Abstract
Background:Due to its profound and long-lasting health impacts, sexual violence is a global public health concern and UK healthcare priority. Sexual violence is prevalent among women yet shrouded in silence and poorly understood. Rooted in gender inequality, sexual violence includes sexual assault and rape as well as more subtle, hidden sexually coercive behaviours intended to exert power and control. Clinical and policy support for a trauma-informed, strengths-based approach to maternity care is increasing as research suggests that survivors can be re-traumatised by aspects of pregnancy, birth, early motherhood and maternity care. However, the evidence base currently focuses on vulnerability, overlooks systemic and structural issues, and lacks survivor involvement. To address these gaps in the literature, my survivor-led PhD used a traumainformed lens and framed survivors as embodied, situated agents. From this position, my thesis explored: (1) sexual violence survivors’ experiences of pregnancy, birth, motherhood and maternity care, and (2) experiences and needs among maternity care providers in relation to supporting survivors.
Methods:
This PhD is an example of survivor-led research: I conducted this research from an explicit standpoint of myself being a survivor of sexual violence and my work was guided by survivor research ethics and epistemology. As involvement and collaboration lie at the heart of traumainformed approaches, I consulted and worked in partnership with survivors and maternity care providers throughout.
I completed three qualitative studies. In study one, I conducted a meta-ethnography and systematic review of 38 qualitative studies about healthcare experiences and expectations among female adulthood sexual violence survivors. In study two, I conducted a thematic narrative analysis of 11 unstructured interviews with women survivors of sexual violence in adulthood. In study three, I conducted a reflexive thematic analysis of semi-structuredinterviews with 13 maternity care providers.
Findings:
In the systematic review meta-ethnography, I explore three themes describing how safety and trust can be built in healthcare. These were: (1) Acknowledgement: shifting shame and blame,(2) Being Seen: respect, validation and responsiveness and (3) Being Heard: choices, empowerment, and shared decision-making. A key finding was that reciprocity (providers trusting women and showing women they were trustworthy) was essential to building trust in healthcare.
In the narrative study with survivors, I present four themes that describe women survivors’ experiences of pregnancy, birth, early motherhood, and maternity care. These were: (1) ‘The most empowering moment of my life’, (2) ‘Something weird and wrong’, (3) ‘I was just a body’ and (4) ‘It’s about so much more than just saying it’. Pregnancy, birth and motherhood created opportunities for women to heal from the impacts of sexual violence. However, dehumanising care disrupted the healing potential of this time. Providing women-centred care needed to foreground values of kindness, empathy and respect that helped survivors feel safe enough to connect with and communicate their needs and wishes.
In the qualitative study with maternity care providers, I consider three themes that describe maternity care providers’ experiences and needs relating to supporting survivors. These were: (1) A window of opportunity for healing and harm, (2) creating safety in the face of uncertainty and (3) caught between women and the system. Providers in this study were deeply committed to supporting survivors but felt constrained by a system that prevented the delivery of traumainformed, individualised and relational care.
Conclusions and implications:
Placing survivors’ priorities at the heart of research is critical to designing services that meet survivors’ needs. As the first survivor-led study about survivors’ experiences of pregnancy, birth, motherhood and maternity care, my research made a significant contribution to a field dominated by biomedical approaches and lacking survivor involvement. Existing research largely focuses on vulnerability, highlighting risks of survivors ‘re-experiencing’ trauma and largely overlooking opportunities for healing. Situating my study within feminist work on embodied subjectivity, my research highlighted the harms caused to survivors by a biomedicallydominated health system and how this could mirror the dehumanisation and silencing of sexual violence. Additionally, my research emphasised that, for some survivors, the perinatal period presented significant and unique opportunities to re-build embodied and relational safety after sexual violence. However, healing had to be supported by care that foregrounded trust, choice, empowerment and empathy. Maternity care providers in my research wanted to deliver care in alignment with trauma-informed values but felt constrained by a system predicated upon reductionism and standardisation. Sexual violence is prevalent among those using maternity and perinatal services, but providers lack of systemic support to deliver trauma-informed care, indicating a need to implement trauma-informed approaches in maternity care. Future research and policy must address the systemic factors that shape survivors’ experiences, and place survivors’ voices at the centre.
| Date of Award | 1 Jul 2023 |
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| Original language | English |
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| Supervisor | Elsa Montgomery (Supervisor) & Angie Sweeney (Supervisor) |