Meet Mechell Duran, DNP, APRN, FNP-C, CDCES, BC-ADM, NBC-HWC, LCCE.  Dr. Duran is a presenter at the 2022 Lamaze International Conference taking place virtually on October 20, 2022.  Dr. Duran will be presenting "Trauma Informed Care as a Universal Precaution for Perinatal Health Professionals" and speaking to childbirth educators and others working with pregnant, birthing and new families about Trauma Informed Care and why it is imperative to recognize the prevalence of trauma in the birthing population and what we can do to provide support and information so that people with a history of trauma can have a positive birthing and early parenting experience. If you have not yet registered for this conference packed with amazing speakers such as Dr. Duran, you can do so here on the conference page.  Valuable continuing education hours, updated relevant information and an opportunity to connect live or watch the sessions recorded for a period of time are all part of this year's event. I appreciate the opportunity to interview Dr. Duran in advance of her session and share that interview with you here. - Sharon Muza, Community Manager, Connecting the Dots.

Sharon Muza: In your estimates, how many birthing people are going through the childbearing year with a history of past trauma? How often is this history shared with their health care team?

Mechell Duran: Trauma Prevalence Based on a Broad Definition

So, there are a couple of different ways I can answer this question and the answer depends on how you define and view trauma, which is a Greek word that means injury. I was trained in a comprehensive trauma program developed by integrative psychiatrist Dr. James Gordon who states in his book the transformation, “we all experience trauma and trauma comes, sooner or later to all of us.¹” In his broad definition of trauma as an injury to the mind, body, and spirit, we come to find out that we are all survivors or trauma or will be in the future.^1,2 Living with a life-threatening illness, having a disability, living with chronic pain, losing a loved one or a career that gave someone meaning and purpose, and being a caregiver to someone with a debilitating disease are all considered trauma.¹ So, if we go by this broad definition, we should expect most if not all birthing people within their childbearing year to have experienced some type of trauma. The question then is to what extent does trauma affect their pregnancy, birth, or ability to parent and how we should adapt our care and mobilize resources in response to their stress reactions.

Trauma Is Pervasive

For the most part, many people have resolved their trauma, but for others there can be long lasting effects in their ability to cope and function in multiple facets of their lives. I think we can all understand the prevalence of trauma having gone through the collective trauma experience of the COVID-19 pandemic and the physical and mental health repercussions reverberated throughout the global community in which birthing parents were not exempt. During the pandemic, birthing people were one of the most vulnerable groups to be affected by the coronavirus, experienced increased ICU admissions because of the infection and incurred multiple losses, experienced grief, and isolation.³ These parents also had to experience birth in a different way with many not being able to be surrounded by family or friends or with the support of a doula.³ It was during this time that we also witnessed human resilience, love, and creativity with the rise of online communities, virtual baby showers, and increased support group meetings for parents with perinatal mood and anxiety disorders an important attribute in trauma recovery.

Trauma Prevalence Based on Adverse Childhood Experiences

While the first half of my answer is foundational to understanding how pervasive trauma is within our society, it is also important that we are specific about the types of trauma we should anticipate in our birthing parents and how they affect pregnancy, birth outcomes and early parenting. First, I would like to interject a more specific definition of trauma, which are “experiences that cause intense physical and psychological stress reactions and can refer to a single event, multiple events or a set of circumstances that is experienced by an individual as physically and emotionally harmful or threatening and that has lasting adverse effects on the individual’s physical, social, emotional, or spiritual well-being.⁴” It can affect individuals, families, groups, communities, specific cultures, and generations and overwhelms their ability to cope and initiates the flight, fight or freeze response.⁴ Adverse childhood experiences (ACEs) which fall under the umbrella of this definition are potential traumatic events that occur before the age of 18 and include many types of different childhood abuse and neglect that range from emotional, physical, and sexual abuse to living in household dysfunction or with people who suffer from mental illness. A landmark study conducted by the Centers for Disease Control and Prevention and Kaiser Permanente from 1995-1997 asked more than 17,000 adults about ACEs. They found that nearly two-thirds of participants experienced at least 1 ACE and more than 1 in 5 noted 3 or more.⁵ ACEs are important because they have been linked to a higher likelihood of chronic diseases, mental health disorders and reduced life expectancy.⁵ In pregnancy, ACEs have been linked to poor birth outcomes.^6,7 There are no national statistics given on how many birthing parents are affected by ACEs in a given year, but when you look at individual research studies that have screened birthing patients for ACEs, we find the amount of parents affected to be similar to the landmark ACE study or even higher. An example of this is a study looking at ACEs and poor birth outcomes among 1,848 low-income women in Wisconsin.⁸ Descriptive analyses showed that 84.4% of women had at least one ACE and 68.2% reported multiple ACEs.⁸ Therefore, we should anticipate that majority of parents have experienced ACEs, and this could potentially impact their birthing experiences.

