Managing Adverse Childhood Experiences in Maternity Care
Hannah Tizard – Midwife at Blackpool Victoria Hospital and Midwifery Media Consultant at All4Maternity and The Practising Midwife
A recent safeguarding update at work inspired me to write this blog about Adverse Childhood Experiences (ACE’s) and the importance of a multi professional ‘ACE informed approach’ to care. The ACE Study was one of the largest investigations into childhood maltreatment and its later effects on health and well-being (Felitti et al., 1998).
The study highlighted links between adverse childhood experiences and severe health and wellbeing outcomes across the life continuum. Similar studies have been replicated across the world and drawn comparable conclusions (Bellis et al., 2014 & Bellis et al., 2016).
What are Adverse Childhood Experiences (ACE’s)?
The following infographics explain ACE’s.
The impact of ACE’s cause alterations to brain stress physiology or toxic stress and predisposes individuals to an increased risk towards health harming behaviours.
This in turn may lead to chronic and multiple adverse illness such as cancer, diabetes, heart disease and mental health disorders, including depression, anxiety, and post traumatic stress disorder (PTSD). Multiple ACE’s may accelerate ageing and lead to premature death, approximately 20 years sooner for those with 6 or more ACE’s.
Considerations for practitioners
The prevalence of ACE’s as shown in the infographics above are widespread, and are not exclusive to poorer socio-economic groups. ACE’s are passed via intergenerational transmission in family settings leading to vicious cycles of inequality and health inequities. Trust demographics showing higher than national averages of poverty and deprivation have more significant challenges. This video explains this effect.
ACE’s and their consequences can be prevented
It goes without saying that women with multiple severe ACE’s are likely to need specialist support during their pregnancy. They may already have input from children’s social care or a mental health team. However many will not reach thresholds for intervention but require understanding and sensitive supportive care.
There are many ‘midwifery ways of being’ that can help to support women with confirmed or suspected ACE’s to experience a positive and safe childbirth journey. This list is by no means exhaustive but offers suggestions for practice:
- Act now: Don’t wait for a disclosure of childhood maltreatment or abuse. Recognise the signs and do your best to provide support that is caring and non judgemental. Women might present to care as “difficult” clients, disengaging, fearful, rude or aggressive. Remember ACE’s disrupt numerous developmental processes, including those that should lead to an individual’s ability to regulate emotion, attend to bodily cues, and navigate trusting relationships (Sperlich et al., 2017). Women may struggle to believe that a midwifery relationship may be fruitful. It is up to you to demonstrate that services can help.
- Connect: Change social norms. Instead of asking “What’s wrong with you?” ask “What has happened to you?”
- Provide a holding environment or sanctuary space: A parent provides a supportive space for a child to feel safe and secure in developing and exploring their emotions (Sperlich et al., 2017). In your capacity to be ‘with woman’, you can provide a space for protection, encouragement, and support. Make references to what and why you are doing this and use the opportunity to discuss human needs.
- Educate: Women with high levels of maltreatment and adversity may lack good models for maternal role development with regard to sensitive, reflective, and protective mothering (Sperlich et al., 2017). Describe how a baby’s brain develops, discuss responsive parenting, provide easy tools for example, the benefits of skin to skin to facilitate closeness and bonding. Babies whose mothers have PTSD and depression are more at risk for bonding impairments.
- Use mentorship skills: You are her guide through childbirth, help her to grow and achieve her birth. Take opportunities to enhance parenting knowledge and assess capacity. Take time to understand her goals, collect evidence of her progress and tell her how well she is doing.
- Employ advanced knowledge: Understand that the woman who goes outside regularly for ‘some air’ does so because substance misuse and smoking are broadly understood to be self-medicating behaviour that is an effort to treat symptoms of toxic stress (Sperlich et al., 2017). It is important to remain non judgemental and woman centred. Instead use the opportunity to tell her you understand her needs.
- Listen: Find out what she’s having difficulty with, what are her stressors? Is it parenting a difficult teenager? Is she concerned about how she’ll cope with three children under five? Signpost to services, improve access to services – you are a font of local knowledge. Children’s centres often offer access to affordable high quality childcare and parenting support groups. They provide children with education and life skills whilst also giving parents opportunity for sanctuary or time to complete other social and health improving tasks. Look for ways which may support a break to the adversity cycle or provide trauma specific interventions.
- Resilience through empowerment: Having a strong relationship with a trusted adult throughout childhood has been found to reduce the long-term negative impacts of childhood adversity (Ford et al., 2015). Empower women in mothering abilities, put information in her hands, ensure she has a safe space to share her thoughts and feelings, encourage her to seek positive peer networks.
- Pain management: Drevin et al. (2015) suggest ACE’s are associated with higher pain intensities and larger pain distributions in late pregnancy, which are risk factors for transition to chronic pain postpartum. Understand that symptoms of pain may be grounded in experience of trauma. Be sympathetic to her needs, ensure pain is well managed and referred for additional assessment where appropriate.
- Don’t be defeatist: The pressures and impact of ACE’s on an already stressed NHS service have the potential to cause frustration. Remember ACE’s don’t define a person they are an opportunity for intervention – for you to make a difference to the lives of others.
Within a safeguarding capacity midwives must practice a child-centric model of care. It is important to evidence concerns factually within documentation and report elevated concerns about safety and parenting capacity to safeguarding teams for structured assessment. If you suspect a child is at risk of harm or in danger you must act and make a referral to children’s social care or the police.
- Use professional curiosity: this is a capacity and communication skill to explore and understand what is happening within a family rather than making assumptions or accepting things at face value. Consider the family holistically, ask questions and keep an open mind, critically evaluate any information you receive and always document anything which stands out or intuitively doesn’t ‘feel’ right. Your comment within a safeguarding log may be the final piece of the puzzle (MSCB and MSAB, 2018).
