Providing Obstetric Care for Women with a History of Sexual Trauma
FEBRUARY 07, 2019
Lauren Sobel, DO, MPH, and Danielle O'Rourke-Suchoff, MD
Lauren Sobel, DO, MPH“When you’re being victimized, you’re feeling hopeless. You feel trapped. You feel like you don’t have any hope. And you know, you feel imprisoned. And you don’t want to feel that way when you are getting medical care.”
Women like this patient are the experts in their own care and sitting across from someone who has just disclosed her history of sexual trauma truly highlights this. As obstetric providers we are empowered to screen for this history, we have referrals and resources available if a patient chooses to disclose, but our most important role in this moment is to listen to her story, her needs, and her preferences for her prenatal and labor and delivery care.
One in five women in the United States will experience sexual assault or rape in their lifetime. Many of these women will go on to have pregnancy and childbirth experiences affected by this history. Currently, guidelines exist to inform the screening and care of women after sexual assault, yet there is a lack of evidence-based guidelines for the care of these women during pregnancy and childbirth.
We asked women with a history of sexual trauma about their pregnancy and childbirth experiences and used their experiences and insight to inform practice recommendations.
Our research team performed one on one interviews with 20 women who self-identified as having a history of sexual trauma and 10 women who did not. Post-traumatic stress disorder and the connections to the experience of childbirth have been increasingly discussed, so our goal was to understand if care preferences differ between women with a history of sexual trauma and women who do not. Not surprisingly, both groups of women wanted compassionate, patient-centered care. They both clearly preferred that their obstetric providers practice trauma-informed care, which is marked by recognition of the prevalence of trauma, acknowledgment of the role trauma may have played in an individual’s life, and the integration of this knowledge into policies, procedures, and practices.
Clear preferences for obstetric care
We found that after disclosing their history of sexual trauma to providers, women felt that it should be appropriately communicated to the labor and delivery care team, as disclosing multiple times was difficult. Some women reported anxiety, fear, or flashbacks during cervical examinations. They wanted their providers to give clear explanations of why exams were being done, control over the start and end of the exam, and control over who was in the room at the time of these exams. Women did not want providers to use language that served as a stressing reminder of prior sexual trauma. While they did not always prefer a female provider, women with a history of sexual trauma wanted to be asked if they were comfortable with a male health care provider. Importantly, some women expressed anxiety about the exposure over their bodies, and in some cases preferred a cesarean section to avoid the exposure of a vaginal delivery.
Nearly every obstetrician will care for a woman who has experienced sexual trauma, which makes trauma-informed practices vital. Fortunately, a majority of the preferences of this population do not require radical practice changes. As recommended by the American College of Obstetrics and Gynecologists, providers should screen for any history of sexual trauma and, with the patient’s consent, include this information in the medical record. Cervical exams can be a physically and emotionally challenging part of labor, but we can give women control over how these exams are conducted. We should discuss the reason for the exam, when the exam starts and stops, and who will be in the room during exams. We should allow women to remain as covered as they like, including wearing their own clothes as medically appropriate, ask about their preference for female providers, and knock and receive permission before entering their room. We must also consider that for some women with a history of sexual trauma elective cesarean section is indicated.
Incorporating These Findings into Our Practice
Many of these skills are already encompassed in the baseline practice of most obstetric providers. In our own experience, providers who do not routinely focus on these aspects of their care are very open to change. It is widely recognized that these changes incur minimal investments in time and expense but have the potential to make a big difference in how a woman feels about her care.
Danielle O'Rourke-Suchoff, MD
This study has already impacted our own practice. For example, in addition to screening our prenatal patients for a history of sexual trauma, we ask them who they would like in the labor room during labor and if this differs from who they would like present during cervical exams. Often times patients thank us for bringing this up, as they had not thought to make this distinction, but they do in fact have strong preferences for who they would like to leave the room.
As obstetrics and gynecology residents on the labor floor, we frequently care for women who we have not met before. The standard on-call obstetric model as well as nursing shift changes can be stressful for any patient, and perhaps more so for patients who have formed a strong bond with their prenatal provider, who is not present for their labor or delivery. We both now introduce ourselves to patients in the context of their prenatal provider. For example, stating, “Hello, I’ll be your doctor today. I work with your prenatal provider and have reviewed your records.” This indicates we have reviewed all important documentation including a history of sexual trauma without disclosing their history to anyone in the room.
Lastly, when we see our patients for post-partum follow-up visits, we ask them to tell us about their labor and delivery experience. This opens the door for patients to reflect on a transformative experience, gain a deeper understanding of any unclear management decisions, as well as offer feedback so that we as providers may continually work to increase our provision of trauma-informed care. We have noted an overwhelmingly positive response when making these changes.
Overall, obstetric providers who are unprepared to support women with a history of sexual trauma during childbirth risk provoking trauma-related distress that could be avoided with more sensitive or appropriate care.
Lauren Sobel and Danielle O’Rourke-Suchoff are third-year Obstetrics and Gynecology residents at Boston Medical Center in Boston, Massachusetts.
The authors would like to acknowledge Erica Holland, MD who is a third-year Maternal Fetal Medicine fellow at Brigham and Women’s Hospital in Boston, MA for her role in the development and implementation of this study.
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