Embedding discussions of previous trauma as a routine component of maternity care, rather than on the basis of clinician concern about individual women, is essential to mitigate clinician bias and ensure equitable care (10). Evidence suggests that both women and clinicians find such discussions valuable and worthwhile (21). Without routine trauma discussions, care providers may miss critical opportunities to support women in distress. Furthermore, even when women choose not to disclose at this time, sensitively raising the issue prepares them for the emotional challenges of the perinatal period and may facilitate future disclosure (37).

However, initiating trauma discussions is not without challenges. Raising the issue insensitively or without adequate forewarning can be futile or even harmful (11). Women may find such conversations unexpected, intrusive, or distressing, potentially leading to disengagement from maternity services (12). Overzealous safeguarding responses or unwarranted referrals to safeguarding or mental health services can further alienate women, while the lack of trauma-informed support services often leaves clinicians ill-equipped to respond effectively (21). These complexities underscore the need for a carefully designed framework to guide trauma conversations in maternity care.

Existing tools and approaches for trauma discussions often fall short. Commonly used instruments, such as the Adverse Childhood Experiences (ACE) score, have been criticised for their potential to harm the clinician-patient relationship and their limited effectiveness in identifying and addressing trauma-related needs (13). Asking patients to complete an ACE questionnaire can trigger shame, embarrassment, or painful memories of past trauma, particularly if administered without adequate support. Pregnant women may worry about the impact of their experiences on their unborn child, which can increase anxiety and feelings of disempowerment (32). Furthermore, ACE scores were designed for population-level research rather than individual risk prediction, and relying on these scores in clinical decision-making can oversimplify complex experiences and inadvertently pathologise patients (33, 34). Standardised questionnaires may also fail to capture protective factors or the socio-political context of trauma, and they can further marginalise vulnerable groups, such as people with low literacy, limited English proficiency, or cognitive differences (21, 35). The EMPATHY study emphasises a woman-centred, compassionate approach that prioritises open communication and empathy, creating a safer environment for discussing previous trauma while minimising potential harms.

Clinicians face significant challenges in conducting trauma discussions. Women who have experienced trauma may exhibit heightened distress, fear, or frustration during perinatal care, which can occasionally manifest as challenging behaviours (14). These behaviours are best understood as responses to past trauma rather than intrinsic traits, underscoring the importance of trauma-informed approaches that prioritise empathy, trust-building, and safety. Hearing distressing disclosures can also evoke personal memories of trauma among care providers, highlighting the need for reflexive supervision and support (15). Without such infrastructure, trauma discussions risk re-traumatising both women and clinicians, complicating the delivery of compassionate care.

Given these challenges, there is a pressing need for a structured, woman-centred framework to guide trauma conversations in maternity care. Such a framework should account for the timing, setting, and methodology of discussions, as well as the training and support needs of clinicians (31). It must also prioritise cultural acceptability and accessibility, particularly for vulnerable populations such as ethnic minorities and socially excluded groups, who are disproportionately affected by trauma, yet less likely to access support (16).

This paper introduces the development and evaluation of the EMPATHY framework, a fresh approach to facilitating discussions about previous trauma in maternity care. Designed to address the limitations of existing practices, the framework promotes equitable, compassionate, and emotionally-centered care. By integrating insights from a systematic review of trauma discussions in maternity care, interview findings, and expert input from lived and professional experience, the framework aims to facilitate meaningful discussions, support women in distress, and ultimately interrupt the intergenerational transmission of trauma.

In developing the EMPATHY framework, we critically reflected on our pre-existing beliefs about routine trauma discussions and how these might influence the design and implementation of the framework.

The research team brought diverse perspectives to the project. JC, a midwife and doctoral student, was uncertain about the benefits of routine trauma discussions, particularly for women facing discrimination based on factors such as race, class, or immigration status. She was concerned that disclosure could lead to unnecessary safeguarding interventions or mental health referrals, potentially causing harm rather than providing support. SD, a midwife with 18 years of clinical experience and a background in maternity care research, shared similar concerns about the potential risks of routine trauma discussions. GT, a maternity care researcher with a psychology background and extensive experience in perinatal mental health research, emphasised the importance of trauma-informed conversations to enable needs-led care. AT, a maternal and neonatal care researcher, highlighted the necessity of a supportive care model to facilitate meaningful trauma discussions. MF, a critical psychology scholar with expertise in participatory work with marginalised communities, contributed insights into trauma as both a source of pain and a site of resilience, knowledge, and activism.

