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Giving Birth with Rape in One’s Past:
A Qualitative Study
Lotta Halvorsen, RN, RM, MHSc, Hilde Nerum, RN, RM, MHSc, Pa
˚l Øian, MD, PhD,
and Tore Sørlie, MD, PhD
ABSTRACT: Background: Rape is one of the most traumatizing violations a woman can be
subjected to, and leads to extensive health problems, predominantly psychological ones. A
large proportion of women develop a form of posttraumatic stress termed Rape Trauma
Syndrome. A previous study by our research group has shown that women with a history of
rape far more often had an operative delivery in their first birth and those who gave birth
vaginally had second stages twice as long as women with no history of sexual assault. The
aim of this study is to examine and illuminate how women previously subjected to rape
experience giving birth for the first time and their advice on the kind of birth care they
regard as good for women with a history of rape. Methods: A semi-structured interview with
10 women, who had been exposed to rape before their first childbirth. Data on the birth
experience were analyzed by qualitative content analysis. Results: The main theme was
“being back in the rape”with two categories: “reactivation of the rape during labor,”with
subcategories “struggle,”“surrender,”and “escape”and “re-traumatization after birth,”
with the subcategories “objectified,”“dirtied,”and “alienated body.”Conclusion: A rape
trauma can be reactivated during the first childbirth regardless of mode of delivery. After
birth, the women found themselves re-traumatized with the feeling of being dirtied, alienated,
and reduced to just a body that another body is to come out of. Birth attendants should
acknowledge that the common measures and procedures used during normal birth or
cesarean section can contribute to a reactivation of the rape trauma. (BIRTH 40:3
September 2013)
Key words: birth experiences, birth trauma, content analysis, rape, re-traumatization
Rape is one of the most traumatizing violations a
woman can be subjected to, with negative conse-
quences for her health and reproductive life (1–3). It is
well documented that a rape can lead to long-term reac-
tions, fear, anxiety, depression, fatigue, chronic pain,
sleep or eating disturbances, self-harm, substance
abuse, and suicidal thoughts or attempts (3–10). It is
the psychological injuries that dominate, and a large
proportion of women develop a form of posttraumatic
stress disorder in the aftermath, termed Rape Trauma
Syndrome, in which the rape is the stressor (11,12).
Sufferers of Rape Trauma Syndrome tend to have more
serious symptoms than individuals in which posttrau-
matic stress disorder is because of other stressors, and
the closer their assault is to the legal definition of rape
(forced, nonconsenting sexual activity) the stronger the
Lotta Halvorsen and Hilde Nerum are Doctoral students at the Uni-
versity of Tromsø, Norway, and midwives at the Department of
Obstetrics and Gynecology, University Hospital of North Norway,
Tromsø. They are equal first authors of the following paper. Pål Øian
is a professor in the Department of Obstetrics and Gynecology, Uni-
versity Hospital of North Norway, Tromsø, and Institute of Clinical
Medicine, University of Tromsø, Norway. Tore Sørlie is a professor
in the Department of General Psychiatry, University Hospital of
North Norway, Tromsø, and Institute of Clinical Medicine, University
of Tromsø, Norway.
Address correspondence to Lotta Halvorsen, Department of Obstet-
rics and Gynecology University Hospital of North Norway, Postbox
100, Langnes, 9038 Tromsø, Norway.
Accepted July 9, 2013
©2013, Copyright the Authors
Journal compilation ©2013, Wiley Periodicals, Inc.
182 BIRTH 40:3 September 2013
symptoms of Rape Trauma Syndrome (3,13). Features
that seem more prominent in victims of rape are shame,
guilt, and suicidal ideation (2,6). The rape crisis is
assumed to strike a core in the woman that affects her
fundamental value as a woman and influences her rela-
tionships with other people in the future (6,14).
