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Why Survivor Care Isn't in Midwifery Training

Writer: Michaela Kalusova
Michaela Kalusova
2 days ago
8 min read

Why caring for survivors of sexual trauma is still missing from the basic education of the people who care for women through birth, and why that is not their fault.


Near the end of my webinar last night, someone in the audience asked a question I have been turning over ever since.


"Why isn't this part of the curriculum? Why isn't it in the basic training?"


It is a fair question. The webinar asks people to look again at things many of them have already seen on shift: the woman who went still during an examination, the woman labelled difficult, the woman who stopped coming to appointments. Recognising them is one thing. Realising you were never given the words for them is another. The question underneath is simple: if this matters so much, why was it not taught?


I want to answer that properly, because the honest answer is more interesting, and more hopeful, than "they forgot."


On paper, it has arrived. In the room, it mostly has not


The first thing to say is that the picture is changing. The Nursing and Midwifery Council's Standards of Proficiency for Midwives, approved in October 2019, expect every newly registered midwife to recognise and respond to violence and abuse. Their glossary is explicit that abuse may be current or may have happened in the past, and that its physical and psychological effects can still show in the present. Elsa Montgomery and Lucy Duckworth, writing in 2025, note this was the first time care of women who have experienced abuse was included. They conclude that it will therefore now be part of the pre-registration midwifery curriculum in the UK.


So the regulator expects it. But expectation and teaching are not the same thing.

In a study published in 2023, Montgomery and Chang ran focus groups and interviews in South London with 37 students and qualified professionals across midwifery, health visiting and medicine. Care of women who have experienced childhood sexual abuse had not been part of their undergraduate or pre-registration education, and it had not been part of specialist training for obstetricians either. Montgomery and Duckworth note that many maternity professionals in practice today have never been taught it.


The international picture is similar. A 2022 integrative review set out to find research on trauma-informed care education for midwives and found only three studies, all from America, none of them midwifery focused. Most of the midwives in those studies had received no previous trauma-informed education and lacked confidence caring for women with lived trauma.


And in 2024, when the All-Party Parliamentary Group on Birth Trauma reported on more than 1,300 submissions, its very first recommendation called for more midwives, obstetricians and anaesthetists, and for mandatory training in trauma-informed care. The inquiry was about birth trauma broadly, not survivors of sexual abuse specifically, but the point stands. You do not recommend something be made mandatory when it is already standard.


So the person who asked me last night was right. If you trained before 2019, it is very likely you were not taught this. If you trained since, you may have met it, but quite possibly as a line in a lecture rather than a skill you practised.


Why the gap exists


The call itself is not new. Lis Garratt's book on survivors and midwifery practice describes Sanctum for Midwives, founded in 2002 to build a national programme of awareness and training, and argues that every professional caring for women should be trained in this. So why, more than twenty years on, is it still patchy? I think there are five reasons. Some are well evidenced. Others are my reading of the evidence, and I will say which is which.


1. It falls between safeguarding and everything else


Most professionals are taught about abuse through safeguarding, and safeguarding is about current risk: who is in danger now, and who needs to be told. That teaching matters. But Montgomery and Duckworth point out that for most survivors in maternity care, childhood sexual abuse is not current. Its impact is. The NMC's own glossary recognises this, yet its proficiency statements on abuse are mostly framed around recognising it, safeguarding and referral.


A woman who was abused at nine and is giving birth at thirty-one may have no safeguarding need at all. What she has is a body that learned to survive, and a care setting that can trigger it. That woman does not fit the safeguarding lecture, and so, in many curricula, she does not fit anywhere. This point is my interpretation rather than a research finding.


2. She is invisible, so the need is invisible


Survivors rarely disclose to maternity professionals. Montgomery and Duckworth describe why: fear of judgement about their parenting, shame, fear of not being believed, and fear that a disclosure will automatically lead to social services or police involvement, whatever their wishes.


The consequence for education is quiet but powerful. Students see survivors on every placement, but they never know it. What looks like a rare, specialist situation is in fact routine. And curricula tend to be built around what people can see.


3. It is personal for the people in the room


This is the reason that is talked about least. In a 2022 online survey of 288 practising midwives in high-income countries, de Klerk and colleagues found that 48.6% disclosed a personal history of sexual violence. People who chose to answer a survey on this subject may not represent all midwives, but the authors conclude that midwives are similarly likely to have experienced sexual violence as the women they care for. Montgomery and Duckworth describe professionals who, during training sessions, disclosed their own abuse and named it as part of why they came into the work.


