Policy, Service, and Training Provision for Women Following a Traumatic Birth: An International Mapping Study

Background: High numbers of women experience a traumatic birth, which can lead to Post Traumatic Stress Disorder (PTSD) onset, and negative and pervasive impacts for women, infants and families. Policies, suitable service provision, and training are needed to identify and treat psychological morbidity following a traumatic birth experience, but currently there is little insight into whether and what is provided in different contexts. The aim of this study was to map policy, service and training provision for women following a traumatic birth experience in different European countries. Methods: A survey was distributed as part of the COST Action “Perinatal mental health and birth-related trauma: Maximizing best practice and optimal outcomes”. Questions were designed to capture ‘country level data’; ‘care provision’ (i.e., national policies or guidelines for the screening, treatment and/or prevention of a traumatic birth, service provision), and nationally mandated pre-registration and post-registration ‘training’ for maternity professionals. Results: Eighteen countries participated. Only one country had national policies regarding the screening, treatment and prevention of a traumatic birth experience/PTSD. Service provision was provided formally in six countries (33%), or informally in the majority (78%). In almost all countries (89%), women could be referred to specialist perinatal or mental health services. Services tended to be provided by midwives, although some multidisciplinary practice was apparent. Thirty-nine percent of the countries offered ‘a few hours’ professional/pre-registration training but none offered nationally mandated post-registration training. Conclusions: A traumatic birth experience is a key public health concern. Evidence highlights important gaps regarding formalized care provision and training for care providers.

healthcare professionals to raise awareness as to how birth can be experienced by women as traumatic has been highlighted (12,(14)(15)(16). There have been recent moves in some countries, such as the UK, to introduce perinatal mental health training for post-qualifying maternity professionals (17). However, to date, there is little known regarding mandated training within pre-or post-registration curriculum for maternity care professionals.

While specialist treatment options for PTSD, namely Eye Movement Desensitisation and Reprocessing and Cognitive
Behavioural Therapy are recommended, there are no recommended or standardised treatment options for women who have endured a traumatic birth (6,18). Arguably, offering an early intervention following a di cult and distressing birth would help to ameliorate women's negative responses, and to prevent PTSD onset (19,20). In the UK (21) and Iceland (22), women are offered an afterbirth service: women who are distressed and traumatised by their birth can meet with maternity professionals to review their birth notes (23). While women can report variable experiences of these opportunities (23), women value being able to understand what happened and why, and to aid memory processing (22,24). A survey of UK afterbirth services (21) found wide heterogeneity in terms of whether the service was formally or informally provided, the times and timing of support, the different professionals involved (e.g., midwives vs. midwives and wider professionals) and the level of service provider training (21). To date, the extent to which these service models re ect those in other international contexts is unknown.
The high number of women experiencing a traumatic birth, and the links between maternal birth-related PTSD and poor developmental outcomes in infants (25) highlights a traumatic birth experience as a key public health concern. However, currently, there is a lack of insight into whether, what or how support for a traumatic birth experience is provided in different contexts and settings (26). Such insights could help identify 'promising' practices, or key service and policy gaps.

Study aim
The aim of this study was to map policy, service, and training provision for women following a traumatic birth within different European countries.

Study context
This study was undertaken as part of the COST Action "Perinatal mental health and birth-related trauma: Maximizing best practice and optimal outcomes" (www.cost.eu/actions/CA18211), which consists of researchers, clinicians, and service users from across Europe and beyond. The authors put forward a call across the Action to elicit interest in collaborating on the general topic of 'after birth support following a traumatic birth'. Two meetings were held in January and February 2020, during which it was agreed that the rst step should be to map information across different European countries on the policies, the types and extent of service provision for women following a traumatic birth experience, and professional training.

