Perinatal services are organised around the assumption that there will be one pregnant parent, who is a woman, and that the other parent will be a man, who lives with the woman, and is the father of the baby (Spidsberg, 2007). These heteronormative assumptions can cause difficulties for all families who fall outside of this model, including single women, pregnant trans men and non-binary people, and pregnant women whose partner is also a woman. The literature shows that pregnant women of a minority sexuality using perinatal services face both direct and indirect homophobia (Dahl et al, 2013). Indirect homophobia can include inappropriate forms that only refer to one father and one mother (Röndahl et al, 2009). Direct homophobia can include everything from refusing assisted conception services to lesbians (Spidsberg, 2007), to physically rough vaginal examinations while in labour (Spidsberg, 2007). Among women of a minority sexuality, co-mothers may also be affected by heterosexism and homophobia. The literature shows that similarly to sexual minority birth mothers, they may face exclusion either because organisational structures are heterocentric or because of professional incompetence and homophobic attitudes from perinatal healthcare providers (Cherguit et al, 2013). Pandemics reinforce existing inequities within societies (Dingwall et al, 2013). This case report demonstrates how the pandemic reinforced inequality for co-mothers in perinatal care.
The global coronavirus pandemic affected expectant parents in the UK in several ways. From March 2020, the antenatal support and restrictions attached to birth support offered by the NHS changed repeatedly. Postnatal care was also affected, with changes to the services available from the NHS and from private care. One aspect of these changes has been to limit the involvement of the non-birthing parent in antenatal appointments and scans, during the birth and in postnatal visiting. These limits have come under scrutiny, with a national campaign entitled ‘But Not Maternity’ campaigning for the limits on partner's involvement to be lifted in line with the lifting of other COVID-19 restrictions (Pregnant Then Screwed, 2020). The limitations for non-birthing parent attendance did not discriminate by gender. However, for some lesbian couples, it is not the birthing parent who intends to be the breastfeeding parent or not the sole breastfeeding parent. In these cases, the non-birthing parent may require direct antenatal support with lactation. If the baby needs to remain in hospital, the non-birthing parent may need to remain with the baby to feed them. In the restrictions imposed during the pandemic, no national guidance or NHS trust policy recognised that co-mothers have specific needs.
This article reports on two cases where the specific needs of lesbian co-mothers were not taken into account in the provision of perinatal services. Permission has been given by the mothers for the publication of this case report, which follows the CARE guidelines (Riley et al, 2017).
The case studies
Demographics
This article reports on the cases of two lesbian non-gestational mothers, and includes details about the gestational mother who is the partner to one of the non-gestational mothers. All have been given pseudonyms.
The first, Ayesha, was a 28-year-old black African woman who completed an online survey run by the author in April 2020, which asked about new and expectant parents’ experiences of approaching birth during the first UK lockdown. Consent for publication of the responses was obtained as part of the survey.
The second case, Jane, approached the author for support (in her capacity as a doula) in April 2021. Jane and her wife Joanne had one child, who Jane gave birth to around 6 years ago. Joanne was pregnant with their second child. Further demographic information was not available for Jane or Joanne. Consent for the use of their data in the case study was obtained separately from both Jane and Joanne. As a result of the differences in how the cases came to the attention of the author, they will be relayed separately.
Contact summaries
The full open questions and narrative responses provided by Ayesha (case 1) in the online survey are shown in Table 1. Contact between Jane (case 2), her wife Joanne, and the author are summarised in Table 2.