The framework was created as the concluding element of the EMPATHY (EMpowering Pregnant women Affected by Trauma HistorY) study, a doctoral project grounded in critical participatory action research (21).

This study was conducted within the UK National Health Service (NHS), where maternity care is publicly funded, universally accessible and primarily delivered by midwives, with escalation to obstetric or mental health services when required. Continuity of care is implemented inconsistently across regions. Although routine perinatal mental health screening is recommended in national policy, routine enquiry about previous trauma is not currently included.

The study was guided by a Research Collective, a group of 18 women which included women with trauma histories, voluntary sector practitioners, and healthcare professionals. The Research Collective first met prior to the doctoral funding application, shaping the study's design and conceptualisation from the outset. They played a central role, providing feedback on the study design, interview methods, and the development of the EMPATHY framework. Across six workshops (five online, one in-person), they offered insights on stakeholder engagement, interview guides, and dissemination strategies. Their contributions ensured the study remained inclusive, equitable, and grounded in real-world perspectives.

Phases of the study are shown in Table 1. A systematic literature review and qualitative evidence synthesis were conducted, incorporating 25 papers from five countries, which included perspectives from 1,602 women and 286 healthcare professionals and voluntary sector experts (21). The review, conducted in July 2021 and updated in April 2022, included 25 papers from five high-income countries published between 2001 and 2022. Study quality was assessed using the Critical Appraisal Skills Programme (CASP) checklist, and findings were thematically synthesised. Confidence in the evidence was evaluated using the GRADE-CERQual approach, with most findings rated as moderate or high.

Semi-structured interviews were conducted with key stakeholders, including experts by experience (n = 4), voluntary sector representatives (n = 7), and healthcare providers (n = 12). Reflexive thematic analysis was used to explore participants’ perspectives on the acceptability, feasibility, and value of routine trauma discussions in maternity care (37).

Findings from the qualitative synthesis and interviews were analysed independently and then combined with input from the Research Collective to formulate an evidence-based framework of guiding principles for discussing previous trauma during the perinatal period. The framework's development also involved a rigorous public consultation, which received 52 responses. The development and evaluation of the framework are described in this paper.

Findings from the review and interviews identified that effective and sensitive trauma discussions require more than just an appropriate tool or methodology; they also need an environment conducive to disclosure. Key elements include addressing concerns about confidentiality, providing sufficient time and context for discussions, and developing trusting relationships. The study also highlighted the need to critically examine assumptions about the benefits of trauma discussions and to assess their acceptability and utility. Practitioner-level data and interview findings revealed that trauma discussions were often incorporated into care providers’ responsibilities without adequate training, resources, or support. Consequently, it was deemed essential to develop a broad-ranging, foundational set of guiding principles outlining all aspects of effective and sensitive trauma discussions.

The framework was informed by the systematic review and qualitative synthesis of existing literature on routine trauma discussions and interviews referred to above (21, 37). In addition, the framework incorporated guidance from seminal documents on trauma-informed care including SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach (17) and NHS England's Good Practice Guide to Implementing Trauma-Informed Care in the Perinatal Period (18).

The framework was developed and evaluated in accordance with the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool, a widely accepted standard for clinical practice guidelines (19, 20). Table 2 presents the six quality domains of AGREE II and how they were addressed in the study.

In March 2023, the Research Collective participated in a workshop to review the draft framework and provide feedback via Google Forms, a secure and user-friendly platform. Eleven members evaluated the framework, assessing each recommendation for clarity, sensitivity, importance, and value. Participants also provided free-text comments on the feasibility and potential harms of the recommendations. Feedback was overwhelmingly positive, with minor revisions suggested to improve clarity and inclusivity.

Key changes based on stakeholder feedback included: -

Replacing the term “midwives” with “maternity care providers” to reflect the diverse range of professionals involved in trauma discussions.

In March 2024, the Research Collective reconvened for a final workshop to review and comment on the framework, which had been updated to incorporate feedback from the public consultation.

Consultation data were analysed using descriptive content analysis, following the three-phase approach outlined by Vaismoradi, Turunen and Bondas (22). 1.

Preparation phase: The data were read and re-read to enable the researcher to become familiar with the content.

The public consultation received 52 responses, including ten interview participants (two of whom were former Research Collective members), 28 individuals approached based on their expertise or interest, and 17 recruited via channels such as Twitter (now X) and conference presentations. While demographic information was not explicitly collected, based on participant familiarity and shared details, 49 respondents identified as female and three as male. Most participants were based in the UK, with additional representation from Cameroon (n = 1), the Netherlands (n = 1), and Japan (n = 1). Only one participant declined to be acknowledged in the published guidance.

