been shaped by terrifying experiences. And those assumptions are often dead wrong. When we don't understand trauma, we inevitably cause more of it. We re-traumatize the very people we are supposed to be caring for. This chapter is about facing that reality. It's about understanding what trauma actually is, how common it is, and how it shows up when people are having babies. What We Get Wrong About Trauma Let's clear something up right away. Trauma is not just a bad memory. It's not just feeling sad about something that happened in the past. When we talk about psychological trauma, we are talking about a fundamental change in the nervous system. We often think of trauma as the big, obvious events: war, natural disasters, or severe physical assault. Yes, those are traumatic. But trauma is much broader. It includes experiences of abuse, neglect, systemic oppression, and even seemingly routine medical procedures. The most useful definition of trauma comes from the Substance Abuse and Mental Health Services Administration (SAMHSA). They break it down using the "Three E's": Event, Experience, and Effect (SAMHSA, 2014). The Three E's

1. The Event: This is the thing that happened. It could be a single incident, like a car accident or a sexual assault. Or it could be chronic, like ongoing childhood neglect, living in poverty, or experiencing daily racism. The event involves a threat to physical or psychological safety.
2. The Experience: This is the critical part. How the individual experiences the event determines whether it is traumatic. If the person feels overwhelmed, helpless, terrified, or trapped, the event is experienced as trauma. Two people can go through the same event, but experience it completely differently. If a person feels supported and validated during a difficult event, it may not become imprinted as trauma. If they feel alone and terrified, it likely will.
3. The Effect: These are the long-term results of the trauma. Effects can be immediate or delayed. They include changes in the brain and body, such as chronic hyperarousal (always being on alert), difficulty regulating emotions, physical health problems, relationship issues, and mental health conditions like PTSD, depression, and anxiety.

Why does this definition matter in midwifery? Because it tells us that we cannot judge whether an event was traumatic based on our own perception of it. Think about birth. You might see a birth as clinically successful-a healthy baby, a stable parent. But if the birthing person experienced that event as terrifying, degrading, or violating, it was traumatic for them. Birth trauma is a specific type of psychological trauma that occurs during or as a result of childbirth. It's not just about the physical injuries, though those certainly contribute. It's about the psychological experience of fear, helplessness, loss of control, and lack of care (Beck, 2004). Examples of events that can lead to birth trauma include:

• Unplanned Cesarean sections.
• Use of forceps or vacuum extraction.
• Severe perineal tearing.
• Hemorrhage.
• The baby going to the NICU.

But here's the thing that often gets missed: birth trauma is frequently caused by how the providers behave. Things like:

• Loss of autonomy and control.
• Lack of consent for procedures.
• Feeling unheard or dismissed.
• Disrespectful, coercive, or abusive language.
• Feeling abandoned or unsupported.

When a midwife performs a cervical exam without asking, or speaks dismissively about a patient's pain, they are creating an event that is likely to be experienced as traumatic. The 45% Reality Prevalence and Statistics You might be thinking, "Okay, I get it. Trauma happens. But how common is it really? Surely most of my clients are fine." Let's look at the numbers. They are staggering. Research consistently shows that a significant portion of the population has a history of trauma. The Adverse Childhood Experiences (ACEs) study, a landmark investigation by the CDC and Kaiser Permanente, found that nearly two-thirds of adults have experienced at least one ACE (Felitti et al., 1998). ACEs include things like physical, emotional, or sexual abuse; neglect; parental mental illness; substance abuse; incarceration; divorce; and domestic violence. Now, let's focus on the perinatal period.

• Birth Trauma: Studies vary, but the consensus is alarming. Up to 45% of birthing people report that their birth was traumatic (Creedy et al., 2000; Harris & Ayers, 2012). That's nearly half of the people you care for.
• Postpartum PTSD: As a result of traumatic births, between 3% and 16% of women develop Post-Traumatic Stress Disorder (PTSD) postpartum (Yildiz et al., 2017). For those with previous trauma histories, the rates are even higher.

Let that sink in. If you see 10 clients, 4 or 5 of them may perceive their birth experience as traumatic. And many more are coming into your care with existing trauma histories that will be reactivated during the perinatal period. Consider Sarah, a 28-year-old pregnant with her first child. She comes to her prenatal appointments seeming quiet and withdrawn. She flinches when the doppler gel is cold and avoids eye contact. When the midwife discusses the upcoming glucose test, Sarah gets agitated and says she doesn't want to do it. The midwife, rushed and tired, tells her it's mandatory and she needs to cooperate for the baby's sake. What the midwife doesn't know is that Sarah has a history of childhood medical trauma. The clinical environment, the lack of control, and the feeling of being coerced are all triggering her trauma response. By pushing her, the midwife is confirming Sarah's deeply held belief that medical providers are unsafe. The statistics are not just numbers. They are the people sitting in your waiting room. Trauma is the norm, not the exception. Therefore, our care must be trauma-informed by default. Types of Trauma Impacting Birth The perinatal period is a time of intense vulnerability. The physical changes, the hormonal shifts, and the psychological transition to parenthood can all reactivate past trauma. It's like the volume gets turned up on everything. Understanding the types of trauma your clients may have experienced is essential for providing safe and effective care. Sexual Abuse and Assault This is a major one. Statistics show that 1 in 4 women and 1 in 6 men have experienced sexual abuse in their lifetime (Black et al., 2011). For these survivors, pregnancy and birth can be minefields. Think about what standard maternity care involves: intimate exams, exposure of genitals, being touched by strangers, pressure in the pelvic area, and a feeling of loss of control. These are all potent triggers for sexual abuse survivors. A cervical exam, which you might view as a routine clinical procedure, can feel like a violation to a survivor. The sensations of labor-the intensity, the pain, the feeling of the body opening-can trigger flashbacks of the abuse. When a survivor is triggered, they may fight back, freeze, or dissociate (we'll talk more about these responses in Chapter 2). They are not trying to be difficult. Their body is responding to a perceived threat based on past experiences. Medical Trauma Many people have experienced trauma within the healthcare system. This can stem from childhood experiences, life-saving but terrifying interventions, chronic illness management, or previous disrespectful care. Medical trauma is the psychological response to stressful medical experiences. It can look like:

• Fear of hospitals or clinics.
• Distrust of medical providers.
• Avoiding necessary care.
• Extreme anxiety during procedures.

If a person has a history of medical trauma,...