Understanding the Childbirth Experiences of Childhood Sexual Abuse Survivors: A Phenomenological Study

This study describes the childbirth experiences of survivors of childhood sexual abuse, using an interpretative phenomenological approach. Data collection involved in-depth, semistructured interviews of four women who gave birth to a baby within the last 5 years. Using Interpretative Phenomenological Analysis, three superordinate themes emerged: control, anxiety, and detachment. This contributes to the current body of research by extending knowledge on what it means to experience childbirth for survivors of childhood sexual abuse, told by the woman herself. These findings are especially important in understanding what is required in providing safe, sensitive care for all childbearing women and has important implications for practice, education, and further research.


INTRODUCTION
Pregnancy and birth are significant times in a woman's life.For some, this period is difficult and leads to significant emotional distress. 1Pregnancy and birth are different and can often be negative for survivors of childhood sexual abuse. 2 Childhood sexual abuse is a significant problem; approximately one in five women have experienced it. 3The intimate nature of pregnancy and birth precipitate the negative effects of childhood sexual abuse for the first time, or past experiences can be re-triggered.][10] Childbirth can also remind CSA survivors of their experiences of abuse. 2 This remembrance can be precipitated by involuntary physical changes during pregnancy, the intimate nature of childbirth, difficulty with trust (particularly in relationships involving a power differential ), and pain in body areas that remind survivors of their abuse.Additionally, childbirth can be an uncontrolled event in which decisions and interventions may be made quickly for the safety of the mother and baby.Interventions during childbirth may have unintended psychological effects on the mother.
The few qualitative studies that have been conducted support the observation that childbirth can be a distressing time for survivors of CSA.2][13] Also, survivors of CSA often experience emotional distress from interventions involving touch. 13These negative childbirth experiences can have a variety of effects on women, including feelings of revictimization, emotional trauma, 11,13 and the emergence or resurfacing of postpartum posttraumatic stress disorder. 14,15Other qualitative accounts have relied on a third party describing behaviour during childbirth, 11 and examining specific aspects of birth such as "touch" 12 or maternity care needs in general. 15,16This study is uniquely situated to explore childbirth as a whole, as described by the survivor herself.

METHODS
An understanding the uniqueness, complexity, and universality of childbirth experience was the basis for exploring the experience of childbirth among CSA survivors by using an interpretative phenomenological approach.Guided by the philosophies of a Heideggerian interpretative phenomenological perspective as proposed by Smith, 17 we asked, "How do childhood sexual abuse survivors experience childbirth?" Interpretative phenomenological analysis (IPA) involves using personal accounts to make sense of people and how they are situated in their world .The researcher and the participant create the research together; Smith and colleagues called this reciprocal analysis a two-step hermeneutic process. 18sing purposive sampling for this study, women were recruited from eight midwifery practices in southwestern Ontario.All clients who were being discharged from midwifery care six weeks post partum were given a pamphlet inviting them to participate in the study.Interested participants contacted the primary researcher via email, and a follow-up telephone call was arranged to determine eligibility.Four women consented to participate in the study.
The hour-long interviews were made up of open-ended questions based on the IPA.The primary researcher asked few questions , and this open process enabled participants to guide the flow of the interview, focusing discussion on the areas and themes that were most important to them.

ETHICS
Ethics approval was obtained through the university's research ethics board.As part of the recruitment strategy, the pamphlet outlining the study made clear researchers' interest in a specific sample of women: survivors of CSA.The research team did not contact a potential participant until that person, because of his or her interest, made initial contact.This method of recruitment was chosen to keep participants from feeling coerced into participating.
The research study was based on the premise that the participants had a history of CSA.Although the methods of the study did not include asking participants to explicitly recall abuse experiences, we recognized that some participants might experience distress in discussing childbirth experiences.As such, participants were advised that they could choose not to answer any question they wished not to answer; they also could choose to terminate the interview at any time.No participant distress was noted during the interviews.However, if distress were noted, the interview was to be stopped and emotional support provided.
As consented to, participants' personal information would be released only in the event that they expressed intention to harm themselves or their infant, or if the interviewer suspected any form of child neglect or endangerment.No participants expressed any suicidal ideations, nor did the interviewer have any concern about child neglect or endangerment.All participants were provided with resources at the beginning of the Participants experienced psychological avoidance or a blocking out of experiences in response to the stressful stimuli to which they were exposed.
[ [ interview, including Healthy Babies Healthy Children, Sexual Assault Centre of Hamilton, Crisis Outreach and Support Team, and Women's Health Concerns Clinic.Although the participants were considered vulnerable (being both women and CSA survivors), this protocol was considered of minimal risk due to the nature of the interview and discussion.

DATA ANALYSIS
The four-step process of IPA presented by Smith-(1) looking for themes in the first case, (2) looking for connections, (3) creating a table of themes, and (4) continuing analysis with other cases-was used to transcribe and analyze the interviews. 17Through an iterative process, the researchers derived themes and clustered the themes by making connections across them.The primary researcher organized the themes (step 3) and continued the data analysis across all interviews.