Trauma Disclosure

So, trauma is not always disclosed to the healthcare team by parents further confounding the process of being able to provide targeted interventions to those affected. A common trauma response is to minimize, dissociate or avoid the trauma as a coping strategy and as a result memories can be lost, and parents may not even remember being traumatized.^7,8 This is one explanation for low reporting of trauma. But another question we should ask of ourselves as perinatal healthcare professionals is how well are assessing the presence of trauma. As a perinatal professional do you ask questions about trauma on your intake forms? Do you screen for ACEs? Do you have referral sources to recommend to parents that need additional support? Do you know how to respond to a positive screen? Another explanation for low disclosure rates of trauma could be that we are not screening parents for trauma enough. However, as I was taught – a decision to screen also means a decision to treat. So before responding to a call to action to screen, make sure you have a way to treat or refer parents to the appropriate mental health resources in your community.

SM: How can previous trauma impact a person’s labor and birth and early parenting experience? 

MD: How Trauma Changes the Birth Experience

So, there are several ways in which trauma can impact labor and birth. First, parents that have experienced ACEs are more likely to have pregnancy and birth complications like Gestational Diabetes, Preeclampsia, pre-term birth and perinatal mood and anxiety disorders.⁷ The presence of these disorders can lead to more medical interventions because they are not able to apply all Six Healthy Birth Practices. High risk pregnancies may involve inductions, elective cesarean sections, more medical monitoring that restricts movement. Standard medical procedures, policies and practices can trigger parents and cause re-traumatization, especially when they are invasive. Blood draws, cervical checks, not providing enough privacy and too much physical exposure of the birthing parent can cause much distress to a person that has been abused.⁹ Examinations can make parents feel violated and if they are not a part of the decision-making process, they can feel powerless, reminding them of times when they had no choice, and their autonomy was taken away by their perpetrator.⁹ Therefore, it is important that care is collaborative and autonomy and parent competence in making decisions is respected and upheld. Parents that have experienced trauma may be hypervigilant and have a distorted view of abuse.⁹ As noted by authors Penny Simkin and Phyllis Klaus in their book, When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse on Childbearing Women, we learn that survivors of sexual abuse view touch as a violation and should never be touched without permission or by surprise.⁹

Trauma and Early Parenting

Trauma can affect bonding and attachment between the birthing parent and child.^7,9 Birthing people that have been sexually abused by may feel fearful and detached from a child who shares the same gender as their perpetrator.⁹ Referring to Simkin and Klaus (2004), [birthing people] who cope with pain and stress through dissociation may have dissociated themselves during labor leaving them unable to immediately bond with the baby.⁹ A traumatic birth may override thoughts of the baby and childhood abuse may leave the birthing parent with little instinct of [parenting].⁹  Breastfeeding issues may involve flashbacks of abuse brought on by the baby sucking and pain, viewing the baby as the perpetrator and modesty issues around exposing the breast.⁹ Children of parents that have experienced ACEs have a higher risk of developmental and behavioral issues that may persist into adulthood because of lack of attachment in early caregiving.¹⁰ The quality of early caregiving is essential in shaping human development but when care is insensitive and inconsistent, children form mental representations of their caregivers as unreliable and untrustworthy leading to insecure attachment that extends beyond parent-child relationships and can impact attachment in future relationships.¹⁰

SM: What is trauma informed care? What kind of training do health care providers (physicians, midwives, and L&D nurses) typically receive that prepare them for supporting people with a history of trauma? 

