Do antenatal preparation and obstetric complications and procedures interact to affect birth experience and postnatal mental health?

BACKGROUND: Antenatal preparation is commonly offered to women in pregnancy in the United Kingdom, but the content is highly variable, with some programmes orientated towards 'normal birth', whilst others may incorporate information about complications and procedures (broader focus). However, the impact of this variability on birth experience has not been explored. We examined the relationship between the content of antenatal preparation received and birth experience, taking into account obstetric complications and procedures. As birth experience can have a profound impact on a mother's postnatal well-being, we also investigated associations with mothers' postnatal mood and anxiety. METHODS: N = 253 first-time mothers completed a cross-sectional survey measuring demographic and clinical factors, antenatal preparation content (categorised as normality-focused or broader-focused), obstetric complications and procedures experienced, birth experience (measured using three separate indices; the Childbirth Experience Questionnaire, emotional experiences, and presence/absence of birth trauma), postnatal depression and anxiety, and qualitative information on how the COVID-19 pandemic had affected birth experience. RESULTS: Regarding birth experience, receiving more broader-focused preparation was associated with a more positive birth experience irrespective of complications/procedures experienced, while receiving only normality-focused preparation was beneficial in the context of fewer complications/procedures. Regarding birth trauma, receiving more broader-focused preparation was associated with lower likelihood of reporting birth as traumatic only in the context of more complications/procedures. Degree of normality-focused preparation was unrelated to experience of birth trauma. Lastly, while more complications/procedures were associated with greater anxiety and low mood, only greater normality-focused preparation was linked with better postnatal mental health. CONCLUSIONS: Antenatal preparation including both normality- and broader-focused information is positively related to women's birth experience. While normality-focused preparation seems most beneficial if fewer complications/procedures are experienced, broader-focused preparation may be most beneficial in the context of a greater number of complications/procedures. As complications/procedures are often unpredictable, offering broader-focused preparation routinely is likely to benefit women's birth experience. This antenatal preparation should be freely available and easily accessible.

A new scale for fear of childbirth: the Fear of Childbirth Questionnaire (FCQ).

OBJECTIVE: To create a clear and acceptable measure of fear of childbirth with satisfactory content validity for use with English-speaking women in the UK. BACKGROUND: Fear of childbirth (FOC) can have a significant impact on a woman's view of her pregnancy, birth and her recovery post birth. Early identification is paramount to ensure that women's needs are recognised so that appropriately tailored care can be provided in pregnancy. Availability of reliable and valid measures to assess FOC in an English-speaking population are sparse, mainly due to issues with definitions of FOC or cultural sensitivity after translation. Recent research from phase one of the Fear of Childbirth study (FOCUS), has established key elements for FOC in an English-speaking UK population, and allows for a culturally sensitive measure of FOC to be developed. The aim was to ensure inclusion of all ten FOC elements and to attend to guidance from women in phase two of the FOCUS study about what would ensure clarity and acceptability. METHOD: A multidisciplinary team developed items in accordance with FOCUS. The measure was then piloted with one reviewer and further refined by the team of perinatal researchers. RESULTS: The FCQ is a new 20-item fear of childbirth questionnaire, which has been developed and is grounded in fears reported by women in the UK. CONCLUSION: A new tool to measure FOC in an English-speaking UK population with good content validity has undergone a preliminary phase of development and now needs testing for reliability and other forms of validity.

Facilitating Perinatal Access to Resources and Support (PeARS): a feasibility study with external pilot of a novel intervention.

