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Open Access

Peer-reviewed

Research Article

An integrative review of how midwives are screening and assessing for trauma in women within perinatal services

  • Fiona Callanan,

    Roles Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Writing – original draft, Writing – review & editing

    Affiliations School of Nursing and Midwifery, Health Research Institute, University of Limerick, Limerick, Ireland, University Maternity Hospital Limerick, Limerick, Ireland

    ⨯
  • Carmel Bradshaw,

    Roles Conceptualization, Formal analysis, Methodology, Supervision, Validation, Writing – review & editing

    Affiliation School of Nursing and Midwifery, Health Research Institute, University of Limerick, Limerick, Ireland

    ⨯
  • Teresa Tuohy,

    Roles Conceptualization, Formal analysis, Methodology, Supervision, Validation, Writing – review & editing

    Affiliation School of Nursing and Midwifery, Health Research Institute, University of Limerick, Limerick, Ireland

    ⨯
  • Maria Noonan,

    Roles Conceptualization, Formal analysis, Methodology, Writing – review & editing

    Affiliation School of Nursing and Midwifery, Health Research Institute, University of Limerick, Limerick, Ireland

    ⨯
  • Sylvia Murphy,

    Roles Conceptualization, Formal analysis, Methodology, Writing – review & editing

    Affiliation School of Nursing and Midwifery, Health Research Institute, University of Limerick, Limerick, Ireland

    ⨯
  • Annmarie Grealish

    Roles Conceptualization, Data curation, Formal analysis, Methodology, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing

    annmarie.grealish@ul.ie

    Affiliations School of Nursing and Midwifery, Health Research Institute, University of Limerick, Limerick, Ireland, Kings Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King’s College London, London, United Kingdom

    ⨯

Abstract

Introduction

There is a growing body of literature on the significance of trauma and abuse in the perinatal period but despite this, trauma exposure and abuse are often not recognised in maternity care settings. Evidence indicates that women experiencing mental distress during the perinatal period are frequently unidentified or inadequately supported. The purpose of this study was to conduct an integrative review on how midwives screen, assess, and respond to women with trauma histories in the perinatal period and to identify the challenges in providing trauma discussions, screening and assessment.

Methods

This integrative review followed Whittemore and Knafl’s five-stage framework as it facilitates the inclusion of different methodological approaches to experimental research. Five electronic databases (PsycINFO, MEDLINE, CINAHL, ASSIA, and Web of Science), reference and citation lists were systematically searched from inception with no date, language or geographical limiters set owing to a dearth of research in this subject area. This review was performed and reported according to the PRISMA guidelines. The findings were analysed and synthesised using narrative synthesis.

Findings

Twenty-two studies met the inclusion criteria and were synthesised using narrative synthesis. Four main themes were identified: 1) Midwives difficulties in asking and discussing interpersonal trauma and abuse and their instinctive use of their observations skills to elicit information; 2) Screening tools to elicit history of interpersonal trauma; 3) Midwife’s response to interpersonal discussions; 4) Training on ‘daring to ask the questions’ and Support on ‘what should I do now’.

Discussion

Our findings demonstrate a deficit in trauma discussion, screening and assessment of trauma within the perinatal care, domestic violence being the exception. Interpersonal trauma is a significant public health concern that if left unrecognized may increase morbidity and mortality in both mothers and newborns. This study makes recommendations for urgent streamlined trauma discussions and specific training and supervision on trauma-informed care for all healthcare professions in their perinatal role using a whole systems approach.

Citation: Callanan F, Bradshaw C, Tuohy T, Noonan M, Murphy S, Grealish A (2025) An integrative review of how midwives are screening and assessing for trauma in women within perinatal services. PLoS One 20(7): e0327253. https://doi.org/10.1371/journal.pone.0327253

Editor: Vidanka Vasilevski, Deakin University Faculty of Health, AUSTRALIA

Received: August 6, 2024; Accepted: June 3, 2025; Published: July 1, 2025

Copyright: © 2025 Callanan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting information files.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The perinatal period which extends from pregnancy to 12 months after childbirth is the most vulnerable time in a woman’s life, as marks a substantial shift in women’s physiological, social and psychological wellbeing [1–4]. During the perinatal period, women’s vulnerability to mental health disorders is increased and is associated with poor maternal and infant outcomes. Prevalence of perinatal mental disorders including depression, anxiety and post-traumatic stress disorder (PTSD) are among the most common morbidities of pregnancy and the postnatal period [3,5–9]. Research suggests that the perinatal period for women is marked by increased vulnerability to interpersonal traumatic events which may be related to complications in pregnancy (e.g., pregnancy loss), labour and delivery or unrelated to their pregnancy (e.g., sexual assault that may have occurred prior to the perinatal period) [10–13]. For the purpose of this review, trauma is defined as an event or circumstance that is perceived as harmful or life-threatening and affects mental, physical, emotional and/or social well-being over the lifespan of the affected person [14]. There are two categories of trauma, Type I trauma is used to identify a single incident or one-off event and Type II or complex trauma which occurs over an extended period, it is often repetitive and anticipated [15].

Although there is a growing body of literature on traumatic experiences and adverse outcomes for women in the perinatal period, this is often not recognised in maternity care settings [10,12,13]. Interpersonal trauma unrelated to pregnancy (e.g., trauma from childhood experiences, sexual assault, rape) and physical trauma (related to childbirth) [1,5,16,17] may be linked to life-threatening or extreme traumatic events, including child maltreatment, intimate partner violence (IPV) and rape, and are highly prevalent among pregnant women [18–23]. Globally, almost one-third (27%) of women aged 15–49 years have experienced some form of physical or sexual violence by their intimate partner [8,22,24–26]. Even higher prevalence rates were reported in a recent review of IPV rates in pregnancy globally ranging from 15.4 to 40% in Portugal, the U.S.A and Australia [27].

