Midwifery is an increasingly changing profession, as the complexities and challenges midwives are presented with continue to grow (Royal College of Midwives (RCM), 2017). The rise in maternal co-morbidities, policy changes, national drives for clinical improvement and continued staff shortages have created an ever demanding and technically proficient role. Alongside competent clinical ability and sound theoretical knowledge, it is vital that midwives have a comprehensive understanding of individual diversities, including sexual orientation, and how they may directly impact care requirements (Nursing and Midwifery Council (NMC), 2021a).
Under current legislation, individuals who identify as part of the lesbian, gay, bisexual, transgender, queer and others (LGBTQ+) community are protected when accessing healthcare by equality, duty and quadrennial reviews of objectives (Ministry of Justice, 2012), the Human Rights Act (1998) and the Equality Act (2010). The NMC's (2011) equality and diversity strategy also aims to safeguard persons by implanting equivalence at the centre of duty, in partnership with the compassion in care strategy (Serrant, 2016) and the 6 Cs of healthcare (NHS England, 2015).
Despite government efforts and educational standards to improve egalitarianism, there remains evidence that LGBTQ+ individuals experience disproportionate health inequalities and poorer clinical outcomes (NHS England, 2019). Historically, some people identifying as LGBTQ+ received suboptimal care in response to their sexual identity, because of both direct discriminative factors and poor midwifery staff awareness (Wilton, 1999; Hinchcliff et al, 2005; Bjorkman and Malterud, 2009). Wilton and Kaufmann (2001) identified elevated levels of anxiety among lesbian mothers in relation to maternal awareness of personal prejudices projected by midwives. These included exemption to care based on cultural or religious belief (although it is illegal to refuse care based on sexuality in the UK as a protective factor under the Equality Act 2010), pre-conceived homophobic ideals, poor individual understanding, and midwife embarrassment. Spidsberg and Sorlie (2012) recognised these concerns were still present 10 years later.
There was a 40% increase in the number of LGBTQ+ families between 2015 and 2019, with 2.7% of the UK population identifying as LGB in 2019 (Office for National Statistics, 2019), and 3.3% identifying as such in 2022 (Office for National Statistics, 2023). Although lesbian motherhood is not a new occurrence (Hodson et al, 2017), rising disclosure rates and changes in legalities surrounding homosexual rights (Gov.uk, 2014) imply a rise in parenthood and access to midwifery services. Research has shown that LGBTQ+ individuals continue to experience discrimination in midwifery settings, highlighting a need to improve standards of care for lesbian women and co-parents (Arias et al, 2021; McCann et al, 2021).
Alongside consideration for the possible challenges that the LGBTQ+ community face in healthcare settings, midwives require an in-depth understanding of the secondary health inequalities encountered by lesbian and gay mothers. The health and social care and LGBT communities enquiry (UK Parliament, 2019) demonstrated that women who identified as LGBTQ+ experienced higher incidence of poor mental health. Public Health England (PHE, 2018) published a review inclusive of lesbian women's health inequalities. In addition to poor mental health, the report highlighted four key areas: increased teenage conception, smoking and substance misuse, self-reported musculoskeletal concerns and cardiovascular disease and hypertension. These are suggestive of increased maternal co-morbidities and mortality in the perinatal periods (MBRRACE, 2019; Todhunter et al, 2022).
Additional evidence has described fetal concerns of mothers who demonstrate these features, including growth restriction, compromised neurological development, miscarriage and stillbirth (Royal College of Obstetricians and Gynaecologists, 2011; 2015; Lund et al, 2025). Although the complexity of maternal comorbidity and fetal compromise is outside of the scope of this study, it is important to recognise the correlation.
In addition to secondary health concerns, there are well-documented risks from a societal stance. Chronic minority stress is frequently reported among stigmatised minority groups and has a multitude of causes, including lower socioeconomic standing, limited social support and discrimination responses to the minority feature (Boskey, 2020). Chronic minority stress has been widely documented among lesbian communities (Heron et al, 2018). Additionally, 44% of lesbian women, in comparison to 35% of heterosexual women, have experienced intimate partner violence, sexual violence and stalking (Domestic Shelters, 2015). These statistics are supported by the National Coalition Against Domestic Violence (2018) and Galop (2021). It is known that domestic violence is more likely to occur during pregnancy (NHS, 2021), meaning midwives have a crucial role in the detection, support and protection of women at risk. It is essential that practitioners are aware and screen for additional risk factors that may complicate the care pathway when caring for lesbian mothers. It is also imperative to be mindful that all factors may be compounded by age, ethnicity, faith, disability or social class (PHE, 2018) and are not applicable to all.