BACKGROUND: Up to 50% of women in areas of high socio-economic deprivation are at risk of developing depressive symptoms in pregnancy. Feeling well supported, can facilitate good mental health perinatally. A brief, innovative intervention to facilitate access to support and resources was developed and tested. This included one antenatal and one postnatal session, each with three evidence-based components: i) support from a non-professional peer to enable a woman to identify her needs; ii) information about local community services and signposting; and iii) development of a personalised If-Then plan to access that support. The aims were to evaluate the intervention and research methods for feasibility and acceptability for perinatal women, maternity care providers and peers, and provide preliminary effectiveness indications. METHODS: Pregnant women living in an area of high deprivation were recruited from community-based antenatal clinics and randomised to intervention or control condition (a booklet about local resources). Outcome measures included women's use of community services by 34 + weeks gestation and 6 months postnatally; mental health and wellbeing measures, and plan implementation. Interviews and focus groups were conducted with women participants, providers, and peers. Data were analysed using framework analysis. Recruitment and retention of peers and participants, intervention fidelity, and acceptability of outcome measures were recorded. RESULTS: Peer facilitators could be recruited, trained, retained and provide the intervention with fidelity. One hundred twenty six women were recruited and randomised, 85% lived in the 1% most deprived UK areas. Recruitment constituted 39% of those eligible, improving to 54% after midwifery liaison. Sixty five percent were retained at 6 months postnatally. Women welcomed the intervention, and found it helpful to plan access to community services. Providers strongly supported the intervention philosophy and integrated this easily into services. The study was not powered to detect significant group differences but there were positive trends in community service use, particularly postnatally. No differences were evident in mental health and wellbeing. CONCLUSIONS: This intervention was well received and easily integrated into existing services. Women living in highly deprived areas could be recruited, randomised and retained. Measures were acceptable. Peer facilitators were successfully trained and retained. Full effectiveness studies are warranted.

Do stress and anxiety in early pregnancy affect the progress of labor: Evidence from the Wirral Child Health and Development Study.

INTRODUCTION: Despite widespread belief that anxiety causes longer labor, evidence of association is inconsistent. Data gathered as part of a prospective epidemiological longitudinal study were used to investigate associations between antenatal anxiety and pregnancy-specific stress, and labor progression was assessed by duration and use of augmentation. MATERIAL AND METHODS: Pregnant primiparous women completed measures for anxiety and pregnancy-specific stress at 20 weeks' gestation (n = 1145). Birth outcome data were extracted from medical records. Regression analyses and a path analysis assessed associations between antenatal anxiety and pregnancy-specific stress, and indices of labor progression (labor duration and augmentation). RESULTS: Anxiety/pregnancy-specific stress were not directly associated with duration of stage 1 labor (HIGH/LOW anxiety: mean difference = 13.94 minutes, SD = 20.66, 95% CI -26.60 to 54.49, P < .50)/(HIGH/LOW pregnancy-specific stress: mean difference = 12.05 minutes, SD = 16.09, 95% CI -19.52 to 43.63, P < .45). However, anxiety/pregnancy-specific stress were associated with epidural use (HIGH/LOW anxiety: 39% vs 31%, P < .042; HIGH/LOW pregnancy-specific stress: 38% vs 29%, P < .001), which was itself associated with longer labor (mean difference: 158.79 minutes, SD = 16.76, 95% CI 125.89-191.68, P < .001). Anxiety and pregnancy-specific stress were associated with increased likelihood of augmentation but these associations were nonsignificant after accounting for epidural, which was itself highly associated with augmentation. However, path analysis indicated an indirect effect linking pregnancy-specific stress, but not general anxiety, to labor duration and augmentation: elevated pregnancy-specific stress led to greater use of epidural, which was linked to both increased rates of augmentation, and increased labor duration. CONCLUSIONS: Contrary to general belief, general anxiety and specific pregnancy stress were not directly linked to longer duration of stage one labor. However specific pregnancy stress was associated with epidural use, which in turn was significantly associated with risk of augmentation, and longer stage one labor. Identification of pregnancy-specific stress could help to identify women for whom psychological interventions could improve birth experience.

Personality factors and vulnerability to post-traumatic stress responses after childbirth.

