Tag Archives | Trauma

Insights into Working with Breastfeeding Mothers Who Have Experienced Trauma

By Dianne Cassidy, IBCLC

Photo by 55Laney69 via Flickr Creative Commons

Photo by 55Laney69 via Flickr Creative Commons

When I first began working with new mothers, it was with a local community program.  The more women I met, the more I saw a link between breastfeeding and trauma.  Most of the women that I assisted had a limited support system available to them, and limited education.  In many instances, we were the only ones who offered the support they needed to initiate breastfeeding.  As a bond was built during pregnancy, sometimes a new mother would open up and talk about her personal history, things that she may have endured during childhood, or in the not-so-distant past.

I have heard some terrible stories.  Many of these stories come with a happy ending of sorts – the fairy tale where the woman finds her strength and confidence and realizes that she is capable.  Some are not as favorable, and can haunt you for years.  I became more and more interested in how abuse can impact a woman’s decision to breastfeed.  I decided to make this the topic of a research project while completing my Bachelor’s degree a couple of years ago. While important, coming face to face with the emotional scars of many of these women was very challenging.

While doing my research, the literature review unearthed some interesting information about abuse and breastfeeding, particularly child sexual abuse (CSA) and how it may impact breastfeeding initiation.  When working with the community programs, one of the focuses of breastfeeding support was teen age mothers.  We have a high rate of teenage pregnancy here (enough that there is an entire high school dedicated to teen mothers) and teen mothers have been known to have a low breastfeeding rate. Childhood sexual abuse prevalence among adolescent mothers is close to 50%. Adolescents who have been abused as children are more likely to become sexually active at a younger age than those not abused.  Adolescent survivors of CSA were 3x likely to become pregnant than those who were not abused.  Studies reflect that breastfeeding is not readily initiated among adolescent mothers.  This is not to say that these mothers will not initiate breastfeeding at all, but those who do initiate are more likely to wean earlier than adolescent mothers who are not victims of CSA.

One of the most wonderful things about breastfeeding is the close, intimate connection between mother and baby.  For a survivor of CSA, this may be an unfamiliar, unwelcome sensation.  Intimacy disturbance and dissociation are consequences that are likely to influence feeding decisions of adolescent mothers.  CSA victims and survivors may struggle with trust issues, building relationships and emotions.  Abusers are often someone that the victim is familiar with – family friend or relative for example, leading to feelings of betrayal and vulnerability.

Trust is a tricky thing.  It’s important that a woman has a good relationship with her provider, a trustworthy relationship.  Without this, information is skewed.  Communication is key.  It may be difficult for a survivor to confide her concerns regarding her feeding choice to someone if a relationship of trust has not been established. When preparing for labor, a provider can gain the trust of their patient if they listen carefully and validate her feelings, exploring what concerns she may have in regards to breastfeeding.  When working with expectant women, or in particular adolescent mothers, education is an important part of breastfeeding initiation.  Educate expectant mothers about their feeding choices in a non judgmental manner.  Mothers with CSA history are likely to have come from a family environment that is chaotic, deprived and emotionally dysfunctional.

As a lactation consultant, it can be difficult to explore options other than breastfeeding with a new mother.  We know that breastfeeding is the optimal choice, and mothers know this to be true as well.  Sometimes, exploring other alternatives is necessary.  The role of the provider is to offer the patient evidence-based information so that the patient can make the appropriate decision.  Once the information has been disclosed, it is the role of the provider to offer support, no matter what that decision is and how the provider feels about that decision.

Every new mother and baby deserves the opportunity to enjoy a breastfeeding relationship, free of distress, no matter what the history may be.  I feel honored that I have been able to assist with offering this to survivors, encouraging mothers and babies to get the best start in their life together.

References:

Bowman KG (2007). When breastfeeding may be a threat to adolescent mothers. Issues in Mental Health Nursing, 28(1), 88-89.

Brooks, EB (2012). Legal and Ethical Issues for the IBCLC. Jones and Bartlett.

photo-2Dianne Cassidy is a lactation consultant in Rochester, New York. She became interested in the field of lactation consulting after breastfeeding her own children.  After spending thousands of hours working with new mothers and babies, she was able to sit for the board exam, which qualified her as an International Board Certified Lactation Consultant (IBCLC). In 2010, she completed her Advanced Lactation certification and BS in Maternal Child Health/Lactation.  She is dedicated to serving mothers and babies, and has the unique ability to identify with the needs and concerns of new mothers. She also has experience working with older babies and mothers returning to work and wishing to continue their breastfeeding relationship. She has worked extensively with women who have survived trauma, babies struggling with tongue tie, birth trauma, milk supply issues, attachment, identifying latch problems, returning to work and breastfeeding multiples.

