11th August 2023
We are delighted to share this Voices blog by Joanne Cull, National Institute for Health Research Wellbeing of Women Doctoral Fellow, which shares the findings of a study of how to best support women who have suffered trauma such as violence or sexual abuse prior to pregnancy – the EMPATHY study: Empowering Pregnant women Affected by Trauma HistorY.
I am a midwife and hold a National Institute for Health Research Wellbeing of Women Doctoral Fellowship to study how best to support women who have suffered trauma such as violence or sexual abuse prior to pregnancy. It is estimated that one in three pregnant women in the UK, which equates to a quarter of a million women each year, are affected by such experiences1. Discussing trauma at antenatal and postnatal contacts provides an opportunity to let women know that difficult previous experiences can impact their health and wellbeing, to reduce stigma, and to signpost or refer to helpful resources2. However, no national guidance has been published on the routine discussion of previous trauma in perinatal care, so NHS trusts have implemented it on a piecemeal basis. There is a risk that if these complex conversations are not handled sensitively, they could be upsetting for women or potentially cause unwarranted and unwelcome referrals to safeguarding and mental health services.
To understand whether and how women should be asked about previous trauma, we reviewed qualitative evidence to find out the views of women and maternity care professionals. The review included 25 research papers from the UK and comparable countries (mainly Australia and the USA)3. The studies were published between 2001 and 2022 and included the views of 1,602 women and 286 healthcare professionals. The review is part of a doctoral study called the EMPATHY study: EMpowering Pregnant women Affected by Trauma HistorY. It is a critical participatory action research study and is supported by a Research Collective of experts by experience, maternity care providers, and voluntary sector experts.
Women’s perspectives on trauma discussions
We found that most women supported routine discussion of previous trauma, even when they did not intend to disclose. The perinatal period was often an intense and challenging time, with women feeling a loss of control and some suffering frightening flashbacks. Even women who were living happy lives and seemed to be far along in recovery could find this period difficult. Talking about previous trauma could help prepare women for this possibility.
However, some women found being asked about previous trauma was unexpected and intrusive. Women were very aware of the widespread belief that the abused become abusers, and fear of judgement was a key barrier to disclosure. Many women said they would only discuss their experiences with a care provider they trusted, and others would not disclose regardless. Handling trauma discussions sensitively was felt to be vital, because otherwise people could disengage from care or avoid healthcare in future. Women with limited English faced an additional challenge as they often did not want to share their experiences with the interpreter or the family member or friend interpreting for them.
Maternity care providers generally felt that discussing previous trauma was valuable and feasible. Partner presence was a commonly identified practical barrier to trauma discussions, as not all women have shared their histories with their partners. While it can be challenging to create opportunities for private conversation when visiting women in their homes, this is crucial when raising the issue of previous trauma, as it is for current abuse4. Some women may be more comfortable with the support of their partners for subsequent discussions.
The review found that it was hard for care providers to listen to stories of domestic abuse, sexual abuse, and other traumas. Clinicians said they worried about women and found it hard to stop thinking about them even when they were not working. None of the studies explored whether trauma discussions might be more difficult for clinicians who themselves have suffered trauma.
In most cases, questionnaires were used to ask about previous trauma, but some participants felt this was impersonal and would inhibit disclosure. Broad, gentle questions were felt to be more likely to encourage women to feel comfortable sharing their histories, although some clinicians felt this would take too long, or position them as a counsellor.
Moving forward with trauma discussions
While the perinatal period can be difficult for women who have suffered trauma, this can also be a time of healing. Health visitors are trusted professionals and are ideally placed to assist families who are suffering after difficult experiences. Central to this is the health visitor’s ability to develop trusting relationships with women and their families.
Our review found that, for both women and care providers, support for routine discussion of previous trauma was contingent on adequate time and resources4. We also found that many women feel ill-prepared for the discussion and are concerned that confidentiality will be breached.
- Based on the findings from the review, there are clear recommendations for practice: Women should be prepared in advance of the appointment that they will be asked about previous experiences.
- Health visitors should work with women to ensure that, within the limits of local and national safeguarding requirements, documentation and information sharing is acceptable.
- Training and support for health visitors is needed to build on their existing skills to enable them to carry out discussions of previous trauma and deal with the emotional impact of these conversations on their own wellbeing.
- Conversations about previous trauma are highly sensitive and must be carried out by skilled, qualified and professionally regulated staff, such as health visitors or midwives.
Using the findings from the review and subsequent interviews, we are working to develop national guidelines to help professionals who work with women in the perinatal period to navigate conversations about past traumas.
- Joanne Cull, National Institute for Health Research Wellbeing of Women Doctoral Fellow, University of Central Lancashire [email protected]
- Professor Gill Thomson, University of Central Lancashire
- Professor Soo Downe, University of Central Lancashire
- Distinguished Professor Michelle Fine, City University of New York
- Dr Anastasia Topalidou, University of Central Lancashire
Joanne Cull is funded by a National Institute for Health Research (NIHR) Wellbeing of Women Doctoral Fellowship (grant number NIHR301525). This paper presents independent research funded by the National Institute for Health Research (NIHR) and the charity Wellbeing of Women. The views expressed are those of the authors and not necessarily those of Wellbeing of Women, the NHS, the NIHR or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
- Crown Prosecution Service. Violence against women and girls report. Crown Prosecution Service. 2019.
- Flanagan T, Alabaster A, McCaw B, Stoller N, Watson C, Young-Wolff K. Feasibility and acceptability of screening for adverse childhood experiences in prenatal care. Journal of Women’s Health. 2018;27(7):903-911. https://pubmed.ncbi.nlm.nih.gov/29350573. doi: 10.1089/jwh.2017.6649.
- Cull J, Thomson G, Downe S, Fine M, Topalidou A. 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(5):e0284119. https://doi.org/10.1371/journal.pone.0284119.
- Home Office. Domestic abuse statutory guidance. 2022. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1089015/Domestic_Abuse_Act_2021_Statutory_Guidance.pdf. Accessed 7.8.23.