RESULTS
From the in-depth data analysis, three main themes emerged: control, detachment, and anxiety (Figure 1).

Control
Aspects of control were noticed in the participants' choice of birthplace, as well as in their desire to feel or avoid pain.A paradoxical presentation was noted: two participants wanted to experience the painful experience of giving birth, whereas two participants wanted to avoid all pain.The former desired to experience childbirth at home, while the latter wished to give birth in hospital.
Aspects of control were also noticed in the participants' experience of interventions involving touch and interventions that limited movement or mobility.One participant, Kat, described the difficult experience of having a stretch and sweep.
I really struggled with the idea of [the obstetrician] doing a stretch and sweep.Because, I think pain…around that…even though birth is painful too, right?I still struggled with…like, I didn't know her; it was just my first visit.Like, I had only seen her once by the time she wanted to do a stretch and sweep, and I just…I really struggled, I hated that I struggled,…I hated that I was having those feelings.…SoI was aware that I was feeling sensitive and vulnerable and not comfortable,…and knew it was related to being abused as a child.
She also described an experience with a male obstetrician conducting a pelvic examination."He couldn't even really examine me, I was so tense.So he said to me, 'if you can't take an examination,…I don't know how you're going to…you know…'" Another participant, Carrie, described her experience of a stretch and sweep as follows: So I had a stretch and sweep done at that time, and it was literally, literally, horrible pain…so, so bad…I was screaming in pain.It hurt so so bad.
Kat felt a strong sense that her body was "broken," unable to do or tolerate what labouring women manage.From the moment I had the epidural, the pain…like, I screamed, and the feeling of loss of move…like you can't move...and the feeling of loss of control really spiraled me to anxiety, actually.I felt like having a panic attack on the table, but I didn't tell anybody, I just kept it to myself thinking, "you should be able to handle this"…I was kind of freaking out.
Two participants made an explicit connection between how their abuse experiences affected their desire or discomfort with these interventions, while other participants did not.

Anxiety
This theme describes the anxiety and worry participants felt about their upcoming childbirth and the anxiety they felt about how their past abuse experiences would affect their labour.The term "anxiety" was used consistently in all participant interviews.
Madison described her anxieties about what labour would be like, as follows: I did a bit of catastrophic thinking, like it's going to be awful.I'm going to be traumatized, I'm going to be immobilized, I'm going to be a wrecking…a bawling mess.I'm not going to feel bonded with this baby.
Carrie expressed anxiety about the pain of childbirth, her anxiousness in focusing on her baby's well-being during labour, and her anxiety about cervical checks.
Oh my God…I would tense up…tense right up, my legs would tense up, I was anxious about it because I knew it would be a little bit uncomfortable.…I was just anxious…anticipating the pain.Like, I didn't know how bad it was going to be, I couldn't imagine, like, a "human" coming out of you… something that big…like, I just did not know how bad it was going to hurt.…I felt like I could not stop watching the monitor and watching the baby's heart rate.…Iwas just making sure that he wasn't stressed out.
"Triggering," as expressed by the participants in this study, was the remembering or reexperiencing of past abuse experiences as a response to their situation.Madison wondered how childbirth may have triggered her sexual abuse experiences.
Kind of worried about this kind of connection to my sexual abuse trauma, so was I going to be retriggered?Was I going to be overwhelmed?What was it going to be like?So not necessarily about the physical…I wasn't worried about the physical piece of it, it was more around the…emotional trauma.
Like, what was it going to feel like?

Detachment
Participants experienced psychological avoidance or a blocking out of experiences in response to the stressful stimuli to which they were exposed.For some, this manifested itself as a gap in their memory of certain experiences in pregnancy and childbirth, as a method of coping .Kat described her detachment from her pregnancy and her bond with her unborn baby.
I think emotionally I don't think I was bonded to her in the same way.…like,this "ok, I'm growing a human being in me," but not sort of knowing the relationship that I would be able to have with her down the road.I don't know if that was anything around depression or anxiety, I think it was just sort of a detachment.
Although pregnancy was not the primary focus of this study, participants did express feelings of detachment from their pregnancies and unborn babies and consistently described detachment during childbirth.They expressed or evidenced detachment in different ways.Another participant, Carrie, intentionally "blocked out" thoughts of her childbirth because she was not comfortable thinking about it: "If I didn't think about it, I didn't have to deal with it."Rather, she thought she would avoid thinking about the birth until it was approaching."I almost blocked it out, the entire pregnancy…up until the end…it was just nerve wracking…" Madison described the detachment she experienced during childbirth as an inability to hear or to focus on external stimuli: And then the piece around…so I was pushing and didn't hear.So I was definitely in a zone because was pushing with gritted teeth, the whole bit.The [midwife] I guess told me to stop because the cord was wrapped around the baby's neck, and I didn't hear her say that, and then they all screamed at me, "you need to stop!"

