Influence of childhood sexual abuse on pregnancy, delivery, and the early postpartum period in adult women

Abstract

Objective

With a prevalence of around 20%, childhood sexual abuse (CSA) is a relevant problem in obstetric care. The aim of our systematic review was to present the current knowledge on the influence of CSA on pregnancy, delivery, and early parenthood.

Data Sources

All English, French, or German primary and secondary literature from the reference lists found after screening the data banks Pubmed, PsycInfo, and Psyndex for publications that include the terms CSA or childhood traumatization and pregnancy, birth, delivery, labor, childbearing, breast feeding, or postpartum, and published after 1970 were reviewed for relevant data.

Methods of Study Selection

Investigations of psychological/medical data banks and cross references revealed 43 relevant studies. Given the paucity of data on this important subject, we opted to review all of these studies.

Tabulation, Integration, and Results

Although research projects on this topic are rare and the methodological quality of studies published to date is generally poor, women with a history of CSA seem to present a variety of long-term sequelae referring to pregnancy, delivery, and early parenthood. These sequelae include risk behaviors during pregnancy and disturbance of delivery by sudden memories of sexual abuse situations. Prenatal care is often complicated by the tendency to avoid situations that can trigger memories.

Conclusions

As effective treatment programs to improve sequelae of CSA are available today, the question of such abuse experiences should be raised as early as possible and adequate interdisciplinary models to care for victimized patients should be established. However, to improve knowledge on the long-term effect of sexual abuse experiences in obstetrical care, methodologically well-designed research projects focusing on the kind and incidence of sequelae, mediating factors as well as prophylactic and therapeutic options are needed.

Introduction

Thanks to the influence of the women's and the child welfare movement, childhood sexual abuse (CSA) has become a public subject and the focus of scientific research over the last several decades. Its prevalence is far higher than generally thought, and it has a great variety of effects on adult health. Obstetrician–gynaecologists and associated childbirth professionals are currently hampered by the lack of knowledge about CSA and the delayed manifestations of abuse that might occur during pregnancy, childbirth, and the mother–child relationship [1], [2]. Therefore, victims of CSA often do not obtain the adapted pre- and postnatal care, which would have favorable effects not only on their pregnancy and birth experience, but which could also open chances for a better parenthood. This review aims to provide information on the current status of research with special attention to obstetrical care.

Prevalences of CSA depend on the underlying definition. If CSA is defined as sexual contact between a child in mid-adolescence or younger and a person at least 5 years older, ranging from fondling to intercourse, the sexual victimization rate is generally considered to be around 20% for females [3], [4], [5], [6], [7]. Examples of different nonobstetrical study groups are presented in Table 1. Prevalences are particularly high in groups of women with known sequelae of CSA, e.g., in adolescent mothers (44%) [8], in substance-abusing pregnant patients (42%) [9], in patients with mental health problems (36–51%) [5], [10], and in battered women (53%) [11]. Although CSA is present in all socioeconomic groups, studies have shown that more severe forms of abuse appear to be associated with lower socioeconomic status [12], [13], [14]. Prevalence of sexual abuse alone is not associated with ethnic background [1], [15] or the level of education [1], and there seem to be no significant differences between countries in rates of abuse [16], [17] as long as the same definitions are applied. The true figure of CSA might be far higher [18], [19], [20] because even today girls rarely make their abuse public at the time of occurrence, and for retrospective evaluations, only parts of the CSA experiences are remembered [21], [22], [23], [24], [25]. In addition, feelings of both guilt and shame are strong motives for keeping CSA a secret [19], [26], [27]. In fact, only 20–50% of incidents come to the attention of authorities [12], [13], [14], [18], [19]. The rate of women informing a physician varies between less than 2% [28] and 28% [21] depending, among others, on the reason for consulting the physician. In addition, sampling methods, methods of data collection, response rates, and the number/types of questions asked about CSA may contribute to the variability in prevalence rates [22], [23].

The question why some women develop short-term or long-term physical and psychological injury after CSA and others do not has only recently appeared in studies on CSA [13], [14]. So far, there is no developmentally sensitive model for conceptualizing those effects and continuity or discontinuity of effects over time [29]. Reactions to CSA show more individual differences [30]. There is increasing awareness among health care professionals that CSA is common and may have serious and long-term psychological and medical sequelae [13], [14], [31], [32], [33], [34], [35], [36], [37], [38], although there is no “postsexual abuse syndrome” [17], [32]. Between 74% and 96% of women with a history of CSA seem to present physical and emotional scars [39]. Although there is a growing list of adult diseases and symptoms associated with CSA, sequelae focusing on pregnancy, childbirth, and the early postnatal period are not known by many obstetricians. As one in five women seems to be a victim of CSA, it was the aim of our analysis to present the current knowledge on the effect of CSA on pregnancy, birth, and the early postnatal period in order to offer a basis for the improvement of obstetrical and perinatal care.