In perinatal care, time is often in short supply. Appointments are brief, staff are stretched and families may feel their concerns are rushed or overlooked. For parents who have experienced trauma or loss during pregnancy or birth, this lack of time and space to be heard can add to their distress rather than ease it.
The impact of these experiences is significant. Around 1 in 4 women experience mental health difficulties during the perinatal period (NIHR, 2024), and suicide remains the leading cause of direct maternal death between six weeks and one year after birth in the UK (Felker A. et al, 2025). When trauma goes unrecognised, it can affect not only the parent’s recovery but also their relationships, their ability to bond with their baby and their wider life (Birth Trauma Association, n.d.).
There has been increasing attention on trauma-informed approaches within healthcare (see previous Mental Elf blogs here and here), which emphasise recognising the impact of trauma, avoiding re-traumatisation and supporting both patients and staff (Law C. et al, 2021). But how should these principles be applied in perinatal mental health, where the challenges and sensitivities are unique?
A systematic review by Benton and colleagues (2024) explores this issue, synthesising recommendations from international guidelines on how trauma-informed maternal mental healthcare should be delivered. Their findings highlight eight key recommendations and place time at the heart of good practice.
After trauma or loss, perinatal mental health difficulties are common, yet services often fail to account for such traumatic experiences in their approach.
Methods
This was a systematic review, conducted with input from an expert by experience, clinicians and a university librarian. The authors searched nine databases for clinical guidelines, policy documents, care standards and practice recommendations on trauma-informed perinatal care.
Records had to be published in English and explicitly provide recommendations (rather than just describe implementation). Eligibility criteria were developed using the PICO framework, which strengthens transparency. Quality was appraised using the AGREE II tool, assessing domains such as scope, rigour and clarity. A narrative synthesis was used to combine findings, with themes agreed across the research team.
Results
The authors initially identified 1,095 records across nine databases and eventually whittled this down to 11 eligible papers. These were published between 2017-2023, meaning the findings include up-to-date information. The majority (7 out of 11) came from the UK, with the others from Ireland, Canada, Australia and the US, so all from high-income settings.
Using the AGREE II quality tool, the authors found that the guidelines generally scored well for scope and purpose (i.e. they were clear about what they were trying to do) and clarity of presentation. However, most fell short on the rigour of development domain. In other words, they didn’t always explain how evidence was chosen, how guidance was reviewed or how updates would be managed. This means that the evidence base for these papers isn’t always transparent.
The results were presented in two main parts:
1. Definitions of trauma and trauma-informed care
Four of the 11 papers didn’t define trauma at all. Those that did usually described trauma in terms of: the event itself, the individual’s subjective experience, and its lasting effects. Definitions of trauma-informed care were equally varied, though many used the SAMHSA (2014) system-level, holistic framework.
The authors highlighted the lack of consensus across publications, which is important to note because different definitions can shape how services are designed and ultimately how effective they are.
2. Synthesised recommendations
The authors then agreed upon eight common recommendations for trauma-informed perinatal care:
| Recommendation | What this means in practice |
| 1. Screening for trauma | Use sensitive tools or questions to identify trauma, but only if follow-up care and support are available. Be alert to non-verbal cues. |
| 2. Access to care | Ensure timely, clear and equitable access to specialist trauma-informed care for women, families and partners. Provide signposting and debrief opportunities. |
| 3. Clear and sensitive communication | Communicate honestly and without technical language. Involve families where appropriate and ensure services communicate with one another. |
| 4. Consistency and continuity of care | Enable women to see the same professionals wherever possible, building trust and reducing the need to repeat traumatic experiences. |
| 5. Individualised care recognising diversity | Tailor care to each woman’s needs and context, including cultural, gender and historical factors. Encourage reflection on staff biases. |
| 6. Collaboration with women, families and services | Actively involve women in decisions, integrate family support (with consent) and ensures services work together seamlessly. |
| 7. Training for care providers | Provide ongoing training at all levels, ideally co-produced with experts by experience. |
| 8. Supervision and peer support for staff | Provide time for reflective supervision and peer debriefs to reduce burnout, compassion fatigue and secondary trauma among care providers. |
The importance of time
A cross-cutting theme was the importance of time:
- time for providers to build relationships,
- time for families to process and be heard, and
- time for staff to reflect and access supervision.
Time is crucial in delivering trauma-informed perinatal care; time allows for relationships to be built, families to process and staff to reflect.
Conclusions
Taken together, these findings show that while there is no single agreed definition of trauma-informed care, there is convergence on what good practice should look like. However, the weaker methodological rigour of many guidelines means we should be cautious about treating them as definitive, they’re instead best viewed as a starting point for service development and evaluation.
The authors state that the findings of this review “provide a foundation for the development, refinement and implementation of perinatal mental health services”.
Strengths and limitations
This review has a number of clear strengths. First, the authors posed a focused and clinically relevant question, looking at how trauma-informed care can be implemented in maternal mental health services in the context of perinatal trauma and loss. They searched nine comprehensive databases, updated the search to capture new material and applied a transparent set of eligibility criteria based on the PICO framework. This search strategy reduces the likelihood that key guidance was missed.