Estimates indicate that 6–36 percent of all women
have been subjected to forced sexual activity or sexual
violence (1,5,7–9,15). Statistics from the United States
show that between 12 and 18 percent of women have
been subject to a rape in the course of their lifetimes
(9). Several studies indicate that the risk of being sub-
ject to sexual assault is highest in late adolescence
(6,15,16). In most studies of the association between
various forms of sexual assault and subsequent birth
outcomes, women with a history of sexual assault have
not been found to have higher incidence of medical
complications or operative delivery than women with-
out such histories (17–19). A study carried out by our
research group has, however, shown that women who
were raped as adults were delivered by cesarean, for-
ceps, or vacuum extraction to a much greater degree,
and that those who gave birth vaginally had second
stages of labor twice as long compared with women
with no history of sexual assault (20). Studies have
shown that a large proportion of women requesting
cesarean for fear of birth have been subject to sexual
assault earlier in life, and have experienced their first
birth as traumatic (21,22). During the many years of
our clinical practice as midwives, we have counseled
numerous women with a history of sexual assault and
rape, many of whom experienced the care they received
during labor as new assaults. The actual birth experi-
ence of women who have been subject to rape previ-
ously has been little researched or described in the
obstetric literature. The aim of this study is to examine
and illuminate the way a first childbirth is experienced
by women previously subjected to rape, and advice on
the kind of birth care they regard as good for women
with a history of being raped.
Method
Design and Population
To examine the women’s experiences, a qualitative
semi-structured interview was used. This approach is
suitable for sensitive topics, and gives access to human
thoughts and experiences (23). The interviews were
carried out according to Kvale’s principles for the qual-
itative research interview (24). This process means that
the informants do not merely answer questions posed
by the researcher, but that through dialogue with the
interviewer they formulate their own experience and
perception of the world they live in. Data were ana-
lyzed qualitatively as described by Graneheim and
Lundman, a method for systematic identification of var-
iation in the text with regard to similarities and differ-
ences (25). Advice on good birth care for women with
a past history of rape is summarized and presented in a
schematic model.
The study population consists of women subjected to
rape after the legal age of consent (≥16 years) and
before giving birth to their first child. The informants
were recruited from a cohort of 808 women who had
been referred for counseling for various psychosocial
problems to a mental health team at the antenatal clinic,
University Hospital of Northern Norway, in the period
from 2000 to 2007. Of the 808 women, 59 reported
having been raped as adults, whereof 50 were part of a
study showing primiparous labor outcome (21). All of
the women had been subjected to vaginal rape with
penetration. The information about the rape was regis-
tered as part of a systematic charting of their reproduc-
tive and mental health during counseling at the
antenatal clinic. The women’s rape history was not
known to their caregivers during pregnancy and
remained unknown to the birth attendants during the
women’sfirst birth. A strategic sample was chosen
using the following criteria: the woman had to speak
Norwegian, not be pregnant, and not be suffering from
serious mental illness at the time of the interview. The
women’s births represented different modes of delivery:
vaginal birth, vacuum extraction, and cesarean section.
Written requests to participate in the study were sent to
11 women, with information about the aim of the study
and what participation entailed. In the letter it was
emphasized that there would be an offer of professional
help if the interview itself caused problematic reactions.
Those who wished to participate posted their consent
directly to the researchers. No reminders were sent.
Ten women consented to participate, and these com-
prise the informants for this study. Their ages at the
time they were raped and at their first childbirth and
the outcomes of those births are described in Table 1.
The interviews were carried out in the period 2009
to 2010 jointly by the two first authors (LH, HN), who
both have extensive clinical experience discussing sen-
sitive themes with women. Eight of the interviews took
place in an undisturbed place at the hospital and two
took place in the homes of the informants. The inter-
views were audio recorded, and lasted on average two
hours each. An interview guide had been developed
with focus on the following themes: the first birth
experience, interaction with birth attendants, what the
informants considered “good birth care,”and asking
the informants to describe their own mental and sexual
health at the time of the interview. The opening ques-
tion was “Tell us about your first childbirth—in as
BIRTH 40:3 September 2013 183
much detail as you can recall.”The subsequent the-
matic order was dependent on what the individual
woman brought up.
