Continuing Education Intervention: Trauma-Informed Pain Management in Labor and Delivery.

BACKGROUND: There is a gap in the availability of continuing education opportunities for labor and delivery nurses regarding trauma-informed perinatal care. METHOD: A continuing education module on trauma-informed pain management in labor was created and distributed to 17 nurses in an intrapartum unit at a hospital in the Midwestern United States. Changes in knowledge, attitudes, skills, and intent to use trauma-informed principles were assessed using a pretest-posttest design and paired t test analyses. RESULTS: Change in knowledge (p = .043) and skills (p = .011) was statistically significant. There were no statistically significant changes in attitudes. CONCLUSION: Continuing education opportunities in trauma-informed perinatal care are needed for health care team members who provide care to trauma survivors in labor. Further research on the effectiveness of trauma-informed pain management in labor and birth is necessary to provide additional resources and recommendations for labor and delivery nurses. [J Contin Educ Nurs. 2024;55(1):21-25.].

The Survivor Moms' Companion Trauma-Specific Perinatal Psychoeducation Intervention in a Community Outreach Program: An Open Pilot.

INTRODUCTION: Posttraumatic stress disorder (PTSD) confers significant risk during the childbearing year, including for maternal substance use, inadequate prenatal care, preterm birth, and impaired maternal-infant bonding. Although several treatments are available for PTSD, few are specific to the perinatal period. The purpose of this pilot study was to evaluate outcomes of a PTSD- and pregnancy-specific psychoeducational intervention, the Survivor Moms' Companion (SMC). METHODS: The SMC includes psychoeducation with tutor support to address maternal posttraumatic stress, affect regulation, and interpersonal sensitivity. This open pilot was conducted in a large city in a mid-Atlantic state within an organization that provides perinatal services via community health workers (CHWs). The majority of participants were aged 20 to 25 years and African American and had low levels of income and educational attainment. The SMC learning modules were supplied to participants by specially trained CHWs who provided weekly face-to-face support during 30-to-60-minute tutoring sessions. Pretest-to-posttest analyses using multiple imputation methodology and paired-samples t tests examined PTSD symptom counts and scores related to theorized mechanisms of affect dysregulation and interpersonal sensitivity. Nonparametric statistical tests examined clinically meaningful changes. RESULTS: Of 56 women who completed pretests, 38 (67.9%) completed the core dose of a minimum of 4 of 10 learning modules. Examination of intention-to-treat (n = 56) pretest-to-posttest scores revealed statistically significant improvements in PTSD symptoms (P < .001), affect regulation (depression [P < .001] and anger expression [P < .05]), and interpersonal sensitivity (P < .001). Per-protocol analyses (n = 38) revealed significant changes from clinical to nonclinical range scores for PTSD (P < .01) and depression (P < .05). DISCUSSION: These findings suggest that a psychoeducational intervention with tutor support can be influential in fostering positive mental health changes in a high-risk perinatal population. CHWs with intervention-specific training can be effective at implementing a trauma-specific intervention.

"I got to catch my own baby": a qualitative study of out of hospital birth.

BACKGROUND: About 1.6% of planned births in the United States occur out of hospitals. Studies indicate that planned out-of-hospital birth (OOHB) is safe and satisfying for women; however, there is great variation among ethnic groups, and Black women are underrepresented. A recent phenomenon is the choice to have an unassisted birth (UAB) with no midwife or other professional maternity care attendant. The purpose of this study is to fill a gap in understanding reasons for choosing OOHB or UAB for two clinically important sub-groups of women: Black women, and women who have experienced childhood physical or sexual abuse. METHODS: This study recruited 18 women who had an OOHB or UAB and who identified as either Black or survivors of trauma to participate in in-depth qualitative interviews concerning their choice to give birth out of hospital. A grounded theory approach was utilized that involved a discursive process of data collection, coding textual passages to identify focused themes, memo writing to document analytic decision-making, and eventual conceptual modeling. RESULTS: All 18 participants endorsed a history of trauma. Focused coding to identify inherent concepts led to the emergence of a theoretical model of the arc of decision-making around choice of place of birth and birth attendant, or lack thereof. Women may choose OOHB or UAB because of a previous trauma, or because they feel discriminated against by healthcare professionals, either because of skin color, age, pregnancy, weight, or some other health condition. Women may choose OOHB or UAB because it affords more control during the process of giving birth. CONCLUSION: Previous trauma and experiences of discrimination were influential factors for women in the study sample in their choice of birthplace setting and choice of provider. These findings can inform clinical understanding for birth professionals, including doctors, midwives, doulas, nurses, social workers, and psychologists, and contributes more broadly to the national conversation about birth choices in the USA.