OBJECTIVES: To investigate whether levels of perfectionism, organization, and intolerance of uncertainty predispose women to more negative birth experiences and post-partum post-traumatic stress symptoms (PTSS). Birth experience was also examined as a potential moderator of the relationship between levels of the personality traits and post-natal PTSS. DESIGN: Prospective survey. METHOD: First-time expectant mothers (N = 10,000) were contacted via Emma's Diary during the perinatal period. At 32-42 weeks' gestation, participants completed measures examining the three personality traits and prenatal mood. At 6-12 weeks' post-partum, instruments assessing childbirth experience, birth trauma, PTSS, and post-natal mood were completed. Data from 418 women were analysed. RESULTS: Higher perfectionism and intolerance of uncertainty were associated with more negative birth appraisals and PTSS. Organization was unrelated to birth experience or PTSS. In a regression, higher intolerance of uncertainty and perfectionism statistically predicted more negative birth appraisals. Only perfectionism predicted PTSS. Birth experience did not moderate the relationship between perfectionism or intolerance of uncertainty and PTSS. CONCLUSIONS: Personality risk factors for negative birth experiences and post-natal PTSS are identifiable prenatally. Maternity care providers could educate women about the unique roles of high perfectionism and intolerance of uncertainty during antenatal birth preparation. PRACTITIONER POINTS: Women who expect themselves to be more perfect or who find it more difficult to cope with uncertainty had more negative experiences of childbirth. Women with higher levels of perfectionism were more likely to experience more symptoms of post-traumatic stress during the early post-natal period. Being more perfectionistic continued to have a more negative effect on women's well-being after birth, regardless of whether they had a positive or negative experience of birth. Integrating these findings into antenatal discussion around birth preferences would increase women's awareness of predisposing and obstetric risk factors that partially explain experiences of unsatisfactory births and post-partum post-traumatic stress.

Cost-effectiveness of PoNDER health visitor training for mothers at lower risk of depression: findings on prevention of postnatal depression from a cluster-randomised controlled trial.

BACKGROUND: There is evidence for the cost-effectiveness of health visitor (HV) training to assess postnatal depression (PND) and deliver psychological approaches to women at risk of depression. Whether this approach is cost-effective for lower-risk women is unknown. There is a need to know the cost of HV-delivered universal provision, and how much it might cost to improve health-related quality of life for postnatal women. A sub-study of a cluster-randomised controlled trial in the former Trent region (England) previously investigated the effectiveness of PoNDER HV training in mothers at lower risk of PND. We conducted a parallel cost-effectiveness analysis at 6-months postnatal for all mothers with lower-risk status attributed to an Edinburgh Postnatal Depression Scale (EPDS) score <12 at 6-weeks postnatal. METHODS: Intervention HVs were trained in assessment and cognitive behavioural or person-centred psychological support techniques to prevent depression. Outcomes examined: quality-adjusted life-year (QALY) gains over the period between 6 weeks and 6 months derived from SF-6D (from SF-36); risk-of-depression at 6 months (dichotomising 6-month EPDS scores into lower risk (<12) and at-risk (⩾12). RESULTS: In lower-risk women, 1474 intervention (63 clusters) and 767 control participants (37 clusters) had valid 6-week and 6-month EPDS scores. Costs and outcomes data were available for 1459 participants. 6-month adjusted costs were £82 lower in intervention than control groups, with 0.002 additional QALY gained. The probability of cost-effectiveness at £20 000 was very high (99%). CONCLUSIONS: PoNDER HV training was highly cost-effective in preventing symptoms of PND in a population of lower-risk women and cost-reducing over 6 months.

Preserving fertility in women with cancer (PreFer): Decision-making and patient-reported outcomes in women offered egg and embryo freezing prior to cancer treatment.