Survey development and data collection
A survey tool (see Additional File 1) was devised by the authors, with collaboration from those who attended the meetings.
The survey collected data in four main areas. First, 'country level data' comprised population level statistics including the number of inhabitants, number of births, and types of birth (setting, mode of birth) based on the most recent/veri able data source; the number of maternity hospitals; and how the maternity system was funded. Second, 'care provision' included questions on whether there were any national policies or guidelines for the screening, treatment and/or prevention strategies for women following a traumatic birth experience, and if yes, to provide further details (authors, what the policies/guidelines are, and who they are provided for). This section also requested information on formal or informal services provided by maternity professionals (formal de ned as service provision outside of normal/usual care that is regularly available and has allocated speci c resources (personnel, time, etc.), and informal de ned as service provision operating on an irregular basis, without allocated speci c resources). If yes, respondents were asked to detail what the formal or informal service comprised, who provided the service, from which type of healthcare, whether it was a national or local initiative, and how the service was funded. A further question was included to capture whether women could be referred to specialist perinatal or mental health services. The last section captured whether there was any 'training' into traumatic birth for maternity professionals involved in perinatal care (i.e., midwives, obstetricians, obstetric nurses). This included questions on: 1) training provided as part of the national/general basic professional training/pre-registration curriculum and; 2) national mandatory requirements for post-registration training. If yes, respondents were asked to detail which professions, and how 'much' training was provided. Finally, participants were asked to detail any other comments, which may be useful to help understand policies, practice or training, in their country.
Individuals from the COST action who were willing to participate were asked to collect data in consultation with experts who had national knowledge of maternity care, perinatal mental health provision and/or pre-registration training (and to detail who these individuals were) in their country. As this study involved mapping existing policies, services and training provision, rather than any individual level or evaluation-based data, ethics approval was not required.
Data collection took place from March 2020 to February 2021. Participants were issued with reminders (up to three) and asked to notify the authors if they were no longer able to collect the data. Follow-up emails were also issued where needed, in attempts to collect a comprehensive data set.

Data Analysis
Data were analysed using descriptive statistics (frequencies and percentages) for numerical (country level data) and dichotomous variables (yes/no). Any qualitative comments that helped to explain the participants' answers were extracted and reported.

Results
While participants from 23 countries originally agreed to participate, completed surveys were received from 18 countries, namely Belgium, Cyprus, England, France, Germany, Greece, Norway, Iceland, the Netherlands, Northern Ireland, Poland, Portugal, Ireland, Scotland, Serbia, Spain, Switzerland, and Turkey. The respondents and those consulted to complete the survey were midwives, psychologists, psychiatrists, obstetricians-gynaecologists, and nurses. In the following sections, the responses to the questions under the three key survey sections -'Country level data'; 'Care provision'; and 'Training for providers' -are reported. As some respondents provided additional comments to help explain issues, such as the challenges in developing policies, or in delivering services following a traumatic birth experience, these have been considered in the discussion.

Country level data
Country level data from the 18 countries are presented in Table 1 (See Additional File 2 for references to data sources in each country). The data on the numbers of inhabitants and births per year was used to calculate the birth rate and showed variations from 7.8% in Greece to 14.2% in Turkey. The percentage of caesarean sections varied from 15.7% in the Netherlands to 56.8% in Greece. The percentage of home births varied from 0% in Cyprus, 2.1% in England, and was highest in the Netherlands at 12.7%. The ratio of maternity hospitals was also quanti ed to allow a comparison between countries. The highest ratio was 28 maternities per 1 million inhabitants in Cyprus and the lowest ratio was 2.4 in England.
Most countries (72%) had a public and private maternity care system, compared with 28% of countries who had public care only.  6 42 maternity clinics and 5 maternity wards 7 18 obstetric units, 19 freestanding midwife-led units and 6 alongside midwife-led units * Country level data was based on the most recent available census, at the time of data collection. Some data were rounded to two decimal places. **The data used to calculate birth rate and ratio of maternity hospitals were sometimes collected for different reference years. ***Care system: 1 = public care only; 2 = public and private care. **** There were inconsistencies in how data was reported -some provided the numbers of maternity hospitals, whereas others detailed the different levels of provision, i.e. numbers of maternity units, consultant led units, etc.

