PCAR Technical Assistance Bulletin Trauma and Lactation For those who are living with the effects of adverse or traumatic experiences, decisions around infant feeding or chest feeding may introduce new challenges and vulnerabilities. To work effectively with parents or caregivers who have experienced any type of trauma, it is important to understand trauma and trauma reactions as well as engagement strategies and opportunities for support. What is trauma? Trauma can be understood by the 3 E’s: It is an event or series of events, that are experienced as physically or emotionally harmful or life threatening, where there are lasting effects on a person’s mental, physical, social, emotional, or spiritual functioning (Substance Abuse and Mental Health Services [SAMHSA], 2014). Trauma can be a one-time event, like a life-threatening medical condition or an isolated assault, a chronic experience, like childhood sexual abuse or interpersonal violence, historic or generational, like racism or persistent poverty, or intersecting where there is exposure to multiple events with long-term impact, such as early childhood abuse and birth trauma. The important thing to understand about trauma is that the effects can be wide-ranging and different for everyone. It is “an emotional response to a distressing event or situation that breaks [a] sense of security” (Mental Health America [MHA]. n.d.). It is important that we reframe trauma responses as adaptations and behaviors that people have used in service of survival and safety and “can be conceptualized as a normal response to an abnormal situation” (World Health Organization [WHO], 2009). There is no one correct way to react to trauma and it impacts each person differently. The Intersection of Trauma and Feeding Decisions The Role of Stress and Pleasure Hormones Stress, especially toxic or chronic stress - the type of stress that many trauma survivors experience - can impact chest feeding or lactation in two crucial ways: access and quantity. The body’s ability to access or produce oxytocin, one of the “happy hormones”, can be impacted by high levels of stress. Oxytocin is an important hormone in the let-down response for milk production. If a lactating parent can’t access the pleasure system in the brain that influences the release of oxytocin, it can impact the ability to initiate the chest feeding experience. Secondly, oxytocin influences the quantity of milk that can get produced. Oxytocin “makes the milk that is already in the breast flow…and helps the baby to get the milk easily” (WHO, 2009). Physical Touch For some trauma survivors, touch or closeness with others is difficult or unwelcome. 93% of childhood sexual abuse is perpetrated by someone known to the survivor. Holding a baby or having a child close may be incredibly uncomfortable or triggering. Additionally, many parents or caretakers may need to manipulate their bodies to comfortably feed or may need the assistance of a coach or lactation consultant or other provider. Any of these human touches may make chest feeding challenging. Lack of Support System Many trauma survivors may experience a disrupted support system. For some, intentional isolation is a tool of abuse while for others, they may have difficulty forming or maintaining strong relationships. Research shows that formal chest feeding support programs and informal social support are effective at prolonging chest feeding (Baño-Piñero et al., 2018; Raj & Plichta, 1998; Van Dellen et al., 2019). While data does not indicate that trauma survivors initiate chest feeding at lower rates, survivors may cease chest feeding earlier. Unpredictable Nature of Babies and Feeding Babies are, by nature, unpredictable. For many survivors who work very hard to regain self-efficacy, a sense of control, and/or who struggle to sleep due to trauma, being woken up unpredictably or in the middle of the night for a feeding can be triggering. The isolation that many experience at night feedings can exacerbate feelings of isolation. Birth Trauma Up to 45% of new mothers experience childbirth as traumatic (Beck, 2018). Black women are 3-4 times more likely to experience dangerous and even life-threatening complications, and more likely to report mistreatment and neglect from medical providers and staff during childbirth (Markin & Coleman, 2021). While some survivors who reported birth trauma experience chest feeding as healing or help make up for a difficult birth, others indicate that it feels