Trauma Informed for the Health of Mom and Baby

As I dragged myself out of my call room and made my way to our OB triage, I reminded myself that there was trauma present for this patient: an individual with minimal prenatal care, a history of substance use disorder (SUD) and refusal to stay despite the warnings of the nurse taking care of her. The fact that she showed up at all was an incredible step and one that was not easy for her to take. I stood next to her bed and explained why I was concerned for her and her baby and why it is important to stay and pursue labor induction.

She behaved reasonably as I sat down next to her and tried to find out why she did not want to stay. I learned more about her history of substance use and the trauma she had experienced, which kept her from following up with her prenatal care. She cared deeply for her baby, but also for her other children at home, which felt more important and pulled her away from the hospital. Though I did not agree with the rationale behind her decision to leave against medical advice, I listened. I wanted her to know that I was going to take care of her in whatever capacity she would allow me to and that what I wanted was the same as she wanted: a safe and healthy mom and baby.

The patience of the staff taking care of her was low and my fatigue was high, but I knew this patient needed and deserved my time and attention. I discussed the concerning variables in her baby’s heart rate which could indicate lack of oxygen to her baby. She listened and reflected on my statement of concern, but ultimately left the hospital. I felt defeated and worried for the rest of the night about this patient and her baby’s safety. I did not have to worry long because a few hours later she returned, in active labor and ready to stay. She thanked me for sitting with her and listening. She felt heard. Although she did not follow my initial advice, she did listen to me and when she got home and started feeling more uncomfortable came back because she felt comfortable returning knowing we would still take care of her.

According to the Substance Abuse and Mental Health Services Administration (SAMHSA) multiple studies have shown that “Women who have a SUD are also more likely to have histories of trauma (Devries et al., 2014), including sexual or physical abuse, and abuse or witnessing abuse in childhood (Cafferky et al., 2018; Muchimba, 2020; Stein et al., 2017; Tripodi & Pettus-Davis, 2013; Ullman et al., 2013).” They often have inadequate or no prenatal care despite coming into contact with the medical community at some point in their pregnancy. If we do not use a trauma-informed lens when we care for these vulnerable patients, we will miss the opportunity (and often only chance) to engage them in care. The California Maternal Quality Care Collaborative (CMQCC) has an incredible resource for providers called the Mother & Baby Substance Exposure Initiative Toolkit, https://www.cmqcc. org/resources-toolkits/toolkits/mother-baby-substanceexposure-initiative-toolkit. It offers a comprehensive review of how to care for our prenatal patients with substance use disorder.

Our pregnant patients with substance use disorder are a marginalized and especially stigmatized subset of patients within an already vulnerable patient population. When I visited one of our treatment centers for opioid use disorder it was heartbreaking to hear that their pregnant patients felt judged by other patients seeking the same treatment. They had to find ways to create a safe space for their pregnant patients so they would feel welcome in the waiting room.

We need to dispel this stigma and create a more welcoming and trauma-informed environment to provide patients with the care they need and deserve. This includes developing coping strategies for trauma or PTSD and relational techniques that take into consideration positive and negative familial and partner influences and promote a safe and caring treatment environment.

One of CAFP’s strategic priorities is to help family physicians practice more intentionally through a trauma informed, resiliency-oriented healthcare lens (TIROH). Please join us at our 2023 family medicine POP conference where we present both a plenary session and a two-hour workshop on this very important topic. Also, visit www.familydocs.org/aces for more helpful information and resources.

Clinical team members who bill Medi-Cal must complete a certified ACEs Aware Core Training to qualify to receive Medi-Cal payment for conducting ACE screenings. Check out AcesAware.org/training.

It is important to advocate for patient autonomy and teach them how to be an integral part of their own care. Empowering our patients to be their own advocates and viewing patient care through a trauma-informed lens helps to increase diversity, equity and inclusion in our medical system and leads to better health for our most vulnerable populations.