The interviewees were encouraged to tell freely about
their experiences related to the various themes. No direct
questions about the rape were included. Clarifying ques-
tions were posed as needed. Before ending, the interview
guide was checked to ensure that all of the themes had
been dealt with. After each interview, individual notes
were made that summed up the interviewers’immediate
reflections on the content of the interview. The first six
interviews were transcribed consecutively (by LH), and
the rest were transcribed by an external person without
any connection to the study. The interviews were
transcribed verbatim in dialect, as close to the oral form
as possible, with noting of laughter, crying, silence, or
other forms of nonverbal communication.
Data Analysis
Interviews consisting of 131,261 words were analyzed
by the two first authors (LH, HN). Because this study
focuses on the first birth experience, only those parts of
the text dealing with labor and the advice of the birth
attendants were used (98,467 words). To get a compre-
hensive picture of the experience as a whole, the inter-
views were listened to and the transcripts re-read
several times. Thereafter, the same two researchers
reflected together on the main themes of the content.
The text was then divided into meaning units that were
coded, condensed, and thematized. The development of
the main theme was an ongoing process throughout the
entire analysis period. Presenting the material in a clear
way was emphasized, without changing the meaning of
the women’s comments. Further analysis was discussed
by the other two coauthors (TS, PØ) to achieve a
greater common understanding of the abstracted mate-
rial in the text. The entire analysis was carried out
manually, without the use of electronic instruments of
analysis.
Ethical Approval
The study was approved by the Regional Committee
for Medical and Health Professional Research Ethics
for Northern Norway (Reference 2009/1146-2).
Results
Descriptions of the Study Population
The informants were aged 21–38 years (Mean 26.2) at
the time of their first childbirths (Table 1). Seven were
married or cohabiting with partners and three were
single. All resided in Northern Norway, and four had
Sami ethnic origin. All had completed secondary
school and four had university educations lasting more
than 4 years. Nine were in full-time employment; one
was temporarily disabled as a result of serious somatic
illness. At the time of the interview, eight had two chil-
dren, whereas two had one child each. They had been
raped when they were 16–26 years old and the first
childbirth occurred 6–16 years after the rape. Nine of
the women had experienced attack rapes by strangers,
two of them by multiple attackers; one woman had
been raped by her partner. In the case of four of the
women, the rape was their sexual debut. One rape had
been reported to police.
Being Back in the Rape
In the analysis, one main theme, two categories, and
six subcategories were identified. The main theme was
“being back in the rape.”The category “reactivation of
the rape during labor”had the subcategories “struggle,”
“surrender,”and “escape,”whereas the category “re-
traumatisation after birth”had the subcategories “objec-
tified,”“dirtied,”and “alienated body.”
Reactivation of the Rape
All of the informants described persistent strong memo-
ries of having been back in the rape during their first
childbirth, independent of whether they gave birth
Table 1. Informants’age at time of rape, at time of first
childbirth, type of onset of labor, and mode of birth
Informant
Age at
rape
(year)
Age at
birth
(year)
Labor
onset Mode of birth
1 22 38 Spontaneous Vacuum
extraction
2 18 22 Spontaneous Vacuum
extraction
3 17 29 Induced Spontaneous
4 16 26 Induced Spontaneous
5 26 29 Spontaneous Vacuum
extraction
6 16 25 Spontaneous Spontaneous
7 16 26 Induced Emergency
cesarean
8 19 23 Induced Emergency
cesarean
9 16 21 Spontaneous Spontaneous
10 16 23 Induced Emergency
cesarean
184 BIRTH 40:3 September 2013
vaginally or by cesarean section. They described it as
switching back and forth between scary memories from
the rape and conditions during labor that reminded
them of the rape.