OBJECTIVE: Women of childbearing age with new cancer diagnoses have to make rapid decisions about fertility preservation (FP) before starting cancer treatment (CT). The aim of the PreFer study was to explore this FP decision-making process and its impact on patient-reported outcomes (PROMs) and health-related quality of life (HRQoL). METHODS: A prospective, mixed-methods design was used (questionnaires, in-depth interviews). Interviews were analysed using thematic analysis. Fifty-eight women with new cancer diagnoses were recruited. Comparisons were made between women who declined FP referral in oncology (Group1) and women who chose referral (Group2). Group 2 was further split into those who had some FP (2A) and those who did not (2B). Questionnaires and PROMs were administered prior to and after the fertility consultation, before the start of CT and 3 months post CT. Interviews were conducted with one participant from Group 2. RESULTS: HRQoL was negatively affected, particularly depression. Women's lack of understanding about the relationship between CT and fertility were evident. Five themes emerged from the interviews as barriers and facilitators to the FP decision-making process. CONCLUSION: The results indicate that better information and support resources aimed at women to support their decision making are needed, such as patient decision-aids. Women from Group 1 were found to suffer significantly worse depression compared with the general UK population, highlighting the need for psychological support in the FP care-pathway and for research exploring the contributions of depression and hopelessness to the decision-making process.

Posttraumatic stress symptomatology following exposure to perceived traumatic perinatal events within the midwifery profession: The impact of trait emotional intelligence.

AIMS: To explore factors associated with, and predictors of, posttraumatic stress symptoms in midwives. To explore factors associated with, and potential moderating effects of, trait emotional intelligence. Secondary analysis explored predictors of resilience. BACKGROUND: Midwives may experience vicarious trauma responses due to exposure to certain perinatal events in their professional lives. This may have adverse psychological outcomes for midwives, and women and children in their care. DESIGN: A cross-sectional, online and paper survey of midwives in the United Kingdom was conducted. METHODS: Between February and October 2016, 113 midwives who met inclusion criteria provided demographic information, and completed scales measuring posttraumatic stress symptoms, trait emotional intelligence, empathy, resilience, social support, and attitudes towards emotional expression. RESULTS: Higher resilience and trait emotional intelligence scores were associated with reduced posttraumatic stress symptoms. Higher empathy, perceived social support, and resilience were associated with higher trait emotional intelligence. Lower resilience significantly predicted posttraumatic stress symptoms. Trait emotional intelligence did not moderate relationships between resilience and posttraumatic stress symptoms, but may protect against posttraumatic stress symptoms in midwives with higher empathy. Higher trait emotional intelligence, and lower empathy and need for support, significantly predicted resilience. Notably, when trait emotional intelligence was higher, the negative relationship between empathy and resilience was reduced. CONCLUSION: Approximately one-fifth of midwives were experiencing posttraumatic stress symptoms at clinically significant levels. Trait emotional intelligence may protect against posttraumatic stress symptoms by supporting resilience, while enabling midwives to remain empathic. The negative correlation between resilience and empathy needs careful consideration by policy makers.

A systematic mixed studies review of women's experiences of perineal trauma sustained during childbirth.

AIM: To explore the quantitative/qualitative literature on women's experiences of perineal trauma sustained during childbirth and the impact it may have on psychological/emotional wellbeing BACKGROUND: Obstetric complications during childbirth can be a risk factor for postpartum psychological distress. Perineal trauma is one of the most frequent obstetric complications and it is important to understand any impact on psychological/emotional wellbeing. DESIGN: A convergent qualitative design using a hybrid deductive-inductive thematic synthesis approach to data transformation was used. DATA SOURCES: Web of knowledge, CINAHL, MEDLINE, AMED, PsyArticles, PsycInfo until May 2017. REVIEW METHODS: Stage 1: transforming findings from the qualitative, quantitative and mixed methods studies into themes using thematic synthesis. Stage 2: integrating themes from the quantitative studies into those derived from the qualitative studies RESULTS: Records (N=2152) found of which 11 qualitative 22 quantitative and 1 mixed methods were included in this review. Five themes were derived from thematic synthesis of qualitative studies 'The mystery of perineal trauma', 'The misery of perineal suturing', 'The postnatal perineum', 'Normalisation and feeling dismissed' and 'Adjusting to a new normal - Coping and compromise' and five themes identified from the quantitative studies, experience of birth (N=4), Sexual functioning (N=12), Social functioning (N=2), Psychological health (N=8) and Quality of Life (N=5). CONCLUSION: Perineal trauma can have a negative impact on psychological/emotional wellbeing, however the literature is conflicted and in need of clarification. Future research should clearly describe the perineal status of the women in the sample, use validated measures and consider the timing of such measures. This article is protected by copyright. All rights reserved.