The involvement of an expert by experience alongside clinicians and researchers is another big strength. This approach increases the practical relevance and credibility of the findings, ensuring they reflect the needs of women and families who actually use perinatal services. Quality appraisal using the AGREE II instrument, carried out independently by three reviewers, is an additional strength, as this tool is widely recognised for evaluating the quality of clinical guidelines (e.g., Dijkers MP. et al, 2020).
There are some limitations to consider. As the authors acknowledged, the review only included English-language records from high-income countries, which risks selection bias. Trauma and maternal mental health are global issues, but guidance from low- and middle-income countries was excluded, which limits the generalisability of the findings. Also, the ‘rigour of development’ domain in AGREE II was weak across most included guidelines, meaning the recommendations were not always backed by transparent evidence-gathering processes.
Finally, while the review offers an excellent basis for policy and service design, it does not explore implementation outcomes such as cost-effectiveness or sustainability, which will be critical for putting these recommendations into practice.
Overall, this is a methodologically strong and timely review that provides a valuable framework for embedding trauma-informed approaches into perinatal mental health services, while also noting areas where further research and evaluation are needed.
While the review has some limitations to consider, overall it provides a methodologically strong and convincing argument for embedding trauma-informed approaches into perinatal mental health services.
Implications for practice
This review offers a clear set of eight recommendations that could meaningfully impact how trauma-informed care is delivered in perinatal services. Many of these, such as prioritising sensitive communication and supporting staff through training and supervision, may sound like good practice we should already expect, but in reality they are not consistently embedded. The findings suggest that services should make such principles routine.
For policy, the review highlights the need for system-level commitment to trauma-informed approaches. While the Women’s Health Strategy for England (2022) makes a commitment to embedding trauma-informed practice, this is often discussed primarily in the context of domestic and sexual violence. The findings of this review suggest a trauma-informed approach is also critical across perinatal services more broadly, where trauma can also arise from pregnancy complications, birth experiences or loss. We should also consider how these recommendations translate for more diverse populations, including those facing language barriers or socioeconomic disadvantage.
From a research perspective, the review opens several opportunities for further work. First, we need more implementation research. The review presents promising recommendations, but we don’t yet know how feasible they are in stretched perinatal services, or what the barriers and facilitators to embedding them might be. Secondly, the evidence base is dominated by guidance from high-income, English-speaking countries. Future research should prioritise perspectives from diverse cultural, linguistic and socioeconomic contexts, particularly given the global burden of perinatal trauma (Jenkins H. et al, 2024). Finally, there is scope for more co-produced research, with experts by experience actively shaping how trauma-informed principles are defined, implemented and evaluated.
On a personal note, I was struck by how often “time” came up. It reminded me of conversations with friends and family who described how even a single empathetic, unhurried interaction with a healthcare professional transformed their experience. Trauma-informed care doesn’t necessarily mean complex new interventions, often it’s just about creating a safe and supportive space.
Trauma-informed care doesn’t necessarily need to mean complex new interventions, but instead can just be about creating a safe and supportive space for women in the perinatal period.
Statement of interests
No conflicting interests to declare.
Links
Primary paper
Benton M, Wittkowski A, Edge D. et al (2024) Best practice recommendations for the integration of trauma-informed approaches in maternal mental health care within the context of perinatal trauma and loss: A systematic review of current guidance. Midwifery 131 103949. https://doi.org/10.1016/j.midw.2024.103949
Other references
Dijkers MP, Ward I, Annaswamy T. et al (2020) Quality of Rehabilitation Clinical Practice Guidelines: An Overview Study of AGREE II Appraisals. Archives of Physical Medicine and Rehabilitation 101(9) 1643-1655. https://doi.org/10.1016/j.apmr.2020.03.022
Felker A, Patel R, Kotnis R. et al on behalf of MBRRACE-UK (2025) Saving Lives, Improving Mothers’ Care Compiled Report – Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2021-23. Oxford: National Perinatal Epidemiology Unit, University of Oxford. https://dx.doi.org/10.5287/ora-4javr692x
Jenkins H, Daskalopoulou Z, Opondo C. et al (2024) Prevalence of perinatal post-traumatic stress disorder (PTSD) in low-income and middle-income countries: a systematic review and meta-analysis. BMJ Public Health 2(1) e000215. https://doi.org/10.1136/bmjph-2023-000215
Identifying mental illness among new and expectant mums. NIHR stories, 20 Aug 2024. https://www.nihr.ac.uk/story/identifying-mental-illness-among-new-and-expectant-mums
Law C, Wolfenden L, Sperlich M. et al (2021) A Good Practice Guide to Support Implementation of Trauma-Informed Care in the Perinatal Period. The Centre for Early Child Development, Blackpool, UK. https://www.england.nhs.uk/publication/a-good-practice-guide-to-support-implementation-of-trauma-informed-care-in-the-perinatal-period/
Substance Abuse and Mental Health Services Administration (2014) SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. https://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/samhsa_trauma_concept_paper.pdf
What is Birth Trauma? British Trauma Association website, last accessed 2 Oct 2025. https://www.birthtraumaassociation.org/what-is-birth-trauma