Trauma Informed Care in the Perinatal Period

• Publisher: Dunedin Academic Press
• Year: 2015
• ISBN:
  9781780465456
• Topic: Politics & International Relations
• Subtopic: Social Policy
• Index: Politics & International Relations

The past two decades have seen a convergence of findings across studies of traumatic stress, attachment, and neurobiology, confirming the crucial importance of well-being within the mother-infant dyad for life-long mental and physical health, and for reaching the fullest developmental potential. It is now established that there are intergenerational cycles of childhood maltreatment and psychiatric vulnerability that warrant a prevention approach. Pregnancy is a crucial point of intersection between generations. During pregnancy, women with a childhood maltreatment history have a 12-fold increased risk of posttraumatic stress disorder (PTSD). Although awareness of the need for trauma-informed care and trauma-specific interventions is increasing in the fields of addiction and mental health treatment in particular, there are no front-line programmes for the childbearing year that address maltreatment-related PTSD. This edited collection addresses the issues of intergenerational cycles of childhood maltreatment and psychiatric vulnerability by providing a resource to facilitate incorporating trauma-informed care and trauma-specific interventions into maternity services with an emphasis on improving outcomes for childbearing women with a childhood maltreatment history.The book will prove of use to those training for or working in child protection and nursing.

CHAPTER 1

Why trauma informed care in the perinatal period?

Julia Seng, University of Michigan

Introduction

Traumatic stress, a component of both toxic stress and intergenerational patterns, adversely affects population health. Traumatic stress caused by child maltreatment is often unresolved for women prior to pregnancy, with implications for her obstetric experience and subsequent relationship with her child. In order to improve perinatal outcomes and long-term health for individuals and at the population level, an emphasis on psychosocial care that is informed by a knowledge about trauma is crucial.

Professionals who work toward optimising child welfare, development and health know that preventing maltreatment is crucial both for individual outcomes and for society. Professionals who care for childbearing women in perinatal settings also realise that it is important to get the mother–infant dyad off to the best possible start. In the past, service delivery to pregnant women has been weighted towards a medical model, giving highest priority to surveillance and treatment for high-risk obstetric conditions and providing maternal support services as a secondary level of care added to address needs of vulnerable women. Currently, this prioritisation is shifting to put medical and psychosocial care on a more even footing because it is becoming clearer to all that some of the intransigent perinatal, lifespan health, developmental and social problems have intergenerational patterns that start in pregnancy.

Research across numerous academic disciplines is now demonstrating that childhood maltreatment trauma is a very important factor in patterns of deprivation, psychiatric vulnerability, ill health and violence. These problems warrant primary prevention for the infant to begin in utero. This presents an opportunity for child welfare professionals and maternity professionals to collaborate in creating new service delivery models that provide trauma informed care across the perinatal period – across pregnancy, birth and the ‘fourth trimester’ that includes the early weeks of parenting.

This book takes a broad definition of child maltreatment, in accordance with the World Health Organization policy:

Child maltreatment, sometimes referred to as child abuse and neglect, includes all forms of physical and emotional ill-treatment, sexual abuse, neglect, and exploitation that results in actual or potential harm to the child’s health, development or dignity. Within this broad definition, five subtypes can be distinguished – physical abuse; sexual abuse; neglect and negligent treatment; emotional abuse; and exploitation (WHO 2014).

The purpose of this book is to provide an overview of information that child welfare and perinatal professionals can use to move towards providing trauma informed care and developing trauma-specific interventions to improve intergenerational trajectories.

In this first chapter we sketch what this new knowledge includes and provide an overview of what follows. More detail about the explanatory concepts prefaced here are dealt with in subsequent chapters.

A convergence of knowledge

Psychosocial care in the perinatal period is the next frontier in advancing maternal and infant outcomes – and indeed the wellbeing of society at large (Shonkoff et al., 2012; Renfrew et al., 2014). That is a rather sweeping statement. But by the time we lay out the information that supports the statement, we think you will agree. Likely you also will allow that we have ‘known’ most of this information for a long time (Herman, 1992). What is true at this moment, as we write in mid-2015, is that there now is a critical mass of research findings to provide a strong impetus to strengthen psychosocial perinatal care. These come from studies conducted in numerous populations and by asking questions from biological, psychological and social standpoints. Synthesis of results provides an impetus to act on what we have surmised for a long time.

Medical advances are not enough to improve the health of the population

Medical approaches to preventing and treating obstetric complications continue to make advances, but in smaller increments than in the past. Nations with advanced healthcare systems are seeing a plateau in improving rates of sentinel public health indicators of population problems, such as prematurity and low birth weight (Martin et al., 2010). Costly technological interventions that disrupt physiological processes are increasing (Childbirth Connection, 2013). While there likely are benefits for individuals from medical advances, the overall cost–benefit profile at the population level is not changing substantially. Addressing many of the remaining sources of morbidity and mortality requires that we look from the pregnant woman’s position outward, to her socio-ecological context, as well as inwards, to her individual health status and biology.

Our current division of labour along bio-psychosocial lines may need revising so that the perinatal care team is acting synergistically to redress the most widespread threats to well-being at the individual and population levels. As Shamian stated in the 2014 series on midwifery in The Lancet:

Interprofessional collaboration is essential to provide quality healthcare in today’s complex world, and to mitigate many of the challenges faced by health systems worldwide. Patients need the range of knowledge and skills that can only be found in a wide array of health professions. Additionally, collaborative practice must include the patient as the key player in the healthcare team (Shamian, 2014, p. e41).