DISCUSSION
13]16 Given the high prevalence of CSA and the influence that it can have in all spheres of women's lives, this phenomenological study is uniquely situated, having captured the childbirth experiences of CSA survivors.
16,19 Rhodes and Hutchison reported that the most prominent observed labour style for survivors of CSA was "fighting."They described "fighting" as the "quintessential" labour style in which women are described as being in conflict with authority; resisting interventions, and examinations .They further state that women who exhibit this fighting style have longer labours, more operative interventions, and greater pain. 11The participants in this study, however, asserted control (or the desire to experience a loss of control) by way of their detailed birth plans, requests for specific birthplaces, and interventions .Control was evident when participants described their hopelessness and worry during painful experiences and during interventions involving touch.Control was also a consistent theme in Montgomery's metasynthesis examining the maternity care needs of women who were sexually abused as children. 16Consistent with the findings in the current study, participants sought to control with a need for self-determination, a need for privacy, and the desire for a controlled environment for birth. 20onsistent with other research, 20 participants reported feelings of anxiety repeatedly.These feelings were manifested in worry about their childbirth, as well as anxiety over how their labour might "trigger" a re-experiencing of their abuse .Hobbins termed this type of anxiety "hypervigilance." 21ther literature explicates the link between anxiety and increased rates of elective cesarean sections. 22lthough the desire to have a cesarean section was not expressed by the participants of this study, the anxiety surrounding childbirth and the interventions that accompany it was.
Triggering can occur over the course of a lifetime, particularly in vulnerable or stressful situations. 11riggering may cause anxiety as it reminds survivors of their past experiences of abuse, and the prospect of being reminded of their trauma may cause feelings of worry and anxiety.Two participants expressed concern over how their childbirth experiences might cause them to remember or be triggered to remember their past abuse.Germane to this point, Rhodes and Hutchison outlined the notion of "forced remembering" as follows: Memories can occur in small fragments or in full.Fragments may be triggered by labor that evokes sensory information present at the time of the original abuse.Sometimes sensory memories are tripped, causing the woman to "remember" the sexual abuse with bodily sensations but not necessarily on a conscious level. 11tachment or avoidance can be described as the psychological process of blocking out ideas, feelings, or upcoming events or situations as a method of coping.Detachment or avoidance can be a conscious decision (like the avoidance of places or people) or can occur subconsciously as a response to uncomfortable or distressing stimuli. 15Waymire stated that birth can be very similar to experiences of childhood sexual abuse: "Birth can recall or reenact previous violations of their body because the anatomy involved in childbirth is typically the same anatomy involved in sexual abuse." 23videnced in this study was the paradoxical nature of responses expressed by the different participants.While some participants experienced anxiety about pain, others readily sought out a natural birth.Some wished to experience an unmedicated birth, whereas others wanted to deliver in hospital because of their perceived need to access pain relief.These differences are consistently seen among individuals with trauma-related disorders such as post-traumatic stress disorder (PTSD) and among those who have been continuously exposed to neglect or abuse, particularly at a young age. 24his juxtaposition of opposite-appearing behaviours is noted by Rhodes and Hutchison and is manifested in the labour styles of women as either "fighting" or "surrendering." 11Participants either exhibited signs of struggle, intense pain, and panic responses (fighting) or underwent labour that was characterized by uninhibited and retreating behaviours (i.e., surrendering)."Retreating is an attempt by the survivor to remove herself emotionally or mentally from sensations that replay the abuse." 11articipants described detachment as the verbalized avoidance of feelings and experiences.Not all women who "detach," "avoid," or "disassociate" realize that it is happening or do so on purpose.Therefore, it is worth noting that participants may have exhibited detachment behaviours that they were not consciously experiencing.
As the degree to which the survivors rebuild and heal from their experience depends largely on individual and contextual factors, there is no typical and reliable presentation of the CSA survivor.Health care providers should be aware that any childbearing woman may be a survivor of childhood sexual abuse.Part of that restoration comes through sensitive nursing care that helps create a positive birth experience." 23Coles and Jones outlined how to make the health care recipient's encounter safer by having a relationship with the health care provider, having access to services, and having a health care provider who has a knowledge of trauma and its implications later in life. 13

CONCLUSIONS
This research has contributed to the body of existing knowledge on childbirth for survivors of childhood sexual abuse by hearing from the women themselves.Their pregnancies and childbirth experiences evidence three prominent themes: control, anxiety, and detachment.Women in this study found that interventions involving touch were particularly difficult.Their anxieties extended throughout pregnancy (in their reflections about birth) and during labour.Last, detachment was seen in their psychological avoidance of their pregnancy and birth and during childbirth.Further research will includes exploring what survivors need in a professional relationship during pregnancy and childbirth, and what helps to minimize distressing feelings during the perinatal period.