Why we Need Trauma- and Violence-Informed Maternal and Child Health Services: New Research from Rwanda and Local Implications

Aimable Nkurunziza, PhD Candidate (Nursing, Western University) and Berman Family Graduate Award Holder ankurun@uwo.ca

Dear reader, please take care when reading the following blog as it refers to issues of sexual and other forms of violence.

Photo by OWUROOLA ADEWALE on Unsplash

Trauma- and violence-informed care (TVIC) recognizes the intersectional impacts of structural inequalities, violence, and traumatic events, emphasizing both historical and ongoing violence. This approach emphasizes how a person’s past and present experiences of violence have shaped them, so problems are viewed as rooted in both their psychological and social conditions.

This sets the stage for why Rwanda is an important case study, given both the collective trauma of the 1994 Genocide against the Tutsi, and the gender-based violence (GBV) that was (i.e., genocidal rape) and is still so prevalent there, as it is here.

These observations are based on my PhD thesis exploring the experiences of adolescent mothers in perinatal services in Rwanda. From December 2021 to March 2022, I interviewed 15 adolescent mothers, 12 nurses and midwives, 12 community health workers (CHWs), and seven key informants (heads of health centers and supervisors of CHWs). I also reviewed two relevant documents that guide professional practice in this area.

Adolescent Mothers: Complexities and Challenges in Rwanda

Although Rwanda has made significant social and economic progress since the 1994 Genocide against the Tutsi, adolescent pregnancies, accounting for 5% of all pregnancies, remain a significant concern. Adolescent pregnancy is considered deviant and shameful in Rwandan culture, and indeed criminalized, thus young pregnant women and girls are often abandoned by the men who impregnated them, and face rejection from families and friends, stigma from the community, and increased rates of domestic violence.  In addition, over half of these pregnancies are the result rape. All of these factors increase the risk for mental health problems among these young women and girls, including high rates of depression and posttraumatic stress.

Violence and Inequities Affect Adolescent Mothers in Rwandan Perinatal Services

Perinatal nurses and midwives support adolescent mothers from antenatal care to the post-partum period and in subsequent child health services. However, to obtain services, a yearly fee of 3000 Rwf (almost $4 CAD) is needed for a health insurance card. Although low by Canadian standards this is out of reach for many Rwandan young mothers, especially if they have been ostracized by their families. So, when these young women and girls first go to a health center, for example when they learn they are pregnant, staff ask them first for their health insurance, which they usually do not have. Whether they receive further care varies; in extreme cases they will be sent back to their village where a leader will need to confirm that they can not afford insurance. The further shame and stigma of this process is an added form of systemic violence and trauma for adolescent mothers.

In addition, at the first pre-natal visit, every woman is required to bring her partner to be tested for HIV. For adolescents, especially those who are pregnant due to sexual assault, these requirements can be extremely (re)traumatizing. Those whose partners abandon them also indicate that hearing a nurse or midwife call the man who impregnated her “a father or husband” is harmful, given his lack of support. Healthcare professionals’ stigmatizing attitudes, disrespectful maternity care and even abuse towards adolescent mothers have been reported in Rwandan health facilities. In other research, only a few nurses and midwives (14%) reported that they were equipped, in antenatal care services, to take care of a client exposed to violence.

Because of these past and ongoing structural and interpersonal forms of violence, and their traumatic effects, pregnant adolescents in Rwanda often feel unsafe in the perinatal environment and sometimes lose trust in healthcare professionals. Others show signs of re-traumatization; a fact which healthcare professionals may not be trained to recognize or respond to. Most professionals try their best to support pregnant adolescents, including teaching and advocating for them, but lack of training and recognition of these issues in health services contexts make this very challenging.

Vicarious Trauma

Vicarious trauma, the harmful effects on providers of hearing stories of violence and abuse among their young patients, is also a concern. Providers may feel immediate emotional responses, and/or they may carry this burden out of the workplace, or, as I found in some of my data, even start to project what happened to those adolescent mothers to their own children, such as by being more protective or not allowing dating relationships. Most of these healthcare professionals do not know how to take measures to mitigate vicarious trauma, and their organizations do not provide needed supports. Therefore, incorporating Trauma- and Violence-Informed Care (TVIC) in Rwandan perinatal services would benefit pregnant and mothering adolescents, healthcare professionals, other perinatal clients, and health and social care systems.

Adolescent Mothers in the Canadian Context

In Canada, teen mothers face challenges similar to Rwandans when mothering; for example, researchers at the University of Alberta found that teenage mothers suffer from abuse and postpartum depression much more than their older counterparts. A study conducted at the Lawson Health Research Institute along with Brescia University College in London, Ont. revealed that teen mothers are more likely to live in poverty, suffer from poorer mental health, and use drugs more frequently. All these factors shape how teen mothers access and utilize perinatal services.

However, nurses and doulas also report disrespectful care and alleged mistreatment in childbirth, which can re-traumatize pregnant adolescents with potential histories of trauma who are experiencing violence. Access can be even more difficult for some; for example rural adolescent mothers find it especially difficult to access resources, with  one study highlighting negative stereotypes among these young mothers. Another study reported stigma and social isolation.

Integrating TVIC strategies in perinatal and other adolescent services will ensure physical, emotional and cultural safety and respectful, compassionate care to the benefit of young mothers, staff and entire organizations.

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Strategic Plan Engagement Opportunities

The City of London has officially started work on the development of the Council’s 2023-2027 Strategic Plan. 

Every four years, the City of London prepares a Strategic Plan that identifies the shared vision, mission, and priorities that will guide our City’s next four years. This Plan reflects the needs and expectations of our community and drives decision-making through the Multi-Year Budget and the Technology Investment Strategy.