The prevalence of women who have experienced childhood sexual abuse has been estimated to be 20% but few women disclose it to healthcare professionals (HCPs) [1,12,13,21,28–30]. History of childhood maltreatment such as physical, sexual, emotional abuse and neglect can have serious consequences on women’s mental health and may include anxiety, depression, PTSD, and posttraumatic stress symptoms (PTSS) [5–10,31]. It also adversely affects physical maternal health, pregnancy outcomes, postpartum maternal mental health, perinatal health risks, bonding, parenting and disrupt family relationships [32–36]. Up to 45.5% of women at 4–6 weeks’ post-childbirth describe their birthing experience as traumatic [37–39]. Maternal trauma exposure is associated with increased prematurity, risk of low birth weight, hypertension, low breastfeeding rates, miscarriage/stillbirth and can disrupt foetal brain development [32,40–43]. Approximately 33% of new mothers have reported the presence of at least three PTSS, primarily anxiety-related, with 9% of these women meeting the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) [44] criteria for PTSD [45–47]. Between six weeks and one-year post-partum, suicide has been reported as the leading direct cause of death [48–51]. Research indicates an association between traumatic experience and adverse outcomes for women resulting in mental health consequences and risk for perinatal depression, anxiety, and PTSD [6,52–58].

With such a high prevalence of interpersonal trauma in the perinatal period it is important for midwives to be aware and informed about best practice when working with women, with the caveat that some women who have experienced interpersonal traumatic event may have completely recovered from their experiences by the time they attend maternity services. HCPs need to be aware that women will respond differently depending on their recovery journey [31]. The Power Threat Meaning Framework [59] offers an alternative to psychiatric diagnosis by identifying patterns of emotional distress. It focuses on what people do and not on the disorders they have, it does not assume pathology but describes coping mechanisms. It is crucial to consider this perspective when working with women who have experienced interpersonal trauma and support them as they navigate their way through their experience.

Promoting women’s health which includes Trauma-Informed care (TIC) is a key priority in perinatal mental health care and is incorporated into the National Health Service [60], Health Service Executive [61,62], U.S. Department of Health and Human Services, Substance Misuse and Mental Health Administration [14,63] and the Mental Health Coordinating Council [64]. TIC takes into account the effect of traumatic experience on current behaviour and can help to minimize re-traumatization during health care encounters [1,65,66]. It helps HCPs move from the concept of “What’s wrong with you?” to “What has happened to you…and how can I support?” [14,63,66]. Screening for trauma is recommended [67–69] and given that maternity services already screen for intimate partner violence and perinatal anxiety and depression it may be feasible to add trauma discussions and PTSD screening to that routine [1,63]. This screening for trauma is imperative for delivery of TIC and it is recommended by numerous professional organizations for HCPs [66–69].

Despite this recommendation, Adverse Childhood Experiences (ACEs) screening has not been widely implemented in antenatal services and current practice in perinatal mental health screening does not usually include discussions focusing on trauma and PTSD [1,12,28,40,63]. It is still rare for assessment to distinguish whether the woman sees her depression and anxiety as related to trauma or not [3,7,22,63,70,71]. It is also important to highlight that some concerns have been raised in relation to universal screening for a history of trauma as this may re-traumatise women, increase the number of referrals for support to healthcare services and potentially stigmatise women [72,73]. However, midwives are ideally positioned to undertake such discussions on trauma given their regular contact with women in the perinatal period [1,12,28,74,75]. Interpersonal traumatic events are often misunderstood in maternity care settings where delayed disclosure impacts on the woman seeking help and support. Women who have experienced interpersonal traumatic events may find the perinatal period difficult in relation to some clinical procedures’ such as positions during labour, intimate examinations, communications with HCPs and loss of control [1,29–31] as these can reactive memories of previous abuse and re-traumatizatise the woman [1].

Given the adverse maternal, perinatal and child health outcomes associated with interpersonal trauma, it is important that midwives can have meaningful trauma discussions with women in the perinatal period. The National Maternity Strategy [76] advises that women who are at risk of developing or experiencing emotional or mental health difficulties in the perinatal period should be identified and recommend a multi-disciplinary approach to assessment and support of these women. Despite women being in regular contact with midwives and other HCPs during the perinatal period, women experiencing mental distress are frequently unidentified or inadequately treated [12,28,74,77]. Many women presenting for care to the maternity services, with a history of interpersonal trauma often do not recognise its effects on their lives. They either do not connect the events to their symptoms or they avoid the topic altogether. This makes it hard to assess and understand someone without knowing about their past [1,12,28,63]. Likewise, midwives may not ask questions that elicit a woman’s history of interpersonal trauma, as they often feel unprepared to address trauma-related issues proactively or may struggle to address traumatic stress effectively within the constraints of the maternity services [1,77,78]. Therefore, this review will examine how midwives can be proactive in trauma-informed screening and assessment, with an aim to enhance the care of affected women.

The NICE guidelines [79] provide all HCPs working with perinatal women a clear remit for assessment of women’s psychological health status. How routine trauma discussions are carried out in the perinatal period remains an important clinical challenge. These trauma discussions are often the first contact between the woman and the midwife, with the woman forming her first impression of maternity services based on their interaction. Thus, how screening is conducted can be as important as the actual information gathered, as it begins the relationship with the woman and may assist or delay disclosures of interpersonal trauma and hence referral for treatment. Assessments for trauma-related experiences require an understanding of perinatal mental health, therefore, instrument selection, trauma-informed screening, assessment tools, and assessment processes will be examined in this review. This paper therefore presents an integrative review conducted to identify how midwives screen, assess, and respond to women with interpersonal trauma in the perinatal period. Specific objectives were to:

  1. 1). Identify knowledge, skills and professional behaviours of midwives in discussing and assessing trauma in women during the perinatal period.
  2. 2). Identify factors that influence trauma discussions, screening and assessment of women during the perinatal period.
  3. 3). Identify challenges in providing trauma-informed discussions, screening, along with specific screening and assessment considerations and guidelines.

Methods

An integrative literature approach was performed to include experimental and non-experimental research [80] to gain a comprehensive understanding of how midwives are assessing for trauma in the perinatal period. This review reflects the same level of rigor as a systematic review using Cochrane guidance [81], reported in accordance with the PRISMA guidelines [82] and protocol registered on PROSPERO (CRD42022383052). Whittemore and Knafl’s (2005) [80] five-stage integrative review framework was employed within this review which includes: (1) problem identification, (2) literature search, (3) data evaluation, (4) data analysis and (5) presentation.