Contrasting reviews of lesbian women's maternity experiences have been available for over a decade (Wilton, 1999; Jackson, 2003; Dibly, 2009), all with similar recommendations for practice: increase awareness for clinical staff, increase individualised care for lesbian women and partners and decrease personal/institutional discrimination. Midwifery care and clientele experience can greatly enhance clinical outcomes (RCM, 2018), a philosophy that was applied to the present study, with the overall objective to promote holistic care values for lesbian and gay mothers. The facilitation of care for lesbian mothers and the effects of midwifery on their experiences is an understudied area of practice, which this study intended to address. By broadening the evidence base for lesbian parenting, the author aims to improve midwifery understanding and women's encounters with midwives.
In response to the dated research, limited resources and evolution of service user's needs, this study explored the encounters of birthing lesbian and gay mothers accessing midwifery services and their interpretations of the care they received. The study aimed to identify whether lessons have been learned, prompting the degree of system-level change that actively improves service users' experiences.
Methods
This was a qualitative, phenomenological study of lesbian and gay mothers' experiences of midwifery care. A hermeneutic phenomenological framework was followed to promote the fusion of lived experiences with current knowledge and clinical practice. Author pre-understandings were identified and an open view to potential prejudices were reflected upon, prior to interview. Transcribed datasets and field notes were reviewed at multiple stages in conjunction with self-reflection to improve immersion with theme development and reduction in bias infiltration (Alsaigh and Coyne, 2021)
Participants
A purposive sample of 10 participants were recruited via social media. Voluntary recruitment was facilitated through Facebook social media adverts approved by admins via a specialised group for LGBTQ+ parents. The sample size of 10 was deemed appropriate for data saturation in view of the single researcher restraints and academic guidance from facilitators.
Inclusion and exclusion criteria were used to engage participants who would best represent the target population. Participants were required to be over 18 years old, have received care in the UK within the last 5 years, be the birthing parent and identify as a lesbian or gay mother. Ongoing litigation in relation to maternity care was excluded. These criteria reduced discussion of unrelated information and supported ethical protection.
Data collection
In-depth data were collected using semi-structured interviews to explore all areas of maternity care. Interviews were transcribed. Virtual interviews were conducted in June 2021 to facilitate flexibility with timing and adhere to social distancing measures. Semi-structured questions were asked to allow for full disclosure of phenomena and guide the direction of conversation to reduce extraneous data. Questions included ‘can you describe your pregnancy/birth/postpartum experience to me?’ and ‘what impact did that have on you?’. The remaining questions were unstructured and followed appropriate, impartial response to the conversation.
The booking appointment is the primary opportunity for women to disclose their sexuality, confirm preferred names/pronouns and discuss any additional care needs relating to physical and psychological status (National Institute for Health and Care Excellence, 2019). General health questions were asked of all women to determine any additional factors that may have impacted their care, as well as identify the model of care they followed. For intrapartum care, information was collected on type of labour, location of care and mode of birth. These details allowed the researcher to identify the team who provided care and recognise any pre-known barriers, for example how busy an acute setting can be (Lund et al, 2025) or psychological discomfort from an emergency scenario (Taghizadeh et al, 2013).
Data analysis
Data were analysed thematically per Lochmiller (2021). Reoccurring topics were open coded and clustered. Potential key themes were created. Transcriptions were re-reviewed following multiple short break periods, selective codes confirmed and revised themes generated. To reduce interpretation bias of the dataset, themes were discussed with an impartial academic tutor, alongside researcher response field notes that were completed during interview. All four primary components were considered to increase research rigour through the implementation of basic member checking, code-recoding, audit trail, simple data triangulation and transferability through thick descriptions.
Ethical considerations
Ethical approval was obtained from Anglia Ruskin University Ethics Committee (reference: FREP20/21/023). The pronouns she/her were confirmed with all participants prior to application. Prospective participants were signposted to additional information via encrypted email. Following the opportunity to ask questions and seek advice, participants were provided an electronic consent form inclusive of the right to withdraw. On receipt of informed consent appointments were made to complete data collection. All personal data were collected and stored in compliance with general data protection requirements and the Data Protection Act (2018). Data were anonymised and numerical identifiers were used.
Results
The participants' demographic details are shown in Table 1. The majority of the participants were White British (70.0%), aged 30–35 years (80.0%), employed full time (60.0%) and experienced midwifery led care (70.0%). Most of the participants reported having no mental health concerns (60.0%).
| Characteristic | Frequency, n=10 (%) | |
|---|---|---|
| Ethnicity | White British | 7 (70.0) |
| White and Black Carribean | 2 (20.0) | |
| Any other White background | 1 (10.0) | |
| Age (years) | 25–30 | 2 (20.0) |
| 30–35 | 8 (80.0) | |
| >35 | 0 (0.0) | |
| Employment | Unemployed | 0 (0.0) |
| Part-time | 4 (40.0) | |
| Full-time | 6 (60.0) | |
| Model of care | Obstetric-led | 3 (30.0) |
| Midwifery led | 7 (70.0) | |
| Mental health concerns | Anxiety | 1 (10.0) |
| Depression | 1 (10.0) | |
| Both | 2 (20.0) | |
| None | 6 (60.0) |
There were four themes: disclosure of sexual orientation; heteronormative language; communication and behaviour towards the non-biological parent, homophobia and stigmatism (including religious teachings and cultural philosophy); and a desire for normality.
