Design

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines¹⁶ and the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement¹⁷. A qualitative evidence synthesis approach was selected to enable in-depth exploration and integration of women’s lived experiences of TIC across diverse maternity contexts. This approach prioritizes meaning, interpretation, and experiential understanding rather than statistical aggregation. This review was registered in PROSPERO (CRD420261280530) on 7 January 2026.

Eligibility criteria

Eligibility criteria were defined a priori using the Population–Phenomenon of Interest–Context (PICo) framework, which is appropriate for qualitative evidence synthesis.

Population

Studies were eligible if they included women aged ≥18 years who were pregnant, giving birth, or in the postpartum period. Studies focusing on women with or without a disclosed history of trauma were included. Studies that exclusively examined healthcare professionals’ perspectives were excluded.

Phenomenon of interest

The phenomenon of interest was women’s experiences, perceptions or views of TIC, trauma-informed approaches or trauma-sensitive practices within maternity services. Studies addressing experiences of safety, autonomy, trust, communication, consent, or re-traumatization in maternity care were considered relevant, even if TIC was not explicitly labeled as such.

Context

Studies conducted in midwifery-led or maternity care settings, including antenatal, intrapartum and postnatal services, were eligible. No restrictions were placed on geographical location or healthcare system.

Types of studies

Qualitative primary research studies employing methods such as interviews, focus groups, ethnography, or qualitative components of mixed-methods studies were included, provided that qualitative findings were reported separately. Quantitative-only studies, editorials, commentaries, protocols, dissertations, and conference abstracts were excluded.

Language and publication status

Only studies published in English in peer-reviewed journals were included. No restrictions were applied based on year of publication.

Search strategy

A comprehensive and systematic search strategy was developed in consultation with established guidance for qualitative systematic reviews. Electronic database searches were conducted in PubMed, Scopus, Web of Science, CINAHL, and PsycINFO on 15 January 2026, which represented the final search date. Given the evolving conceptualization of TIC within maternity services, no temporal limits were applied during the search to avoid the exclusion of relevant foundational qualitative studies. The full search algorithms used in each database are presented in Supplementary file Table 1.

Study selection

All records were imported into reference management software, and duplicates were removed prior to screening. Titles and abstracts were screened against the eligibility criteria, followed by full-text assessment of potentially relevant articles. Two reviewers independently screened titles and abstracts against the eligibility criteria. Full-text articles were subsequently assessed for inclusion. Any disagreements were resolved through discussion and, where necessary, consultation with a third reviewer.

Data extraction

Data were extracted independently by two reviewers using a predefined data extraction approach developed for the purposes of this review. Extracted information included author, year of publication, country, participant characteristics, trauma context, data collection methods, analytical approach, and key qualitative findings relevant to women’s experiences of trauma-informed care. Following independent extraction, the reviewers compared the extracted data, and any discrepancies were resolved through discussion and consensus.

Quality appraisal

The methodological quality of included studies was appraised using the Critical Appraisal Skills Program (CASP) qualitative checklist¹⁸. A qualitative methodology was appropriate given the focus on women’s lived experiences and perceptions of TIC within maternity services. Quality appraisal was conducted to enhance transparency and interpretive depth; no studies were excluded based on methodological quality, and no numerical scoring was applied. The CASP tool comprises ten items assessing clarity of research aims, appropriateness of qualitative methodology, recruitment strategy, data collection, researcher–participant relationship (reflexivity), ethical considerations, rigor of data analysis, clarity of findings, and overall value of the research.

Quality appraisal was undertaken to enhance transparency and interpretive depth rather than to exclude studies based on quality alone. All included studies were considered to provide sufficiently rich qualitative data to contribute meaningfully to the synthesis. Variations in methodological reporting were noted and considered during the interpretation of findings. In addition, recruitment strategies were generally appropriate to the study aims, enabling inclusion of women with relevant lived experiences of maternity care.

Data synthesis

A thematic synthesis approach, as described by Thomas and Harden¹⁹, was used to integrate findings across the included studies. This method was selected to allow for systematic comparison and interpretation of qualitative evidence derived from diverse maternity care contexts while preserving women’s lived experiences.

Synthesis proceeded through three iterative stages: 1) line-by-line coding of extracted findings relevant to women’s experiences of TIC; 2) development of descriptive themes by grouping conceptually similar codes across studies; and 3) generation of analytical themes that captured higher order patterns and shared meanings across the dataset. Only data derived directly from women’s accounts were coded and synthesized. Where studies included additional participant groups (e.g. healthcare professionals), these data were used solely to contextualize women’s experiences and were not included in the analytic synthesis. Throughout the process, attention was paid to how women described safety, trust, autonomy, communication, validation, and experiences of re-traumatization or support within maternity care. Two reviewers independently participated in the coding and development of themes. Discrepancies in coding or interpretation were discussed and resolved through consensus among the research team. The synthesis aimed to move beyond individual study findings to produce an integrated, interpretive understanding of women’s experiences of TIC in midwifery and maternity services.

