Pregnancy and childbirth is a formative period in a woman's development during which physical, emotional and psychological growth is accelerated. If all goes well, a competent and nurturing mother-self evolves from past childhood and adult experiences and role models, as well as from the experience of bringing forth life-an experience which can enhance or disturb the woman's image of herself as a mother and a woman.

My clinical experience, as well as research done by others, supports the idea that how a woman experiences birth has long-reaching effects on her sense of self-esteem as a woman and on her ability to feel confident with her newborn.

Many women who have suffered sexual, emotional or physical abuse have come to me for childbirth preparation. Some come for a first labor; others come for a subsequent delivery. Often, a woman's childbirth stories echo childhood experiences of humiliation, helplessness and terror. Themes of betrayed trust, unexpressed needs and ineffective communication are prevalent, resulting in intimidation and helplessness.

A heightened sense of dependency during pregnancy and labor makes women-and particularly abused women-vulnerable to reliving old parent-child wounds through their caregivers. The ways in which they related to parents who did not protect them can be repeated in one of two distinct responses to their caregivers.

First, a woman may subconsciously idealize her caregiver and fantasize that she is the "good and loving parent." Because of her clouded judgment and childhood memories of intimidation, she may be unable to clearly communicate her concerns and needs so they can be realistically addressed by her caregivers.

An example of this is a woman who came to me for healing after her first childbirth. Her father had been absent from the family and her stepfather had sexually abused her. In order to protect herself from further emotional and physical pain, she became "invisible." And because she idealized her obstetrician and did not voice her needs during her pregnancy and labor, she became "invisible" to him as well. Her doctor induced her unnecessarily and she had one intervention after another. She was also upset because her doctor handled most of her care during labor by phone. She described her labor as "a horrifying experience."

She changed obstetricians with her next baby, but didn't check on his protocol regarding inducement of labor or presence at birth. She realized that she was setting the stage for another bad birth experience and decided to come to me for counseling.

I encouraged her to relate to her obstetrician as an equal and taught her the skills she needed to effectively communicate with him. She was able to discuss her feelings about the previous birth and tell him what she needed for this birth.

The second distinct response an abused woman may show is distrust of her caregiver. This results in antagonistic, nonproductive relationship patterns between the woman and her caregiver. Unlike the woman who idealizes her caregiver and sees him or her as the "good parent," this woman projects a "bad parent" image onto her caregiver. She is unable to communicate, except from the standpoint of feeling victimized. She must depend upon someone to assist at her birth, yet it calls up childhood memories of having to depend on a parent who didn't protect her and often abused her.

The idea of expressing her needs is frightening, but she must be encouraged to develop an equal relationship with her caregiver. Discussions with the woman usually focus on the idea that the caregiver is "human" and has needs of her own which must be acknowledged by the woman. Once the abused woman has some understanding of this, destructive communication patterns gradually end and the caregiver can encourage a more positive exchange with her client and find out who she is and what she needs from her prenatal care.

An example of this is a woman who experienced neglect and sexual abuse in childhood. Feelings of abandonment were repeated during her firs/childbirth when she was left alone in a delivery room to deliver a stillbirth. The physician she had been depending upon was vacationing out of town, and the doctor on call was unresponsive to the special needs of her situation.

She changed doctors for her second pregnancy, but when she overheard her obstetrician's secretary talking about an upcoming vacation, she assumed the worst. In addition, she neither asked the doctor about her vacation schedule nor explained what had occurred in her previous childbirth experience.

She was angry but did not feel she could influence the situation. Instead, she expressed her tension and anger nonverbally during her prenatal visits and was, in fact, "punishing" her doctor for all the neglect she had experienced both in her childhood and in her previous childbirth. This was destroying her ability to form a trusting relationship with her doctor.

Because of her vulnerability to abuse, she required counseling to acknowledge that both she and her doctor had needs, and that perhaps they could find a way to mutually cooperate. I encouraged her to be open and honest with her doctor. Instead of attacking her physician, which had been her initial approach, she told her doctor that she understood her need for a vacation and that though this was reasonable, she had particular fears due to her previous experience and needed to talk about how those fears could be laid to rest. To her surprise, her doctor not only understood that she would need extra care following the experience of a stillbirth, but told the woman that she did not have plans to be away and would be willing to be called when she went into labor, even if she wasn't on call.

For all women, but particularly for women with abuse in their backgrounds, trust is the key: trust of the person they are depending upon, and trust in themselves to stay present through the normal and inevitable pain of the labor process. This is especially important for women who have experienced pain associated with sexual humiliation or degradation on physical and/or psychological levels. Also important for these women is body-centered preparation for childbirth. In order to experience labor as powerful, regardless of whether it is a natural birth or a birth where medical intervention is necessary, a woman needs to feel that she can cope with what is happening. These feelings can be encouraged simply by respecting her individuality so she can meet the pain actively, rather than feel victimized by it. In addition, the healthy pain of labor must be discussed and portrayed in ways that the body absorbs, not by intellectual understanding alone.

Postpartum follow-up is an important part of my work with childbearing women. Reviewing the labor and childbirth, as well as all of the feelings -- both positive and negative -- that went with it, and sharing that information with another nurturing female is the first vital step toward healing. Rejoicing with her at the empowering feelings, sharing her sadness over any disappointments or struggles, nurturing her as she holds her newborn all of this can go a long way toward how she sees herself at the threshold to motherhood. An attitude of respect and caring for her journey honors her as a woman and as a new mother, and empowers her in her new role and identity.

One last thought I have is this: I hope we are not "singling out" women who have been abused and labeling them with a kind of "scarlet letter" indicating the potential for birth complications. In my experience, singling out has not been the case. Women who are physically abused have deep scars; however, every woman in our culture deals with, and has suffered from, some kind of psychological hurt and shame associated with her sexuality. Childbirth, by its nature, should be an empowering experience. The fact that it is not for so many women, whether they give birth vaginally and without drugs or with medical intervention, is due to our psychological attitudes toward women in our society. Women should be given support and those who help, such as midwives, should be commended for doing so.