Trauma-Informed Care Must Be Synonymous With Maternal Health Care

The following op-ed by Lena Perenchio is one of five standout essays written as part of an assignment for the Columbia MPH Core and published online on the Columbia Mailman news page.

Trigger Warning: The following Op-Ed discusses emotional, physical, and sexual abuse. Please skip ahead if that would be harmful to you to read.

As the OB/GYN performed a prenatal pelvic exam on my birth doula client, my client tightened her grip on my hand. I increased the noise of my breath, audibly inhaling and exhaling, inviting her to breathe more deeply. When the door shut, signaling that the OB/GYN had left the exam room, my client poured her pain and terror out to me. She shared with me, for the first time, her history of emotional, physical, and sexual abuse. The pelvic exam had triggered her.

With my client's permission, I disclosed her history of trauma to her medical care team and shared, with them, some trauma-informed care strategies, which visibly shifted the type of care she received during labor—it became gentler, slower, and more personally responsive. During her next pelvic exam, conducted to assess labor progression, the OB/GYN talked her through the procedure, step-by-step, including her in it. This time, the exam happened with her instead of to her.

My client's experience reveals how the medical community relies on the assumption that all patients will disclose their history of trauma voluntarily through self-measures or screening. But how can we expect that all trauma survivors, especially those who have experienced sexual abuse, will come forward in a society that repeatedly does not believe them, and further blames them? And why should the burden fall on them at all?

The American College of Obstetricians and Gynecologists (ACOG) endorses shifting the responsibility to the medical community by implementing universal trauma-informed care. In other words, they recommend that trauma-informed care should be the standard of care for all pregnant patients. But that's not what's happening, so providers, untrained in trauma-informed approaches, continue to, unintentionally, inflict great harm. The prevailing narrative of disbelief and blame, compounded by the pervasiveness of sexual violence in the United States, dictates that trauma-informed care simply becomes synonymous with maternal health care. To achieve this, medical schools must adopt it into their core curriculum, and state licensing boards need to prioritize the integration of trauma-informed care through required continuing education courses.

True trauma-informed care involves more than obtaining consent and being gentle. Evidence-based, it integrates understandings of trauma and retraumatization, into the system of policies, procedures, and practices surrounding maternal health care. For the successful integration of trauma-informed approaches, OB/GYNs, as well as other maternal health care providers, must understand the inherent vulnerability labor and birth asks of a birthing person and how it can retraumatize those experiencing it. The combination of "pressure and pain" in, "increased attention" to, and "numerous procedures" involving an individual's genital region during the perinatal period can be re-triggering for a birthing person who has existing bodily trauma in that area. Additionally, the ingrained power imbalance between a care provider—a trusted authority figure, either known or unknown—and a patient, can further exacerbate that retriggering or alone can trigger a birthing person. Even when trauma-informed approaches are applied universally, there remains a need for providers to be able to recognize and respond appropriately to different trauma responses. Equipping providers with these additional skills embed further safeguards into care practices in the event a patient still becomes triggered during their antenatal experience. Through the use of trauma-informed approaches, like active consent and other competencies that reduce harm throughout procedures, providers can resist causing or perpetuating further trauma and create an environment within medical care that transmits safety, transparency, trust, collaboration, empowerment, humility, and responsiveness between patients and their care providers.

The Accreditation Council for Graduate Medical Education (ACGME) must incorporate comprehensive trauma-informed care into all required curricula for maternal health care training. Additionally, ACOG's Council on Resident Education in Obstetrics and Gynecology (CREOG) should require and test affiliated OB/GYNs on trauma-informed maternal health care practice to ensure that these approaches are synonymous with provided care and are being implemented universally. Together, ACGME and ACOG need to apply pressure on state licensure boards to require continuing education courses directed at the universal integration of trauma-informed care for licensing and membership, which would ensure that providers who have already completed their initial medical school education are also reached and accounted for.

Initially, the integration of trauma-informed approaches into maternal health education requirements and standards of care may be expensive; however, the long-term benefits of this care approach would decrease retraumatization among birthing people and consequently, decrease the expense of post-traumatic care therapies following their birth, as well as reduce costs of treatment for trauma-related physical adverse health outcomes. Since there are already maternal health education requirements and care guidelines, this adjustment could easily be integrated through existing structures.

The absence of universal trauma-informed care causes and perpetuates trauma among birthing persons. Therefore, the integration of trauma-informed maternal health care into medical school training, testing, and continuing education presents an opportunity to eradicate unnecessary suffering, and instead create an environment of care where birthing persons feel respected and empowered through their pregnancy, labor, birth, and postpartum. This expansion of care will improve maternal mental and physical health outcomes in all persons but will be especially impactful in reducing a cycle of trauma among those who are the most disenfranchised.

Lena Perenchio is a first-year MPH student in the Heilbrunn Department of Population and Family Health.