Study characteristics

A total of 162 records were identified through database searching, including 46 from PubMed, 12 from Scopus, 52 from EBSCO, 30 from Web of Science, and 22 from PsycINFO. After completion of the screening and eligibility assessment process, 15 studies met the inclusion criteria and were included in the qualitative synthesis. The study selection process is illustrated in the PRISMA flow diagram (Figure 1).

Figure 1

Flow chart of the included studies

The studies were published between 2017 and 2025 and were conducted across a range of high-income countries, including the United Kingdom, the United States, Canada, Ireland, and Australia. All included studies employed qualitative or mixed-methods designs with a clearly identifiable qualitative component capturing women’s experiences of maternity or midwifery care in the context of trauma. The populations studied consisted exclusively of adult women, including pregnant women, postpartum women, and women reflecting retrospectively on their maternity care experiences. Trauma contexts varied across studies and are summarized in Table 1. Several studies focused on women with multiple or cumulative trauma exposures^20-24. Several studies focused on women with multiple or cumulative trauma exposures^25,26.

Data collection methods predominantly involved in-depth semi-structured interviews, although some studies also used focus groups, arts-based approaches, or open-ended qualitative survey responses. Analytical approaches included thematic analysis, reflexive thematic analysis, qualitative content analysis, and interpretative phenomenological analysis. Where studies included additional participant groups (e.g. healthcare professionals), only findings derived from women’s accounts were extracted and synthesized, with professional perspectives used solely to contextualize women’s experiences. Across studies, TIC was not always explicitly labeled as such; however, women consistently described care experiences in relation to core trauma-informed principles, including emotional and physical safety, trust, respectful communication, autonomy, informed consent, validation, and avoidance of re-traumatization. These shared experiential dimensions formed the basis for the subsequent thematic synthesis^{15,20-27,29,31-33}. Table 2 provides an overview of the characteristics, trauma contexts, and reported outcomes of the included studies.

Methodological quality assessment

The methodological quality of the included studies was assessed using the CASP Qualitative Checklist. Overall, the studies demonstrated satisfactory methodological quality. Most studies clearly stated their aims, employed appropriate qualitative methodologies and research designs, and provided adequate descriptions of recruitment, data collection, and findings. Ethical considerations were generally well addressed. The criterion least consistently reported was researcher reflexivity and consideration of the researcher–participant relationship. Variability was also observed in the depth of reporting of analytical procedures. Nevertheless, all studies were considered sufficiently robust to contribute meaningful qualitative evidence to the synthesis. A summary of the methodological quality assessment is presented in Supplementary file Table 2.

Thematic synthesis

The thematic synthesis generated four overarching analytical themes that captured shared patterns in women’s experiences of TIC across maternity and midwifery services. These themes reflect how women described safety, communication, power, and emotional validation within care encounters, particularly in the context of prior trauma.

Theme 1: Creating safety and preventing re-traumatization

This theme was identified across seven studies^{15,21,24,25,27,29,31} and reflected women’s experiences of physical and emotional safety within maternity care. Across studies, women consistently emphasized the importance of physical and emotional safety within maternity care^21,25,29,31. Trauma-informed care was experienced positively when healthcare environments, clinical interactions, and procedures minimized the risk of re-traumatization. Women described feeling unsafe when care was rushed, invasive, or poorly explained, particularly during intimate examinations or labor interventions. Women reported feeling unsafe when care was rushed, invasive, or inadequately explained, especially in the context of previous sexual abuse, intimate partner violence, or cumulative trauma histories^15,27,31. Conversely, practices such as respectful pacing, attention to personal boundaries, and provider awareness of trauma histories contributed to feelings of security and trust. For many women, perceived safety was a prerequisite for engaging with maternity services and maintaining continuity of care²⁴. Women frequently described the importance of feeling emotionally and physically safe within maternity care encounters. A supportive and trusting relationship with care providers was often perceived as essential for mitigating distress and facilitating engagement with care. As one participant described²⁵:

Theme 3: Validation, trust, and emotional attunement

This theme was identified across seven studies^{15,20,25-27,29,31} and reflected women’s experiences of emotional validation, trust, and attuned relationships with maternity care providers. Across studies, emotional validation and attuned care emerged as central relational outcomes, closely associated with trust in care providers and women’s perceived emotional safety within maternity services. For example, women highlighted the significance of being believed, heard, and emotionally validated by maternity care providers. TIC was characterized by providers’ ability to acknowledge women’s fears, prior experiences, and emotional responses without judgment or dismissal^29,31. Trust developed when women perceived providers as empathetic, attentive, and responsive to emotional cues^25,26. Conversely, dismissive or minimizing responses undermined trust and intensified feelings of vulnerability^20,27. For many women, emotional attunement and validation were as important as clinical competence in shaping their overall care experience¹⁵. Women frequently described the importance of emotional validation and sensitive responses from care providers when discussing difficult birth experiences or trauma histories. Emotional attunement and acknowledgment of women’s experiences were perceived as essential for building trust within maternity care relationships. As one participant described²⁹:

Theme 4: Power, control, and women’s agency in care

This theme was identified across seven studies^{20-22,25-27,32} and reflected women’s experiences of power, control, and agency within maternity care encounters. Women’s experiences indicate that agency and shared decision-making constitute critical experiential outcomes of trauma-informed maternity care, influencing women’s engagement, confidence, and sense of control across the perinatal continuum. Experiences of TIC were closely linked to women’s perceptions of power and control within maternity services. Women described positive care encounters when they felt involved in decision-making, respected as knowledgeable about their own bodies, and supported to exercise choice^21,25,26. In contrast, hierarchical care structures and authoritative decision-making practices often reinforced feelings of disempowerment, particularly for women with prior experiences of trauma or marginalization^20,27,32. Trauma-informed care was therefore experienced as care that actively redistributed power, enabling women to reclaim agency within maternity and midwifery contexts²². Women frequently described experiences of diminished control and disempowerment when maternity care deviated significantly from their expectations or preferences. When decision-making processes were perceived as dominated by clinical authority or institutional constraints, women reported feelings of loss of agency during childbirth. As one participant described²² :

Implications for future practice

The findings of this review have important implications for the implementation of TIC within maternity services. Given their sustained and often continuous contact with women across pregnancy, childbirth, and the postpartum period, midwives are particularly well positioned to operationalize trauma-informed principles in everyday maternity care^8,11. Practices such as clear and respectful communication, ongoing consent, emotional attunement, and support for women’s agency align closely with the core competencies and relational orientation of midwifery practice. When enacted consistently, these practices are likely to support key care-related outcomes identified in this review, including psychological safety, trust in care providers, women’s sense of autonomy, and sustained engagement with maternity services. Future implementation efforts may benefit from strengthening midwifery-led roles within multidisciplinary maternity teams, particularly in relation to continuity of care, shared decision-making, and advocacy for women’s preferences. Embedding trauma-informed principles within midwifery education, clinical supervision, and reflective practice frameworks may support more consistent and sustainable implementation across care settings. At a service level, implementing trauma-informed principles requires organizational conditions that enable relational care, including adequate time, continuity models, and supportive leadership, rather than reliance on individual clinician skills alone. Taken together, the findings suggest that women perceived trauma-informed maternity care as supporting psychological safety, trust, autonomy, and emotional validation. These experiences appeared to be shaped by both interpersonal relationships and organizational contexts and may be relevant to the development of more responsive maternity care services.

Future research should further explore how trauma-informed principles can be implemented consistently across different maternity care settings and healthcare systems. In particular, longitudinal and implementation-focused studies are needed to examine how trauma-informed approaches influence maternal wellbeing, service engagement, and early relational outcomes such as mother–infant bonding. Additional research in diverse cultural and healthcare contexts, including low- and middle-income countries, would also contribute to a more comprehensive understanding of trauma-informed maternity care and its potential benefits for women and families.

Strengths and limitations

A key strength of this qualitative systematic review lies in its focus on women’s lived experiences of TIC across the perinatal continuum. By synthesizing qualitative evidence from diverse maternity settings and trauma contexts, the review provides a nuanced understanding of how trauma-informed principles are perceived and enacted in everyday maternity care. The use of systematic and transparent methods, guided by PRISMA and ENTREQ frameworks, enhances the rigor and credibility of the synthesis, while thematic analysis enables the identification of higher order themes relevant across different care models and health systems. By foregrounding women’s experiential accounts, the review also highlights outcome-relevant domains – such as psychological safety, trust, autonomy, and engagement with care – that are often underrepresented in outcome-focused maternity research.

Several limitations should be acknowledged. The review was restricted to studies published in English, which may introduce language bias and limit the inclusion of potentially relevant studies published in other languages. In addition, TIC was not consistently defined across studies, requiring interpretive synthesis of experiences aligned with trauma-informed principles. However, this interpretive approach is consistent with qualitative evidence synthesis methodologies and was applied systematically to enhance analytical transparency. As with all qualitative syntheses, the findings are shaped by the quality and reporting depth of the included studies. Despite these limitations, the review offers robust insights into relational and experiential processes that inform trauma-informed maternity care, with clear relevance for future practice, education, and service development. In addition, the review included only peer-reviewed journal articles and did not incorporate grey literature, which may introduce publication bias. The included studies also represented diverse trauma contexts (e.g. childhood abuse, intimate partner violence, migration-related trauma, and birth trauma), and this heterogeneity may limit the extent to which general conclusions can be drawn. Although methodological quality was assessed using the CASP checklist, no studies were excluded based on quality, meaning that some included studies were small-scale qualitative investigations. Finally, most studies relied on women’s self-reported experiences, which may be influenced by recall bias or social desirability bias.