This study shares information from qualitative interviews with Black women and women who are survivors of abuse regarding their choice to have a planned out-of-hospital birth, or to choose an unassisted birth (UAB) with no midwife or other professional birth attendant. Black women are less well represented among those who choose OOHB, and little is known about the reasons that they may choose OOHB. Previous studies show that women who have experienced childhood physical or sexual abuse may prioritize having a sense of control and autonomy during their birthing experiences; however, little is known about their specific choice for OOHB. Our study recruited 18 women who had an OOHB or UAB and who identified as either Black and/or survivors of trauma to participate in in-depth interviews concerning their choice to give birth out of hospital. Through qualitative research methods, we analyzed transcripts of these interviews and developed a theoretical model about women's decision making related to OOHB or UAB. We found that women may choose OOHB or UAB because of a previous trauma, or because they feel discriminated against by healthcare professionals, either because of skin color, age, pregnancy, weight, or some other health condition, and that choosing OOHB or UAB allowed them to have more control during the process of giving birth. Understanding the role that previous trauma and experiences of discrimination play in birthplace choice may help birth professionals to consider bodily autonomy, physical and emotional safety, anti-racism, and independence as important factors in their clinical interactions with birthing women.

"I Thought It Was Normal:" Perspectives of Black Nursing Students From High-Risk IPV Communities on Causes and Solutions to IPV in the Black Community.

Black individuals are at high risk for intimate partner violence (IPV) but are less likely to utilize existing IPV services and supports. In an effort toward developing more culturally responsive IPV solutions for the Black community, researchers set out to understand how residents of high-risk IPV communities explained the high rates of IPV in their community, and what they thought possible solutions would entail. A purposive sample of 22 Black nursing students (20 female, 2 male) from a high-IPV risk predominately Black community in Western New York who were students enrolled in a Licensed Practitioner Nursing (LPN) program attended four focus groups that utilized a semi-structured interview format. Their verbatim responses were analyzed using qualitative inductive thematic analysis. Participants identified five major causes of IPV in Black communities: (a) weakened family structure, (b) IPV is normalized (c) community lacks IPV knowledge, (d) mistrust of formal resources, and (e) mental health. They also identified 10 solutions to IPV in Black communities: (a) counseling, (b) peer support groups, (c) use of technology, (d) resources to create self-sufficiency, (e) education, (f) culturally specific resources, (g) reduce stigma, (h) public service announcements, (i) substance abuse treatment, and (j) IPV screenings. Research and clinical implications of the research are discussed, including how these might inform the creation of culturally responsive interventions.

Scoping Review of Barriers and Facilitators of Breastfeeding in Women on Opioid Maintenance Therapy.

OBJECTIVE: To synthesize the literature on the barriers and facilitators of breastfeeding among women on opioid maintenance therapy (OMT) to inform nursing interventions and improve breastfeeding outcomes. DATA SOURCES: We searched 11 databases using the following key terms: breastfeeding, barriers, facilitators, promotion, and opioid. STUDY SELECTION: We included articles published in English since 2015 that addressed barriers and facilitators of breastfeeding in women on OMT. We did not limit our search to specific types of studies. Our search produced 65 records. After reviewing titles and abstracts, we assessed 21 full-text articles and excluded seven for lack of data related to our key terms. As a result, we included five qualitative studies, three reviews, three mixed-methods studies, two retrospective cohort studies, and one case report (14 articles) in our final review. DATA EXTRACTION: We extracted data from each article and sorted them in a table for analysis and synthesis. Data included study purpose, research questions, design and methodology, and findings specifically pertaining to the identification of barriers and facilitators of breastfeeding for women on OMT. DATA SYNTHESIS: We identified three themes related to facilitators of and barriers to breastfeeding: Information, Support, and Health Care System Factors. CONCLUSION: The results of our review suggest that most barriers and facilitators of breastfeeding in women on OMT are manageable with improved health care practices. Primary and acute care health professionals should modify practices to minimize barriers to breastfeeding. Nurses should provide better breastfeeding education and preparation, sensitive care in the immediate postpartum period, and extended follow-up after hospital discharge for women on OMT.

