What Survivors Face
According to the Washington State Department of Health (2010),
- 10% of women reported physical, psychological, or sexual abuse by an intimate partner around the time of pregnancy.
- Nearly 22% of teens (ages 15-19) report experiencing physical, psychological, or sexual abuse around the time of pregnancy.
When a woman has undergone sexual assault, intimate partner violence, or stalking, it may have a profound impact on their experience of pregnancy and childbirth. Abusive partners are not likely to provide the kind of practical and emotional support that women need during pregnancy and birth; moreover, abusers often isolate their partners from family and friends who might also provide needed support. The posttraumatic effects of sexual assault can be a major concern due to the triggering of traumatic reactions during pregnancy and birth. Many aspects of prenatal care and the birth experience may trigger severe anxiety for survivors. Women may avoid necessary medical care because of these fears, or they may be so devastated by their experiences that they have difficulty enjoying and caring for their newborns.
Any advocate who encounters survivors during pregnancy, childbirth, or the postpartum period can help advocate for more appropriate, trauma-informed care by considering how these experiences may affect a woman or teen who has been victimized. Helping connect survivors to appropriate support people (such as midwives or doulas) can facilitate a healing experience rather than one that further traumatizes the new mother.
Specific Forms of Abuse
Many women and teens who seek advocacy services have experienced reproductive and sexual coercion in their ongoing relationships. New developments in research and practice show that survivors benefit from specific attention to these issues (Miller, 2009). Therefore, expanding advocacy practices to address these all-too-common aspects of women's lives in a proactive manner allows for better understanding of the totality of survivors' experiences.
Recent work by Futures Without Violence, has led to the development of new terminology related to intimate partner sexual violence (IPSV), domestic violence (DV), sexual and reproductive coercion. The terms below come from Futures Without Violence's Addressing Intimate Partner Violence, Reproductive and Sexual Coercion: A Guide for Obstetric, Gynecologic and Reproductive Health Care Settings.
- Reproductive coercion: involves behaviors that a partner uses to maintain power and control in a relationship related to reproductive health. The following definitions are examples of reproductive coercion.
- Birth control sabotage: is active interference with contraceptive methods by someone who is, was, or wishes to be involved in an intimate or dating relationship with an adult or adolescent. Examples of birth control sabotage include:
- Hiding, withholding, or destroying a partner's birth control pills
- Breaking a condom on purpose or forced non-condom use
- Not withdrawing when that was the agreed-upon method of contraception
- Pulling out vaginal rings or IUDs
- Tearing off contraceptive patches
- Pregnancy pressure: involves behaviors intended to pressure a partner to become pregnant when that partner does not wish to be pregnant. These behaviors may be verbal or physical threats or a combination of both. Examples of pregnancy pressure include:
- Threatening to leave if the partner doesn't get pregnant
- Threatening to have a baby with someone else if the partner don't become pregnant
- Pregnancy coercion: involves threats or acts of violence if a partner does not comply with the perpetrator's wishes regarding the decision of whether to terminate or continue a pregnancy. Examples of pregnancy coercion include:
- Forcing a partner to carry to term against that partner's wishes through threats or acts of violence
- Forcing a partner to terminate a pregnancy when the pregnant partner does not want to
- Injuring a partner in a way that the pregnant partner may have a miscarriage
- Sexual coercion: involves a range of behaviors that spans from coercing a partner to have unwanted sex, to forcing a partner to have sex against their will, to interfering with a partner's choice to practice safer sex. Sexual coercion may involve verbal pressure without threats of harm, threatening with physical injury, physically restraining, holding down, inflicting injuries, or giving alcohol or drugs to incapacitate a person or impair their judgment. Examples of sexual coercion include:
- Sexual assault/rape
- Forced non-condom use or not allowing other prophylaxis use
- Pressure or force to engage in intercourse following the birth of a child and before being medically cleared, which can contribute to a rapid repeat pregnancy
Making Connections to Specialized Support
Advocates have the opportunity to help survivors find medical and support services that are sensitive to their needs. Medical personnel (including physicians, nurse-practitioners, and nurse-midwives) with special training on the needs of survivors can offer trauma-informed care, helping survivors to feel safer and therefore to participate more fully in their own care. Other support people, such as childbirth educators, lactation consultants, and doulas (trained individuals who offer support during pregnancy, childbirth, and early parenting), can help survivors in a variety of ways.