Search strategy

A comprehensive search of the Grey literature including Open Grey, Prospero, Joanna Briggs Institute, ProQuest Dissertations and Theses Global, PROSPERO and Cochrane library were searched to ensure no other previous or ongoing reviews was conducted. This search results found a dearth of literature related to how midwives are assessing for trauma in the perinatal period. A Population, Exposure and Outcome (PEO) framework was used to develop the selection of terms used in the search strategy and formulate the following review question: ‘What are midwife’s competencies, knowledge and ability to assess and respond to trauma in women during the perinatal period?’

Five electronic databases were systematically searched from inception to date of searches (Feb 2024): PsycINFO, MEDLINE, CINAHL, Applied Social Sciences Index and Abstracts (ASSIA) and Web of Science with no date, language or geographical limiters set owing to a deficiency of research in this subject area. Identical searches were used for all databases, using Medical Subject Headings (MeSH) terms and associated text words in the title and abstract, and combined using Boolean operators “OR”/ “AND” to refine, expand and combine the three PEO concepts (See Supplementary file 1 for search terms). Forward and backward citation searches was performed on all retrieved articles by manually hand inspecting the reference lists and tracking citation index of included studies to identify articles for additional studies.

Eligibility criteria

Studies were included if they: i) reported primary research that sampled a qualified or registered midwife’s competency in assessing or screening for trauma in women during the perinatal period ii) examined the midwife’s competency in assessing for trauma using any mode iii) were primary published studies using quantitative, qualitative, mixed-method design or review studies iv) focused on women over 18 years with self-reported or diagnoses of trauma (Type 1 which is a single/one-off event or Type 2 trauma or complex trauma which occurs over an extended period of time) during the perinatal period. Studies were excluded if they did not meet the outlined PEO framework and were not primary studies, e.g., published in non-peer reviewed journals, dissertations, protocols, conferences, and expert opinion.

Study selection

All returned citations retrieved from the database were imported into Covidence (https://www.covidence.org) for title/abstract screening and full-text review which removed duplicates across the electronic databases. All titles and abstracts and full-text screening were independently screened involving four reviewers (FC, AG, CB, MN ) against eligibility criteria with any uncertainties and discrepancies resolved collaboratively between all authors.

Quality assessment

Methodological quality of the primary studies was independently assessed by two reviewers using the Joanna Briggs Institute Critical Appraisal tools (JBI) [83] and the Mixed Method Appraisal tool (MMAT) for the mixed-methods studies [84]. The methodological quality of each study was independently assessed and rated by two reviewers (FC, AG) for rigor, trustworthiness, credibility, relevance and results in accordance with their research methodology (see Supplementary file 2). Discrepancies between the two reviewers were resolved collaboratively through discussion among the remaining authors.

Data extraction

A Microsoft Excel data extraction form (see Supplementary file 3) was developed and piloted by the review team to extract data from each study including author, year, country, aim, study design, sample size, participant characteristics, data collection/analysis methodology and variables of interest such as type of trauma (type I or II), midwives’ experiences of assessing for trauma within the perinatal period and results (main findings, limitations and future recommendations/gaps in knowledge). The authors developed the coding instructions and guidelines independently in order to reduce the subjectivity of decisions made. Two authors (FC, AG) independently extracted data from the included studies and any questions were resolved through discussion with the other authors to ensure the accuracy of extractions.

Data analysis

Due to the methodological heterogeneity across the studies in terms of design and outcomes, a narrative synthesis was used to integrate their findings. Narrative synthesis is a procedure for describing, comparing and combining heterogeneous synthesis of findings from multiple studies using text and illustrations to ‘tell a trustworthy story,’ of the findings to meet the review’s aim [85]. Three elements of Popay et al.’s (2006) [85] guidance on narrative synthesis techniques was used to explain the findings of the synthesis: (1) developing a preliminary synthesis; (2) exploring relationships in the data and (3) assessing the robustness of the synthesis. This technique increased the transparency and reliability of the narrative synthesis and the identification of patterns or themes relevant to the research questions to determine midwives’ competencies, knowledge and ability to assess for trauma in women during the perinatal period.

Results

Search results

The database search produced 3034 studies from five databases, 1471 were duplicates, 1563 titles and abstracts were screened, 1385 were excluded with reason, 178 studies were reviewed for full-text screening and 10 studies were identified for inclusion. Hand searching backward and forward citation yielded 14 studies, following full text examination, 12 studies were deemed eligible leaving a total of 22 studies for inclusion in the review. Summary of the systematic search strategy and screening process of eligibility criteria is reported in Fig 1.

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Fig 1. PRISMA 2020 Flowchart.

https://doi.org/10.1371/journal.pone.0327253.g001

Study characteristics

An overview of the study characteristics is presented in Table 1. All studies were published between 2003–2021 and conducted across ten countries/regions: eight in the U.K, four in Sweden, two in Australia, two in Italy and one each respectively in the Republic of Ireland, South Africa, New Zealand, Netherlands, Norway, and the U.S.A. Most of the included studies were qualitative designs (n = 13) using data from interviews and focus groups, seven were quantitative designs using cross-sectional studies (n = 7) and two were mixed method studies (n = 2).

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Table 1. Study Characteristics.

https://doi.org/10.1371/journal.pone.0327253.t001

The included studies reported a combined total of 2615 midwives involved in the care of women with history of trauma. Study sample sizes ranged from 4 to 488 midwives, the mean age reported from eleven studies was 40 years old [74,90–92,94,96,97,99,100,103,105,106]. Clinical experience in midwifery ranged between 6 months to 32 years, with the average amount of clinical experience reported to be over ten years in thirteen of the studies [74,86–89,91,94,95,97,99,102–104,106]. All midwives in the included studies were women (n = 2615). Ethnicity was reported by only two studies, with both studies classifying most of the sample as Caucasian or white English/Welsh/Northern Irish/British [99,103].

Many of the studies (n = 14) focused on midwife’s experiences of caring for women with a history of domestic violence [87–90,94,96–103,106] and the remainder on sexual abuse [95], Adverse Childhood Experience (ACE) [93], both ACE and domestic violence [74,86,88] and traumatic birth/PTSD [91,104,105].

