Sara Johnson is an Obstetrician Gynecologist at La Clínica de la Raza in Contra Costa County. She advances trauma-informed care in reproductive health and focuses on supporting patients’ power to create health and well-being across the life course and across generations. Dr. Johnson was the team lead for La Clínica’s California ACEs Learning and Quality Improvement Collaborative (CALQIC) project, which implemented prenatal ACE screening, and with an ACEs Aware grant developed a supplemental training entitled, ACE Screening and Trauma-Informed Care in Reproductive Health. She is the lead author of California Maternal Quality Care Collaborative’s recommendations for addressing adversity in prenatal care, to be published in the June edition of Obstetrics and Gynecology.
1. What inspired you to introduce ACE screening and trauma-informed care in your practice?
I was drawn to medicine as an opportunity to serve and be deeply connected to other people and my own humanity, but my medical training and experience didn’t always feel aligned with my soul’s reason for entering the profession. Trauma-informed care feels like a huge piece of the puzzle in caring for human beings, which connects with why I went to medical school.
When we understand the significance of how our experiences affect our physical health, and our need to feel safe and connected, how can we not address our patients’ adversity, support their resilience, and provide trauma-informed care? The possibilities open up when we emphasize relationships and a holistic understanding of health and thriving. I’m so grateful to have encountered this area of medicine. It’s made my own work so much more rewarding and hopeful and feels like a way forward for our challenged system.
2. How does trauma-informed care help new and expecting mothers build resilience?
The perinatal period is such a pivotal time for expectant mothers. It’s a time of increased medical and psychosocial risk, but also a time when patients are experiencing hope and motivation for a good outcome. They are engaging with the health care system, so there is a huge opportunity to support them and create a solid foundation for the health and thriving of the baby and family.
Often in our culture, resilience is conceptualized as an individual trait in which someone is supposed to personally overcome hardship and challenge without any support. However, healing and thriving occur in relationships, and through the lens of trauma-informed care, we can see resilience as a capacity that comes from relationships and supports that enable well-being and thriving. Principles of trauma-informed care, such as trust and transparency, collaboration, empowerment, and cultural humility, are elements we would want in any relationship, and give us guidance about how to work with all patients and to imagine what supports might help.
When we think of prenatal care as supporting this broad capacity, we see that in many ways we have tools to do this in our current systems, that we can adapt and build upon — to provide concrete assistance for basic needs; social support; mental health care; holistic options to support well-being, such as focusing on sleep and nourishment; ways to enable ease and a sense of control during the birth process; postpartum care that supports lifelong health; and the parent-child connection that is so key to the health and resilience of the next generation. Doulas and dyadic care are examples of programs supported by recent legislation that help enable these elements.
3. Looking to the future, where do you see opportunities in the health care setting to improve maternal health and interrupt intergenerational transmission of ACEs and toxic stress?
There are so many. There is literature documenting pregnancy experiences of patients who experienced early adversity, and we know that for these patients pregnancy and birth can be empowering, retraumatizing, or both — and that we can help make the difference. Patients may need support with trusting a provider, coping with reminders of childhood trauma, enabling a sense of control during pregnancy and the birth process, and nurturing hope for their own and their child’s well-being and thriving. They may be at increased risk for challenges with food insecurity and other social drivers of health that affect prenatal care engagement and pregnancy outcomes. We should intentionally build responsiveness to these needs into our standard care.
Another important opportunity exists in applying the foundational relational principles of trauma-informed care as a way of establishing more trusting and collaborative relationships with patients. There is warranted mistrust of the medical establishment, especially among communities that have the highest exposure to adversity, and this impacts our ability to address pressing threats to maternal health. We know, for example, that prenatal aspirin can prevent a significant amount of pre-eclampsia and preterm birth (which disproportionately affect patients with high cumulative adversity), but a small fraction of patients who would benefit take the medication, affecting both maternal and neonatal outcomes and life course health for both generations. The medical knowledge is not enough; a relational approach that emphasizes trust, collaboration, and empowerment is needed.
I love that we have the opportunity to think about interrupting the intergenerational transfer of adversity and toxic stress. Supporting maternal and mental health is key — a mother who is physically and mentally healthy and delivers a term infant in a context of strong psychosocial support and with her basic needs met, is well-positioned to provide the stable, nurturing environment that sets the stage for her baby’s thriving. Continuing to support the family postpartum — including the fathers and partners — can make a big difference for the mother’s lifelong health, the health of a subsequent pregnancy, and the early environment and experiences of her child. Postpartum support is increasingly enabled by new legislation expanding postpartum Medi-Cal coverage, and we must build our postpartum care intentionally to seize opportunities to interrupt intergenerational transfer of adversity and poor health.
Also, we can focus more deliberately on the dyad — teaching and supporting parents in providing those positive early experiences for baby — which we can do during pregnancy as well as after the birth. This can get really elaborate, but there are simple things to do as well. In my clinic, we found a study that showed a huge increase in the rate of healthy parent-child attachment in patients who were randomly assigned to receive soft baby carriers. So we used grant money to start giving out baby carriers in the third trimester, along with some conversation about how patients feel about their relationship with the baby and becoming a mom, and education about babies’ cues and the value of human contact for the baby. Patients love it — they feel like we care about them and want to have a good experience, so it supports trust as well.
I have experienced some poignant conversations with patients who experienced early trauma and are having ambivalence or anger about their pregnancies and then worry that these feelings mean they won’t be a good mother. I took the opportunity to normalize these feelings, point out strengths I observed, and let them know that it’s not a sign they won’t be a good mother. That’s an example of an opportunity that wouldn’t exist if we weren’t asking patients about trauma histories, and if we weren’t focusing on the dyad, but it feels so important. I can’t imagine being someone’s partner in their pregnancy without addressing this. This focus on the dyad can grow and be more supported. It’s exciting to see new policies supporting dyadic care that can add to what we offer.