MD: Defining Trauma Informed Care

According to Substance Abuse and Mental Health Services Administration (SAMHSA), trauma informed care (TIC) is an intervention and organizational approach that recognizes how trauma may affect an individual’s life and their response to healthcare services from initial contact to treatment.⁴ There are many definitions of trauma and various frameworks used across organizations to deliver trauma informed care but I favor the definition offered by SAMHSA because it is comprehensive and optimistic describing survivors as strong and resourceful rather than a disease process. According to SAMHAS, TIC is a strengths-based delivery service approach “that is grounded in understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment.⁴” It involves being vigilant in anticipating and avoiding re-traumatization and upholds the importance of consumer participation in the development, implementation, and evaluation of trauma services.⁴ Providers who practice from a trauma informed approach view survivors of trauma as strong, resilient and recognize that trauma related symptoms and behaviors originate from adapting to trauma experiences rather than labeling them as pathology.⁴

SAMHSA also notes there are three unifying principles to TIC including 1) realizing the prevalence of trauma; 2) recognizing how trauma affects all individuals involved in the program, organization or system including patients and their own workforce and 3) responding by putting the knowledge into practice.

Healthcare Provider Training on Trauma

I don’t believe healthcare providers like myself receive enough training in school to understand how trauma impacts every area of someone’s life and how that trauma can impact their experience with healthcare and the power dynamics that exists between patients and their medical provider. In Western medicine, we separate the mind and body while many eastern cultures view the mind, body and spirit as one unit. This means that we treat physical and mental issues separately even though mental health issues can cause physical conditions and vice versa. When we separate the two, we miss the whole picture and compromise our ability to deliver comprehensive care that is truly healing and restorative. When you think of ACEs as just as psychological risk factor and fail to link it to biological or medical conditions like Gestational Diabetes and Preeclampsia, you miss the opportunity to counsel and coach parents on how to reduce their risk for these conditions and refer them for additional mental health and community-based resources that could benefit them.

Trauma Awareness Depends on Specialty

I think the amount of training healthcare providers receive on trauma has a wide range and depends on their specialty and interests in treating patients from a holistic framework. Certainly, mental healthcare providers are adept at understanding the effects and long-lasting impact of trauma on an individual’s mental and perhaps their physical health. I’m not so sure other healthcare providers share this same aptitude as their mental health counterparts. As a Family Nurse Practitioner with pediatric experience, I can vividly remember being taught in school and on the job about atraumatic care and being careful not to traumatize our pediatric population i.e. performing invasive procedures in the treatment room rather than their hospital bed so they would not associate pain in their safe space and where they rest. Unfortunately, I do not remember such precautions being taught in the care of adults or primary care. It took me thirteen years from the time I graduated with my bachelor’s degree in nursing until 2019 when I was first introduced to the mind-body connection and how stress from trauma could cause epigenetic changes and lead to disease, disability, and increased mortality in trauma survivors. In 2020, I learned about ACEs for the very first time and how it was connected to health, well-being, and longevity. So, there are a plethora of continuing education programs that address the effects of trauma that healthcare providers can undertake.

Trauma Informed Care in Academia

In my experience as a practitioner and in academia, I believe we can do a better job of integrating TIC into curricula from the very beginning of someone’s training in healthcare. I attempted to do this in a graduate nursing course I was teaching in the Spring of 2020 when I asked my class why Black women suffer from poorer pregnancy and birth outcomes than other cultural groups. These students were sharp and gave me great answers based on physiological and genetic differences that may predispose Black women to the health disparities we see here in the United States and globally. They were shocked to learn that historical trauma from slavery, racism and harsh political climates are types of traumas that cause chronic stress leading to poor pregnancy outcomes. Helping students make the connection between trauma and mental health and chronic medical conditions is important and needs to start while they are still in school. This rings true for every type of healthcare provider from physicians, nurses, midwives, ultrasound technicians, pharmacists and every person or specialty that interacts with parents during the childbearing year.

