Trauma-Informed Maternal Care

Key Points

• Trauma-informed care (TIC) in obstetrics acknowledges that past or current trauma — including intimate partner violence (IPV) — profoundly affects pregnancy outcomes and healthcare engagement.
• SAMHSA’s six core TIC principles: Safety, Trustworthiness and Transparency, Peer Support, Collaboration and Mutuality, Empowerment/Voice/Choice, and Cultural/Historical/Gender Issues.
• IPV is associated with serious obstetric risks: miscarriage, preeclampsia, preterm birth, low birth weight, and perinatal death.
• Universal screening for IPV at every prenatal visit is recommended by ACOG, USPSTF, and AWHONN — always screen in private, without the partner present.
• The nurse’s role is to listen, provide resources, and support patient autonomy — not to pressure the patient to leave the relationship.

Pathophysiology

Trauma — including domestic violence, sexual abuse, and adverse childhood experiences (ACEs) — activates a chronic stress response that elevates cortisol and inflammatory markers, disrupting normal physiological regulation. In pregnancy, this stress response is linked to:

• Hypertension, preeclampsia, and placental insufficiency
• Premature rupture of membranes and preterm labor
• Low birth weight and intrauterine growth restriction
• Perinatal death and miscarriage
• Postpartum depression, anxiety, and PTSD

Physical violence during pregnancy is reported at higher rates among women of color, transgender persons, and those experiencing poverty. The risk of maternal morbidity and mortality is disproportionately elevated in these populations.

SAMHSA Six Core TIC Principles in Maternal Care

Principle	Application in Obstetrics
Safety	Create a physically and emotionally safe environment; screen patients privately away from partners
Trustworthiness and Transparency	Explain all procedures before performing them; maintain confidentiality clearly and honestly
Peer Support	Connect patients with community resources, peer advocates, and survivor support programs
Collaboration and Mutuality	Share decision-making; avoid authoritative or coercive communication styles
Empowerment, Voice, and Choice	Reinforce patient’s right to make their own healthcare decisions, including about their relationship
Cultural, Historical, and Gender Issues	Recognize intersectionality; acknowledge how systemic inequity shapes vulnerability and access to care

Nursing Assessment

NCLEX Focus

Universal IPV screening is a high-yield nursing priority in maternal care. The nurse must ensure privacy (partner not present), use a framing statement normalizing screening for all patients, and use professional interpreters — never family members — for patients with language barriers.

IPV Screening Framework:

• Screen at every prenatal visit — increased risk of IPV during pregnancy is well established
• Use framing statement: “We talk with all of our patients about healthy relationships because it affects health”
• Ask direct questions privately: “Has your partner ever threatened you or made you feel afraid?” / “Has your partner ever hit, choked, or physically hurt you?”
• Never allow the partner to answer for the patient or remain in the room during screening
• Use standardized tools when available (for example HITS, where score above 10 supports positive IPV screening concern).
• Consider computer-assisted self-interview options in settings where privacy or verbal disclosure is difficult.
• Recognize signs even without disclosure: unexplained injuries, delays in seeking care, chronic anxiety/depression, frequent emergency visits, a partner who speaks for the patient or refuses to leave

Assessing trauma history:

• ACEs history (childhood abuse, neglect, household dysfunction) elevates risk of depression, anxiety, and poor prenatal engagement
• Screen for PTSD symptoms: hypervigilance, avoidance of procedures, exaggerated startle, flashbacks triggered by physical exams or vaginal procedures
• Assess social determinants: financial abuse, housing instability, and isolation are markers of IPV severity

Nursing Interventions

• Non-judgmental listening: validate the patient’s experience without directing them to leave the abuser — readiness to leave is a process that the patient controls
• Provide resources regardless of disclosure: offer hotline numbers (National Domestic Violence Hotline), shelter information, and reproductive coercion resources to all patients in a normalized, private way
• Safety planning when the patient is ready: discuss safe exit strategies, emergency contacts, and documentation of abuse for legal purposes
• Include referral pathways to counseling, legal-assistance options (for example restraining-order support), shelters, and national hotline resources.
• Mandatory reporting awareness: know your state’s mandatory reporting requirements for IPV; report only when legally required and transparently explain any required disclosures to the patient beforehand
• Trauma-sensitive physical exams: explain each step before performing it, obtain verbal consent for vaginal exams, allow the patient to stop at any time, and minimize unnecessary exposure

Reproductive Coercion

Reproductive coercion — a partner controlling contraception, forcing pregnancy, or sabotaging birth control — affects up to 20% of women in family planning settings. Screening must include questions about contraceptive control alongside physical and emotional abuse. Providers should offer reproductive health support without requiring the patient to discuss their relationship.

Related Concepts

• domestic-and-intimate-partner-violence — Core clinical framework for recognizing and responding to IPV in clinical settings.
• trauma-informed-care — SAMHSA TIC principles and application across healthcare settings.
• postpartum-infections — Stress and physiologic disruption from trauma increase postpartum infection susceptibility.
• conditions-limited-to-pregnancy — Preeclampsia and preterm labor risk are elevated by IPV-related chronic stress.
• grief-and-loss — Trauma-exposed patients may experience pregnancy loss at higher rates; grief-sensitive care applies.
• culturally-competent-care — Cultural humility is essential when providing TIC to diverse maternal populations.

Self-Check

1. A nurse is conducting a prenatal intake with a new patient. The patient’s partner insists on staying in the room. What should the nurse do before screening for IPV?
2. A pregnant patient discloses that her partner has been hitting her. She says she is not ready to leave. What is the appropriate nursing response?
3. Which obstetric complications are specifically associated with IPV during pregnancy?