violating, physically painful, facilitates flashbacks, and leads to a sense of detachment. Birth trauma can impact survivors’ capacity to chest feed and their emotional response to it (Beck & Watson, 2008). Historical and Generational trauma Given the pervasive health disparities among people of color and the high rates of Black maternal mortality, it is critical to name the impact of historical and generational trauma on chest feeding. Intergenerational trauma, “the…trauma experienced by a specifical cultural groups that has a history of being systematically oppressed,” (Administration for Children & Families, n.d.) impacts descendants physical and emotional well-being in significant ways. Many historical traumas remain perpetual and impactful because they are linked to current and ongoing structural racism, bias, and institutional discriminatory practices (Centers for Disease Control & Prevention [CDC], 2023). The trauma of systemic discrimination, for example, can increases the body’s stress response, leading to challenges in chest feeding as discussed above (Sawyer et al., 2012). The early, pervasive legacy of slavery and exploitative practices that white Americans perpetrated may reinforce current aversion toward chest feeding as “embodied experience of historical trauma” (Johnson et al., 2021). Health disparities, especially those disproportionally affecting Black women, are associated with lower rates of chest feeding and Black women have the lowest rates of chest feeding initiation and continuation (Johnson et al., 2015). When working with BIPOC survivors, it is critical to consider the impact of historical and generational trauma in feeding decisions. Engagement strategies Promoting Safety and Collaboration • Go slowly and build authentic connection. The effort that providers put in to creating safety builds a strong foundation. One way to do this is by asking survivors what they would like to talk about first or by offering a moment to breathe and settle in before starting your meeting. • Promote wholeness. Remember, the survivor is more than the presenting issue. For example, you can ask “Are there any life experiences that you feel are important for me to know about?” • Use inclusive language and consider people’s preferences around language, pronouns, identities. If you don’t know, ask! It’s important that we pronounce people’s names correctly and use identified pronouns. An example of how to do this may be “Do you have any information or preferences that you’d like to share with me that would make you feel more comfortable?” • Center the survivor’s voice and experience. Survivors are the experts in their own lives. It’s important to honor their experiences and coping strategies as we look to support them in ways they are asking. Starting the interaction with a question like “Would you prefer to talk with the door open or closed?” sends a message that you’re respecting the survivor’s knowledge about what feels safe. • Ask before touching or doing anything for a survivor. You can ask “Is it okay if I sit next to you?” or “Would it be okay if I made a referral for that issue?” • Be curious with clients, it decreases the power differential in the room. You can ask “Is there anything you would like me to know about you today before we get started?” Employing a Strengths-Based Framework • Try and hold back the temptation (we all have it!) to ask survivors if they tried x, y, or z. We often jump into problem-solving mode. • Intentionally starting with a strength can be helpful to shift someone’s mindset from what’s going wrong, to what’s going right and what challenges exist. • Utilize the power of yet. Someone may not be able to do something at the moment; adding “yet” to the end of their sentence offers the possibility of hope. For example: “I can’t do this yet” or “I don’t know yet” or “I’m not good at this yet.” • Careful listening of past successes places us in a position to better understand resources to draw on. This can help when survivors feel helpless or hopeless. Some questions to help elicit strengths: • Can you describe the last time you managed to get free of (the problem) for a couple of minutes? • How have you handled (stress, disappointment) in another situation? • What has helped you succeed when you’ve been at another point like this? • Tell me one good thing that’s happened with the baby in the last day or two. Feeding Inquiry Feeding inquiry is using language that promotes strengths and curiosity on the part of