Examining the content and moderators of women's fears for giving birth: A meta-synthesis.

AIMS AND OBJECTIVES: This meta-synthesis aimed to identify key elements contributing to FOC derived from women's own reports. BACKGROUND: Fear of childbirth (FOC) encompasses fear or anxiety about giving birth, which can resemble a phobic response. FOC holds implications for women's antenatal and postnatal well-being, and decisions made about the birth but a clear definition of the construct does not exist. METHOD: A meta-synthesis was conducted by searching databases (Web of Knowledge, CINAHL, EBSCO, MEDLINE, PsychInfo and PsychArticles) for qualitative studies describing women's perspectives with respect to fear, anxiety, concerns, phobia or stress about birth. A total of 25 papers, reporting findings from 24 studies, fulfilled eligibility criteria and were included in the synthesis. RESULTS: Six key elements of FOC were identified; fears of the unknown, potential for injury, pain, capacity to give birth, losing control and adequacy of support from care providers. A single overarching theme linking all elements was "the unpredictability of childbirth." Three moderators of FOC were also identified; awareness of negative birthing experiences, information received about birth and support received from care providers. CONCLUSIONS: Findings highlight the role of uncertainty in the birthing process as an overarching theme underpinning women's fears. Enhancing tolerance of uncertainty may be a way to reduce women's FOC. RELEVANCE TO CLINICAL PRACTICE: Identification of the elements and moderators of FOC provide an insight into the potential mechanisms that contribute to women's fears, which can be used to inform methods of identifying women with FOC or a basis upon which to base supportive strategies to reduce women's fears for giving birth.

"Nothing's actually happened to me.": the experiences of fathers who found childbirth traumatic.

BACKGROUND: Given the limited research into men's experiences of being present at childbirth this study explored the experiences of fathers who found childbirth traumatic. The aim of the research was to investigate how men coped with these experiences; the impact on their lives; and their views on what may have helped to reduce distress. METHODS: Participants were recruited via websites relating to birth trauma and parenthood. A consent and screening questionnaire was used to ensure that participants met the inclusion criteria of: being resident in the UK; being 16 years or older; having been present at the birth and answering yes to the question "At some point during the childbirth I experienced feelings of intense fear, helplessness or horror". Semi-structured telephone interviews were completed with 11 fathers who reported finding childbirth traumatic. Participants also completed the Impact of Event Scale as a measure of trauma symptoms. Template Analysis was used to analyse the interview data. RESULTS: Childbirth was experienced as "a rollercoaster of emotion" because of the speed and unexpectedness of events. Men described fears of death, mirroring their partner's distress; trying 'to keep it together' and helplessly watching a catastrophe unfold. Fathers felt themselves abandoned by staff with a lack of information. Men were subsequently distressed and preoccupied with the birth events but tended to feel that their responses were unjustified and tried to cope through avoidance. Men described the need for support but reluctance to receive it. CONCLUSIONS: Fathers may experience extreme distress as a result of childbirth which is exacerbated by aspects of current maternity care. Maternity services need to be aware of the potential impacts of fathers' attendance at childbirth and attend to fathers', as well as mothers', emotional responses.

'They've invited me into their world': a focus group with clinicians delivering a behaviour change intervention in a UK contraceptive service.