Struggle
The informants described having carried on an intense
internal struggle during labor, in which the rapist and the
birth attendant switched roles as main actor. One of the
informants described her fight with the rapist this way:
I recall the birth as dark and ominous, a big black hole I was
afraid to fall into, because there he stood, the man who raped
me and he was grinning this awful grin. I know I fought not
to fall down the hole, because if that happened I would lose
my mind. It was vital to stay on the edge and not fall in. My
husband realized I was struggling in my own world, fighting
with someone outside the room. It cannot have been easy to
be him while I was battling another man in the midst of the
birth of our child. (3)
In the battle with the birth attendants, the women
were in conflict with themselves and their own needs,
and the ward’s procedures and routines.
I was alone against them. All information was given with their
hands inside me…I tried to tell myself “Relax!Get a grip!”
but it was no use. (10)
The birth attendants’touching of intimate parts of
their bodies was experienced as an invasive procedure,
and this intrusion was intensified when the attendants
without warning touched them without the women
understanding what the attendants were doing, and
why. The women tried actively to maintain control over
their bodies by protecting themselves with clothes or
bedding. They described the feeling of once more
being held captive, held forcibly in positions they
expressed strongly that they did not wish to be in. Pro-
cedures such as vaginal examinations to monitor pro-
gress in labor were tied to their experiences of the
violent vaginal penetration during the rape. The pain
experienced by the lower part of their bodies once
again became the main body part, which once again
was subject to events reminiscent of the rape.
I felt he was brutal, it was just kind of a “whoosh”…felt he
just broke my legs apart, and right in and just go ahead and
check me. It was such a helpless situation to be lying there…
in way like…a bit of a violation really. Even though I tried
to tell myself, sort of sensibly that “they do have to do this”
and “I guess they need to check that everything is OK.”(4)
The alternating battle with the birth attendant and the
rapist was experienced over time as a useless one, in
which the women finally simply surrendered.
Surrender
The women felt that their physical and emotional
reactions were either overlooked or overrun by the
birth attendants. Through the unintended unfortunate
interaction with the birth attendants, in which they tried
in vain to resist, the women gradually allowed them-
selves to be dominated and finally surrendered.
I did not want to be on my back with my legs up, but they
held my legs. Something happened to me around that, being
held in place. For me, it led to just giving up, they could do
whatever they wanted. It was kind of…all the way up to that
point, I was protesting. (9)
When they laid me on the operating table I felt as if I died.
My whole body disappeared. I felt nothing, I was gone, I had
no way to get away, I could not get away. (10)
When the woman gave up, the birth attendants inter-
preted the situation as an inability to give birth, and their
next move was an even more active intervention to deli-
ver her. The women perceived this interference as if they
were unable to master the task and that their bodies had
failed them. When they had surrendered, they saw no
other option than to mentally escape out of their bodies.
When they put in that “vacuum cup”it was the first time I
really had thought about the rape in years. I was back in it,
being held down and not being able to move. In any case I
was completely naked. I felt a kind of shame too. Up to this
point I was kind of angry, in a way. But then it was a little
bit like when “he”(the rapist) –it was kind of too late. Noth-
ing left to fight for. Afterwards I felt I’d done such a terribly
bad job. (2)
Just lying there on your back and you’re in the same position
when you again go into the same state as when you were raped,
plain and simple. You′re lying there and things happen down
there (points between her legs), the feeling of being held down.
It was really strange…my body held back and would not do it.
I wanted to give birth but my body would not do it. (1)
Escape
Both the birth and the rape were experienced by the
informants as unavoidable and uncontrollable situa-
tions. They let their captive bodies remain, and saw
themselves from outside, or from above.
