According to the World Health Organization, 1 in 3 women in the world will experience physical or sexual violence during their lifetime. Intimate partner violence is the most common form of violence, impacting an estimated 641 million women worldwide. Lockdowns and disruptions in access to support services due to the COVID-19 pandemic have exacerbated the prevalence of gender-based violence (GBV).

GBV is most common during women’s reproductive years. Sexual trauma can cause a variety of lasting physical effects—including chronic pelvic pain and vaginismus—and is associated with adverse sexual health outcomes including sexually-transmitted infections, HIV, and unplanned pregnancies. For women who give birth, past sexual violence can worsen pregnancy and birth experiences.

GBV is associated with depression and anxiety disorders, and survivors of GBV are at increased risk of experiencing perinatal mental health disorders. Women who report some form of emotional, sexual, or physical abuse during adulthood had an 80 percent increased risk of experiencing post-partum depression. Yet, there are no formal guidelines for caring for pregnant women with a history of physical or sexual trauma.

Today, COVID-19 has compounded a mental health crisis acutely felt by pregnant women and mothers. Common stressors for pregnant women during the pandemic include the impact of contracting COVID-19 themselves or spreading it to their fetus, giving birth during the pandemic, and the lack of control over aspects of their birth including their birth plan and the number of people in the delivery room. For women with a history of sexual trauma, the overlapping crises of GBV, maternal mental health, and COVID-19 are potentially catastrophic.

Survivors of Sexual Trauma Have Unique Needs During Pregnancy

Many women with a history of sexual trauma find gynecological examinations and birth to be triggering. During cervical examinations, survivors often experience anxiety, fear, or flashbacks, and therefore may be less likely to have regular Pap tests and seek prenatal care. Birth can also provoke feelings of “being back in the rape,” as described by participants in a study of women in Norway who were raped prior to their first childbirth experience. Participants said the physical aspects of giving birth in the same position as their rape and the unwanted touching by health care professionals–especially without warning or explanation–led to re-traumatization. Participants also reported feeling objectified or alienated from their bodies and feeling “dirtied” by touching during frequent examinations.

Encouraging and supporting survivors to make decisions during delivery can be an important factor in improving their experiences. A U.S. study of women who gave birth with a history of sexual trauma found that participants wanted control over certain aspects of their birthing process, including the timing, pace, and termination of cervical examinations, who was allowed in the labor room, and whether they had a female or male health care provider. Participants also valued clear and sensitive communication from health care providers about the reasonings for cervical examinations and verbal acknowledgement that cervical examinations can be challenging. They wanted to control the exposure of their bodies during childbirth, and many wanted to wear clothes during labor when it was medically possible.

Like delivery, breastfeeding can be particularly challenging for survivors of violence. While the World Health Organization recommends exclusive breastfeeding for the first six months postpartum, studies show that women who have experienced intimate partner violence are less likely to initiate breastfeeding and are more likely to terminate breastfeeding early. In contrast, some survivors find breastfeeding empowering and a means to create positive connections to their bodies. “My body has so many bad memories associated with it that the idea of being able to use it [to] do something positive for my body was really, really like an important thing for me,” said one survivor.

Innovations in Health Care and Policy Action Improve Pregnancy Experiences

Due to the overwhelming global prevalence of GBV, obstetric care providers should routinely screen for a history of sexual trauma to help providers and survivors create birth plans that best support survivors’ needs. Additionally, screening for a history of sexual trauma can help detect cases of postpartum depression. Health care providers can be an important ally for survivors by offering support and referring them to mental health professionals.

Trauma-informed care can improve communication between providers and patients and allow women to have agency during pregnancy, delivery, and the postpartum period. The American College of Obstetricians and Gynecologists suggests that during examinations that bring up feelings of fear or powerlessness, “the patient should be allowed to suggest ways to lessen her fear.”

Recent U.S. policies address the overlapping crises experienced by women during the pandemic. The Biden Administration is committed to addressing GBV in the United States and abroad, including the escalating prevalence of violence during the COVID-19 pandemic. President Biden’s recent Executive Order established the White House Gender Policy Council, which has a mandate to “coordinate a comprehensive, interagency response to gender-based violence at home and abroad” through intervention, prevention, and public health strategies. The Council will also support policies and programs to address the impact of COVID-19 on women and girls, especially as it relates to their overall health and GBV.

The Black Maternal Health Momnibus, which is composed of twelve individual bills and is sponsored by the Black Maternal Health Caucus, “builds on existing legislation to comprehensively address every dimension of the maternal health crisis in America.” The bill package includes provisions to address the risks of COVID-19 during the perinatal period through the Maternal Health Pandemic Response Act, and expand access to maternal mental health services through the Moms MATTER Act.
Implementing these policies and standards of care can ensure that survivors of gender-based violence have adequate support during pregnancy, birth, and the postpartum period. These innovations are critical to improving maternal health in the United States and abroad.