"Is there anything else you would like me to know?": Applying a trauma-informed approach to the administration of the adverse childhood experiences questionnaire.

Nearly ubiquitous agreement exists regarding the potentially negative impact of adverse childhood experiences (ACEs) on health and well-being across the lifespan. This has propelled a movement across the nation for consistent screening of ACEs. Despite agreement regarding the consequences of ACEs, little research related specifically to the administration of the ACE questionnaire exists. Using data from a mixed-methods study of first-time mothers as means of illustration, this paper examines shortcomings of the ACE questionnaire. Participant responses revealed ambiguity with item structure, limited breadth of included events, and failure to capture the gravity of the experience. These shortcomings underscore inadequacies of the measure in accurately understanding individuals' lived experiences and call for the application of trauma-informed (TI) values, both in its content and administration. We apply the main tenets of a TI framework to the ACE questionnaire and make recommendations for its administration, translating theoretical underpinnings of a TI approach into action.

Preference, knowledge and utilization of midwives, childbirth education classes and doulas among U.S. black and white women: implications for pregnancy and childbirth outcomes.

This secondary analysis explored preference, knowledge and utilization of midwifery care, childbirth education and doula care among 627 black and white women at three Midwestern U.S. health clinics. Women who were white, more educated, not living in a high crime neighborhood, and privately insured were more likely to attend childbirth classes. Sociodemographic factors that predicted having heard about doula care included being more educated and having a partner. None of the sociodemographic variables predicted midwifery care. Education about existing childbearing resources and availability of low-cost options should be expanded, particularly for black women and those with low resources.

Gestational and Postnatal Cortisol Profiles of Women With Posttraumatic Stress Disorder and the Dissociative Subtype.

OBJECTIVE: To test the hypothesis that women with posttraumatic stress disorder (PTSD) have greater salivary cortisol levels across the diurnal curve and throughout gestation, birth, and the postpartum period than women who do not have PTSD. DESIGN: Prospective, longitudinal, biobehavioral cohort study. SETTING: Prenatal clinics at academic health centers in the Midwest region of the United States. PARTICIPANTS: Women expecting their first infants who fit with one of four cohorts: a nonexposed control group, a trauma-exposed control group, a group with PTSD, and a group with the dissociative subtype of PTSD. METHODS: In the first half of pregnancy, 395 women provided three salivary cortisol specimens on a single day for diurnal data. A subsample of 111 women provided three salivary cortisol specimens per day, 12 times, from early pregnancy to 6 weeks postpartum for longitudinal data. Trauma history, PTSD, and dissociative symptoms were measured via standardized telephone diagnostic interviews with the use of validated epidemiologic measures. Generalized estimating equations were used to determine group differences. RESULTS: Generalized estimating equations showed that women with the dissociative subtype of PTSD had the highest and flattest gestational cortisol level curves. The difference was greatest in early pregnancy, when participants in the dissociative subtype group had cortisol levels 8 times greater in the afternoon and 10 times greater at bedtime than those in the nonexposed control group. CONCLUSION: Women with the dissociative subtype of PTSD, a complex form associated with a history of childhood maltreatment, may have toxic levels of cortisol that contribute to intergenerational patterns of adverse health outcomes.

Integrating Trauma-Informed Care Into Maternity Care Practice: Conceptual and Practical Issues.

