This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
Pregnancy can bring back painful memories for women who have experienced abuse. These women may face additional challenges during pregnancy; trauma can have an impact on their mental and physical health, their relationship with their partner, and bonding with their child.
Discussions about previous trauma can be difficult for pregnant women and for their care providers. This research explored their views, and suggested ways to improve discussions.
Researchers analysed 25 papers exploring the views of pregnant women and clinicians about trauma discussions. Both groups thought discussions were valuable and worthwhile, as long as there was both adequate time to have the conversation and support available for those who need it. Women wanted to know in advance that the issue would be raised and to speak with a clinician they knew and trusted.
These discussions are complex and require careful thought and sensitivity. The researchers suggested ways to improve trauma discussions that are acceptable to pregnant women. For example, clinicians could signpost support to all women in case they feel unable to discuss traumatic events.
For more information about mental health during pregnancy, visit the NHS website.
The issue: are trauma discussions helpful in pregnancy?
Evidence suggests that approximately 1 in 3 women in the UK have experienced trauma such as abuse, violence, or traumatic birth. Some of these women find pregnancy difficult because memories of trauma can resurface at this time and maternity care procedures can remind them of abuse.
A discussion about trauma can identify those at risk of mental health problems or violence, and allow clinicians to provide appropriate support. The American College of Obstetricians and Gynecologists recommends that all pregnant women should be screened for trauma. UK guidelines do not make the same recommendation but in some hospitals, women are routinely asked about previous traumatic experiences.
Trauma discussions are intended to help women. But they could be harmful if they bring back painful memories or increase safeguarding referrals unnecessarily.
Researchers reviewed studies on pregnant women and healthcare professionals’ views on trauma discussions. They explored whether trauma discussions are helpful and if so, how they should take place, and how best to support women.
What’s new?
Researchers analysed 25 papers (published between 2001 and 2022) on the views of 1,602 pregnant women/mothers and 286 healthcare professionals/voluntary sector experts. They were from 5 wealthy countries: Australia (12 papers), USA (9), Sweden (2), England (1) and Canada (1).
They identified several themes.
Should clinicians ask pregnant women about previous trauma?
Many pregnant women and clinicians felt discussions about trauma were acceptable and worthwhile. But women wanted to be told in advance about the discussion, and for it to take place only if clinicians had enough time and skills to provide support. Some women said they would not broach the topic if the clinician did not ask. One said: “I did not know how to say it, and no one asked me.”
How should trauma discussions take place?
Women wanted the conversations in private, comfortable surroundings. Broad, gentle questions allowed them to speak; closed questions (‘Have you experienced trauma in the last year?’) could dismiss previous trauma. Clinicians suggested that a checkbox in records could remind staff to have these conversations. Flagged notes could alert team members about previous trauma and prompt them to be extra sensitive.
Trust
Trust was built over multiple encounters with the same clinician. One woman said: “I opened up to my midwife because I felt comfortable with her.” Women wanted clinicians to be kind, caring, sensitive, non-judgmental, and compassionate. Some did not report trauma because they were afraid that their child may be taken away from them. For example, one said: “You guys are bound by law. . . You say it is confidential. . . but you are going to report me.”
Having others at appointments
Including a partner at appointments could be challenging. Some women felt more comfortable with the support of their partner. But others may have been abused by their current partner, or not told their partner about their history. Trauma discussions were more difficult for women with limited English, because they often did not want to share their experiences with the interpreter, or the relative or friend interpreting for them.
The impact of trauma discussions on clinicians
Clinicians were open to discussing trauma when they had good quality support services and enough time to have the conversation and provide support. But trauma discussions could be emotionally challenging. One clinician said: “At the end of the day, it’s hard not to want to neck a bottle of wine to cope...” It could impact their home life. Another said: “For me, I explode at home, I don’t explode… [at work]… I do it to my kids, and that’s not very good.” It may be that these discussions are particularly difficult for clinicians who have themselves experienced abuse, but none of the papers explored this.
Why is this important?
The research team, which is led by a midwife, worked with survivors of trauma, charities and maternity care providers. Together they developed suggestions for trauma discussions with pregnant women based on these findings.
The researchers suggest that trauma discussions take place:
- in a private environment, when the woman has been prepared in advance that the issue will be raised
- when the clinician has time to respond thoughtfully and can provide resources for follow-up
- once the clinician and woman have built a trusting relationship.
Staff needed training, time and mental health support to carry out these discussions. The research team notes that understaffing presents a challenge to continuity of care and can make building relationships between individual staff and pregnant women difficult.
What’s next?
The researchers suggest that recommendations from US Substance Abuse and Mental Health Services Administration are helpful. For example, staff would benefit from knowing the signs of trauma, how widespread it is, and its impact on behaviour. Training could help them avoid re-traumatising women during discussions.
More research is needed to explore the effect of socioeconomic class, ethnicity, and immigration status on trauma discussions. Different populations may require different approaches, the researchers say.
The team is using the findings from the review and subsequent interviews to develop national guidelines to help maternity care professionals navigate conversations with women about past traumas.
You may be interested to read
This is a summary of: Cull J, and others. Views from women and maternity care professionals on routine discussion of previous trauma in the perinatal period: A qualitative evidence synthesis. PLoS ONE 2023; 18: 1 – 22.
A NHS guide on delivering care to pregnant women who have experienced trauma.
General information about trauma from the NHS.
Funding: This study was funded by the NIHR Wellbeing of Women Doctoral Fellowship.
Conflicts of Interest: None declared.
Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