Care provision
National policies or guidelines Apart from the Netherlands, there was no other country that had a national policy or guidelines for screening, treating, or preventing psychological issues linked to a traumatic birth experience. While respondents from Scotland indicated there were policies to prevent women from having a traumatic birth experience, they related only to physical trauma (i.e., to reduce anal sphincter injury or stillbirth rate). Other respondents, such as those from Poland, reported on more general policies to improve birth outcomes and maternal wellbeing, such as "[…] pre-birth education aimed at reducing anxiety associated with labour and early motherhood", but nothing […] that would speci cally address the prevention of traumatic birth". Likewise, there were general guidelines in France for the screening of postpartum psychological disorders and also "[…] to avoid obstetric complications of childbirth […]", but no national policies or guidelines speci cally related to the screening, treatment and/or prevention of a traumatic childbirth experience.
The Dutch guideline was mentioned as very recently published (2019) (27), and the respondent highlighted two important recommendations for screening: -Ask women how they have experienced labor and delivery: in the rst week after birth, at the 6 weeks check up appointment, and at the beginning of a new pregnancy. -"Make use of a validated screening instrument for postpartum PTSD in women who report a traumatic delivery experience and in women who are at increased risk of developing postpartum PTSD".
The guideline detailed treatment options for women with traumatic experiences, who had PTSD symptoms or a PTSD diagnosis, as commented by the respondent: "In case of PTSD: treat as you would treat PTSD after other trauma, namely: psychoeducation combined with EMDR or trauma-focused CBT". It also considered prevention in terms of how to care for women during childbirth "Aim for continuous 1-on-1 care, for example by a trained lay person not involved in medical care and decision making (e.g. Doula)" as well as an early intervention such as expressive writing to help women process their memories about the birth "Consider a short expressive writing exercise aimed at emotions, thoughts and initial expectations about labor and delivery".

Service provision
All countries, except for Cyprus and Turkey, had some form of service provision. Thirty-three percent of the countries (England, Iceland, Northern Ireland, Ireland, Scotland, and Switzerland) indicated that formal services were available, 78% had informal services, and 89% were able to offer referrals to specialist services. The six countries with formal services also had informal services and referral options for specialist provision.
It is important to note that formal service provision was not always routinely provided for all women. For example, in Scotland, it was reported "In most NHS [national health service] boards a follow-up debrief is offered with a consultant obstetrician for women whose births were considered objectively traumatic, i.e. emergency CS, large blood loss, 3rd degree tear", suggesting that it was only available for those with pre-supposed clinical needs. Formal services were also not available in all the country's maternity hospitals. For example, in Ireland, only two of the maternity units provided 'a birth re ection type of service, where women can discuss their birth experience. One service is a dedicated collaborative clinic". Whereas in Iceland, there were "only two counselling clinics for women experiencing traumatic birth". Similarly, in Northern Ireland it was reported that "services vary across the HSCTs [health and social care trusts] in Northern Ireland and includesupport, debrie ng & limited perinatal mental health service provision for some women in individual Trusts where they have access to therapy".
One hospital in Switzerland that currently provides a formal service to women and their partners had funding for one year and was then due to be reviewed. Moreover, the formal provision offered in England was reported to be variable and insu cient: "Some Trusts provide a formal afterbirth debrie ng service for women who have had a di cult/distressing/complicated birth (but lack of governance/procedures to underpin service delivery)".
Formal services were provided mainly by midwives, either solely or in conjunction with obstetricians in Switzerland and Scotland (33%), or with obstetricians and/or mental health counsellors in England, Iceland, Northern Ireland and Ireland (67%). For example in Ireland: "The perinatal birth trauma service is a collaborative service facilitated by an advanced midwife practitioner, a psychiatrist and a psychologist who liaise closely with a named obstetrician". Nearly all available formal services were reported to be local initiatives (83%), except in Scotland. The majority of services were provided in hospitals, and were publically funded (83%), although in some countries, this was mixed. For example, in Ireland, three services are publically available within public and privately funded maternity services.