Participants represented a range of professional backgrounds, including: -

Voluntary sector representatives from organisations such as the Birth Trauma Association (the only UK charity solely supporting those affected by traumatic birth), For Baby's Sake (supporting expectant parents experiencing domestic abuse), Birth Companions (addressing inequalities during pregnancy and early motherhood), and Birthrights (advocating for human rights in childbirth).

The final framework can be found in Appendix 1.

The framework includes a preamble emphasising the importance of collaborative development with stakeholders, including experts by experience, maternal mental health services, voluntary sector organisations, and maternity care providers. It underscores the need to prioritise women's choice, control, and agency throughout the process.

The framework is structured around six core principles: 1.

Whole system approach: Routine trauma discussions should be integrated into maternity care as part of a broader system-wide transformation, supported by policy changes, training, and resource allocation. Policies should specify who will conduct discussions, when and where they will take place, and referral pathways. Resources should also support ongoing staff supervision and reflective practice.

Full stakeholder feedback is provided in Supplementary Table 1. Of the 22 recommendations presented, 11 remained substantially unchanged, with minor adjustments for clarity. The remaining 11 were revised based on feedback, and one new recommendation was added: maternity services should develop a comprehensive written policy for routine trauma discussions, including provisions for implementation, communication, staff training, supervision, evaluation, and review.

The following section presents a summary of participants’ responses to open-ended questions about the framework, offering insights into their perceived value, feasibility, acceptability, potential impact on disadvantaged groups, and risk of harm. Each subsection includes illustrative quotes, with consultation respondents identified as R1, R2, and so on. Respondents have been identified by category (e.g., woman with lived experience, maternity care provider, maternity educator, voluntary sector expert) to provide context while maintaining confidentiality. Some respondents have overlapping roles and experiences, and may be represented in more than one category.

The majority of respondents regarded the framework as highly valuable for women who have experienced trauma. Participants described it as “absolutely invaluable” (R9, voluntary sector expert), with one noting, “there is much that is very important and valuable in these guidelines” (R8, maternity care provider) and another stating, “I feel grateful to read these very well thought through and trauma-sensitive directions to talk with our clients about difficult experiences” (R25, maternity care provider). One participant highlighted the transformative potential of the framework, suggesting that its implementation “would lead to a dramatic shift in perinatal experiences and significantly reduce retraumatisation” (R41, woman with lived experience).

The framework was seen as addressing a critical gap in current practice. While awareness of trauma-informed care is growing, respondents noted that “there is much less available about what this means or looks like in practice” (R9, voluntary sector expert). The inclusion of clear recommendations for training maternity care providers was particularly well-received. One participant even expressed interest in piloting the framework within their NHS trust, underscoring its practical relevance.

Although the framework was generally well received, some respondents identified areas for improvement. Suggestions included expanding its scope to address commissioning services and aligning it with existing safeguarding and domestic abuse guidance and training. Participants also stressed the importance of sensitive implementation and the establishment of robust support pathways, both of which have been addressed in the final version of the framework. While several respondents recommended extending the framework to include co-parents or partners affected by trauma, this falls outside the scope of the EMPATHY study.

The challenge of finding appropriate language to discuss trauma was another recurring theme. As one participant noted, “not everyone will identify as a trauma survivor,” even if they exhibit symptoms of post-traumatic stress disorder (R41, woman with lived experience). A respondent with expertise in sexual violence and maternity care described the framework as “excellent” (R36, woman with lived experience) but advocated for a stronger survivor voice in its implementation. They argued:

Respondents expressed mixed views on the feasibility of implementing the framework. Some believed it could be seamlessly integrated into existing practices, particularly given its alignment with mental health and emotional well-being assessments. However, others highlighted significant challenges, including resource constraints and the overwhelming demands on maternity services. One participant captured this sentiment succinctly: “The NHS is tired, very very noisy with “change” initiatives and nothing really changing” (R28, maternity care provider).

Despite these challenges, many respondents emphasised the importance of the framework, arguing that improving care for women who have experienced trauma is essential. As one participant stated plainly, “If they aren’t [achievable], something has to change” (R31, woman with lived experience). Others acknowledged the inherent difficulties in changing practice, noting that “there will never be a [right] time” (R9, voluntary sector expert) and that partial implementation could still yield significant benefits: “If even half the guidelines were implemented, that would make a huge difference” (R41, woman with lived experience). Additionally, several respondents stressed the importance of continuity of carer, with one describing it as “paramount” (R52, maternity care provider) to enabling women to feel safe when disclosing previous trauma.