This new plan will build from the existing Strategic Plan. With a continuous improvement mindset and a focus on data-driven decision-making, Council’s 2023-2027 Strategic Plan will reflect all the services the City provides and will uphold commitments to equity and inclusion, fiscal stewardship and sustainability.

Building an evidence informed plan that is truly reflective of community priorities is an essential goal of the strategic planning process. We encourage you to visit  Getinvolved.london.ca/strategicplan to share input and feedback during each step of the Strategic Plan development.

Invitation to Join Advisory Panel to Inform Implementation of Cancer Screening Recommendations for Two-Spirit, Trans and Nonbinary People

Invitation: Join Advisory Panel to Inform Implementation of Cancer Screening Recommendations for Two-Spirit, Trans and Nonbinary People

Photo by Andrew Ridley on Unsplash

Please share with patients, community members, and health providers in the hopes of finding some wonderful members of the Two-Spirit, Trans, and Nonbinary communities who might be willing to share their time and experience with Ontario Health to better inform future cancer screening policies.

Interested participants please email Logan Broeckaert obsp_pd@ontariohealth.ca by December 2


The Ontario Breast Screening Program is convening an advisory panel to implement recommendations from Ontario’s first cancer screening policy for trans and nonbinary people. The advisory panel is made up of clinicians who provide breast screening, clinicians with expertise in the primary care of trans people, and members of the Two-Spirit, transfeminine and nonbinary community. The work of the panel will be conducted in English.
We are currently seeking three panel members who are Two-Spirit, transfeminine or nonbinary, preferably eligible for breast screening (e.g., 50-74 with history of feminizing hormone therapy). Having some knowledge of the health care system or cancer screening is an asset but not required.
If you are interested, please email Logan Broeckaert, obsp_pd@ontariohealth.ca by December 2, 2022

What is the opportunity for panel members?

  1. Attend the advisory panel meeting in January/February 2023 (2 hours)
  2. Complete offline review of final guidance documents February – June 2023 (estimated time to be determined but I expect 3-5 hours at the most)
    Advisors who are not engaged with the Government of Ontario or the wider public sector will be offered honoraria for their time.
    What is the Ontario Breast Screening Program?
  3. The OBSP is a screening program designed to encourage people in Ontario to get screened for breast cancer. Regular screening can find cancer early when treatment has a better chance of working. The OBSP provincial program provides mammograms for anyone in the province who is eligible for breast cancer screening.
    What is Ontario Health?
  4. We are an agency created by the Government of Ontario to connect, coordinate and modernize our province’s health care system. We work with partners, providers and patients to make the health system more efficient so everyone in Ontario has an opportunity for better health and wellbeing.


The Global Health Equity @ Western hub team would like to invite you to create a Blog on the topic of RACIAL JUSTICE AND GLOBAL HEALTH.

Racial Justice is the systematic fair treatment of people of all races, resulting inequitable opportunities and outcomes for all. Unfortunately, due to racial injustice, many inequities arise and marginalized populations do not have access to the same resources as others making them more vulnerable to negative health outcomes. These include higher chronic disease risk (diabetes & cardiovascular disease), reduced health seeking, higher levels of unhappiness, loneliness, and depression. BInequities for racialized populations in access to health and care have been further underlined during the COVID-19 pandemic, exemplified by inequities in COVID-19 morbidity, mortality and vaccine distribution.

The Global Health Equity @ Western hub goal is to instigate discussion beyond calls for equity, trans-national solidarity and responsibility, to identify actionable interventions and shifts in thinking that can advance racial justice as it pertains to health.

For this year’s Power & Global Health Day with its theme of Racial Justice, you may consider producing a blog about (for example, but not limited to)…

  • Lived experiences of racial (in)justice
  • Indigenous Health
  • Community-based healing and advocacy
  • Access to Healthcare
  • Environmental Racism
  • Microaggressions
  • Gender inequities
  • Gender Rights and Health
  • Culture and Migration Experiences and Policies

Submissions are welcome from the entire Western community as well as external community members. Current students’ Blogs will be submitted to a panel composed of students, faculty, and community representatives, with the most compelling 5 submissions awarded a prize of $100 and featured on the Global Health Equity HUB @Western University

You do not need to be a current member of the Western community to submit. We want to hear from you! All Blogs meeting submission criteria will be featured on Western’s Global Health Equity website.

Blogs will be accepted from now until October 30th at midnight. Winning student submissions will be announced on Thursday November 24th, 2022, at Power & Global Health Day.

Blogs should not exceed 1500 words and should align with the general blog guidelines for the GHE hub which can be found here.

Please send your submission here

The Global Health Equity @ Western hub looks forward to hearing from our community and holding these important conversations. Please also join at Power and Global Health Day on Thursday, November 24th, 2022

Call for Members: Ontario Public Health Emergencies Science Advisory Committee (OPHESAC)

The Ontario Public Health Emergencies Science Advisory Committee (formerly the Ontario COVID-19 Science Advisory Table) is a group of independent, multi-disciplinary experts whose role is to enhance provincial capacity to respond to a spectrum of public health emergencies with the best available evidence. OPHESAC provides independent scientific advice to PHO, and where appropriate through PHO to Ministry of Health, to inform the management of public health emergencies, including COVID-19.

The Ontario Public Health Emergencies Science Advisory Committee (OPHESAC) is currently recruiting members with diverse expertise including health equity and social justice. Interested candidates should send their expression of interest, with a curriculum vitae and complete contact details to secretariat@oahpp.ca by Friday, September 30, 2022 at 11:59 p.m. ET.