I no longer knew I was giving birth. It was very unreal, but
so is a rape. I felt that in a way, I left my body, like when I
was raped. I did not know where I was, if I was above myself
looking down. But it felt very similar. (4)
I was stuck in the bed, they could do what they wanted with
me. They were saying something about them seeing that I am
in pain, but “they will be quick.”They pull away the duvet I
BIRTH 40:3 September 2013 185
am clinging to for dear life and they pull up my top. Lying in
bed, vulnerable, I leave the room; they can just do whatever
they have to. (10)
Looked down and saw myself from above, like a slaughtered
animal lying there that they could do whatever they wanted
to. Could not move a muscle, and real scared. I am lying there
stunned, and cannot get away. Cannot take in what is happen-
ing. I am good at leaving the crime scene. (7)
The informants described the way they experienced
being treated as a passive object instead of a partici-
pant. Their intention was to collaborate with the birth
attendant, something that gradually seemed as an
impossible task. They described birth attendants who
seemed stressed, and who they felt had no time or
inclination to work with them. They experienced their
own reactions as deviant and inappropriate, and per-
ceived that the attendants focused exclusively on the
baby’s birth, to which the women themselves com-
prised an obstacle.
Re-traumatization after birth
The informants had tried to deal with the rape as a
“non-event”in their lives. The shame of having been
raped was so overwhelming that the trauma remained
unspoken and thereby unprocessed. In pregnancy they
had thought that the rape might influence the birth, but
the thought had been shoved aside. After the birth, they
experienced that the same patterns of reaction and the
same defense strategies elicited by the rape, also had
been activated during labor.
Objectified
What they had attempted to communicate to the birth
attendants had not been received; their body language
had been overlooked and not given consideration—as
though they had not even been present. They felt reduced
to a “birth machine”and were ashamed that they had not
been able to prevent this process from happening.
That the midwife did not talk to me, did not address me—and
that I was not allowed to be involved. I was just a kind of
“robot machine body”that was there to give birth to a baby—
where nobody saw “me.”There is something very degrading
about being treated like a birth machine that is just something
to be repaired. You are not a machine that is going to give
birth to a kid, you are there as a person too. You are not just
a body that another body is going to come out of. So in a
way it is “a body”that gave birth—but it was not me. (2)
It was sort of the baby it was all about, not “me”at all. It was
so strange really—as if I was not even there—I was not there.
I was just—I was not even a patient, really—was actually
nobody. There was just a baby who was going to come out of
me. (4)
The women recognized well the same unworthy feel-
ing of being useless, like some random object, and they
again assumed the blame for it having turned out that
way.
Dirtied
The women described the way all forms of touch by
unfamiliar hands invaded and dirtied their bodies. “Dirt-
ied”in the sense that the feeling came as a consequence
of something they were subjected to from outside them-
selves, and that had stuck to their bodies. Immediately
after the birth or the cesarean section there arose an
acute and pressing need to wash themselves clean.
Recall that I felt dirty!I felt violated, and I really wanted to
brush my teeth. I felt I wanted to brush away something or
other. And this has something to do with me feeling really
dirty—and those old nightmares about the hands came back. (1)
It got so important to get on my feet again, after the cesarean
section. Everything had to be washed away, sweat, blood,
filth, bits of tape, and most important, hands. All the hands
that had been there, had to go. (10)
I felt I had to have a shower. Not so much the birth, because
I do not know if I was bloody, I have no idea—I am sure I
was, and sweaty too, but there was something else I had to
shower off. Felt I had to make myself clean in some way or
another. After that rape I have always been like that—felt that
I had to—all this stuff about cleanliness. (4)
The feeling of being dirtied persisted far into the
puerperium; they felt they had bodies they did not rec-
ognize as their own, and this feeling made it difficult
to carry out the natural tasks of mothering.
Alienated Body
The birth became a new assault in which the women
experienced being violated in a similar way to when
they were raped. They recognized the degradation of
having been objectified and reduced to a physical thing
that others had made use of. The feeling was not
directly tied to how the child was born, but to how the
interaction between the women and the birth attendants
had developed during the birth.
I felt just gross. They shoved me further and further away
from myself, just slammed on. They stood there all three with
their heads in me, down there. Was not that nobody saw me
or talked to me. I was just empty. I hate my body, thinking of
186 BIRTH 40:3 September 2013
myself as one thing, my body as something else, and we are
not working together. My body is just gross. (10)
Well, it feels like certain of your body parts are not yours no
more. It is just something someone takes all away from you.