To enhance feasibility, participants suggested aligning trauma discussions with established workstreams on domestic abuse, safeguarding, and mental health. These areas already have specialist maternity care teams, guidelines, and a presence in mandatory training, making them a natural fit for integration. Strong leadership and the appointment of implementation champions were also seen as critical, with one participant proposing that a funded coordinator role could facilitate successful implementation (R50, voluntary sector expert).

Participants generally agreed that women would find the framework acceptable if the rationale for trauma discussions was clearly communicated and handled with sensitivity. Even for those without personal trauma histories, such discussions were seen as an opportunity to “help women share all manner of concerns” (R49, maternity care provider), raise awareness, and reduce stigma. Respondents shared examples of women responding positively to trauma discussions, often expressing gratitude and understanding, even if they had not experienced trauma themselves.

Drawing parallels with routine domestic abuse enquiries, participants noted that trauma discussions are generally well-received. As one respondent observed, “Women are very supportive if they think it will help other women” (R32, maternity care provider). This suggests that, when framed appropriately, trauma discussions can foster a sense of solidarity and collective benefit.

Guideline respondents highlighted challenges in addressing trauma during booking appointments. One maternity care provider explained, “we ask lots of questions at booking that relate to trauma but have not built up a trusting relationship at that point” (R6), while another noted that “the booking appointment…may not be the place as there may not be sufficient time to respond adequately” (R21). Concerns about partner presence were also raised, with one respondent observing that “Some women can still find it difficult to talk when their partner is in another room… I don't feel that within this time a relationship can be established and a women would want to disclose. Time is something that will need to be offered” (R52, maternity care provider). In response, the framework was revised to recommend an additional antenatal appointment focused on women's well-being. This protected space allows women to disclose trauma when they feel ready and ensures adequate time for sensitive, meaningful discussion.

Most respondents believed the framework would particularly benefit women facing inequality and disadvantage, highlighting the complex interplay between trauma, inequality, and lack of support. One participant explained:

The framework was seen as having the potential to improve care for vulnerable groups, including women seeking asylum, individuals from ethnic minorities, and those facing socio-economic challenges. One participant suggested that the approach outlined in the framework “could be the most impactful way to challenge health inequalities and reach those people who do not have trust in the system” (R9, voluntary sector expert).

However, some respondents raised concerns about barriers to disclosure within certain ethnic and socio-economic groups. As one participant noted, “They are the ones least likely to disclose because of fears of consequences” (R3, maternity care provider). Addressing language barriers, ensuring cultural safety, and maintaining ongoing anti-racist efforts were identified as essential to make the framework inclusive and effective for all. Additionally, several respondents recommended using inclusive language to acknowledge individuals who are biologically female but do not identify as women.

Most participants believed the framework itself was unlikely to cause harm, with comments such as “no more so than current fragmented care” (R19, maternity care provider), “far less than the harm caused when we don’t know about previous trauma” (R37, maternity care provider), and “more harm comes from women suffering guilt and blame for experiences that were not their fault” (R5, woman with lived experience).

However, participants expressed significant concern that inadequate implementation could undermine the framework's effectiveness. One participant warned, “Of course there are harms from disclosures if they are not managed well or if there is not sufficient time/corners are cut” (R9, voluntary sector expert). Others feared the guidance could become “a tick-box exercise” (R38, voluntary sector expert) or “another document uploaded in a cloud that nobody looks at” (R42, voluntary sector expert), potentially raising unrealistic expectations for both women and care providers.

Insufficient training was identified as a key risk, potentially leading to insensitive discussions or coercion, which could worsen women's experiences and deter future disclosures. Participants also highlighted the potential for inappropriate handling or recording of trauma disclosures, which might stigmatise women. Additionally, there were concerns about burdening maternity care providers with additional responsibilities without adequate resources or support, leading to low uptake of the guidelines. Respondents stressed the importance of providing emotional support for staff to manage the challenges associated with trauma discussions effectively, with one eloquently summing up the pressures on maternity staff and the imperative of providing support to maintain a healthy workforce:

The EMPATHY framework addresses a critical gap in the literature by providing practical, evidence-based recommendations for routine trauma discussions during the perinatal period. A key strength lies in its development through a critical participatory action research approach, which ensured the active involvement of diverse stakeholders, including experts by experience, healthcare professionals, and voluntary sector representatives. Perspectives from over 1,600 women and 250 healthcare professionals were integrated through a systematic review, qualitative synthesis, interviews, and public consultation, enhancing the framework's validity and applicability.

