The Need for Trauma-Informed Healthcare Systems

It’s hard to concretely characterize the causes and effects of “trauma”, as it can take a variety of forms. Trauma can stem from adverse childhood experiences (ACEs), singular traumatic events, or historical and intergenerational consequences from deeply rooted societal structures. Generally, it is defined as a “response to a deeply distressing or disturbing event that overwhelms an individual’s ability to cope, causes feelings of helplessness, and diminishes their sense of self and their ability to feel a full range of emotions” (Routsis, 2022). Trauma has a large impact on health as it disturbs proper nervous system functioning—and for marginalized communities that often lack the support to heal, this can have severe downstream effects on other aspects of biological and social function. Because of a lack of trauma-informed healthcare systems, marginalized populations don’t receive adequate and equitable care, and are less likely to utilize healthcare overall. Righteously so, minorities also have mistrust in the western medical system because of the colonial, exploitative history of using people of color for the advancement of medicine. This sustains barriers to care that are exacerbated by the system’s oversight of trauma.

So, how can healthcare systems become more trauma-informed to support minority and marginalized groups? The change must occur on a system-wide and institutional level, but individual hospitals or healthcare providers can also implement trauma-informed care in their practice. One approach is to implement collaborative care models that screen for trauma and stress in patients, normalizing and encouraging the consideration of trauma in healthcare. Medical treatment and actual delivery of care should then be adjusted, and patients should be provided behavioral and social health referral options—which hopefully can improve overall patient prognosis. Some hospitals currently screen children for ACEs, but adults are not screened for chronic trauma and toxic stress. Of course, there are many ethical considerations associated with trauma screening that hospitals must navigate before implementing such procedures on a broader level. It’s important not to stigmatize, discriminate against, or ostracize groups through this process, and hospitals must be careful as to not retraumatize patients or create unnecessary discomfort for vulnerable patients. We must also question if trauma awareness and education should be incorporated in the same sphere as healing, as it is still unclear whether open conversation surrounding trauma generally helps or hinders the healing process. Exposure to the idea of trauma in an educational setting can help some people question what their feelings of loneliness and anxiety are attached to, yet for others, it may cause inadvertent harm.

Healthcare providers must also be aware of their own culture and perspectives, and how that affects how they serve patients from similar or different backgrounds. For some patients, healing from trauma comes from resilience and connecting with their culture. However, the western medical system has excluded many aspects of traditional and holistic health approaches that may be more suitable and effective for people of different cultures, and exposure to the western biomedical model could be traumatic. Thus, there must be more discourse surrounding trauma and culture in healthcare amongst a diverse workforce, so that a better system is created to improve quality of care for the marginalized.

Edited by: Kelly Ma

Graphic Designed by: Priya Meesa

References

1. Center for Violence Prevention and Recovery. (n.d.). Trauma-Informed Care Tips Sheet for Healthcare Providers. BIDMC of Boston. Retrieved October 2022, from https://www.bidmc.org/centers-and-departments/social-work/center-for-violence-prevention-and-recovery

2. Key ingredients for successful trauma-informed care implementation - samhsa. (n.d.). Retrieved October 2022, from https://www.samhsa.gov/sites/default/files/programs_campaigns/childrens_mental_health/atc-whitepaper-040616.pdf

3. Roberts, A. L., Gilman, S. E., Breslau, J., Breslau, N., & Koenen, K. C. (2011). Race/ethnic differences in exposure to traumatic events, development of post-traumatic stress disorder, and treatment-seeking for post-traumatic stress disorder in the United States. Psychological medicine, 41(1), 71–83. https://doi.org/10.1017/S0033291710000401

4. Routsis, F. (2022, June 2). What is trauma? - definition, symptoms, responses, types & therapy. Unyte Integrated Listening. Retrieved October 2022, from https://integratedlistening.com/what-is-trauma/

5. Trauma and Resilience. Wilder foundation. (n.d.). Retrieved October 2022, from https://www.wilder.org/sites/default/files/imports/AnokaCountyMWCtrauma%20Snapshot_10-14.pdf

6. What are aces? and how do they relate to toxic stress? Center on the Developing Child at Harvard University. (2020, October 30). Retrieved October 2022, from https://developingchild.harvard.edu/resources/aces-and-toxic-stress-frequently-asked-questions/

An Ethical Duty to Remember

Most Americans who were alive and conscious during the 80s and 90s have some remembrance of the beginning of the AIDS crisis. For some, it was a distant truth that barely tapped into reality, or perhaps a karmic consequence for deviant “others.” For many members of the LGBTQ+ community, it was a period of terror and immense loss that has never been fully healed. Today, for every story we do hear, there are thousands that may never see the light of day.