You sit there or lie there, just like that, and just ARE like a
carcass or a beached whale in my case. I felt like I was just
laying there, stuck, and could not come back to my own self.
I feel I’m still lying there, when I ought to be lying out to
sea, swimming. (9)
The rape trauma had invaded the entire birth experi-
ence so that instead of feeling like a proud new mother,
this woman remained re-traumatized.
Caring in labor for women with a past history of rape
Figure 1 shows advice on what kind of care in labor
the informants would have liked, and their advice to
birth attendants on the kind of care they regard as good
for women who have been raped previously. They were
very clear that the most important condition for the best
possible outcome is good interaction between the
woman and her attendants. It is important that the birth
attendants understand that routine procedures used dur-
ing labor or a cesarean section can contribute to a reac-
tivation of the rape trauma. They state that the woman
should have enough time and a calm atmosphere in
which to give birth to her baby, with as few interven-
tions or disturbances as possible that may remind her
of the rape. All of our informants reflected on how giv-
ing birth vaginally and spontaneously without operative
intervention can give a feeling of self-efficacy and thus
contribute to moving forward in processing their attack.
Those informants who had given birth twice recounted
that the memory of the rape was most prominent
during their first childbirth.
Discussion
The findings of this study show how our informants dur-
ing their first childbirth were caught by their bodily
experiences and memories from the rape. This experi-
ence led to a chaotic mixture of the rape in the past and
their labor in the present, and was unrelated to whether
the woman gave birth spontaneously, was operatively
delivered by vacuum extraction, or was delivered by
cesarean section. In the literature this chaotic mixture is
described as the person behaving as though the trau-
matic situation poses a current threat, with a desire to
defend herself against the threat in the way she tried in
the original situation, without success (10). It has been
documented that unprocessed traumatic life events can
force themselves on the individual so they experience
that the event is occurring again (10,26,27). In the theo-
retical model in Fig. 1, the central expressions of how
the memories of the rape were triggered in the birth situ-
ation are shown. During labor, the informants noted that
several of the same reactions and defense strategies as
they experienced during the rape were elicited. After
birth this phenomenon made them feel as if they had
been raped again.
It has been described previously that childbirth can
reactivate memories of rape (26–30). Rhodes and
Hutchinson have described four different extremes of
behavioral patterns during labor, which can be associ-
ated with posttraumatic stress reactions after sexual
abuse or assault: fighting, taking control, surrendering,
and retreating (29). The same patterns can be seen in
our informants when they describe that in the unin-
tended poor interaction with their attendants, they first
tried to resist, but after a while allowed themselves to
be dominated and surrendered, and finally ended up
feeling that their bodies were alien to them. The infor-
mants described how the birth attendants “doing as
they pleased”with their bodies, externally and inter-
nally, without preparing them for this act, contributed
to their being drawn back in time to the rape in their
past. The informants described being very disturbed by
all of the interventions used during labor. The methods
used for pain relief did not help against what they
found painful, but rather enhanced the feeling of being
paralyzed and out of control. Burgess has described
that the immediate reactions that automatically arise
during a rape give a surreal feeling in which the body
no longer reacts or carries out the orders given by the
brain, and the woman becomes physically unable to
remove herself from the situation (11).
The predominant feeling the informants in various
ways communicated, and the feeling they were left with
after birth, was a deep shame. They were ashamed that
their body once again had been invaded and they had not
been able to prevent a new assault. They were ashamed
that they had not managed to communicate and cooper-
ate with their birth attendants. The shame of not measur-
ing up as a woman giving birth, nor as a mother, was a
burden they carried in silence as they went on with their
lives. The most prominent expression of deep shame is
silence, and the perception of one’s own worthlessness
(31). Being raped is more than experiencing vaginal pen-
etration against one’s will; it involves an injury to the
core of the self, a violation of one’s human dignity, and
those who have been subjected to it frequently assume
the blame for what happened.