Although teenage conceptions rates in the United Kingdom (UK) have seen a downward trend recently, it remains imperative that contraceptive services for young people continue to improve. To ensure that evidence-based interventions are sustained in clinical practice, it is useful to assess the experiences of those delivering them. This study explores the experiences of sexual health clinicians who were trained to deliver a one-to-one behaviour change intervention aiming to improve contraceptive use in young women. The intervention was set in a UK NHS contraceptive and sexual health service and involved clinicians' facilitating (within one-to-one consultations) the formation of implementation intentions (or 'if-then' plans) that specified when, where and how young women would use contraception. A focus group was conducted with seven clinicians who had delivered the intervention. A thematic analysis of the focus group revealed three overall themes: (1) How the intervention worked in practice; (2) barriers and benefits to delivering the intervention; and (3) positive changes to individual consultation style and wider 'best practice' within the clinic. Our findings show that, with support, clinical staff would be in favour of incorporating if-then planning as a strategy to help promote contraceptive adherence in young women.

Maternal-fetal medicine specialists' experiences of conducting feticide as part of termination of pregnancy: a qualitative study.

OBJECTIVES: This study aimed to explore maternal-fetal medicine specialists' experiences of conducting feticide in late termination of pregnancy. METHODS: Participants were recruited via email. Purposeful sampling resulted in ten maternal-fetal specialists. Semistructured interviews were used to examine their experiences of conducting feticide. Interviews occurred across four English National Health Service hospitals. Interpretative phenomenological analysis was used. RESULTS: An ongoing doctor-patient relationship when conducting feticide facilitated participants' self-image as clinicians rather than technicians. Coping involved rationalisation, with feticide viewed as 'part of the job'. Supportive team relationships helped keep emotional expression within control. Participants were not distressed if they felt, through relationship-based decision-making, that the feticide aligned with their values and legal interpretation. To avoid negative judgements, they disclosed selectively, only telling trusted individuals that they conducted feticides. CONCLUSIONS: Participants experienced conducting feticides as difficult but necessary, eliciting pride from the skills involved. Some noted management of personal distress. Optimal conditions were involvement in the process from the initial decision-making and team support. Providing feticides was deemed as potentially stigmatising, with selective disclosure employed. Training in managing feticides and guidance on providing optimal service conditions may decrease selectivity of disclosures and enhance staff well-being and the quality of feticide provisions. © 2015 John Wiley & Sons, Ltd.

Relationships between paranoid thinking, self-esteem and the menstrual cycle.

This study aimed to investigate whether paranoid experiences and levels of self-esteem fluctuate over the menstrual cycle and whether levels of self-esteem are lower when perceived persecution is felt to be deserved. Measures of anxiety, depression, persecution, deservedness and self-esteem were completed on-line by 278 women over their menstrual cycle. Responses were compared at the paramenstrual (3 days before and after menses onset) and mid-cycle phase. At the paramenstrual phase persecution, negative self-esteem, anxiety and depression were higher and positive self-esteem was lower than at mid-cycle. A greater proportion of women experienced persecution as deserved at the paramenstrual phase. This was associated with higher depression and negative self-esteem scores. Increased levels of deservedness significantly strengthened the relationship between persecution and negative, but not positive, self-esteem. These findings suggest that the paramenstrual phase is a time of vulnerability to increased paranoid experiences, an increased likelihood that feelings of persecution will feel deserved and lowered self-esteem. The findings support the view that interpersonal sensitivities may be key to menstrual cycle symptoms and have an impact on relationships. Further, the study illustrated that ideas developed for psychosis could make a valuable contribution to understanding and managing this aspect of menstruation-related distress.

Enhancing relationship functioning during the transition to parenthood: a cluster-randomised controlled trial.