Emerging new conceptualisations

The emerging focus on toxic stress as a concept being applied at the forefront in child well-being may help shift attention from focusing primarily on the individual woman’s health and mothering behaviour to concentrating attention on her context – which likely is shared with a whole community or population of women (Shonkoff et al., 2012). Environmental justice and reproductive justice movements may be contributing ideas that will have an impact on the perinatal arena. Both movements call into view the reality that the social gradient in contexts parallels the social gradient in outcomes. But perhaps the most important shift this toxic stress conceptualisation produces is its orientation towards the form of action required, from individual efforts to more systemic ones. In a major position paper, toxic stress is defined and elevated to a significant risk factor warranting healthcare attention:

Toxic stress can result from strong, frequent, or prolonged activation of the body’s stress response systems in the absence of the buffering protection of a supportive, adult relationship … The potential role of toxic stress and early life adversity in the pathogenesis of health disparities underscores the importance of effective surveillance for significant risk factors in the primary healthcare setting (Shonkoff et al., 2012, p. e236).

Historically, we have expected individuals to manage their own stress. But we do not count on individuals to ‘manage’ toxins. We seek public policy and programmatic means to control, treat or eradicate them. This opens avenues to bridge the focus on individual behaviours and the focus on environments.

When it comes to toxic stress, a single intervention is not likely to make all that much difference. So concepts of ‘stepped’ or ‘tiered’ intervention are being articulated. These pair well with the stressbiology concept of allostatic load and the notion that allostatic load can be countered by allostatic support. Allostatic load relates to the notion that repeated or unrelenting stressors do not permit a return to baseline via homeostasis, explained this way:

When early experiences prepare a developing child for conditions involving a high level of stress or instability, the body’s systems retain that initial programming and put the stress response system on a short-fuse and high-alert status. Under such circumstances, the benefits of short-term survival may come at a significant cost to longer-term health (Shonkoff et al., 2009, p. 2,257).

Instead, repeated or unrelenting stressors result in a shift in baseline towards a more activated level that is evident in allostatic load: up-regulating of cardiac, respiratory, metabolic, immune and neuroendocrine functions used to counter threat. By this theory, no one stressor and no one incremental physiological change is fatal, but each single alteration entails others until the cumulative load results in morbidity. By the same token, no one intervention is likely to fix the stressors of the human condition. So every element of support that decreases one stressor or mitigates one physiologic alteration should be useful in a cumulative series of such support efforts. This body-based concept is important in framing perinatal psychosocial care because it is a mechanism, or link, that makes it logical that the provision of social care (i.e. addressing stressors and stress) can result in better outcomes not only in the social and psychological realms but also in the medical or health domains (i.e. lower rates of prematurity, fewer stress-related diseases in later life).

Maternal stress has long been implicated in adverse perinatal outcomes. Stress is one of five key pathways to prematurity articulated by the foremost US foundation that supports prevention research – the March of Dimes – and it is a priority area of research where multipronged strategies are expected to be needed:

The March of Dimes Scientific Advisory Committee created this prioritised research agenda, which is aimed at garnering serious attention and expanding resources to make major inroads into the prevention of preterm birth, targeting six major, overlapping categories: epidemiology, genetics, disparities, inflammation, biologic stress and clinical trials. Analogous to other common, complex disorders, progress in prevention will require incorporating multipronged risk reduction strategies that are based on sound scientific discovery, as well as on effective translation into clinical care (Green et al., 2005, p. 626).

Much of the funded research on maternal stress involves examining the maternal, placental and fetal contributions and pathways at the biological level, focusing on hormones in the primary stress response systems. But more macro concepts are relevant as well. Evolutionary biology theories such as life history or life course theories are being applied to understand how survival and reproduction are traded off against each other in stressful circumstances and across generations. Developmental (or fetal) origins of disease theory frame examination of how the symbiotic relationship between mother and infant results in programming in utero so the infant is prepared to live in the mother’s world. Epigenetics extends these concepts to focus on how a person’s genetic make-up is not entirely deterministic because parenting behaviour and other environmental factors can also change gene expression and affect the infant – for better or for worse:

Early life stress has a strong impact on DNA methylation and histone modifications with subsequent alterations of gene expression and behaviour. Genome-wide approaches will very likely reveal interesting patterns of gene classes or transcription factor binding sites that are preferentially altered by early life stress, leading to the complex behavioral and medical consequences of early life stress … These inherited differences in the susceptibility to epigenetic changes after trauma exposure may thus serve to integrate genetic vulnerability and environmental exposure to define behavioral phenotypes (Heim and Binder, 2012, p. 108).

These macro theories draw our attention to how the mother’s stress causes adaptations that may aid immediate survival yet compromise health across the lifespan. The notion of pregnancy as a stress test for life is also gaining ground, so the outcomes of stress being examined are not only those of the infant but also those of the mother (Williams, 2003). For example, we see that insulin resistance or hypertension that appears under the stress of childbearing is likely to appear again for the woman, and much earlier in the lifespan for her than for others who tolerated the ‘stress test’ with no adverse effects. These macro stress theories are embedded in the body, but are attentive to the larger social context. Thus the need to involve social care professionals to address stress and achieve better macro-level outcomes for the childbearing year is not a new notion, but the impetus to do so is becoming stronger.

Psychological and relational health

The psychological level within these ecological theories is also important. The middle ground of the psychological context of the woman in pregnancy and of the mother–infant dyad postnatally also has a burgeoning scientific literature. Although much of this science focuses on normative processes, to a great extent it is moving ahead rapidly now by looking at how the exception explains the rule (Schore, 2003a). From a normative perspective, the human infant learns to regulate its body, emotions and interactions in a symbiotic relationship with its primary caregiver. If all goes well, its physiology, feelings and contacts with others function well in response to daily life and to extraordinary stressors, consistent with the notion of resilience. But if all does not go well, dysregulated physiology, overwhelming affect and disruptions...