Intimate Partner Violence and Trauma-Informed Care: What Does It Mean for the NICU?

In the January 2024 issue of NeoReviews, we published "Fetal Injury from Maternal Penetrating Abdominal Trauma in Pregnancy" (10.1542/neo.25-1-e60). In this circumstance, the mother was harmed by her teenage son; thus, she was a victim of intimate partner violence. Intimate partner violence includes violence by anyone with a close interpersonal relationship; it does not have to be a current partner, only someone with a personal connection to the injured party.

Yearly, an estimated 1.5–4.0 million US women are victims of intimate partner violence with the highest rates occurring in women ages 18–34 (reproductive age).^1,2 Intimate partner violence includes sexual and psychological violence, stalking, and attempting to control the victim's reproductive health.^1,2 Intimate partner violence causes an increased risk for placental abruption, preterm birth, low birth weight, and small-for-gestational-age infants.¹ Trauma during pregnancy, specifically sexual trauma or injury to the abdomen, can increase the risk of spontaneous abortion and neonatal death.¹ Women at a higher risk for experiencing intimate partner violence are generally younger in age, those with lower socioeconomic status, lesser education, and those with housing concerns.²

Recognizing intimate partner violence during prenatal visits is critical for the physical and mental health of the baby and mother. If a woman reveals she is a victim of violence, it is important to connect her with community agencies, safe havens, and mental health support.² When a mother is experiencing trauma and violence during her pregnancy, she frequently abandons her own well-being by not attending healthcare appointments or maintaining proper nutrition.¹ Infants born to mothers who experience intimate partner violence often suffer adverse long-term outcomes including impacts on mental, cognitive, and physical health.² Specifically, children are at an increased risk of developing depression, anxiety, posttraumatic stress, low self-esteem, anger and irritability, and risky behaviors.² They have issues in school, deficits in cognitive and executive function, delays in reaching neurodevelopmental milestones, and struggle in social situations. ²

Recognizing the prior effect of trauma on an individual’s life, seeing how they currently respond to stressful situations or traumatic experiences, recognizing signs/symptoms of a trauma response, and taking steps to prevent traumatic experiences are all part of our job as clinicians.³ Intimate partner violence is a cause of trauma as is having an infant in the NICU. To those caring for the babies, we often don’t realize how much of an impact simply having one’s baby in the NICU can have on parents’ relationships with each other, their mental health, and even the bond with their baby. We have to remember that everyone has a past, and this impacts how they respond to current stressors in their life. We have the ability to “provide supportive care that enhances the client’s or patient’s feelings of safety and security, to prevent their re-traumatization in a current situation that may potentially overwhelm their coping skills.”³

While most parents experience some level of stress or anxiety while their infant(s) are in the NICU, we hope to prevent toxic levels of stress through the implementation of trauma-informed care, thus positively affecting the neurodevelopmental outcomes of the neonate.³ Dysregulation of cortisol secretion and increased stress during pregnancy have been correlated to poor developmental outcomes. Mothers who experience stress, anxiety, or depression during pregnancy have infants who respond differently to traumatic events post-delivery, including a slower recovery from stressful procedures. Initially, premature neonates have a heightened response to stress; however, as they are repeatedly exposed to stress their responses become diminished. Pain and stress decrease white and gray matter maturation.

Providing trauma-informed care in the NICU is one way to assist our families during a very difficult time in their lives. Trauma-informed care includes empowerment, encouragement, collaboration and support, and creating a safe, trusting relationship with families.³ Families experience a lack of control in the NICU and allowing them to be part of the team creates an optimal care-giving environment and subsequently decreases stress.

Trauma care for the infant focuses on the implementation of developmental care including family-centered care, the protection of sleep/wake cycles, and adequate pain/sedation.³ It is critical to foster a trusting, collective relationship between the staff, family, and neonate with the aim to manage stress in order to improve outcomes.³ Parents are the “co-regulators” for the infant’s stress response while in the NICU.

Care does not end with discharge. Neonatal follow-up, including developmental follow-up, assists families with the transition from NICU to home and allows the continuation of a trusting provider-patient relationship. Postpartum support and close monitoring of maternal mental health is necessary for a healthy mother-infant dyad.

References

1. Donovan B, Spracklen C, Schweizer M, Ryckman K, Saftlas A. Intimate partner violence during pregnancy and the risk for adverse infant outcomes: a systematic review and meta‐analysis. BJOG Int J Obstet Gynaecol. 2016;123(8):1289-1299. doi:10.1111/1471-0528.13928
2. Hahn CK, Gilmore AK, Aguayo RO, Rheingold AA. Perinatal Intimate Partner Violence. Obstet Gynecol Clin North Am. 2018;45(3):535-547. doi:10.1016/j.ogc.2018.04.008
3. Sanders MR, Hall SL. Trauma-informed care in the newborn intensive care unit: promoting safety, security and connectedness. J Perinatol. 2018;38(1):3-10. doi:10.1038/jp.2017.124