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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