Methodologically, the study is grounded in robust empirical evidence, combining findings from a systematic review and qualitative interviews. It is the first to integrate the perspectives of both women and maternity care professionals on routine trauma discussions, offering a comprehensive understanding of the challenges and opportunities involved. Rigorous search strategies and measures to minimise bias, such as positionality and reflexivity, further strengthen the reliability of the findings.

Finally, the framework goes beyond identifying issues to propose practical solutions, demonstrating a commitment to translating research into actionable policy and practice. These strengths collectively enhance the study's credibility and potential to advance trauma-informed care in perinatal settings.

Despite its contributions, the study has several limitations. Challenges in recruiting women with limited English proficiency may affect the broader applicability of the findings. Additionally, the lack of data on participants’ personal trauma histories raises the possibility that certain types of trauma were under- or overrepresented. Although efforts were made to encourage open discussion in Research Collective workshops, some members of the Collective may have felt inhibited in sharing their views, particularly in the presence of healthcare professionals.

The EMPATHY framework represents a critical, evidence-based resource for integrating routine trauma discussions into UK maternity care. To support its effective implementation, it should be embedded within national maternity guidance and backed by dedicated, ring fenced funding. This funding must extend beyond initial training to include delivery, ongoing supervision, and system-level coordination, particularly in light of persistent understaffing and resource constraints that threaten implementation fidelity.

Strategic investment in the framework has the potential to generate long-term savings by facilitating earlier access to mental health services and mitigating the intergenerational transmission of trauma. Equally, policies must prioritise comprehensive support structures for staff, including access to independent psychological support and clinical supervision. These supports are essential for preventing burnout and vicarious trauma and for sustaining trauma-informed care over time.

The EMPATHY framework offers clear, actionable guidance for embedding trauma discussions within maternity services. It advocates for a whole-systems approach, ensuring healthcare providers are equipped with the necessary skills, time, and confidence to approach these conversations sensitively and effectively. Central to the framework is a commitment to building trust and upholding women's autonomy and informed choice.

A key innovation is the recommendation for a dedicated antenatal appointment focused on mental health and emotional well-being, scheduled shortly after the first maternity care appointment. This allows time for trust-building, enables women to prepare for the conversation, and creates an opportunity to provide independent access to support. By demonstrating parity between physical and mental health, this appointment could address long-standing limitations in current practice and facilitate safer, more meaningful trauma discussions.

It is important to note that the framework has not yet been implemented. Several practical challenges identified in the study—including limited appointment time, variable continuity of care, insufficient supervision and referral pathways, and the need for appropriate training—may affect how the framework can be operationalised. Without adequate infrastructure, routine trauma discussions risk causing harm, potentially retraumatising women or exposing staff to ethical and emotional challenges for which they are unprepared.

Trauma-informed care must not become a symbolic gesture or a box-ticking exercise; successful implementation requires the ethical and practical readiness of the entire maternity care system. Reflecting on these implementation challenges in practice highlights the need for careful planning, resource allocation, and ongoing evaluation to ensure the framework achieves its intended impact.

The development of the EMPATHY framework highlights several critical areas for further research. First, there is an urgent need to co-design culturally safe, context-specific tools for initiating trauma discussions in the UK. Existing tools, such as the Adverse Childhood Experiences (ACE) questionnaire, have been found to be inappropriate or potentially harmful when used in maternity settings. Research should prioritise collaborative development of resources that centre women's lived experiences and uphold trauma-informed principles.

Second, future research should focus on producing and evaluating national implementation materials. These include policies, training curricula, and women-centred information resources that are co-developed with stakeholders from practice, voluntary organisations, and communities with lived experience. Additionally, the prevalence and impact of trauma among maternity staff must be examined, to inform organisational strategies that support staff well-being and improve workforce retention.

Finally, a robust framework for monitoring and evaluation is crucial to ensure that the EMPATHY framework does not inadvertently cause harm and continues to meet the needs of diverse populations. Future research should focus on tracking and improving implementation over time. Key areas for investigation include developing clear evaluation metrics to assess clinical outcomes, practitioner adherence, and the quality of trauma discussions, as well as considering patient-reported outcomes such as satisfaction with care, sense of safety, and perceived support. Additionally, staff experience, including emotional impact, confidence, and training effectiveness, should be examined, alongside feedback mechanisms that enable continuous input from both healthcare providers and women receiving care. Equity monitoring is also necessary to assess how well the framework serves minoritised and underserved groups, using disaggregated data to address disparities. A structured, participatory approach to evaluation will be essential to ensure the framework remains responsive, ethically sound, and effective in real-world practice.