the provider so that survivors can feel heard and validated. To support survivors with questions or concerns around feeding, the following may be helpful in responding to different situations: Validate and reflect back what they’ve said • “That sounds incredibly difficult to not be able to breastfeed/feed like you wanted to.” Ask open-ended, yet specific questions • “Can you tell me how feeding in the afternoon has been going” • “What have you heard about breast feeding?” or “What have you heard about feeding options?” Notice what you’re seeing in the moment • “I hear a some tension/stress in your voice.” • “It sounds like you might feel overwhelmed." Remember your scope and role • “I want to make sure you’re getting support and this is outside my area of expertise – I worry that I can’t give you the best advice here. Can I connect you with…” References Administration for Children & Families. (n.d.). Trauma [Webpage]. U.S, Department of Health and Human Services. https://www.acf.hhs.gov/trauma-toolkit/trauma-concept#:~:text=Historical%20trauma%20is%20cumulative%20and,%2C%20and%20self%2Ddestructive%20behavior Baño-Piñero, I., Martínez-Roche, M. E., Canteras-Jordana, M., Carrillo-García, C., & Orenes-Piñero, E. (2018. Impact of support networks for breastfeeding: A multicentre study. Women and Birth, 31(4), e239-e244. https://doi.org/10.1016/j.wombi.2017.10.002 Beck, C. T., & Watson, S. (2008). Impact of birth trauma on breast-feeding: A tale of two pathways. Nursing Research, 57(4), 228-236. https://doi.org/10.1097/01.nnr.0000313494.87282.90 Beck, C. T., Watson, S., & Gable, R. K. (2018). Traumatic childbirth and its aftermath: Is there anything positive? The Journal of Perinatal Education, 27(3), 175-184. https://doi.org/10.1891/1058-1243.27.3.175 Centers for Disease Control and Prevention. (2023). Racism and health [Webpage]. U.S. Department of Health and Human Services. https://www.cdc.gov/minorityhealth/racism-disparities/index.html#:~:text=The%20data%20show%20that%20racial,compared%20to%20their%20White%20counterparts Johnson, A., Kirk, R., Rosenblum, K.L., & Muzik, M. (2015). Enhancing breastfeeding rates among African American women: A systematic review of current psychosocial interventions. Breastfeeding Medicine, 10(1), 45-62. https://doi.org/10.1089/bfm.2014.0023 Johnson, A. M., Menke, R., Handelzalts, J. E., Green, K., & Muzik, M. (2021). Reimagining racial trauma as a barrier to breastfeeding versus childhood trauma and depression among African American mothers. Breastfeeding Medicine, 216(6),493-500. https://doi.org/10.1089/bfm.2020.0304 Markin, R. D, & Coleman, M. N. (2021). Intersections of gendered racial trauma and childbirth trauma: Clinical interventions for Black women. Psychotherapy, 60(1), 27-38. https://doi.org/10.1037/pst0000403 Mental Health America. (n.d.). Understanding trauma and PTSD [Webpage]. https://www.mhanational.org/understanding-trauma-and-ptsd Raj, V. K., & Plichta, S. B. (1998). The role of social support in breastfeeding promotion: A literature review. Journal of Human Lactation, 14(1), 41-45. https://journals.sagepub.com/doi/10.1177/089033449801400114 Sawyer, P. J., Major, B., Casad, B. J., Townsend, S. S., & Mendes, W. B. (2012). Discrimination and the stress response: Psychological and physiological consequences of anticipating prejudice in interethnic interactions. American Journal of Public Health, 102(5), 1020-1026. https://doi.org/10.2105/ajph.2011.300620 Snyder, H. N. (2000). Sexual assault of young children as reported to law enforcement: Victim, incident, and offender characteristics (NCJ 182990]. U.S. Department of Justice, Bureau of Justice Statistics. https://bjs.ojp.gov/content/pub/pdf/saycrle.pdf Substance Abuse and Mental Health Services. (2014). Trauma-informed care in behavioral health services (Treatment Improvement Protocol (TIP) Series 57). https://store.samhsa.gov/sites/default/files/d7/priv/sma14-4816.pdf Van Dellen, S. A., Wisse, B., Mobach, M. P., & Dijkstra, A. (2019). The effect of a breastfeeding support programme on breastfeeding duration and exclusivity: A quasi-experiment. BMC Public Health, 19(1), 993. https://doi.org/10.1186/s12889-019-7331-y World Health Organization. (2009). Infant and young child feeding: Model chapter for textbooks for medical students and allied health professionals. https://iris.who.int/bitstream/handle/10665/44117/9789241597494_eng.pdf?sequence=1 © 2023 Pennsylvania Coalition to Advance Respect. A division of Respect Together. www.pcar.org