SM: What can childbirth educators do to be sure that they are a)meeting the needs of people in their classes who may have a trauma history (disclosed or undisclosed) and b) not doing anything (even unintentionally) that causes further harm to this vulnerable population?

MD: Childbirth educators can meet the needs of parents affected by trauma by applying the three unifying principles of TIC.

Realizing the prevalence of trauma. That begins with realizing how pervasive trauma is among birthing parents which can range anywhere from two-thirds to eighty-four percent of parents based on different research studies.⁸ If your class is representative of the general population and reflect any of the studies that have been done looking at ACEs, it is probably safe to assume that every 1 in 2 parents attending your class has experienced some type of trauma before the age of 18. Intake questionnaires may include questions about trauma but be ready to offer parents resources like a recommendation to a trauma informed therapist if you receive a positive screen. If it is within your scope of practice and comfort level, you can use instruments like ACEs to screen for the presence of early trauma. In some cases, parents may still not disclose their trauma history and that’s okay. Given the high rates of ACEs, we should be using TIC as a universal precaution and anticipate the possibility of trauma from our initial contact with parents irrespective of screening.^{4, 11}

Recognizing how trauma affects the individual. The second unifying principle is recognizing how trauma affects individuals involved in your classes. Simkin and Klaus (2004) note that survivors of sexual abuse can respond to childbirth classes with boredom, sleepiness and/or hostility.⁹ Don’t be offended if you notice these behaviors in your parents and remember that some of the behaviors originated to cope with past trauma. Be aware of what teaching methods are not getting the engagement you desire from participants and be flexible in adopting strategies that resonate with your audience. Be aware that parents with pregnancy complications (medical and psychological), increased fear and anxiety around childbirth, and severe pregnancy symptoms such as intense nausea/vomiting may be related to past trauma.⁹

Responding by putting knowledge into practice. Since we are aware of the prevalence of trauma and the signs and symptoms it may cause, the last step is to put your knowledge into practice. Practicing TIC requires that we try not to re-traumatize parents through our communication, interactions, practices, and procedures.^4,7,11 TIC is compassionate and respectful of parents and involves upholding their autonomy and competence in collaborative decision making. Be mindful that certain invasive procedures such as cervical checks, blood draws and catheterization may trigger some parents.⁹ Teach parents in childbirth classes how to advocate for themselves and their privacy during childbirth. Realize that certain language like “surrender to pain,” environmental stimuli like dimming lights and playing music, certain smells or having parents lie on the floor to practice comfort measures may be perceived differently by those that have been abused.⁹ Although we place categories on the type of trauma an individual experiences, their trauma experience and response is unique, and as such they will be the best resource to inform you of what works and does not work for them. Remind parents that they are in control of their learning experience and if something doesn’t resonate with them or feels uncomfortable, they can always disengage from the activity.

SM: How would you answer this question: “My session at the 2022 Lamaze Conference will be a success if…”

MD: Become trauma informed. My hope is that after this session, participants will be more aware of the pervasiveness of trauma within our society and perinatal community. They will realize the universal effect of trauma, recognize how it presents in the perinatal population being careful to employ practices that avoid re-traumatization. Given the high rates of trauma in the lives of birthing people, TIC should be used as a universal precaution regardless of whether trauma screenings such as ACEs are used or not.¹¹

Be compassionate. The Latin word for compassion means to suffer along with. When we are compassionate, we see someone else’s suffering with a desire to alleviate it by responding with kindness. Some of the parents you encounter will have endured the most severe hardships early in life that have adversely affected their physical, mental, emotional, social/economical, and spiritual health. Be gentle and patient with them. Show them they are valued member of the healthcare team by including them in the decision making process. Ask them about their birth preferences and what modifications in their birth plan would make them feel comfortable.

