Penny Simkin, PT, is a physical therapist who has specialized in childbirth education and labour support since 1068.  Author of several books and developer of teaching materials and videos, Penny estimates she has prepared over 14,000 women, couples, and siblings for childbirth, and has assisted hundreds of women and couples through childbirth as a doula.  Penny is co-founder of DONA International and PATTCh (Prevention and Treatment of Traumatic Childbirth).  Currently, she serves on the editorial board of the journal Birth: Issues in Perinatal Care and on the senior faculty of the Simkin Center for Allied Birth Vocations at Bastyr University.  Penny works actively as a presenter at many conferences and workshops, and has given well-received presentations for CAPC Training Conferences in BC.

Studies indicate that the range was between 25% - 40% of all women, as many as a million women a year in Canada.  Penny commented on the potential impact this has for breastfeeding:  “If a woman, as a child has been abused, her feelings about her own body may be distorted, that her body is damaged, or is a source of evil because it was her fault that she was abused, and the perpetrator will give her that feeling.  She may feel that she is defective, that she can’t give birth very well.  She may have modesty issues.  With that kind of general feeling, you can see that breastfeeding may be problematic, if she has these beliefs around her own body. “

Particularly where the breasts have been a locus of abuse, and where a woman’s breasts were hurt and used cruelly, a woman may find it difficult emotionally cope with the reality of sharing her body, even though, intellectually, she may be quite committed to breastfeeding.

The importance of feeling in control of her body can also be a major issue.  Penny notes, “Many young girls, when they are being abused, feel that if they can just figure out how to keep it from happening, by always being very good, by always obeying, to the extent of magical thinking like ‘if I don’t step on the cracks in the sidewalk’, and a sense of need to be in control develops at that time.  Then, the process of becoming a mother, the pregnancy, the birth process itself, is the ultimate of not being in control, and with a new baby, who does not operate to a schedule, who has very few ways to let his or her needs be known, the mother often feels she can’t control this situation, and it becomes very stressful and quite upsetting…. The mother can feel trapped in a situation where she has lost her ability to self-regulate and is under the control of another person.  This can lead to her feeling very uncomfortable when the baby is suckling, and can even, on occasion, trigger feelings of violence towards the baby.”

Penny expressed her great admiration for survivors she has known who, despite finding that direct feeding is too much for them to cope with, have persisted for months with pumping milk because of their commitment to having their baby have the benefits of breast milk.  As well as pumping milk, some women find using a nipple shield helpful.  Penny advocates that counsellors should recognize that there are times when we have to accept that this is as good as it is going to get, and celebrate the mother’s achievement and commitment and not to impose judgement or feelings of inadequacy on the woman that are going to be damaging to her. 

Other issues that may arise for mothers who are survivors are that they may want to cut the breastfeeding session short, or delay feeding until the last minute, which can interfere with milk supply.  Sometimes, too, because of the tension around the breastfeeding experience, the letdown doesn’t develop as one would hope it would, and sometimes there is unusual pain in the breasts or nipples during feeding.  These experiences can lead a mother to believe that her body just doesn’t work.   Penny stresses that is where some loving support, with a lot of knowledge behind it, can come up with some really good strategies to help the mother and make a terrific difference.

When asked why we hear so little about links between abuse survival and reluctance to breastfeeding,   Penny expressed her belief that we don’t talk about because we don’t know what to do about it.  There is a generalized ignorance around this issue, but even people who know may find it very difficult to bring up.  She suspects it is also an issue with early dropout rates amongst women who are initially committed to the concept of breastfeeding.

Penny’s book, When Survivors’ Give Birth, talks about how empowering it can be for a survivor to breastfeed successfully.  Penny notes that for a survivor to find that her body isn’t defective and that she can overcome the feelings that she had about herself is a significant experience.  To find that she can take pleasure in breast feeding, that her child is thriving, is a true affirmation of her normalcy, of her strength, her goodness, and her “perfect motherness”.  When this happens, it can transform women into powerful breastfeeding advocates, because they have felt such triumph in succeeding themselves.  However, Penny cautions that it is not a universal experience, and it is important to that an abuse survivor should not be made to experience a sense of failure if she has not been able to start or sustain breastfeeding because of the trauma she carries in her body.

For some women there is a great empowerment in just deciding that “I am going to pump and feed”, because they recognize that breast feeding is too much for their body, and working out a compromise that works for them and supports their baby.  There can also be empowerment for the woman who says, “I gave it my best shot and it is just not working for my body, and because my relationship with my baby has been suffering because I am dreading feeding, I am going to go ahead and just switch over to formula.”  For her to make that decision for herself, and not be forced into it, can be empowering.    