Public health and responsibility; ACE informed initiatives?
Over the last few years there appears to be a movement towards a societal acceptance that punishing adults or children for negative behaviours is not conducive to transforming lives.
I have recently seen innovative reports on social media:
- ‘meditation for pupils instead of detention’
- ‘volunteer run shops opened to support the community in trading skills or repair of broken household items’
- ‘the barber who gives up a day a month to groom the homeless in preparation for job hunting’
Indeed enhanced local community, individual generosity, understanding and support are the pillars to intervening and preventing the cycle of adversity which ACE’s may cause.
Positive concepts and individual contribution to help change social norms are vital and social media can be used to facilitate this. These act’s have a potential to help improve individual social and personal belief systems, resources and physical capacities.
The Centres for Disease and Control Prevention (CDC, 2017) suggest a 5 strategy approach to preventing ACEs;
- Strengthening economic support for families
- Changing social norms; support parents and positive parenting
- Quality childcare and education in early life
- Enhancing parenting skills to promote healthy child development
- Intervening to lessen harms and prevent future risks
The success of an ACE informed approach not only depends on community collaboration but also a multidisciplinary responsibility between health, schools and the police.
In the spirit of this month’s theme. Give a little… your efforts and sensitivity can help to make a difference to people. We all have a responsibility to improve the future of our communities.
As yet routine enquiry about ACE’s in maternity care is not mandatory, however the REACh Study (Routine Enquiry about Adversity in Childhood) (Larkin, 2016) has demonstrated:
- Most clinicians were not aware of the impact of adversity on later life outcomes before the training
- Professionals, when adequately trained and supported, are confident in holding difficult conversations around ACEs, and feel the approach is valuable and can deliver improved outcomes
- Routine enquiry does not appear to increase demand on services, but instead allow individuals already accessing support to have their needs more effectively met
A further recent American study by Flanagan et al. (2018) suggests ACEs screening as part of standard prenatal care is feasible and generally acceptable to patients. Women’s health clinicians are willing to screen patients for ACEs when appropriately trained and adequate behavioural health referral resources are available.
Providing ACE informed care as part of midwifery practice has the potential to prevent adverse outcomes, helps break intergenerational cycles of maltreatment and mental health disorders, and change the mother’s and child’s life-span trajectories into a positive direction (Seng and Taylor, 2015).
It is likely given the breadth of research on this subject and the compelling case for routine enquiry that we can expect a national roll out by the Department of Health.
Public Health England (2016) have suggested further research is needed. Including, feasibility and good practice to enquiry with children, enquiry into challenges and solutions of implementing routine enquiry within a multi agency partnership and further research to identify evidence based strategies which could help to prevent ACE’s and mitigate their impact.
Watch this space…
For more information please go to: Blackburn and Darwin Council Website
Infographics produced by Centre for Public Health
Bellis, M., Ashton, K., Hughes, K., Ford, K., Bishop, J. and Paranjothy, S. (2016). Adverse Childhood Experiences (ACEs) in Wales and their Impact on Health in the Adult Population. European Journal of Public Health, 26(suppl_1).
Bellis, M., Hughes, K., Leckenby, N., Perkins, C. and Lowey, H. (2014). National household survey of adverse childhood experiences and their relationship with resilience to health-harming behaviors in England. BMC Medicine, 12(1).
CDC.gov. (2018). Adverse Childhood Experiences (ACEs). [online] Available at: https://www.cdc.gov/violenceprevention/acestudy/index.html [Accessed 13 Mar. 2018].
Drevin, J., Stern, J., Annerbäck, E., Peterson, M., Butler, S., Tydén, T., Berglund, A., Larsson, M. and Kristiansson, P. (2015). Adverse childhood experiences influence development of pain during pregnancy. Acta Obstetricia et Gynecologica Scandinavica, 94(8), pp.840-846.
Flanagan, T., Alabaster, A., McCaw, B., Stoller, N., Watson, C. and Young-Wolff, K. (2018). Feasibility and Acceptability of Screening for Adverse Childhood Experiences in Prenatal Care. Journal of Women’s Health.
Ford, K., Butler, N., Hughes, K., Quigg, Z. and Bellis, M. (2015). Adverse Childhood Experiences (ACEs) in Hertfordshire, Luton and Northamptonshire. Centre for Public Health, Liverpool John Moores University.
Larkin, W. (2016). Routine Enquiry about Adversity in Childhood (REACh). [ebook] Birmingham: Public Health England. Available at: http://file:///C:/Users/Hannah/Downloads/PHE_Routine_Enquiry_ACES_2016.pdf [Accessed 13 Mar. 2018].
MSCB and MSAB (2018). Professional curiosity – resources for practitioners – Manchester Safeguarding Boards. [online] Manchester Safeguarding Boards. Available at: https://www.manchestersafeguardingboards.co.uk/resource/professional-curiosity-resources-practitioners/ [Accessed 13 Mar. 2018].
Seng, J. and Taylor, J. (2015). Trauma Informed Care in the Perinatal Period. Edinburgh: Dunedin Academic Pr Ltd.
Sperlich, M., Seng, J., Li, Y., Taylor, J. and Bradbury-Jones, C. (2017). Integrating Trauma-Informed Care Into Maternity Care Practice: Conceptual and Practical Issues. Journal of Midwifery & Women’s Health, 62(6), pp.661-672.
Sperlich, M., Seng, J., Rowe, H., Fisher, J., Cuthbert, C. and Taylor, J. (2017). A Cycles-Breaking Framework to Disrupt Intergenerational Patterns of Maltreatment and Vulnerability During the Childbearing Year. Journal of Obstetric, Gynecologic & Neonatal Nursing, 46(3), pp.378-389.