A commonly held sentiment is that we need to remember the AIDS crisis. This is absolutely true, but we do not often talk about why we need to remember it. If we fail to remember our past, we are doomed to repeat it. If we fail to learn from our present, we are doomed to become trapped in it. The AIDS epidemic is far from over. In 2021, 40 years after it was first reported, over 500,000 people died from AIDS-related illnesses globally. This anniversary of the ongoing crisis was met with the COVID-19 pandemic, which, despite growing public apathy, is also far from over. Looking back to the start of the AIDS epidemic, it is not only important that we accurately remember what happened but also that we learn from it. Today we are at a pivotal point, both in remembering the past and in learning from the present.

In terms of science and medicine, there is a lot that we have learned throughout the AIDS epidemic that continues to ring true. The value of community-based health programs cannot be underscored. Scientific advancements in treatments and prevention measures mean little to nothing if they aren’t accessible to the most vulnerable–and often most marginalized–groups. Unfortunately, in the first years of both the AIDS epidemic and the COVID-19 pandemic, denial and the spread of misinformation delayed advancements and led to preventable deaths. It is clear that accurate and timely communication both within the healthcare field and to the public is paramount.

Among those directly involved with science and medicine, few would deny the importance of learning these lessons, but for those on the outside, they can often feel intimidating. Historically, this has silenced important voices and further alienated already marginalized groups, but we have an opportunity to change that. When healthcare feels far-removed, and the sphere of public health feels understandably daunting, we have to ask ourselves, what can we start on a smaller scale that can still have a big impact?

One thing that has been abundantly clear throughout the AIDS epidemic is the danger of stigmatization. Our initial response to HIV/AIDS was largely nonexistent because those in power saw it as a consequence for deviant behaviors, such as being gay or using intravenous drugs. This hateful rhetoric quickly incited public fear, not only of the disease, but of the people who contracted it. As is the case with many public health crises, the stigma can often spread faster than the disease itself. In a world where words carry as much weight as they do, the language we attach to diseases is incredibly important. That starts with small, one-on-one conversations, but needs to spread into the media and public discourse to truly make an impact.

The language we use in these conversations matters, but so do the conversations themselves. We have a responsibility to remember what is happening and to share this knowledge in any way we can. As we have seen in the decades since the start of the AIDS epidemic, history can easily be forgotten or rewritten. We cannot let this happen.

As we continue to live through the AIDS epidemic, the COVID-19 pandemic, and the future public health crises that we will inevitably face, one thing is clear. We have an ethical duty to remember for those who cannot.

Edited by: Laila Khan-Farooqi

Graphic Designed by: Catie Fristoe

Stillbirths

65 babies die every day in the second half of pregnancy in the US, which totals to 23,000 stillbirths annually in one of the most developed countries in the world. Although the rate of stillbirths has decreased in the US since 1990, it has recently begun to level off in the past two decades. From 2000 to 2015, the US stillbirth rate has decreased by only 0.4%, which shockingly contrasts the 6.8% drop in the Netherlands. This issue is awful and unacceptable, but it can be prevented if proper measures are taken.

Stillbirth is defined as the loss of a baby anytime after 20 weeks of a pregnancy. Some likely causes and contributors to stillbirth include problems with the placenta, birth defects, infections, problems with the umbilical cord, high blood pressure disorders, and maternal medical problems. A research project that studied over 500 stillbirths over the course of 2.5 years also determined that women were more likely to have a stillbirth if they experienced stress before their delivery. Furthermore, the risk of stillbirths was doubled or tripled when the mother smoked tobacco, marijuana, took prescription painkillers, or used illegal drugs during pregnancy.

A study analyzing 512 stillbirths showed that one quarter of stillbirths that were due to medical complications, placental insufficiency, multiple gestation, spontaneous preterm birth, or hypertensive disorders were all preventable. These preventable stillbirths were correlated with low socioeconomic status, public health insurance, and smoking.

The cause of stillbirths is never determined in one half to one third of stillbirths, and therefore labeled an anomaly. This statistic shows the lack of education, research, and attention surrounding the epidemic of stillbirths in the United States. One of the most shocking statistics regarding stillbirths is that 50% occur at or near full term, and many of the babies are completely healthy. This data further supports the claim from the well known organization, Every Mother Counts, that “almost all global maternal deaths can be prevented by ensuring that women have access to quality, respectful, and equitable maternity care.”

Among stillbirths in the US, major racial disparities exist. For instance, Black women are more than twice as likely to experience stillbirths. These stillbirths are more likely caused by infections or complications during labor which could stem from lack of access to quality healthcare, institutional bias, increased stress during pregnancy, and racism. However, the cause of these racial disparities is yet to be fully understood and studied through a statistical lens.