All studies (n = 22) recruited midwives (n = 2615) from maternity services. In six studies midwives conducted assessments in antenatal clinics in hospital settings [87,88,92,94,104,106] with another five studies midwives collected data in antenatal, intrapartum and postnatal settings in a hospital-based setting [74,86,90,91,95]. Seven studies reported data from midwives both in hospital and community settings [96–98,100–102,105] and the final two reported from community-based settings within the maternity services [89,103].

Methodological quality

The methodological quality of the 22 included studies was considered good using the JBI checklist for qualitative and quantitative studies [83] and the MMAT tool for mixed-methods studies [84] (see Supplementary file 2). The studies were of good quality, achieving over 88% of the JBI quality criteria. The mixed-methods studies (n = 2) met all five MMAT criteria and were rated as good quality. None of the studies were excluded based on quality ratings but this was taken into consideration during the analysis and synthesis when deciding how much weight to put on the findings of each study which underlines the strength and credibility of our findings to a certain extent.

Thematic analysis

Data Analysis produced four main themes: Theme 1, Midwives’ difficulties in asking and discussing interpersonal trauma and abuse, and their instinctive use of their observation skills to elicit information. Theme 2, Screening tools to elicit history of interpersonal trauma. Theme 3, Midwife’s response to interpersonal discussions. Theme 4, Training on ‘daring to ask the questions’ and Support on ‘what should I do now’. To illustrate synthesis, the main themes are narratively presented with the addition of a thematic summary diagram (Fig 2) and detailed information on the analytic themes and supporting quotations is provided in Table 2.

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Table 2. Analytic Themes and Supporting Quotations.

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Fig 2. Main Themes.

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1) Midwives’ difficulties in asking and discussing interpersonal trauma and abuse, and their instinctive use of their observation skills to elicit information.

This theme focuses on how midwives are having trauma discussions using both direct questioning and using their innate observation skills. Six studies [74,96,98,100,105,106] provided valuable insights as to how midwives ask about trauma (See Table 2). Midwives in Fenne Fredriksen et al. [106] felt that their questions sometimes were not good enough and wondered if their phrasing of the questions led to non-disclosures of violence. No specific examples of direct questions were provided and it was reported that midwives used different approaches in how and when to ask the questions [106]. A quantitative study by Carroll et al. [74] reported on self-reported skill in discussing sexual abuse (Mean = 2.15, Standard Deviation = 1.02) and intimate partner violence (Mean = 2.20, Standard Deviation = 1.06), both were rated below the midpoint of the scale (Mean = 4.48, Standard Deviation = 1.82), demonstrating midwives discomfort with questioning around these issues. The majority of midwives in this study reported never asking women about sexual abuse/sexual violence (62.2%, n = 258), intimate partner violence (54.1%, n = 225) reasons for this not individually addressed.

There were no examples provided of questions asked by the midwives in Lanzenbatt et al. [96]. Only 38% of midwives reported asking the question about domestic violence, mainly because the partner was in the room [96]. Lanzenbatt and Thompson-Cree [100] reported that 28% of Midwives asked questions about domestic violence, some asked direct questions and others asked indirect questions. No specific examples of questions used were provided [100]. Eustace et al. [98] reported that some midwives asked women directly about domestic abuse at the booking interview. No examples of questions were provided. The majority of participants perceived that the lack of clear processes within their health service added to their worries around asking direct questions about domestic violence [98].

Questioning on fear of childbirth and birth experiences were reported in de Vries et al. [105] with 57.6% (n = 117/203) of midwives reported always asking open questions on fear of childbirth in the antenatal period. In the same timeframe 40.9% (n = 83/203) of midwives reported only asking in specific situations where signs and symptoms were picked up by observation. In relation to birth experiences 81.1% (n = 150/185) of midwives asked directly within one week after the birth. At the six-week postpartum check-up all midwives confirmed asking women about their birth experiences but the types of questions asked by midwives was not reported [105].

Across seven studies [87,91,92,95,97,103,105], midwives stated that they relied on observation skills to detect signs and symptoms for abuse or trauma. In the study by Finnbogadóttir and Dykes [87] domestic violence was often picked up by the midwives in the postnatal period due to visible bruises and disclosures from the women about domestic violence in the household. The visible bruises were described as having something “concrete” to start the conversation about domestic violence. Similarly, in Shamu et al. [92], physical violence was reported to be easier to detect in comparison to other forms of violence because it can be seen therefore is more obvious, it is easier to ask when there is visible evidence one midwife stated:

“Perhaps if there are quite obvious marks from battering such as some bruises” (Anna, Midwife, Mutenda Clinic) [92].

Comparable findings were reported in Mauri et al. [97] where most of the midwives reported difficulties in recognising violence unless it has ‘striking effects’ and that it is easier to identify violence by seeing physical signs (bruising) for example one midwife reported:

“Well… I think that physical signs might be easier to recognise… but I’m not so sure because I have never met a battered woman who disclosed to me… so… besides physical signs – such as bruises – I don’t know what else I could notice… “ (interview No. 2: MIDWIFE, p.499) [97].

Midwives instincts were used to recognise psychological signs of abuse such as insecurity, anxiety, fear, low self-esteem, they did not formally screen for these but depended on the midwife’s “gut feeling” [97]. Midwives also reported how the use of observation skills to detect domestic violence was further refined by three triggers [103] that lead to “gut reactions” or suspicions of abuse. These included 1) behavioural clues, 2) physical signs and symptoms and 3) cultural clues for example one midwife stated that:

“Sometimes, honestly, just a gut reaction and the gut reactions of my co-workers as well, the other midwives I work with. And as we are meeting and we are discussing patients we say...something is not right here so it is that gut…. and if that is all we relied on, we would miss opportunities.... p.218 [103].