When breast feeding is challenging, it can be a very isolated experience for women.  It can make a huge difference to find support in a group setting, with other women and with a trained, empathetic breastfeeding counsellor, who is loving and patient, and who is not trying to force or push the mother.  In that situation, the women often feel, “I can give it another week; I can try one more time”, and then it gets better.  Penny talked about how difficult it can be for survivors to share their story, and offered a reminder of the importance of not projecting our own feelings and opinions onto others, noting, “If you are in a group where women aren’t breast feeding, try to keep in mind that there is probably a very good reason….   Sometimes women are not able to breast feed their first child, but find they can with a later child, and having respect and love and support and camaraderie with other mothers can make all the difference down the road. “

Penny also talked about the legal responsibilities of professionals working with women and having an obligation to ask about sexual abuse.  She comments, “Many savvy abuse survivors will just say no, because they don’t want to go there, and they sense that the person with whom they are dealing, and the situation they are dealing with, especially labour, is not the best time or place to have this discussion.  So, it is a secret that many women carry.  Moreover, there are often other people in the room, and the perpetrator may even be present if it is an ongoing situation.  There are a lot of reasons for a woman not to answer, or to answer negatively.”  She also noted that there is a significant group of survivors who have lost the memory of the abuse.  As children, they may have dissociated in order to survive.  A woman might say no, and really believe it, and still be a survivor, so in breastfeeding counselling, Penny’s, and many other counsellor’s, practice is not to ask, but knowing some of the ‘red flags’ is very useful. 

When a woman is training to breastfeed, but is having trouble or experiencing pain, it is good practice to accept that the woman has good reason for the challenges she is experiencing.  And one might notice that if touching her breasts is a challenge, or extreme modesty, are particular issues for the woman, then the counsellor might work from that the woman may be an abuse survivor.  It is not necessary to say anything, or to ask directly, but if the counsellor thinks this is possible a factor, then it can be included in the practices one follows in working with the woman, enhancing caring and sensitivity in one’s approach.  

Practices might include asking more questions about the woman’s experience of trying to breast feed, and making sure one offers lots of opportunity for her to express what she wants to happen, and what she thinks might help her.  If she responds that she is uncomfortable with having the baby feed directly from her breast, then brainstorm with her to elicit her ideas of what would improve the experience for her and meet her needs, such and pump and feed, or using nipple shields, for example.  Penny cites an example of a woman who found nighttime feedings particularly stressful, because she was woken out of the blue, which had traumatic memories for her.  This woman found it helpful to time her feedings and set an alarm every 2.5 hours, so that she had a predictable pattern to work with.  That helped her through the first few weeks until she had established a workable pattern that she could sustain.  Sometimes, a small thing can make a big difference for an individual.

Asking the mother to describe her individual problem in detail, and be part of finding a solution that works for her, makes a big difference.  There is no point in just telling people what they ought to do, and offering a set way of going about things.  Establishing a successful breastfeeding relationship between mother and child is individual to those two people.  It can be empowering for the woman to have her opinion asked, to be listened to, and to be given the opportunity to make decisions for herself.  This is an experience that can be new to survivors, many of whom have been ordered around and have lost confidence, or not been allowed, to make decisions for themselves. 

Penny talked about the services that are available to survivors who want to get help for childbirth and breastfeeding.  Sometimes women find it safe to be on an online chat group and there is an organization called Solace that is for people who have had traumatic births, which is a little bit more likely in an abuse survivor.  She notes that they have over 400 people on that group and it is completely anonymous, so people can receive supportive and encouraging comments from other group members.  It is facilitated and monitored by a professional therapist. 

Penny also recommends that people learn about the La Leche meetings in their area to see if those would be helpful to them.  If a woman is a survivor, or feels kind of alone in her experience in a regular La Leche group, because she is using a pump or bottle feeding, if she is able to talk to the leader about some of her history, or at least say that she has thought through her decision very carefully, and would like respect for that and would like the support of a group. 

Preparing for birth and postpartum, Penny notes that if a survivor has a doula with her, her needs are more likely to be met, whether or not she has disclosed her abuse history.  Studies have also shown that women have more success breast feeding if they have had a doula present with them during the birth.  Postpartum doulas get good training on some of the postpartum mood disorders, including the kinds of things that can come from a childhood history of sexual abuse. 

Penny recommends getting access to professional assistance: counsellors, lactation consultants, and facilitated mother-baby groups in the community.  If a woman has taken a childbirth class and she felt some affinity with the teacher, she can tell her that she would really like to be linked up with community and breastfeeding supports after the birth.  Without having to share her history, she can say that she is concerned that she may experience some challenges with isolation and may have need of community supports.

Other people women might connect with could be a community nurse, midwife, or physician.  It is also good to know about psychiatrists, because sometimes medications are going to be the answer, and there are medications that are considered to be safe for breast feeding.  Many abuse survivors have been in counselling and therapy, which has been helpful for them in helping them cope and in finding strategies to cope with the effects of the abuse, and when a woman has been in therapy for a mood disorder, she may be more likely to recognize it in the postpartum period and seek help right away, which is hugely helpful.