Table 1. Survey responses from Ayesha, received April 2020
| Questions | Responses |
|---|---|
| Before the pandemic, what were your plans for birth? | Birth in the labour ward. My partner has some medical complications, which mean this is safest. She will not be able to breastfeed. The plan was that I would stay in the hospital and breastfeed. I have been following a lactation protocol. |
| Have your preparations for birth (such as attending antenatal classes, using a doula, having pregnancy massages) changed because of COVID-19? | I cannot go to antenatal appointments anymore, which means I cannot talk to the midwives about me breastfeeding. I have lots of questions but I cannot speak to anyone to get answers. |
| What effect has it had on your plans for birth? | Not really on the birth, but on breastfeeding. I don't know what will happen. Will I be able to take the baby home after 2 hours? That will leave my partner, who has just given birth, alone in the hospital. If I can express milk, will our baby be able to be cup-fed milk? I don't think I will be able to get the support I was going to get from the midwives postnatally to breastfeed either, and I am really worried. My partner cannot breastfeed at all because of the medication she takes. |
Table 2. Contact with Jane (case 2) and Joanne (her wife)
| Date | Summary of contact | Quotations from text messages |
|---|---|---|
| Mid-April | Jane contacted the author requesting breastfeeding support. By text, she explained her breastfeeding intentions, and described local postnatal restrictions that allow partners to remain with the parent who gave birth and their baby on the postnatal ward for only 2 hours after birth, to mitigate the COVID-19 infection risk. During a subsequent zoom call, Jane explained she feared her wife (Joanne) would not be able to breastfeed, but that because of COVID-19 restrictions, their baby would be given formula rather than Jane being allowed into the ward to breastfeed. Formula was unacceptable to both Joanne and Jane. Additionally, Joanne had not been given information about how to introduce co-breastfeeding without endangering her milk supply. Jane had not been offered appropriate support to re-lactate. Joanne had a medical condition that means a hospital birth is advisable. Jane and Joanne had been given little information about how Joanne's medical condition might affect her birth choices, and no-one had made a postnatal or breastfeeding plan that included Jane.Both Jane and Joanne had a negative experience of the care Jane received postnatally, which left both of them with some trauma. Joanne was uncomfortable giving birth in the hospital, and Jane was concerned about leaving her wife and baby in the hospital after birth. Previous birth trauma had not been considered for Joanne, because this was her first pregnancy. Jane did not appear to have been considered as a mum who might have experienced birth trauma, but rather as the partner of a primigravida. Self-referral routes were complicated as Jane was not allowed to attend midwife appointments with Joanne. | ‘I have been pumping my breasts for months to relactate so I can breastfeed our baby (potentially alongside my wife, she isn't yet confident she can or not) who is due to give birth mid-June. After she's healed from maternity leave, I will be the main carer for the baby as I am with our other child I gave birth to… The [COVID-19] restrictions for [the local] hospital are heartbreaking for me and causing me so much distress.’ |
| Early May | After a meeting between Jane, Joanne and the head of midwifery, Jane texted the author a list of phrases used in the meeting, which she found difficult. | ‘No other lesbians or paternal parents have behaved the way you have’‘Your wife is fully capable to care for the baby, you trust her don't you? They'll be fine.’‘Well you don't want to compromise your wife's breastfeeding journey or affect her milk levels?’‘Your wife's colostrum is more beneficial for baby than yours as you are regarded a donor, so you would be unfortunately the last resort.’‘It's been much nicer and calmer on the wards without partners coming and going, the women have even said they prefer it this way.’‘You'll be needed at home to look after your daughter won't you, won't she be needing her mum?’ |
| Mid-May | It is agreed that Joanne can have a private room on the postnatal ward, and that Jane can remain with her and their baby after the birth. | |
| 24 May morning | Joanne gives birth at 36 weeks. Jane is not allowed into the hospital and missed the birth. Jane is informed that if she left the postnatal ward to go to the canteen for food, she would not be allowed to return. Both Joanne and Jane fed their baby on the postnatal ward. | ‘She said if I go to get food, I'll have go home as [I would be] exposed to COVID-19.’ |
| 24 May evening | The baby was admitted to neonatal care to be treated for jaundice. A doctor working in the neonatal intensive care unit said the baby needed to be ‘topped up’ after Joanne fed him, but Joanne was informed that Jane's milk was not appropriate. Jane was directly informed that she was not allowed to feed her baby. Their baby was given formula. | ‘They told Jane my milk could make him poorly.’‘They said they'll have to look into whether its OK for me to feed as donor milk is normally tested and paturised [sic] and I'm a donor.’ |
Ethical considerations
The first case study comes from a research project, which was approved by King's College London, BDM Research Ethics Subcommittee. The patients/participants provided their written informed consent to participate in this study. Jane and Joanne provided explicit written consent to share their story.