A study by Jackson et al. [95] explored midwife’s ability to identify women with a history of sexual abuse and discussed both the physical and the psychological signs of sexual abuse. Most comments were related to women’s reluctance, refusal, fear of or difficulty with procedures such as: ‘Very, very distressed when needing a vaginal examination’s, p.257 [95]. Midwives in this study described a range of descriptors on how to recognise the signs and symptoms of survivors of sexual abuse such as: women feeling frightened, distressed, distraught, fearful, afraid, anxious, tense, nervous, agitated and tearful. Jackson et al. [95] also explored the physiological indicators that midwives use to observe for sexual abuse, these included: vaginal discharge, bruising, swelling, recurrent urinary tract infections, and recurrent or early history of sexually transmitted infections, vaginal lacerations, history of dyspareunia, vaginismus, frigidity and history of termination of pregnancy. Midwives emphasized the importance of observation skills when screening and assessing for trauma as they serve as a starting point to determine which women may benefit from follow-up care and a referral for psychological support or treatment [95].

Midwives’ perceptions of fear of childbirth (FOC) among women was a key focus in Salomonsson et al. [91] study. Midwives reported that women were more inclined to report their FOC with or without being asked and symptoms such as panic, crying and the need for continuous personal support during labour demonstrated how midwives were using their observation skills to detect fear of childbirth [91]. A quantitative study by de Vries et al. [105] found that a high number of midwives cared for women with FOC. It was reported that 82.8% (n = 207/250) of the midwives saw > 5 women with FOC in a given a year. They also found that, 77.8% (n = 200/257) of midwives recognised psychological signals in relation to the symptoms of fear of childbirth, whilst 59.5% (n = 153/257) reported being able to recognise the physical signs. The same study also looked at PTSD and midwife’s ability to recognise symptoms. Of the participants 69.8% (n = 157/225) could identify one or more DSM-5 (APA, 2013) criteria whereas 18.2% (n = 41/225) could not name any signs or symptoms of PTSD.

2) Screening tools to elicit history of interpersonal trauma.

This theme outlines the screening tools used in the included papers. Six of the included studies [86,88,93,94,98,101,103] reported on trauma screening tools or validated trauma outcome measures used by midwives (see Table 2). Despite 14 studies reporting on the topic of domestic violence only two studies [94,101] utilised the validated Abuse Assessment Screen (AAS) [107] which detects domestic abuse (intimate partner violence) in pregnant and non-pregnant women. An ACE screening tool was utilised by midwives to detect history of ACEs in pregnant women in Mortimore et al. [93]. Most midwives felt comfortable asking the ACEs questions at booking. However, if a midwife had experienced ACEs themselves, the task was more difficult. This tool was well received by HCPs and women in the study [93]. Two studies [88,94] screened for a history of trauma using psychosocial assessments with some questions adapted from AAS [107]. Similar findings in Hindin et al. [103], no specific screening tool was used but questions were based on the AAS [107] and their own clinical style. Finally, a study by McKenzie-McHarg et al. [86] did not use a specific screening tool to assess for trauma but did use a pink sticker system to identify women with mental health concerns.

3) Midwife’s response to interpersonal trauma discussions.

This theme explores midwives responses to having trauma discussions with women with a history of interpersonal trauma. Lack of confidence in relation to assessment was reported by three qualitative studies [87,94,98]. Midwives in Eustace et al. [98] acknowledged feelings of being unprepared and unsupported in their role, leading some midwives describing genuine feelings of fear and anxiety around the possibility of a positive disclosure of intimate partner violence:

“We are potentially opening this can of worms here; I’m asking a woman some really difficult questions, what on earth will I do with the answers? If I can’t do anything then I should not be asking, and if I’m not ready to deal with some pretty nasty disclosures then I shouldn’t ask.” (Alison, p.11) [98].

In relation to dealing with definitive disclosures of sexual abuse (56%/n = 207) midwives, responded either ‘no’ or ‘definitely no’ that they could not deal with a disclosure of sexual abuse [94]. Midwives’ expressed fear of reporting domestic violence, as well as lack of knowledge concerning how to handle the situation if women did disclose such violence [87]. The midwives sometimes blamed themselves for having missed signs of domestic violence during the pregnancy and for not being aware of what the woman had been going through. Midwives were also afraid of reporting to the authorities when the man was very aggressive, some reported fear of being perceived negatively by the woman if they questioned about domestic violence. Midwives recognised that avoidance of questions on the experience of violence during pregnancy may be regarded as a failing not only the pregnant woman but also to the unprotected and unborn baby [87]:

“There are probably many I have missed, for sure” (Focus group 2, p.184).

Midwives in Carroll et al. [74] did not feel confident in discussing sexual abuse and intimate partner violence with scores reported as (Mean = 2.15, Standard Deviation = 1.02) for sexual abuse and (Mean = 2.20, Standard Deviation = 1.06) for intimate partner violence, all of which were rated below the midpoint of the scale [74]. Midwives in Rollans et al. [88] often modified their questions demonstrating their level of discomfort with the topic. In relation to screening midwives felt they were forced into a new role and were not equipped for it. They also often feared for their own safety and the safety of their families following disclosures [101,106]. Many midwives in Fenne Fredriksen et al. [106] study reported how they felt embarrassed asking questions about domestic violence. A midwife in the study reported that she felt that she did not have the capacity to deal with such a disclosure of violence [106].

Other studies reported on midwife’s experience when caring for women with trauma histories. Midwives reported positive experiences when caring for women with Fear of childbirth (FoC 83.0%, N = 176/212) and Post Traumatic Stress Disorder (PTSD 74.2%, N = 158/213) [105]. This contrasts with Salomonsson et al. [91], where the midwives (n = 21) reported the challenges in meeting the women with FOC professionally, because it is emotionally demanding. Midwives also reported how FOC can be time consuming and described how sometimes women’s fearful behaviour could provoke anger in the individual midwives. They also described how birth plans may invoke a negative attitude towards the woman among midwives. Meeting women with fixed ideas on her labour can be difficult for midwives as it can be stressful to meet their expectations. Despite this, the midwives pointed out the importance of identifying women with FOC and providing professional support adjusted to women’s individual needs [91].

4) Training on ‘daring to ask the questions’ and support on ‘what should I do now’.