This randomised controlled trial examined the feasibility of enhancing relationship functioning in couples during the transition to parenthood through the development and delivery of a low-intensity antenatal intervention. The 2-h psycho-educational programme marks the first of its kind to be trialled in the UK and was delivered as an adjunct to existing antenatal classes provided through the National Health Service. A cluster randomised design was used as antenatal classes rather than participants were randomly allocated to either treatment condition. Feasibility was assessed on the basis of pragmatic delivery and acceptability of the intervention. Data from 47 participants who received the intervention and 36 participants who did not was then compared to provide a preliminary indication of its effectiveness. Outcomes were assessed in terms of relationship satisfaction, couple communication and psychological distress. The intervention appeared feasible in terms of pragmatic delivery, rates of uptake and attendance at sessions. Participant evaluation forms also indicated that people were reasonably satisfied with the intervention and would recommend it to friends. Three significant phases × condition interactions were indicated using mixed-methods analyses of variance (ANOVAs); women in the intervention condition reported significantly less deterioration in relationship satisfaction (F(1, 44) = 3.11; p = 0.021; eta(2) = 0.07), while men in the intervention condition reported significantly less deterioration in couple communication (F(1, 35) = 2.59; p = 0.029; eta(2) = 0.08) and significant improvement in their experience of psychological distress (adjusted z = 1.99; p = 0.023; Cohen's d = 0.47). These positive preliminary indicators lend support to future large-scale investigation.

Modification and preliminary use of the five-minute speech sample in the postpartum: associations with postnatal depression and posttraumatic stress.

Little is known about what constitutes key components of partner support during the childbirth experience. This study modified the five minute speech sample, a measure of expressed emotion (EE), for use with new parents in the immediate postpartum. A coding framework was developed to rate the speech samples on dimensions of couple support. Associations were explored between these codes and subsequent symptoms of postnatal depression and posttraumatic stress. 372 couples were recruited in the early postpartum and individually provided short speech samples. Posttraumatic stress and postnatal depression symptoms were assessed via questionnaire measures at six and thirteen weeks. Two hundred and twelve couples completed all time-points. Key elements of supportive interactions were identified and reliably categorised. Mothers' posttraumatic stress was associated with criticisms of the partner during childbirth, general relationship criticisms and men's perception of helplessness. Postnatal depression was associated with absence of partner empathy and any positive comments regarding the partner's support. The content of new parents' descriptions of labour and childbirth, their partner during labour and birth and their relationship within the immediate postpartum may have significant implications for later psychological functioning. Interventions to enhance specific supportive elements between couples during the antenatal period merit development and evaluation.

An integrative review of the impact of indirect trauma exposure in health professionals and potential issues of salience for midwives.

AIMS: To explore responses to indirect trauma reported by health professionals and to identify issues of potential salience for midwives. BACKGROUND: Indirect exposure to a traumatic event can lead to the development of distressing and potentially enduring responses. Little is understood about the impact that perinatal trauma exposure could have on midwives. DESIGN: An integrative review design was used. DATA SOURCES: PsychInfo, Medline, PsychArticles, Web of Knowledge, CINAHL, MIDIRS and Scopus databases were search for papers published between 1980-November 2012. REVIEW METHODS: Studies providing quantitative or qualitative exploration of healthcare professionals' responses to indirectly experienced traumatic events were selected. RESULTS: Forty-two papers fulfilled the inclusion criteria. Four of these studies included professionals engaged in maternity care or exposed to traumatic perinatal events. Findings indicate evidence of intrusion, avoidance and arousal in healthcare professionals, with differing degrees of frequency. Empathy, work-related stress and the extent of professional experience were identified as associated with traumatic stress responses. CONCLUSIONS: Evidence derived from healthcare professionals suggests that indirect exposure to the traumatic events of recipients of care can sometimes elicit traumatic stress responses. Factors increasing risk for traumatic stress were identified as empathy and organizational stress. These factors hold specific salience in midwifery. Responding to trauma in a midwifery context, as informed by findings from other healthcare professionals, could adversely affect midwives' well-being, care provided to women and contribute to an adverse organizational climate. Large-scale research considering the experiences of midwives is recommended.