Adverse childhood experiences have a strong negative impact on health and are a significant public health concern. Adverse childhood experiences, including various forms of child maltreatment, together with their mental health sequelae (eg, posttraumatic stress disorder, depression, dissociation) also contribute to adverse pregnancy outcomes (eg, preterm birth, low birth weight), poor postpartum mental health, and impaired or delayed bonding. Intergenerational patterns of maltreatment and mental health disorders have been reported that could be addressed in the childbearing year. Trauma-informed care is increasingly used in health care organizations and has the potential to assist in improving maternal and infant health. This article presents an overview of traumatic stress sequelae of childhood maltreatment and adversity, the impact of traumatic stress on childbearing, and technical assistance that is available from the National Center for Trauma-Informed Care (NCTIC) before articulating some steps to conceptualizing and implementing trauma-informed care into midwifery and other maternity care practices.

A Cycles-Breaking Framework to Disrupt Intergenerational Patterns of Maltreatment and Vulnerability During the Childbearing Year.

We propose a cycles-breaking conceptual framework to guide perinatal research, interventions, and clinical innovations that can prevent or disrupt intergenerational cycles of childhood maltreatment and psychiatric vulnerability. The framework is grounded in literature, clinical observations, team science collaboration, and empirical research from numerous disciplines and is specific to the childbearing year. Adoption of the framework has the potential to speed the progress of research on the social problems of intergenerational childhood maltreatment and psychiatric vulnerability.

Where Do You Feel Safest? Demographic Factors and Place of Birth.

INTRODUCTION: The vast majority of planned out-of-hospital births in the United States occur among white women; no study has addressed whether black women prefer out-of-hospital birth less or whether this racial disparity is due to other causes such as constrained access. This study sought to answer the question of whether white and black women feel safest giving birth in out-of-hospital settings at different rates and whether this answer is associated with other socioeconomic indicators. METHODS: An interview of 634 nulliparous women during the third trimester of their pregnancy in Michigan provided data regarding where women felt safest giving birth. Feeling safest giving birth out-of-hospital was examined in relation to socioeconomic factors including race, age, household income, education, residence in a high-crime neighborhood, partnered status, and type of insurance. RESULTS: This study found that black and white women say they feel safest giving birth in out-of-hospital settings at similar rates (11.5% and 13.1%, respectively). Logistic regression results showed that poverty and having education beyond high school were the only sociodemographic indicators significantly associated with feeling safest giving birth out-of-hospital. DISCUSSION: Disparities evident in planned home birth and birth center rates cannot be explained by racial differences in feelings toward out-of-hospital birth and should be addressed more specifically in public policy and future studies.

A Quasi-experimental outcomes analysis of a psychoeducation intervention for pregnant women with abuse-related posttraumatic stress.

OBJECTIVE: To test the effectiveness of a trauma-specific, psychoeducational intervention for pregnant women with a history of childhood maltreatment on six intrapartum and postpartum psychological outcomes. DESIGN: Quasi-experimental study comparing women from a single-group, pretest-posttest pilot intervention study with women matched from a prospective observational study. SETTING: Rural and university-based prenatal clinics. PARTICIPANTS: Pregnant women entered the study by responding to an advertisement or by referral from a maternity care provider. Women could take part whether or not they met posttraumatic stress disorder diagnostic criteria. Outcomes data exist for 17 pilot intervention study participants and 43 matched observational study participants. INTERVENTIONS: Participants in the observational study received usual care. Participants in the pilot intervention study received usual care plus the intervention, a fully manualized, self-study program supported by weekly phone tutoring sessions with a health professional. MAIN OUTCOME MEASURES: The National Women's Study PTSD Module, the Peritraumatic Dissociation Experience Questionnaire, the Perception of Care Questionnaire, the Postpartum Depression Screening Scale, the Postpartum Bonding Questionnaire, and a semantic differential appraisal of the labor experience. RESULTS: Participants in the intervention study had better scores on all measures. Differences in means between participants in the intervention study and participants in the observational study equated to medium effect sized for dissociation during labor, rating of labor experience, and perception of care in labor and small effect sizes for postpartum posttraumatic stress disorder (PTSD) symptoms, postpartum depression symptoms, and motherinfant bonding. CONCLUSION: This trauma-specific intervention reaches and benefits pregnant women with a history of childhood maltreatment.

Childhood abuse history, posttraumatic stress disorder, postpartum mental health, and bonding: a prospective cohort study.