This theme investigates how training and support can facilitate HCP’s in their role in working with women who have experienced trauma. In order to implement organisational change to support midwives in promoting trauma screening and assessing, midwives require specific training, knowledge, organisational support and clinical supervision in trauma care practices [90,93,95,99,101]. Qualitative studies highlighted the need for trauma training and clinical supervision [86–88,92,94,97]. The majority of midwives (n = 347) perceived that increase in education, organisational support and reflective supervision would improve their confidence and quality of care they provided to women with history of trauma.

“We could all benefit in some really good solid training. If there was more guidance for us, then we would feel more confident about asking these questions.” (Lyn, p.13) [98].

Training and Education: Jackson et al. [95] found that many midwives had little if any education in the area of disclosing sexual abuse and felt unable to deal effectively with disclosures. Midwives felt that basic skills such as listening were all they could offer as a response to disclosures.

“It is not an area in which I have had any experience and not an area I feel particularly comfortable with, the only thing I feel I could offer is a listening ear” p.260 [95].

Midwives interviewed in a qualitative study by Fenne Fredriksen et al. [106] felt their knowledge about domestic violence and screening was “sketchy” [106]. The majority reported not having any training on this issue during their training. There was also a concern raised by one participant about the lack of a standardised training programme. The midwifes felt that courses available in practice had different areas of focus and that midwives were approaching the subject differently as a result of different angles covered on training programmes [106]. Carroll et al. [74] reported on midwives perceived lack of knowledge and skill in relation to PTSD. Those without any perinatal mental health education rated lower on recognising PTSD (Mean = 2.18, Standard Deviation = 1.02) compared to those who did receive training (Mean = 2.73, Standard Deviation = 1.05). This demonstrated that specialised education programs can have positive effects on training midwives to work with women who have been affected by trauma in their pregnancy.

This was also echoed by Baird et al. [89] who provided midwives with specific training programs for dealing with women’s disclosure of domestic violence. Participants in Baird et al. [89] study were asked to reflect on their domestic violence training in 2004/2005 and the effect it had on improving their knowledge of domestic abuse in general. This was collated using the indicators “a great deal; a moderate amount; a minimal amount; not at all, or unsure” to assess improvements in knowledge. Increased confidence in ‘how to deal with a positive disclosure’ of domestic abuse was reported when comparing 2010 data with 2005 data that was pre-training. In 2010, 39.5% of midwives reported ‘a great deal’ compared to 21.1% in 2005 (p¼0.034) [89]. Midwives in 2010 were 2.4 times more likely to report ‘a great deal’ than those in 2005 (odds ratio ¼2.44, 95% confidence interval ¼1.06–5.63). This demonstrates that improvements in knowledge have been maintained following training [89]. Baird et al. [89] also reported on the effectiveness of training on midwives’ knowledge of screening for domestic violence and found that there was increase in knowledge of screening for domestic violence when comparing the 2010 data with 2005. In 2010, 41.5% of midwives reported being able to routinely enquire about domestic violence at least 80% of the time compared with only 12.7% in 2005 (po0.001) and were also creating more opportunities to ask women about abuse than in 2005 [89]:

“Yes, I would say that midwives feel much more confident in asking now” (Midwife 5, p.1007).

Continuity of Care: Fragmented and busy maternity care systems with a lack continuity of care for women are proposed as mitigating factors against midwives screening for trauma, dealing as they are with heavy and complex caseloads [97,98,103]. Many of the midwives (n = 59) highlighted the importance of building a relationship with the woman to identify violence [97,98,102,103,106]. The ability to establish a trusting relationship is a key component for successful intimate partner violence screening and one of their greatest screening strengths [97,98,103,106]. Some midwives demonstrated discomfort asking trauma questions at initial booking, they felt uncomfortable asking these sensitive questions when they had never met the woman before and felt that screening would be more appropriate when they had built up a trusting relationship with the woman [102,106].

“If you don’t build an intimate and trusting relationship with the woman, she will never disclose abuse. You could ask any question you want but she would never say a word…” (interview 8: senior midwife, p.501) [97]

The provision of continuity of care throughout the perinatal period by a known midwife enhances the likelihood of effective routine enquiry across time; and provides opportunities to link women with support services and to bolster their social support network (p.14) [98].

Referral Pathways and working with the Multidisciplinary Team: Another key aspect for midwives (n = 1426) was the ability to respond effectively to positive disclosure and making appropriate referral to another caregiver which involves working collaboratively with the multidisciplinary team and wide range of agencies [74,89,95,97,99,105]. For instance, midwives reported:

“Collaborating in such situations is always useful: it helps us and it helps the women” (interview No. 1: midwife p. 502) [97].

‘I would probably prefer to refer to someone with training in this field. I would be worried about making an inappropriate response and making the situation worse’ p.260 [95].

Midwives reported having liaison meetings with colleagues as a form of support [106]. Meeting their supervisor and asking advice on how to raise and phrase questions on domestic violence was seen as beneficial to junior colleagues [106]. Baird et al. [89] found that training increased knowledge of the referral process and collaboration with other agencies. This was supported by Carroll et al. [74] relating to consulting with and/or refer to other professionals or services, the mean ratings were above the midpoint to the scale colleagues (Mean = 3.97, Standard Deviation = 0.98), managers (Mean = 3.87, Standard Deviation = 1.06) and perinatal mental health services (Mean = 3.61, Standard Deviation = 1.16), apart from discussing referral to child protection services (Mean = 2.51, Standard Deviation = 1.14) [74]. Shamu et al. [92] found that midwives frequently did not take any action once they became aware of cases of violence other than just noting them as social problems. On other occasions, midwives responded by reporting some cases of violence to a referral (tertiary) hospital or to the police. Midwives mentioned referral to a non-governmental referral centre for women who experience gender-based abuse [92]. The main obstacles to reporting IPV identified by Shamu et al. [92] were lack of education, lack of screening tools, conflicting opinions on whether IPV is a social problem, a healthcare problem or the norm.