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Childbirth-Related Psychological Trauma: An Issue Whose Time Has Come

By Kathleen Kendall-Tackett, Ph.D., IBCLC, RLC, FAPA

I first became interested in childbirth-related psychological trauma in 1990. Twenty-three years ago, it was not on researchers’ radar. I found only one study, and it reported that there was no relation between women’s birth experiences and their emotional health. Those results never rang true for me. There were just too many stories floating around with women describing their harrowing births. I was convinced that the researchers got it wrong.

To really understand this issue, I decided to immerse myself in the literature on posttraumatic stress disorder (PTSD). During the 1980s and 1990s, most trauma researchers were interested in the effects of combat, the Holocaust, or sexual assault. Not birth. But in Charles Figley’s classic book, Trauma and Its Wake, Vol. 2 (1986), I stumbled upon something that was quite helpful in understanding the possible impact of birth. In summarizing the state of trauma research in the mid-1980s, Charles stated that an event will be troubling to the extent that it is “sudden, dangerous, and overwhelming.” That was a perfect framework for me to begin to understand women’s experiences of birth. It focused on women’s subjective reactions, and I used it to describe birth trauma in my first book, Postpartum Depression (1992, Sage). {ed. note – this book is now in its 3rd edition and is titled Depression in New Mothers (Routledge, 2010).}

Photo by Tristan Wallace via Flickr Creative Commons

Photo by Tristan Wallace via Flickr Creative Commons

Since writing my first book, there has been an explosion of excellent research on the subject of birth trauma. The bad news is that what these researchers are finding is quite distressing:

High numbers of American women have posttraumatic stress symptoms (PTS) after birth.

Some even meet full criteria for posttraumatic stress disorder. For example, Lamaze International’s Listening to Mothers’ Survey II included a nationally representative sample of 1,573 mothers. They found that 9% met full-criteria for posttraumatic stress disorder following their births, and an additional 18% had posttraumatic symptoms (Beck, Gable, Sakala, & Declercq, 2011). These findings also varied by ethnic group: a whopping 26% of non-Hispanic black mothers had PTS. The authors noted that “the high percentage of mothers with elevated posttraumatic stress symptoms is a sobering statistic” (Beck, et al., 2011).

If the number of women meeting full-criteria does not seem very high to you, I invite you to compare it to another number. In the weeks following September 11th, 7.5% of residents of lower Manhattan met full criteria for PTSD (Galea et al., 2003).

Take a minute to absorb these statistics. In at least one large study, the rates of full-criteria PTSD in the U.S. following childbirth are now higher than those following a major terrorist attack.

In a meta-ethnography of 10 studies, women with PTSD were more likely to describe their births negatively if they felt “invisible and out of control” (Elmir, Schmied, Wilkes, & Jackson, 2010). The women used phrases, such as “barbaric,” “inhumane,” “intrusive,” “horrific,” and “degrading” to describe the mistreatment they received from healthcare professionals.

“Isn’t that just birth?” you might ask. “Birth is hard.” Yes, it certainly can be.

But see what happens to these rates in countries where birth is treated as a normal event, where there are fewer interventions, and where women have continuous labor support. For example, in a prospective study from Sweden (N=1,224), 1.3% of mothers had PTSD and 9% described their births as traumatic (Soderquist, Wijma, Thorbert, & Wijma, 2009). Similarly, a study of 907 women in the Netherlands found that 1.2% had PTSD and 9% identified their births as traumatic (Stramrood et al., 2011). Both of the countries reported considerably lower rates of PTS and PTSD than those found in the U.S.

How Does This Influence Breastfeeding?

Breastfeeding can be adversely impacted by traumatic birth experiences, as these
mothers in Beck and Watson’s study (Beck & Watson, 2008) describe:

“I hated breastfeeding because it hurt to try and sit to do it. I couldn’t seem to manage lying down. I was cheated out of breastfeeding. I feel that I have been cheated out of something exceptional.”

“The first five months of my baby’s life (before I got help) are a virtual blank. I dutifully nursed him every two to three hours on demand, but I rarely made eye contact with him and dumped him in his crib as soon as I was done. I thought that if it were not for breastfeeding, I could go the whole day without interacting with him at all.”