INTRODUCTION: Research is needed that prospectively characterizes the intergenerational pattern of effects of childhood maltreatment and lifetime posttraumatic stress disorder (PTSD) on women's mental health in pregnancy and on postpartum mental health and bonding outcomes. This prospective study included 566 nulliparous women in 3 cohorts: PTSD-positive, trauma-exposed resilient, and not exposed to trauma. METHODS: Trauma history, PTSD diagnosis, and depression diagnosis were ascertained using standardized telephone interviews with women who were pregnant at less than 28 gestational weeks. A 6-week-postpartum interview reassessed interim trauma, labor experience, PTSD, depression, and bonding outcomes. RESULTS: Regression modeling indicates that posttraumatic stress in pregnancy, alone, or comorbid with depression is associated with postpartum depression (R(2) = .204; P < .001). Postpartum depression alone or comorbid with posttraumatic stress was associated with impaired bonding (R(2) = .195; P < .001). In both models, higher quality of life ratings in pregnancy were associated with better outcomes, while reported dissociation in labor was a risk for worse outcomes. The effect of a history of childhood maltreatment on both postpartum mental health and bonding outcomes was mediated by preexisting mental health status. DISCUSSION: Pregnancy represents an opportune time to interrupt the pattern of intergenerational transmission of abuse and psychiatric vulnerability. Further dyadic research is warranted beyond 6 weeks postpartum. Trauma-informed interventions for women who enter care with abuse-related PTSD or depression should be developed and tested.

Exploring dissociation and oxytocin as pathways between trauma exposure and trauma-related hyperemesis gravidarum: a test-of-concept pilot.

Posttraumatic stress disorder (PTSD) is associated with gastrointestinal and genitourinary comorbidities. These map onto the somatization disorder symptoms in the Diagnostic and Statistical Manual of Mental Disorders ( American Psychiatric Association, 1994 ) and the dissociative (conversion) disorders symptoms in the International Classification of Diseases taxonomy ( World Health Organization, 2007 ). Hyperemesis gravidarum (HG) is one of these symptoms and a gastrointestinal comorbidity of PTSD occurring in pregnancy. It is an idiopathic condition defined as severe vomiting with dehydration, metabolic imbalance, wasting, and hospital care seeking. HG is more severe than the normative phenomenon of nausea and vomiting of pregnancy. This test-of-concept pilot (N = 25) explored the hypothesis that there is a trauma-related subtype of HG characterized by (a) high levels of dissociative symptoms and (b) altered plasma concentrations of oxytocin. This hypothesis is informed by a theory of posttraumatic oxytocin dysregulation that posits altered oxytocin function as a mechanism of gut smooth muscle peristalsis dysfunction. A 4-group analysis compared controls with nausea and vomiting of pregnancy (NV only) and cases with HG only, NV and PTSD, or HG and PTSD. Oxytocin was correlated with the nausea and vomiting symptom severity score (r = .464, p = .019) and with the dissociation symptom score (r = .570, p = .003). Women in the group with both PTSD and HG (the trauma-related HG subtype) had the highest levels of dissociation and the highest levels of oxytocin. A linear regression model indicated that the independent association of the trauma-related HG subtype with oxytocin level was mediated by high levels of dissociative symptoms.

Marginalized identities, discrimination burden, and mental health: empirical exploration of an interpersonal-level approach to modeling intersectionality.

