The challenges of creating gender-inclusive birthing services

As society's understanding of gender and sex evolves, our use of language evolves, too. Maternity wards and pregnancy care have, traditionally, largely used language oriented around women: the word 'maternity' itself, for one, but also 'midwife', 'matron', or 'sister'. And while cisgender women remain the primary patients in such services, a rising number of trans and non-binary people, who may not identify as women, are also engaging with pregnancy planning and birth-related services,

Being excluded by the language used in birthing settings could lead to these parents feeling othered by the experience of bringing a child into the world, and potentially plant the seed for further-reaching mental health impacts. With giving birth being as stressful as it is, plus the risk of post-partum mental health struggles, efforts should be made to give all patients the best standard of care available.

A new study by a UK-based research team explored the experiences, opinions, and educational needs of perinatal staff as related to the needs of trans and non-binary service users. Through their investigations, they found generally welcoming attitudes throughout staff, but a lack of awareness of trans and non-binary issues, suggesting a number of steps that could improve services for these populations. 

One hundred and eight perinatal staff working in the UK took part in the study's online survey. The first part of the study looked at participants' knowledge and attitudes of trans issues using a 29-item scale, with participants indicating how much they agreed with questions such as "I would feel comfortable having a transgender person into my home for a meal," or "If you are born male, nothing you do will change that". A higher score indicated a more positive attitude towards, and increased knowledge of issues related to, trans and non-binary people.

Next, staff answered questions designed to measure their confidence in providing care to trans and non-binary people, indicating how much they agreed with statements such as "how confident do you feel in forming a care plan in partnership with a childbearing trans person?" and "how confident do you feel in providing effective care to a childbearing trans person?" Finally, four long-form response questions explored participants' experiences, challenges, educational needs, and opinions about providing care to trans and non-binary patients. 

Most of the 108 participants had a positive attitude towards trans and non-binary people, despite only 20% having knowingly provided perinatal care to these populations. Many also had a good working knowledge of issues related to trans people, sharing experiences they had had with trans and non-binary people and engaging deeply with ideas on how to improve colleagues' knowledge and experience too.

When exploring their experiences of providing care for childbearing trans and non-binary people, participants stated the need to recognise the individuality of each case: every trans or non-binary parent is different. Staff noted that it was important to take into consideration individual differences, different pronouns, and different points in transition, rather than applying the same assumptions to all. Several participants noted that some colleagues were transphobic, while others reported nervousness about providing care, slipping-up with inclusive language, or saying something unintentionally upsetting. 

The sample also identified notable challenges in providing suitable care. Perhaps most obviously, the cisheteronormative model of care that focused on binary gender presented some issues; language used that focuses exclusively on mothers, for example, rather than using more inclusive, less exclusively feminine language of 'parenting'. 

This, however, was not without controversy, even within this small sample. Some midwives shared concerns that trans-inclusive care may diminish focus on cisgender parents. Though specifics as to how increased inclusivity would disempower cisgender women were not provided in this instance, others have raised similar concerns that some patients may find inclusive language alienating, or find it difficult to understand terms such as "people with a cervix". It is worth nothing that in places where efforts to use inclusive language have already begun, however, trusts report that they are careful "not to exclude the language of motherhood." Participants did not necessarily see these stances as contradictory, reporting that "Trans rights do not undermine women's rights… One can be a feminist and also provide understanding, accepting care to transgender people."

Despite this ongoing discussion, participants enthusiastically shared their ideas for progress when it came to education around trans childbirth and parenting. They noted the importance of explaining the practicalities of childbearing while trans; a trans man, for example, might manage a pregnancy differently to a cisgender woman, both physically, practically, and psychologically. 

The healthcare workers involved expressed a desire to create educational resources alongside trans and non-binary people themselves, "and for them to be involved in co-creating a more effective service." Sharing good practice around working with trans people was also drawn out as a potential way forward, and for inclusive care "to be openly discussed and addressed."  

Overall, this research highlights the ways in which trans and non-binary people are often excluded by maternity services, despite a general acceptance of trans and non-binary people by staff. Many staff indicate material changes can and should be made: changes of policies, more co-production, and increased education around language used and material challenges for gender nonconforming parents. Future research could look at the experiences of trans and non-binary people in these services, as understanding more about the patient experience could help develop strategies to ensure birthing services support the wellbeing of all patients.

Read the paper in full: https://doi.org/10.1177/08912432221138086