Training for providers
Seven countries (39%), i.e., Cyprus, France, Iceland, the Netherlands, Northern Ireland, Portugal, and Scotland indicated that training into traumatic birth/birth-related PTSD was part of the national/general basic professional training/preregistration curriculum for some of the key professionals involved in perinatal care. This training was provided for midwives in all countries, but also for obstetricians in France, medical doctors in Iceland, and obstetric nurses in the Netherlands. However, there was very little basic education, i.e., only a few hours' training provided for some curricula in all these countries. In Iceland, training into traumatic birth was not included in speci c courses, "[…] but it is discussed in some modules". Moreover, some respondents reported optional courses and/or local ad hoc training provided for midwives, psychologists and obstetricians, in the Netherlands, for psychologists, midwives and doctors in Norway, for maternity healthcare professionals in Ireland, and for psychiatrists and psychologists in Greece. Regarding postregistration training into traumatic birth, there was no national mandatory requirement for maternity care professionals in any country.
The main results regarding the presence/absence of national policies or guidelines, formal service provision, and training for providers are visually presented in Fig. 1.

Discussion
The aim of this study was to map policy, service, and training provision for women following a traumatic birth experience within different European countries. The ndings from 18 countries across Europe revealed that only one country had national policies or guidelines in place regarding the screening, treatment, or prevention of a traumatic birth experience. Formal services offered to women experiencing a traumatic birth were only available in six countries (33%). However, the respondents indicated that this type of service was informally provided in the majority of countries (78%), with a possibility for women to be referred to specialist perinatal or mental health services (89%). The formal services were generally provided in hospitals, publicly funded, and provided mostly by midwives. More than a third of the countries (39%) offered training into traumatic birth as part of national basic professional training for maternity professionals. None of the countries had any national mandatory requirement to receive post-registration training into traumatic birth/birthrelated PTSD.
A key nding was the almost total lack of national policies/guidelines in care provision for traumatic birth/birth-related PTSD. Except for the Netherlands, no guidelines related to the screening, treatment, or prevention of traumatic birth exist. The Dutch multidisciplinary guideline recommends the use of validated screening tools, such as the Primary Care PTSD screen for the DSM-5 (28). However, although this questionnaire assesses PTSD symptoms following a stressful/traumatic event, it does not speci cally assess childbirth-related PTSD symptoms. The City Birth Trauma Scale (CiBTS) (29), which has already been validated in several languages, might be more appropriate and should be recommended for use in routine clinical practice. A systematic screening procedure is essential for the detection of women reporting a traumatic childbirth experience, in order to promote their access to appropriate care. This is particularly important given that women often avoid professional contact following a traumatic childbirth (10), may lack insight into how to access help (9,30), and may be reticent to disclose poor mental health for fear of repercussions (31).
The ndings of our study also highlight a lack of formal services for women experiencing a traumatic birth. While informal service provision was more common, the lack of formalised provision raises obvious concerns over availability and sustainability, as indicated by a comment within the Norway survey "There are some good offers here and there, but this is mostly based on passionate souls." Our nding that formal provision was not always routinely provided for all women is also in line with a UK-based study showing that women were more likely to self-refer (79.6%), rather than be referred via routine screening (11.1%), or according to obstetric criteria (27.8%) (21). Several respondents also indicated the availability of formal services for women following childbirth, but most of the time, they were not speci cally dedicated to birth trauma. Instead, an allocated speci c budget was commonly devoted to women with objective obstetrical complications (i.e., emergency caesarean section, stillbirth, etc.), with depressive symptoms, and/or experiencing family, social or personal complexities, rather than women's subjective experience of their childbirth having been traumatic. A further challenge was the evident controversy about whether childbirth can be considered a traumatic event and to lead to PTSD onset. The French respondent related "[…] some feedback mentioning that the entity of birth-related PTSD is seen by some trainers as controversial, considering that PTSD is most probably related to another event than traumatic birth. As if birth cannot be traumatic!". This lack of clarity could be due to different terms, such as traumatic birth (5,10,13,32) or negative birth experience (33)(34)(35) being used interchangeably, as well as trauma being used in the obstetric/medical literature to indicate physical rather than psychological trauma. The denial of childbirth as a potentially traumatic event is obviously a concern, as without this recognition, dedicated policies, appropriate service provision, and training are unlikely to follow. Further work to raise awareness of the prevalence, indicators, and impacts of this phenomenon is therefore crucial.
Service provision was often described as an interview, during which women could discuss their childbirth experience, but others referred to it as debrie ng, counselling, information and/or re ective listening sessions. This is re ective of wider arguments concerning the lack of de nition as to what afterbirth services comprise (36). In the UK, the National Institute of Health and Clinical Evidence postnatal guidelines stipulate that women should not be offered a debrief, rather to have a conversation with their midwife about their labour and birth (37). This is due to Cochrane reviews concluding there is insu cient evidence for debrie ng interventions (38,39), although important to note that this conclusion is based on heterogenous intervention designs that target different populations (i.e., women with perceived clinical and/or psychological need) (23). Further work to develop effective and evidence-based afterbirth support is needed (9). In the Netherlands, insurance does not cover the service provision of many midwives for women following a traumatic birth experience because "their status [is] not o cial […], [and] […] controversial (i.e., professional organisations of psychologists do not approve of them offering, for example, EMDR, while the midwives' association has accredited the training to become such a counsellor), and the background of these providers is very diverse.". As midwives are at the forefront of providing care for pregnant and postpartum women, and women often want to receive care from maternity professionals following a traumatic birth experience (9), the implementation of a validated, specialized and nationally recognized training for midwives, as well as other maternity healthcare professionals is essential. At the same time, discussion of professional responsibilities and boundaries, e.g., a detailed discussion about the birth experience and screening for trauma-related psychological symptoms by maternity professionals as part of the after birth service but referral of those with trauma-related psychological symptoms to specialist perinatal mental health services, should take place on a national level with relevant professional organisations.
The strengths of this study are that it is the rst mapping exercise to explore whether there are any national guidelines, services, or training provision for women who have experienced a traumatic birth in different European contexts. Such evidence helps to identify promising practices, key gaps, and to inform future research priorities. The limitations relate to a lower response rate than intended. While originally 23 countries agreed to participate, and despite calls for other country representatives, overall only 18 were included. All the included countries have high income-status, and the evident gaps in these contexts would suggest that the situation is even worse in middle or low-income countries. The survey only collected information on what was available, rather than any individual level or evaluation-based data. As many of the countries provided 'some' form of service provision (albeit informally), research to elicit further insights into what and how services are provided, as well as the outcomes and bene ts for women is needed. This work could help identify key mechanisms of effectiveness and to progress towards developing standardised, evidence-based interventions to improve outcomes for women and families.