A trauma informed society. Finally, I hope participants will be moved to be more trauma informed in their communities, neighborhoods, churches, school, work and anywhere and everywhere they encounter people who have likely experienced trauma creating a more trauma informed society. It has become clear to me, through training, experience and sifting through the research, that the way we dismantle the debilitating effects of trauma is through love, kindness, and compassion. TIC in healthcare settings and organizations that interact with patients and the perinatal community is just the beginning, if we are to see a true, robust trauma response that produces a healthier society that enjoys longevity it will take all of us being aware of the presence of trauma, its signs and symptoms and a response of kindness to those who have suffered.

References

1.     Gordon J. The Transformation: Discovering Wholeness and Healing After Trauma. Harper Collin Publisher; 2019.

2. Clark D. Transforming Trauma Self-Care Resources: James Gordon M.D. Published March 15, 2022. Accessed on September 19, 2022. https://www.carrolup.info/transforming-trauma-self-care-resources-james-gordon-md/.

3.     Hall S, White A, Ballas J, Saxton SN, Dempsey A, Saxer K. Education in trauma-informed care in maternity settings can promote mental health during the COVID-19 pandemic. Journal of Obstetrics Gynecology and Neonatal Nursing. 2021. May; 50(3):340-351. DOI:https://doi.org/10.1016/j.jogn.2020.12.005

4.     Substance Abuse and Mental Health Services Administration. Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) 13-4801. Rockville, MD: Substance Abuse and Mental Health Services

Administration, 2014.

5.     National Conference of State Legislatures. Adverse childhood experiences. Accessed September 19, 2022. https://www.ncsl.org/research/health/adverse-childhood-experiences-aces.aspx.

6.     Racine N. Ereyi-Osas W., Killam T., McDonald S. & Madigan S. Maternal-child outcomes from pre-to post implementation of a trauma-informed care initiative in the prenatal care setting: A retrospective study. Children. 2021; 8 (1061). https://doi.org/10.3390/children8111061.

7.     Sperlich M.,Seng JS., Li Y., Taylor J. & Bradbury-Jones C. Integrating trauma-informed care into maternity care practice: Conceptual and practical issues. Journal of Midwifery & Women’s Health. 2017; 62:661-672.

8.     Mersky JP. & Lee CTP. Adverse childhood experiences and poor birth outcomes in a diverse, low-income sample. BMC Pregnancy and Childbirth. 2019; 387; https://doi.org/10.1186/s12884-019-2560-8.

9. Simkin P. & Klaus P. When Survivors Give Birth: Understanding the Effects of Early Sexual Abuse on Childbearing Women. Classic Day Publishing; 2004.

10.   Cooke JE, Raine N., Plamondom A., Tough S. & Madigan S. Maternal adverse childhood experiences, attachment style, and mental health: Pathways of transmission of child behavior. Child Abuse and Neglect. 2019; 93; 27-37. https://doi.org/10.1016/j.chiabu.2019.04.011

11.   Racine N., Killam T. & Madigan S. Trauma-informed care as a universal precaution: Beyond the adverse childhood experiences questionnaire. Jama Pediatrics. 2020; 174(1):5-6. doi:10.1001/jamapediatrics.2019.3866

About Mechelle Duran, DNP, APRN, FNP-C, CDCES, BC-ADM, NBC-HWC, LCCE

Dr. Mechell Duran is a trauma-informed pregnancy health coach, diabetes specialist, and a Lamaze-certified childbirth educator. She has over fifteen years of healthcare experience as a nurse and family nurse practitioner and has been trained to facilitate comprehensive trauma programs by the Center of Mind Body Medicine. She is the owner of Sugar Bump Coach, a community where women with Gestational Diabetes can be inspired and informed with recipe ideas and evidenced-based information from pregnancy to the 4th trimester. She resides in South Florida with her husband, their 4-year-old son and two furry children, sugar and brownie. In Dr. Duran’s spare time, she enjoys cooking, making aromatherapy recipes, journaling and attending her local church.

Published: September 21, 2022

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