That means any lecture on this subject is being taught to, and sometimes by, survivors. Done badly, it can harm. Teaching it safely takes time, preparation and skill. I suspect that, faced with that, some programmes simply leave it out, or keep it brief and abstract.


That last point is my inference rather than a finding.


4. It cannot be reduced to a checklist


The professionals in Montgomery and Chang's study wanted to know what survivors wanted from them, and some kind of checklist would have eased their anxiety. But the authors note a checklist would risk taking power away from the very women it was meant to help. One survivor in their focus groups put it plainly: the answer is not to assume you know what survivors want, it is to ask.


That is exactly why it is hard to teach in a lecture hall. Trauma-informed care is not a protocol to memorise. It is a way of communicating, noticing and waiting for a real answer. It has to be practised, and practice needs time a crowded programme may not have.


5. The curriculum is full, and the evidence is young


Pre-registration programmes carry an enormous amount: emergencies, physiology, pharmacology, safeguarding, public health. The NMC states its standards as outcomes and gives universities flexibility in how they meet them, so each university decides how much room any topic gets. My reading is that psychological safety tends to lose that competition to things that look more urgent, even though, for a survivor, it is just as clinical.


And the teaching evidence is still thin. The 2022 review found only three studies on trauma-informed education for midwives. Educators who want to build this in have little tested material to build from.


What the gap costs


When something is not taught, it does not stop happening. It just happens without understanding.


For women, the cost is that ordinary care can repeat the shape of the original harm.


Montgomery's research with survivors in UK maternity care shows how unpredictable the triggers can be. One woman, admitted to an antenatal ward, was frightened by the sound of footsteps approaching her curtain at night when staff came to turn off her light. Another was labouring well at home with a midwife she trusted and had disclosed to. The midwife used a torch during an examination to keep the room dim and calm. Her abuser had used a torch. Something shifted in her head, and she began to feel she needed to go to hospital. She was later admitted.


Nobody in either story did anything wrong by the standards they were taught. That is the point. Without education, kind and skilled professionals cannot see what they are walking into, and the woman pays for it.


For professionals, the cost is a particular kind of helplessness. Montgomery and Chang describe students and staff who felt unprepared, awkward when they suspected a history of abuse, and inclined to avoid the subject because they did not know how to respond. The title of their paper sums it up: "What do I do?"


And for services, the cost is misreading. Garratt describes survivors who coped with birth by leaving their bodies, and notes that carers were likely to see these women as excellent patients. A woman who has frozen looks compliant. A woman who is terrified can look difficult. Without training, we record the behaviour and miss its meaning.


What closing it looks like


There are real signs of movement. The NMC standards now name it. The Women's Health Strategy for England names the health impact of violence against women and girls as a priority, and commits to making evidence-based resources easier for professionals to access. Montgomery and Duckworth's co-produced e-resource, built with survivors, has been approved for the NHS Learning Hub, and work to test it in pre-registration midwifery programmes is being prepared. The APPG has asked for trauma-informed training to be mandatory.


But policy does not change what happens in the room at 3am. People do. And the most useful thing the research tells us is what that change actually looks like.


It is not a list of rules for survivors, because you will rarely know who the survivor is. It is a universal way of caring: assume trauma may be present whether or not anyone has disclosed it, explain before you touch, ask rather than tell, and wait for a real answer.


Montgomery and Duckworth end their paper by arguing that every professional should be equipped to offer that kind of individual care, disclosure or no disclosure. That is the same principle the SAFER Birth model is built on.


So, to answer the question


Why isn't this in the basic training? Because it fell between safeguarding and everything else. Because the women who need it rarely tell us. Because it is personal for many of the people who would teach and learn it. Because it is a skill, not a fact, and skills need time. And because, until recently, no one with the power to require it did so.


None of that is a failure of the people who were not taught. It is a gap in what they were given. And it is a gap that can be closed.


That is what the SAFER Birth Project exists to do. The free one-hour webinar is where most people start. The Foundational Training is where the skills are practised: recognising trauma responses, communicating under pressure, and keeping consent alive throughout care. If you teach student midwives, nurses or doctors and you want to bring this into your programme, I would very much like to hear from you.


The question from last night deserves more than an answer. It deserves a change.

If anything in this article is close to home, support is available. Rape Crisis England and Wales runs a free 24-hour support line on 0808 500 2222. Sexual Assault Referral Centres can be reached on 0800 148 8888. If you are outside the UK, please use your national sexual violence support service.

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