Examining Jane and Ayesha's experiences
The written narratives from both Jane and Ayesha show mothers-to-be in a great deal of emotional distress. NHS antenatal services for lactation support do not always guarantee support for mothers-to-be who are not pregnant, but may have been provided on an ad hoc basis by individual midwives or through peer-support (Farrow, 2014). In the absence of face-to-face appointments that can include partners, these parents seem to have been left without services. The COVID-19 restrictions have exposed this gap in the structure of service provision, but this gap existed prior to and outside of the pandemic. It was also highlighted in the creation of 26 new perinatal mental health ‘hubs’, where the available services for mothers experiencing mental health difficulties, birth trauma or bereavement assume that the mother has themselves been pregnant (NHS England, 2021).
There are complexities to reproductive journeys where both partners have the ability to become pregnant, give birth or breastfeed that are not recognised by these policies. Two such complexities are shown in the cases of Ayesha and Jane. The first complexity relates to infant feeding, where there is an assumption that breastfeeding will be carried out by the person who has given birth, and that if this does not happen, the baby will be bottle-fed infant formula. This situation could be resolved with an inclusive infant feeding policy, which makes provision for co-mothers to breastfeed (Juntereal and Spatz, 2019).
The second complexity is with emotional and psychological support. Ayesha's survey responses showed emotional distress and indicated a need for support during the antenatal period. Jane and Joanne's case demonstrated the effects of a previous negative birth experience and potentially untreated birth trauma. The literature shows that when women have experienced a traumatic birth, they may disappear from perinatal services once discharged from midwifery care (Gamble and Creedy, 2009; Beck et al, 2013; Zauderer, 2014; Hinton et al, 2015; Greenfield, 2017; Canfield and Silver, 2020; Hayden, 2022). Negative sequalae may or may not be treated by their GP practice. Frequently, birth trauma will not be addressed until women reappear within perinatal services, during a subsequent pregnancy (Hopper et al, 2004; Alder et al, 2006). For families where both partners have the ability to conceive, this situation can be more complex. In this case, unresolved issues from Jane's early postnatal care impacted both her and Joanne's experiences in Joanne's pregnancies, but services were not available to Jane because she was not pregnant. Her experiences after Joanne had given birth of being denied access to her child and told that she was not a mother may have caused additional trauma, which services may not be experienced in resolving. The resolution to this complexity for families may be more complicated than the issue of infant feeding, as it requires policymakers and practitioners to redesign pathways into services that take account of non-heterosexual families. Importantly, it also highlights the need for consideration of non-heterosexual families across services, including as a minimum, in maternity, perinatal mental health and neonatal departments.
The cases presented were limited by having only brief contact with the women. The report is limited to discussion of the data reported by the individuals, without triangulation from clinicians or medical notes. However, despite the difficulties inherent in such self-reports, these cases highlight the difficulties faced by non-gestational mothers when accessing perinatal services. Further work to explore how women are affected by such difficulties, and to create policy and practice solutions, is required.
Conclusions
Heterosexist policies and practices within perinatal services presented difficulties for two co-mothers during their partners’ pregnancies, as presented in these two case studies. Co-mothers may need access to lactation support during the antenatal period, which may require new national policies around who is a patient in maternity care. Visitor policies for postnatal and neonatal wards need to take account of breastfeeding co-mothers and perinatal mental health services should be aware of individuals who may have been both the pregnant parent and the non-pregnant parent at different times in their reproductive history. Making these adjustments will prevent other parents from receiving inadequate care, such as that demonstrated by these case studies.
Key points
- In some same-sex families, the non-gestational mother may intend to breastfeed her baby, either alongside or instead of the gestational mother.
- During COVID-19, there were strict visitor restrictions to postnatal wards, which were based on heterosexist assumptions about infant feeding.
- These two case studies highlight difficulties faced by lesbian co-mothers, as the heterosexist policies caused significant distress, made access to lactation support difficult and limited babies’ access to human milk.
- Policies must be updated to reflect that some babies have two mothers, who may both wish to feed their baby.
CPD reflective questions
- Where do the services that I work within make heterosexist assumptions?
- Where within my own practice might I make assumptions about sexual orientation or parent's roles?
- Can I undertake activities that improve the inclusivity of the services I work within?
- Do I have the knowledge and skills to support a non-gestational mother who wishes to breastfeed?
- How can I update my knowledge about LGBTQ+ parents’ needs?