Advocates can make this compassionate care more readily available by:
- Participating in cross-training with the professionals described above
- Identifying those professionals in your community who offer trauma-informed care and including them on referral lists
- Assisting survivors with navigating the health care system and expressing their needs
- Assisting survivors during pregnancy and childbirth (think outside the box when providing medical advocacy)
Pregnant women and teens are at risk for intimate partner violence, so safety planning is vitally important. Pregnant survivors may be reluctant to access needed health care because it triggers their trauma memories, or they may be dealing with coercive control by a partner who is reluctant for them to access services. Advocates can help by assisting survivors to identify and articulate their needs to health care professionals, and by including access to medical services in the safety plan they develop with the client. They can also offer practical and emotional support to those survivors who may be facing the consequences of an unintended pregnancy that resulted from sexual assault, birth control sabotage, or pregnancy pressure.
After Giving Birth
Women are generally advised to abstain from sexual intercourse during the period after giving birth until they have a medical check-up. However, abusive partners may not honor this waiting period, and may pressure their partners to have sex before they are physically or emotionally ready to do so. Because new mothers may not have resumed using birth control, this sexual coercion may also lead to rapid repeat pregnancies. Because women in abusive relationships are more likely to have an unintended pregnancy in the months after giving birth, advocates can let clients know that there are birth control methods that are not readily detectable and suggest that they discuss family planning options with their health care provider.
Women who have experienced sexual assault (either as an adult or as a child) may have difficulty with breastfeeding. Experiences that may affect breastfeeding for survivors include:
- If the assault or abuse involved manipulation of the breasts
- The baby's nursing may serve as a trauma trigger that provokes feelings of fear, anxiety, depression, or disgust
- Women who are in physically abusive relationships, or who have experienced physical abuse at any time in the past, may dislike the closeness required by breastfeeding.
- Anyone currently in an abusive relationship will feel stressed, drained, and unsupported, and these feelings may very well make it difficult for a woman to be physically and emotionally available for the intense relationship created by breastfeeding.
- An abusive partner may be jealous of the nursing relationship or so demanding of the mother's attention that they will be hard-pressed to find the time to relax and nurse.
- In addition, some survivors are very uncomfortable with physical assistance from a health care provider as they learn to position their babies correctly for nursing.
The Importance of Advocacy
It is important to know many times survivors come to advocacy programs with a wide range of needs. Pregnancy and support in parenting may not be something a survivor thinks your program can assist with. Be sure and practice being comfortable asking questions that address these specific needs of any person that has the ability to become pregnant.
- Don’t Ask; Just Tell
- Normalize offering emergency contraception, pregnancy tests and condoms at your program
- Tell everybody
- Don’t limit offering EC, pregnancy tests and condoms to who you assume needs them. These services should be offered by your program to every person during intake, regardless of age, gender, sexual orientation. Remember even if the survivor in front of you does not need it, they may know someone who does!
- Ask questions
- “Are your worried you may be pregnant or could become pregnant?”
Domestic violence, sexual assault, and stalking are all-too-common experiences for women and teens that are pregnant or have recently given birth. The goal of these guidelines is to present an integrated, multidisciplinary approach to service delivery in order to meet the needs of pregnant and parenting survivors of these forms of victimization.
WCSAP collaborated with the Washington State Coalition Against Domestic Violence, The Washington State Department of Health, and The Washington State Office of the Attorney General to produce these guidelines.
- Ready, Set, Go! Start the Conversation with Teens about Emergency Contraception and Birth Control
- Pregnant Survivors Website
- Frequently asked questions about making over-the-counter medication available in domestic violence (DV) and sexual assault (SA) programs
Breastfeeding and survivors
- Breast-Feeding as a Rape or Sexual Abuse Survivor
- Making the Connection: Intimate Partner Sexual Violence and Public Health