Breastfeeding can also be enormously healing, and with gentle assistance can work even after the most difficult births.

“Breastfeeding became my focus for overcoming the birth and proving to everyone else, and mostly to me, that there was something that I could do right. It was part of my crusade, so to speak, to prove myself as a mother.”

“My body’s ability to produce milk, and so the sustenance to keep my baby alive, also helped to restore my faith in my body, which at some core level, I felt had really let me down, due to a terrible pregnancy, labor, and birth. It helped build my confidence in my body and as a mother. It helped me heal and feel connected to my baby.”

What You Can Do to Help

There are many things that lactation consultants can do to help mothers heal and have positive breastfeeding experiences in the wake of traumatic births. You really can make a difference for these mothers.

  • Anticipate possible breastfeeding problems mothers might encounter. Severe stress during labor can delay lactogenesis II by as much as several days (Grajeda & Perez-Escamilla, 2002). Recognize that this can happen, and work with the mother to develop a plan to counter it. Some strategies for this include increasing skin-to-skin contact if she can tolerate it, and/or possibly beginning a pumping regimen until lactogenesis II has begun. She may also need to briefly supplement, but that will not be necessary in all cases.
  • Recognize that breastfeeding can be quite healing for trauma survivors, but also respect the mothers’ boundaries. Some mothers may be too overwhelmed to initiate or continue breastfeeding. Sometimes, with gentle encouragement, a mother may be able to handle it. But if she can’t, we must respect that. Even if a mother decides not to breastfeed, we must gently encourage her to connect with her baby in other ways, such as skin-to-skin, babywearing, or infant massage.
  • Refer her to resources for diagnosis and treatment. There are a number of short-term treatments for trauma that are effective and widely available. EMDR is a highly effective type of psychotherapy and is considered a frontline treatment for PTSD. Journaling about a traumatic experience is also helpful. The National Center for PTSD has many resources including a PTSD 101 course for providers and even a free app for patients called the PTSD Coach. In addition, the site HelpGuide.org also has many great resources including a summary of available treatments, lists of symptoms, and possible risk factors.
  • Partner with other groups and organizations who want to reform birth in the U.S. Our rates of PTS and PTSD following birth are scandalously high. Organizations, such as Childbirth Connection (take the opportunity to view their reports on the important issues regarding birth in the US HERE) , are working to reform birth in the U.S. 2013 may be a banner year for recognizing and responding to childbirth-related trauma. The new PTSD diagnostic criteria will be released in May in the DSM-5, and more mothers may be identified as having PTS and PTSD.

There has also been a large upswing in U.S. in the number of hospitals starting the process to become Baby Friendly, which will encourage better birthing practices. I would also like to see our hospitals implementing practices recommended by the Mother-friendly Childbirth Initiative.

There is also a major push among organizations, such as March of Dimes, to discourage high-intervention procedures, such as elective inductions.  And hospitals with high cesarean rates are under scrutiny. This could be the year when mothers and care providers stand together and say that the high rate of traumatic birth is not acceptable, and it’s time that we do something about it. Amy Romano, of Childbirth Connection,  describes it this way:

As we begin 2013, it is clear from my vantage point at the Transforming
Maternity Care Partnership that the transformation is underway. In Childbirth Connection’s nearly century-long history, we’ve never seen so much political will from leaders, so much passion from grassroots advocates, and so much collaboration among clinicians and other stakeholders. This new landscape presents many new opportunities for educators and advocates.  

There is much you can do to help mothers who have experienced birth-related trauma. Whether you join the effort to advocate for all mothers, or simply help one traumatized mother at a time, you are making a difference. Thank you for all you do for babies and new mothers.

Here are some helpful links to share with mothers:


Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA is a health psychologist and board-certified lactation consultant. Dr. Kendall-Tackett is Owner and Editor-in-Chief of Praeclarus Press. She is a research associate at the Crimes against Children Research Center at the University of New Hampshire and a clinical associate professor of pediatrics at Texas Tech University School of Medicine in Amarillo, Texas. She is Editor-in-Chief of the journal, Clinical Lactation, a Fellow of the American Psychological Association, and is president elect of the APA Division of Trauma Psychology. This post is a preview of her editorial in the Vol 3-4 of Clinical Lactation. You can read more about Kathy at www.KathleenKendall-Tackett.com.

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