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Women who already experienced past trauma – and others who also experience the loss of a child and/or other related perinatal losses – have doubly challenging circumstances to overcome on their path to parenthood. There are not many resources about trauma’s real impact in birth, and even less on the combined impact on survivors AND loss around birth. A classic book in the field is: When Survivors Give Birth - Understanding and Healing the Effects of Early Sexual Abuse on Childbearing Women by Penny Simkin and Phyllis Klaus (published in 2004 and second edition 2005). The book was a valuable contribution that accelerated building awareness about the reality and negative impacts of sexual abuse and related trauma on women birthing. The authors highlighted key issues that are important to understand:

  1. past history of sexual abuse has real implications through the whole timeline of pregnancy, labor, birth and after (p. xv);
  2. any of the pieces of this timeline may be when the trauma of past abuse can recur (p. xvi); and
  3. if there is recognition and awareness, it can be used to support and empower women through these times. There is a way the time around childbirth can be uplifting, freeing and very healing for women. (p. xvii).  

The explicit, detailed definition of abuse (p. 4), and descriptions of forgetting or disassociation (p. 9), as well as recall of past incidence is important to understand (p. 12-13), as are the different levels where the impacts can emerge [sexual behaviors, physical and “somatic manifestations, psychosocial disturbances, and mental health disturbances] (p. 22). It’s also key that before the time of this book, sexual abuse was not really part of the conversation in many  cultural discussions about birth or in most medical settings. In both areas, there is still more to understand and discuss.

Powerful Healing is Possible

This book also brought to the forefront that powerful healing can happen to women through pregnancy, labor and birth. One strength of this book is specific information about working through issues and giving the best support through labor/birth (chapter 4) and the postpartum time (chapter 5). For labor and birth understanding triggers and issues of control are important (p. 79-82), and after birth, post traumatic stress disorder (PTSD) and watching for mood disorders are key. The book also does an excellent job of sharing varied women’s stories to give an idea of the scope of abuse impact, ways to shift and transform them, and of the potential of women’s power. It is wonderful that these stories were interspersed throughout, to bring personal perspectives to the more theoretical writing.

Past Understanding and Evolving Understanding

The evolution of this discussion continues. For example, the book discusses the history of recognition of abuse, specifically by Freud – how his 1896 published paper linked hysteria to early childhood abuse (p. 9) but then in 1897 he denied his findings: “…if his patient’s stories were true, and his theories correct, he would be forced to conclude that what he called ‘perverted acts against children’ were endemic… among respectable bourgeois families where he had established his practice. The idea was simply unacceptable.” (p. 9-10) Since then, the evolution of understanding about trauma impacts on these issues shifts ( still too slowly), and this book took a major leap forward in revealing so much about the awful impacts of abuse and the power of conscious care and potential healing.

Role of Caregiver in the Medical Model - Limits and Expansion

This book focuses first on the role of the caregiver/taking a more cautious approach in regard to how the medical model can invalidate women’s needs in the case of past abuse. They discussed how the caregiver can support women (versus how they can empower themselves). In chapter 6, the conversation about “The Relationship Between the Woman and Her Doctor or Midwife” is excellent. Hopefully, the conversation about the value of a true midwifery model keeps evolving as part of healing and empowerment. (That model includes care from another woman [ideally the same one] through the antenatal months, giving mom time for feeling safe and having wishes heard over time, a relationship with depth of and consistent care, and ensuring there is someone who really knows and honors the mother’s hopes and needs.) The midwifery model can give parents what the book’s introduction (by Sue Blume) mentions is so significant – their own sense of value and deserved boundaries (p. xxii).

Empowering More Ideal Caregiver Support - With Parent Input

The second focus is empowering the caregiver. This is where the valid and real experience of Penny Simkin and her colleagues occurred, which helped them understand in more depth how to best support women with challenging pasts. Focusing from the caregiver’s perspective is useful. For example - communication issues (chapter 11) the value of birth plans (p. 172, 367), how to do pelvic exams with care (chapter 12), and nursing plans (chapter 13). Also, it is good some chapters give valuable information aimed at the pregnant parents themselves. For example, there is discussion about choosing a caregiver, disclosure and delayed recognition of abuse (chapter 3) as well as information on self-help (chapter 9), counseling (chapter 10), the role of psychotherapy (chapter 11), and informed consent (chapter 14). 

Visioning a Future Birthspace that Prioritizes Healing

Where does this discussion go from 20 years ago to today in 2024, and beyond? For sure, it’s a multistakeholder conversation - and empowering and deep listening to the voices of those who experienced past trauma/abuse - and especially those also with perinatal loss - must be prioritized.

With respect to the medical establishment (where most doulas and some midwives work today), we can come  together to be more truthful. It needs to be said - the medical model – as well as legal systems, insurance limitations, pharmaceutical companies, patriarchal cultures and religions in many places – extremely limits recognition of the reality of abuse (plus often allows harm or trauma to persist). The model we birth in does not build awareness for medical providers well (especially medical students who may see no or few births (or ones where mom is on her back), who become general practitioners and gynecologists facing pressure to save time and liability). These gaps limit care, support and healing that could be so transformational on many levels for women, as well as medical providers and society through time. A true midwifery model is ideal to return to (including one midwife being there through labor to the birth AND following up after). Childbirth education (especially early on!) and doula support are key components, especially for this population who have so much to overcome and so much to gain - personally and for their families - in their healing paths.

Over time, leaders in the birth field can focus the conversation on empowering women themselves, because really they are the ones to choose to take the path of awareness and healing; their care providers assist (and doctors in a minor way compared to most doulas and midwives). In BirthWorks, we hear more and more that families feel they can challenge the limitations of the system!!! This is so important for informed consent, and as the voices of those with challenging pasts are brought into this conversation more - to help them heal and improve care for others in the future too. We must understand more of how to support/companion people with a past that included trauma and perinatal losses… and doing so can reveal how the intersection of survivors and loss intersects with the possibility of  transformation of pregnancy and birth.

This classic book was a wonderful contribution to evolution in the birth field. It highlighted a huge gap and even bigger need. Hopefully, this conversation Penny and Phyllis started and continued through her life keeps being carried forward by birth organizations and leaders. We can take the amazing opening, and now look at the growing field of evidence-based research on the impacts of trauma. This will help us together continue to find ways for women’s voices to be heard, tell our birth stories AND our loss stories more. Together, we can find ways to create more and more peaceful, loving ways and places for women to birth - honoring their needs, wishes, power and mental wellness. This also assures they optimal safety, health and wellness for our babies’ development!


One of the authors of the book, Phyllis Klaus, is on BirthWorks Board of Advisors. The other we would like to honor… Penny Simkin passed away April 11, 2024. She was an exceptional woman who left a beautiful legacy in the birth field. She was a physical therapist specialized in childbirth education and labor support since 1968. She helped over 15,000 people prepare for childbirth, as well as supported hundreds of families as a doula. She authored several books for both parents and professionals, as well as produced training materials. She co-founded DONA International and PATTCh (Prevention and Treatment of Traumatic Childbirth). You can read more about her here. Our heart is with you Penny, and with your family, colleagues and friends who can truly celebrate your amazing life.