Intersectionality is a term used to describe the intersecting effects of race, class, gender, and other marginalizing characteristics that contribute to social identity and affect health. Adverse health effects are thought to occur via social processes including discrimination and structural inequalities (i.e., reduced opportunities for education and income). Although intersectionality has been well-described conceptually, approaches to modeling it in quantitative studies of health outcomes are still emerging. Strategies to date have focused on modeling demographic characteristics as proxies for structural inequality. Our objective was to extend these methodological efforts by modeling intersectionality across three levels: structural, contextual, and interpersonal, consistent with a social-ecological framework. We conducted a secondary analysis of a database that included two components of a widely used survey instrument, the Everyday Discrimination Scale. We operationalized a meso- or interpersonal-level of intersectionality using two variables, the frequency score of discrimination experiences and the sum of characteristics listed as reasons for these (i.e., the person's race, ethnicity, gender, sexual orientation, nationality, religion, disability or pregnancy status, or physical appearance). We controlled for two structural inequality factors (low education, poverty) and three contextual factors (high crime neighborhood, racial minority status, and trauma exposures). The outcome variables we modeled were posttraumatic stress disorder symptoms and a quality of life index score. We used data from 619 women who completed the Everyday Discrimination Scale for a perinatal study in the U.S. state of Michigan. Statistical results indicated that the two interpersonal-level variables (i.e., number of marginalized identities, frequency of discrimination) explained 15% of variance in posttraumatic stress symptoms and 13% of variance in quality of life scores, improving the predictive value of the models over those using structural inequality and contextual factors alone. This study's results point to instrument development ideas to improve the statistical modeling of intersectionality in health and social science research.

Disparity in posttraumatic stress disorder diagnosis among African American pregnant women.

To determine whether African American women expecting their first infant carry a disproportionate burden of posttraumatic stress disorder morbidity, we conducted a comparative analysis of cross-sectional data from the initial psychiatric interview in a prospective cohort study of posttraumatic stress disorder effects on childbearing outcomes. Participants were recruited from maternity clinics in three health systems in the Midwestern USA. Eligibility criteria were being 18 years or older, able to speak English, expecting a first infant, and less than 28 weeks gestation. Telephone interview data was collected from 1,581 women prior to 28 weeks gestation; four declined to answer racial identity items (n = 1,577), 709 women self-identified as African American, 868 women did not. Measures included the Life Stressor Checklist, the National Women's Study Posttraumatic Stress Disorder Module, the Composite International Diagnostic Interview, and the Centers for Disease Control's Perinatal Risk Assessment Monitoring System survey. The 709 African American pregnant women had more trauma exposure, posttraumatic stress disorder symptoms and diagnosis, comorbidity and pregnancy substance use, and had less mental health treatment than 868 non-African Americans. Lifetime prevalence was 24.0% versus 17.1%, respectively (OR = 1.5, p = 0.001). Current prevalence was 13.4% versus 3.5% (OR = 4.3, p < 0.001). Current prevalence of posttraumatic stress disorder (PTSD) was four times higher among African American women. Their risk for PTSD did not differ by sociodemographic status, but was explained by greater trauma exposure. Traumatic stress may be an additional, addressable stress factor in birth outcome disparities.

Previous experience of spontaneous or elective abortion and risk for posttraumatic stress and depression during subsequent pregnancy.

BACKGROUND: Few studies have considered whether elective and/or spontaneous abortion (EAB/SAB) may be risk factors for mental health sequelae in subsequent pregnancy. This paper examines the impact of EAB/SAB on mental health during subsequent pregnancy in a sample of women involved in a larger prospective study of posttraumatic stress disorder (PTSD) across the childbearing year (n=1,581). METHODS: Women expecting their first baby completed standardized telephone assessments including demographics, trauma history, PTSD, depression, and pregnancy wantedness, and religiosity. RESULTS: Fourteen percent (n=221) experienced a prior elective abortion (EAB), 13.1% (n=206) experienced a prior spontaneous abortion (SAB), and 1.4% (n=22) experienced both. Of those women who experienced either an EAB or SAB, 13.9% (n=220) appraised the EAB or SAB experience as having been "a hard time" (i.e., potentially traumatic) and 32.6% (n=132) rated it as their index trauma (i.e., their worst or second worst lifetime exposure). Among the subset of 405 women with prior EAB or SAB, the rate of PTSD during the subsequent pregnancy was 12.6% (n-51), the rate of depression was 16.8% (n=68), and 5.4% (n-22) met criteria for both disorders. CONCLUSIONS: History of sexual trauma predicted appraising the experience of EAB or SAB as "a hard time." Wanting to be pregnant sooner was predictive of appraising the experience of EAB or SAB as the worst or second worst (index) trauma. EAB or SAB was appraised as less traumatic than sexual or medical trauma exposures and conveyed relatively lower risk for PTSD. The patterns of predictors for depression were similar.