Conclusion
This mapping exercise into policy, services, and training associated with a traumatic birth experience within 18 different European countries highlighted a lack of national policy guidance on the prevention, care, and treatment of a traumatic birth experience, an absence of formal afterbirth services, as well as a lack of mandatory pre-and post-registration training. Potential barriers to formalized and mandated provision pertain to uncertainties regarding the de nition of traumatic birth, a lack of evidence-based early interventions for women following traumatic birth, and a lack of public funding of afterbirth care services. Further work is needed to determine the essential ingredients of effective, evidencebased afterbirth care provision, the development of policy guidance, as well as professional training, to optimize maternal and familial wellbeing.

Declarations
Ethics approval and consent to participate The study was reviewed by the Chair of the Health ethics sub-committee at the University of Central Lancashire. Full ethics approval was waived as the project did not collect any participantrelated information and all the information was in the public domain and/or non-con dential.
Informed consent was not obtained as there were no human participants involved in the study.

Consent for publication
Not applicable Availability of data and materials The full dataset used and/or analysed during the current study are available from the corresponding author on reasonable request.
Competing interests Figure 1 International insight into service provision for women following traumatic birth (18 countries) Supplementary Files This is a list of supplementary les associated with this preprint. Click to download. AdditionalFile1SurveyMappingofserviceprovisionforwomenfollowingatraumaticbirth.docx AdditionalFile2Referencesandweblinksforcountryleveldata.docx