Discussion

The authors examined the role of midwives in trauma discussions with women in the perinatal period as reported by the literature. Synthesis of these findings adds to the body of evidence in this area, incorporating recommendations to enhance practice and care of women who have experienced trauma. It is important to distinguish between screening and assessment to contextualise the findings and make them more meaningful to practice. Screening identifies people at risk of a condition but is not diagnostic whilst assessment is more in depth, can be diagnostic and can aid treatment [44]. All of the twenty-two included studies reported on midwives screening for trauma in the perinatal period, but none reported on midwives assessing for trauma. This may be explained by assessment for trauma being outside the midwives’ scope of practice. Across the studies there is variation on how and when to screen for trauma and there was a lack of a clear process to guide broaching such a sensitive subject within the various health care settings. Midwives in the included studies clearly indicated the importance of asking women specific questions to elicit their experience of trauma [74,96,98,100,105,106]. This finding is corroborated in the literature where women report wanting to be asked about abuse, but many health professionals do not feel comfortable or confident asking about abuse [12,28,74,77].

Of the 22 studies examined, two studies [88,94] provided examples of direct or indirect questions asked to women relating to trauma in the perinatal period and highlighted the sporadic and non-structured screening habits of the midwives interviewed. A more trauma-informed approach to screening questions was provided by LoGiudice et al. [108] such as “many people I provide care to have a history of sexual violence or trauma” followed by asking about history using sensitive language and finishing with a power shifting statement. Midwives in this study valued direction in using open questioning techniques when dealing with sensitive topics. This was also supported by Paterno and Draughon [109] highlighting that the use of trauma sensitive and non-judgemental language was key to providing a safe space for women to disclose abuse. Carlin et al. [110] presented an argument against using direct questions as they may result in women disengaging from the process, broad questioning was recommended in its place. Good communication skills, including the use of sensitive and non-judgemental language are essential to the delivery of high-quality healthcare [111,112]. Midwives demonstrated their competence in using their observation skills to detect signs and symptoms of abuse in many of the included studies [87,91,92,95,97,103,105]. The value of the midwife’s observation and communication skills, developed via their experience and knowledge cannot be underestimated when having trauma discussions in the perinatal period. These are skills midwives use in everyday practice and are transferable for use in screening. Listening skills and non-judgemental responses to disclosure are valuable when working with women that have experienced trauma [1,12]. Midwives need to recognise and be empowered to use their core communication skills as an integral tool in managing trauma as this review demonstrates that midwives have many essential skills which are transferable to the effective screening for trauma. A recent review [31] found that many women will not disclose their trauma histories to professionals, unless a therapeutic relationship has been established with the professional. This copper fastens the importance of establishing therapeutic relationship with all women, and the development of therapeutic relationships is a priority for all midwives when providing care.

Despite their communication expertise, lack of confidence in screening for trauma was reported by many of the midwives within the review [87,94,98]. Many midwives felt unprepared, unsupported and afraid when screening for trauma and often blamed themselves for missing signs of violence when abuse was reported. Similar findings were reported by nurses in Poreddi et al. [113,114] reporting lack of confidence in screening for violence and attributing this to inadequate training. In the UK routine enquiry for domestic abuse is part of the national care pathway and it is possible that training has led to changes in some of the findings by Baird et al. [89], but lack of confidence was reported in several of the included studies, which echoes recent research [87,94,98]. Midwives need for trauma specific training and clinical supervision was evident in the findings of this review [86–88,92,94,95,97]. The majority of midwives (n = 347) considered that an increase in education, organisational support and clinical supervision would improve midwife’s confidence, and the quality of care provided to women with history of trauma. This finding is supported by Kirk and Bezzant [75] who note the most dominant barrier to screening by health care professionals is a lack of training and education. Midwives require continuous professional development opportunities that address knowledge, attitudes to perinatal mental health, communication and assessment skills [2,28,115]. Education and training on perinatal mental health among health care professionals has been enhanced in recognition of the morbidity and mortality of perinatal mental health disorders for women and their families [62,76]. However, there is limited education available for midwives and other HCPs to inform and implement impact on trauma-informed care (TIC) [1,116]. Such deficits in education and training of midwives particularly in this area is of concern, as midwives, key providers of care antenatally, intranatally and postnatally, are best placed to provide TIC to women (where appropriate) in the perinatal period [116]. Training improves practice by enhancing competence and confidence and a standardised, evidence-based approach to such education would promote consistency in care provided by midwives [1,106,115].

The potential exposure to secondary trauma or vicarious trauma needs to be acknowledged as an occupational hazard for midwives [117]. Midwives reported their response to a traumatic birth event left them predominantly experiencing horror (74.8%) and feeling guilty (65.3%) about what happened to the woman [117]. More than two-thirds of midwives in this study were present during a birth that involved interpersonal care-related trauma, and of these approximately 17% of midwives met the criteria for PTSD [117]. In recognition of the impact of vicarious trauma, debriefing and support from peers was recommended as benefiting midwives and midwifery students affected by secondary trauma [108]. Shorley and Wong [115] also reported midwives feeling guilty and self-blaming after adverse events and reported lack of support from colleagues and noted organisational responses influenced their ability to deal with the trauma and to stay in the profession. A proposed solution to the effects of vicarious trauma is the use of reflective supervision in practice [28,118], in response to midwives feeling overwhelmed with trauma disclosures. The effectiveness of clinical supervision when carried out in a safe space reported improvements in staff confidence, reduction in stress and burnout, increase in staff retention and satisfaction, and professional sustenance [119,120].

Fourteen of the studies reported on midwife’s experiences of screening women for a history of domestic violence during pregnancy [87,89,90,92,94,96–103,106]. This focus on domestic violence screening is not surprising, considering policy recommendations internationally and nationally and the emphasis on education and training in this area in recent years [26,62]. The remainder of the studies focused on screening for sexual abuse [95], ACE [93], ACE and domestic violence [74,86,88] and traumatic birth/PTSD [91,104,105]. Midwives’ experiences of screening for other types of traumas such as sexual abuse, ACE and birth trauma are poorly represented in the literature in comparison to screening for domestic violence which demonstrates a significant gap in practice impacting women who have or are experiencing trauma other than domestic violence.