For our informants, the rape had been such an
extreme event that a reactivation during their first child-
birth was inevitable. The informants in this study had
all been subjected to a violent vaginal penetration; for
nine of them, the rape had been part of an attack in
which they had feared for their lives. Other studies
BIRTH 40:3 September 2013 187
Memories of the rape
Brought to the fore during labor
Lying supine, forcibly restrained
Violent approach to the body/genitals
Painfully forced entry and vaginal penetration
Perpetrator takes over control of her body
Struggle, shouting, crying for help
Darkness, blood, semen, sweat, breath
Feels unclothed, despised
Helpless, degraded
Gives up, lets it happen, feels ashamed,
leaves her body, disappears
Conditions during labor
Reminding woman of the rape
Being placed supine, physically restrained
Legs forced apart, placed in stirrups
Invasive procedures, not being listened to or seen
Invasive vaginal examinations
Unfamiliar hands touching body, being overruled
Sight / smell of blood, amniotic fluid, feces, sweat
Dimmed lighting/being unclothed
Bodily integrity not ensured
Being tied to bed or operating table, giving up
Birth attendants control body, room, time
Being back in the rape
Alienated from body
Retraumatized
After birth
Dirtied
Objectified
Informant’s advice on good birth care for women with past history of rape
That birth attendant knows about the rape before labor, shows understanding for her reactions
Not talking about the rape during labor
Being included in treatment decisions, being addressed directly, with eye contact
Being encouraged and supported, helped to stay in the present during labor, “being brought back” to present task
Protection of bodily integrity, as little manipulation of the bod y as possible, fewest possible vaginal exams
Help to maintain an upright position, avoid being placed supine
Awareness that epidural can give same paralyzed feeling as during rape, and both nitrous oxide
and pethidine can give unpleasant fogginess and feeling out of control
Informing her in advance of any touching of her body by anyone, allowing time for her to cooperate freely
As few unfamiliar people as possible in the labor or op erating room
Allowing her enough time, especially in second stage
Creating a calm space and time for giving birth
Understanding her need to wash and freshen up immediately a fter birth
Gettin
g
to talk throu
g
h labor with her birth attendants afterwards
Reactivation
During labor
Struggle
Escape Surrender
Memories of
the rape LaborRape
Figure 1. Schematic model of reactivation of the rape during labor, re-traumatization after the birth, and the kind of
birth care the informants consider as good birth care for women who have a past history of rape.
188 BIRTH 40:3 September 2013
have shown that when rape is associated with mortal
fear, and when the attack is not reported, or for other
reasons remains hidden by silence, the psychological
problems are more serious in the aftermath (3,6,11).
Only one of our informants had reported the rape to
the police.
For most of the women the trauma had been sup-
pressed and unprocessed. Childbirth was for all of
them a new and shocking confrontation with their pre-
vious trauma. We believe that the degree to which
childbirth reactivates a rape trauma depends on, among
other things, the quality of the interaction with the
birth attendants. This belief, however, poses certain
requirements to charting previous trauma, working
through this trauma before the birth, and tailoring the
birth situation to the woman’s needs. Our informants
expressed how important it was to be seen, and to be
addressed directly. They wanted help to protect their
bodily integrity from the view and touch of those pres-
ent, and they needed sufficient time to prepare so they
could cooperate with necessary procedures such as
vaginal examinations. They wished to be encouraged
and supported to be present in their bodies during
labor, so that they did not surrender and escape men-
tally from the situation. This approach requires that the
birth attendant has knowledge of reactivation of
assault, and that the attendant is familiar with the con-
ditions during labor, which may remind the woman of
her assault. Birth attendants often lack knowledge
about the woman’s history, and the woman may not
think that the assault will have any significance during
childbirth. One explanation for this lack may be that
the theme of assault, and of rape in particular, is laden
with shame and therefore surrounded by silence in
such a way that it is difficult to approach for the
woman and her helpers alike. The shame of having
been raped can be overwhelming for the woman, and
difficult for her helpers to identify. Health care person-
nel who provide antenatal care frequently feel they do
not have the necessary competence or preparation to
take in the woman’s history of assault, and this feeling
may be a factor in leaving the theme untouched upon
(32). When those caring for pregnant women for vari-
ous reasons do not give attention to the theme of sex-
ual assault, it can send a signal that burdensome life
experiences and psychological problems are not seen
as factors of significance for birth. When working with
women who have had a traumatic birth experience,
one should ask oneself whether she has had other trau-
matic life experiences, which could potentially be reac-
tivated during the birth.