Many organizations like Every Mother Counts and Push Pregnancy have focused on advocating for greater research, raising awareness around stillbirths, and specifically cutting the US Stillbirth rate by 20% by 2030. However, there is still a dire lack of awareness and change surrounding this topic, many motivated mothers who have personally experienced stillbirth have begun to take action. After seeing the stillbirth rate in Scotland improve by 23% since the Children Quality Improvement Collaborative began in 2013, a young mother who lost her son to a preventable stillbirth took action to work with Ariadne and the Star Legacy Foundation to implement these proven preventative strategies through the Implementation Innovation Learning Collaborative. The goal of this program is to reduce the stillbirth rate by 15% and focus on hospitals predominantly serving Black women.

The shockingly high rate of stillbirths in the US not only highlights racial disparities in our healthcare system, but also sheds light on a major flaw in our medical system: 23,000 deaths per year that are preventable through greater awareness, effective fetal monitoring, and reducing smoking. Overall, a lack of information surrounding the causes of stillbirths exists, which is why it is imperative to invest in research surrounding this global health issue.

Edited by: Rohan Gupta

Graphic Designed by: Kidest Wolde

References

1. Mission & Values. PUSH Pregnancy. (n.d.). Retrieved October 23, 2022, from https://www.pushpregnancy.org/mission

2. Page, Jessica M. MD; Thorsten, Vanessa MPH; Reddy, Uma M. MD, MPH; Dudley, Donald J. MD; Hogue, Carol J. Rowland PhD; Saade, George R. MD; Pinar, Halit MD; Parker, Corette B. DrPH; Conway, Deborah MD; Stoll, Barbara J. MD; Coustan, Donald MD; Bukowski, Radek MD, PhD; Varner, Michael W. MD; Goldenberg, Robert L. MD; Gibbins, Karen MD; Silver, Robert M. MD. Potentially Preventable Stillbirth in a Diverse U.S. Cohort. Obstetrics & Gynecology: February 2018 - Volume 131 - Issue 2 - p 336-343 doi: 10.1097/AOG.0000000000002421

3. Centers for Disease Control and Prevention. (2022, September 29). What is stillbirth? Centers for Disease Control and Prevention. Retrieved October 23, 2022, from https://www.cdc.gov/ncbddd/stillbirth/facts.html#:~:text=Stillbirth%20affects%20about%201%20in,stillborn%20in%20the%20United%20States.&text=That%20is%20about%20the%20same,the%20first%20year%20of%20life

4. U.S. Department of Health and Human Services. (n.d.). What are possible causes of stillbirth? Eunice Kennedy Shriver National Institute of Child Health and Human Development. Retrieved October 23, 2022, from https://www.nichd.nih.gov/health/topics/stillbirth/topicinfo/causes#

5. Ibid

6. Ibid

7. Page, Jessica M. MD; Thorsten, Vanessa MPH; Reddy, Uma M. MD, MPH; Dudley, Donald J. MD; Hogue, Carol J. Rowland PhD; Saade, George R. MD; Pinar, Halit MD; Parker, Corette B. DrPH; Conway, Deborah MD; Stoll, Barbara J. MD; Coustan, Donald MD; Bukowski, Radek MD, PhD; Varner, Michael W. MD; Goldenberg, Robert L. MD; Gibbins, Karen MD; Silver, Robert M. MD. Potentially Preventable Stillbirth in a Diverse U.S. Cohort. Obstetrics & Gynecology: February 2018 - Volume 131 - Issue 2 - p 336-343 doi: 10.1097/AOG.0000000000002421

8. Ibid

9. Meshdesign. (2022, May 4). The issue. Every Mother Counts (EMC) | Improving Maternal Health. Retrieved October 23, 2022, from https://everymothercounts.org/our-story/the-issue/

10. Pruitt, S. M. (2020, September 17). Racial and ethnic disparities in fetal deaths - United States, 2015–2017S. Centers for Disease Control and Prevention. Retrieved October 23, 2022, from https://www.cdc.gov/mmwr/volumes/69/wr/mm6937a1.htm

11. U.S. Department of Health and Human Services. (n.d.). What are possible causes of stillbirth? Eunice Kennedy Shriver National Institute of Child Health and Human Development. Retrieved October 23, 2022, from https://www.nichd.nih.gov/health/topics/stillbirth/topicinfo/causes#

12. After A Death, Bringing Stillbirth Prevention To The US, Marny Smith, Health Affairs 2022 41:1, 147-149

13. Ibid