Considering that validated screening tools are in existence, only five studies [88,93,94,101,103] reported on trauma screening tools or validated trauma outcome measures used by midwives (see Table 2). Although the Abuse Assessment Screen (AAS) [107] is a well validated tool used to detect domestic abuse in pregnant and non-pregnant women [121–123] only three studies utilised this tool. A study by Mezey et al. [101] used a variation of the tool three times in the perinatal period, Stenson et al. [94] used the trauma questions from the tool as part of a psychosocial assessment and whilst Hindin [103] did not use the tool explicitly but adapted questions from the tool for their study.

Using a valid and reliable tool is important when screening as this has considerable public health benefits relating to the prevention and detection of GBV/IPV [26,69] and ensures evidence best practice is implemented [109]. Other validated screening tools also include the Humiliation, Afraid, Rape, and Kick (HARK) questionnaire suitable for antenatal care settings [124], the ACE screening tool [93], the Antenatal Risk Questionnaire (ANRQ) for perinatal health risk assessment tool for trauma [125], and the short version of the Women Abuse Screening Tool (WAST) for IPV [126]. Whilst these tools (AAS, HARK, ACE, ANRQ, WAST) are recommended, their use by midwives were limited in this review in particular the ANRQ as a screening tool to detect trauma. Despite recommendations for the use of screening in practice there are also some counterarguments presented in the literature. A Cochrane review [127] of screening for IPV found for example that although screening was likely to increase identification it did not increase referrals to support services, reduce IPV, nor had a positive impact on women’s health. The authors concluded that screening for IPV increases identification, but it is a problematic concept when traditional screening criteria are applied, as it is a complex social phenomenon rather than a disease. A scoping review [72] into the evidence base for routine enquiry into ACEs found that HCPs were generally comfortable asking the questions and found it easier than expected. However, this review concluded that enquiry did not usually change the care in the visit or the follow up plan. This Cochrane review [127] focused on women’s experiences of violence found that screening did not reduce IPV post enquiry, and reported on women’s health outcomes post enquiry found no change to the women’s wellbeing when followed up post enquiry.

Screening for ACEs among pregnant women has not been widely implemented in antenatal care often attributed to lack of training and education for HCPs [1,40]. When training and resources on ACE screening was provided to HCPs, a significant improvement in the pre-post pilot scores on the willingness of HCPs to screen and discuss ACE’s with women was demonstrated [115,128]. However, a recent study found insufficient evidence for the implementation of an ACE screening programme [129]. Moreover the same study found limited evidence that the routine enquiry/screening for ACE’s resulted in reductions in morbidity and mortality rates. Further criticisms of the introduction of the ACE screening programme to practice, included advice against placing weight on ACE scores as a means to determine risk or to make treatment decisions for individuals [130]. None of the studies in the review examined the impact on the woman’s wellbeing or service utilization following use of routine enquiry for ACE’s. There is however a potential to cause harm to women by having these trauma discussions in an insensitive manner or when no follow up is provided following disclosure. This demonstrates the need for careful consideration when advocating for the introduction of such programmes.

Strengths and limitations

To our knowledge, this is the first integrated review which synthesises twenty-two studies on the experiences of midwives screening/assessing for trauma in the perinatal period. This review draws upon the views of a large number of midwives (n = 2615), from a variety of geographical backgrounds, educational levels, years of experience and related to both type I and II trauma in the perinatal period. This review highlights the deficits in screening and assessment of trauma among midwives, impacting considerably on the appropriate care of those women affected by trauma, and gives rise to several recommendations to enhance care in practice. Although women were from various backgrounds and geographic locations, similarities were found in their experiences of screening/assessing for trauma in maternity services, indicating potential transferability of the findings. While this is not the first review to focus on trauma discussions in maternity care [31], it is the first to include quantitative studies. A limitation of the review was the explicit focus on midwife’s experiences of discussing, screening and assessing interpersonal trauma which may have excluded the voice of other HCPs who also have a role in the care of women with history of interpersonal trauma in the perinatal period.

Recommendations for practice

This review highlighted the need for further education and training for midwives in screening, assessment and how to care for women with a history of trauma in the perinatal period. Mandatory training in relation to screening/having trauma discussions is essential based on the findings and the repeated call for more training and education in this area. The review also identified the sporadic and non-structured screening habits among midwives, calling for a need for a more standardised approach to asking questions about trauma in the perinatal period. Midwives need to be empowered to recognise their contribution to screening for trauma using their existing communication skills, developed via their knowledge and experience of practice, with their valuable contribution to the care women receive commended. Where screening does occur, the limited use of validated screening tools is also an interesting finding and one for consideration for maternity settings. It may be beneficial to consider the use of a standardised screening tool which is effective for trauma, for example, for example AAS, HARK, ACE, ANRQ, WAST. However, further research needs to be carried out on the feasibility of this from a HCPs perspective.

It is important to view trauma discussions as complex and require a whole systems approach, including staff training, continuity of carer, support for staff and evaluation of services [31]. This needs to be sustained to ensure a quality of service and to ensure the 6 key principles of TIC which include safety; trustworthiness and transparency; collaboration and mutuality; peer support; empowerment, voice and choice and cultural sensitivity [14]. A woman who has previously experienced trauma may feel unsafe, and this can be escalated by the care received, e.g., physical examinations or specific pregnancy, childbirth and postpartum trauma [1,12,78]. Therefore, the goal is to find a technique that elicits information that does not re-traumatise women. Further studies are recommended on how trauma is recognised in practice and the effectiveness of screening and assessing for trauma services once introduced. Such research would help further the development of a quality TIC service within maternity services.

Conclusion

This integrative review has highlighted the variations in having routine trauma discussions within the perinatal care, the need for more streamlined screening and assessing practices, and the urgent need for training and reflective supervision in TIC for all HCPs in their perinatal role. This review adds to the body of knowledge on how midwives are screening and assessing for trauma in the perinatal period. Appropriate trauma discussions should be used so that women can receive the care and appropriate treatment for trauma in order to decrease morbidity and mortality in both mothers and newborns. Despite the awareness of the adverse effects of trauma on women and their families [5,7,13,22,57], the literature [1,26,52] highlights that interpersonal trauma is often not detected by HCP’s in the perinatal care. Midwives as key caregivers to women in the perinatal period are best placed to screen, at a minimum and potentially assess affected women in the perinatal period, highlighting the urgent need for education and training on TIC.

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