One can imagine the possibility that performing a
planned elective cesarean section might be a way to
avoid reactivating a rape trauma in labor. However,
our informants who were delivered by cesarean
reported similar reactions to those who gave birth vagi-
nally. They described among other things that being
touched by strangers’hands, placed in supine position,
anesthetized, and fixed to an operating table reactivated
the rape trauma in the same way. They felt just as
objectified, dirtied, and alienated from their bodies as
those who gave birth vaginally. The informants also
reflected on how a planned cesarean section would not
be able to prevent a reactivation as it necessarily
involves being touched by others as well as insertion
of intravenous and urinary catheters, washing of the
surgical field, and being tied to necessary equipment.
It is also possible to view reactivation of a trauma as
an opportunity to connect with the traumatic event and
to begin processing it (33). Childbirth holds the poten-
tial to enter a dialogue with one’s body, a dialogue
that can lead to growth in the longer term. Having a
new experience can give a feeling of self-efficacy,
which itself is important for the confidence that one
can protect oneself in the future. All of the informants
reflected on how a vaginal birth without operative
intervention would promote an experience of mastery,
and the informants in this study who had given birth
to subsequent children described the memory of the
rape being most intrusive during their first child’s
birth. This reflection may be interpreted as performing
elective planned cesarean section to protect the woman
in the short term may hinder her opportunity for
growth in the long term. None of the women in this
study wanted a cesarean delivery.
Limitations and Strengths of the Study
Our informants were very clear about their main motive
to participate in the study. By sharing their experiences
they hoped to contribute to increased knowledge of
how rape can affect birth, so that both birthing women
and their attendants may benefit from this sharing in
the future.
A limitation of this study is that all of the informants
were recruited from the cohort of women who were
referred for counseling for psychological problems by a
mental health team at a hospital antenatal clinic; these
informants’experiences may not apply to all women
with a history of rape. Even though no direct questions
were asked about the rape, all of our informants spon-
taneously gave in-depth descriptions of the attack. The
close association between the memories of the rape and
the birth experience strengthens the supposition of an
internal association between the two.
The interviews, however, were performed 1–12 years
after the first birth and for the women who had given
birth twice, even though they described their labor
experiences very clearly and separated the first and sec-
BIRTH 40:3 September 2013 189
ond ones, the possibility of confusion cannot be ruled
out.
Clinical Implications
This study presents the way women subjected to rape
experience their first childbirth. We know little of how
the birth attendants experienced the interaction with the
women. More in-depth studies of the relationships
between birth attendants and women in labor, seen
from both sides, will increase the understanding of the
dimension of trauma in their interactions. Provided that
there exists a good relationship with the birth atten-
dants, childbirth can also carry the possibility of pro-
gress in working through a rape trauma.
Conclusion
A rape trauma may be reactivated during the first child-
birth, independent of mode of birth. The birth for our
informants came as a shock, a confrontation with the
past trauma in which the woman was emotionally para-
lyzed and alienated from her body, feelings that per-
sisted for a long time after birth. Birth attendants
should acknowledge that common measures and proce-
dures used in labor and during cesarean section can
reactivate the rape trauma. Future research should focus
on how best to provide care in labor and birth to
women with a past history of rape.
Acknowledgments
The study was supported by the North Norway Regio-
nal Authority Clinical Research fund, Helse Nord RHF,
8038 Bodø, Norway. We wish to thank our informants
for their participation in this study. They based their
willingness to participate on their hope that sharing
their experiences could help improve care in the future
for other women with a history of being raped. We
thank Rachel Myr for her translation of this paper.
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