Disclosure of sexual orientation
When asked about the opportunity to disclose sexuality, all participants reported indirect facilitation to ‘come out’ to their midwife. All 10 participants experienced similar conversations where their sexuality was outed among general booking questions, as well as the assumed use of pronouns. None reported a separate question that directly asked how they identified. When asked how they viewed the initial encounters regarding their sexual orientation, five participants were impartial. The sentiment that care was not altered was well received using terms such as ‘we're the same’ and ‘it's not a big deal’. The other five participants reported dissatisfaction and their sexuality being ‘brushed over’ or ‘unimportant’.
The participants' interpretation of the booking appointment appeared to surround terminology and appropriate use of language. All participants commented on the mannerisms of what was said, rather than the content. None of the participants reported direct discriminative factors. The researcher did note frequent referrals to ‘normal’ and a perceived desire to be described as such.
‘Although we didn't talk directly about us being lesbians, we didn't need to. She just accepted it and treated us like normal people’.
Only four women attended antenatal education classes, with two highlighting that they feared attending.
‘I was worried the classes wouldn't be aimed at couples like us, and that other parents might look at us differently’.
‘I just didn't want us to feel weird, you know? It bothered me, so we just didn't sign up’.
The four women who did attend antenatal care reported impartial experiences. They were satisfied with the level of information provided; however, all education was delivered with a heteronormative approach and no consideration appeared to be given to families outside of this dynamic.
Regarding intrapartum care (Table 2), all 10 women reported having to disclose their sexuality and family dynamic to each midwife who cared for them during the first stage of labour.
| Variable | Frequency, n=10 (%) | |
|---|---|---|
| Labour | Spontaneous | 6 (60.0) |
| Induced | 4 (40.0) | |
| Mode of birth | Elective caesarean | 0 (0.0) |
| Unassisted vaginal | 5 (50.0) | |
| Instrumental assisted vaginal | 3 (30.0) | |
| Emergency caesarean section | 2 (20.0) | |
| Location of care | Midwifery directed unit | 3 (30.0) |
| Obstetric unit | 7 (70.0) |
‘Most of my labour was pretty good, great to be fair. I had an epidural, so I was comfortable, and we had the same midwife for her whole shift. The only problem we had was when she went on break, with the lady who took over … The midwife barely spoke to us, but when we mentioned two mummies, she kind of sucked her teeth. We live in the city and know what that means, it was embarrassing … so we just stopped talking and waited for [midwife] to come back. Thankfully she didn't come to theatre with us … [Her reaction was] like a way of saying something is wrong, or you don't agree. Like because we're gay, she didn't agree with us having a baby’.
The remaining nine participants did not specify any direct discriminatory concerns with their care related to their orientation. The overall feedback was positive or impartial.
Communication and behaviour towards the non-biological parent
Secondary to repetitive disclosure and avoidance of acknowledgement, additional comments were made regarding a lack of midwives and a task orientated philosophy among the multidisciplinary team. Six participants reported an error in parental naming at some or multiple stages during the birth of their child, particularly during emergency scenarios where the team attended for short periods of time.
‘I just remember getting rushed for a caesarean due to baby's heart dipping quite low. It was really scary, and I felt completely out of control … someone said, “dad needs to sit here” … I was so upset, even at this stage in my labour no one had a clue about our family’.
‘As baby was put on my chest, the doctor asked if dad would like to cut the cord, [partner's] face dropped, and she looked so embarrassed. What had been a difficult birth was made harder by the fact the team of doctors were oblivious. The midwife was great though, she corrected him without missing a beat’.
Homophobia and stigmatism
Two of the participants (5 and 6) reported high levels of care and were happy with their birth experiences overall. However, one recalled an event that they felt demonstrated direct discrimination during second stage labour.
‘[The midwife] refused to look after me. They stood in the corner as the first midwife told her my history and what had been happening. When [the midwife] said we were a lesbian couple and [partner] was my wife, the new midwife looked at us disgusted, looked back at the other midwife, and said “no I can't”. She asked to speak to her outside the room and never came back in. About 10 minutes later, our first midwife came back in, she looked as awkward as we felt, she explained someone else was coming to take over, she wished us well and left. I'd already been told I was at 10cm and we were just waiting for baby to come down, those 10 minutes felt like hours’.
The participant was asked how they interpreted the refusal to care, reporting that they felt it was because of their sexual orientation.
‘It's because we're lesbians. She made it so obvious. I've never in my life been looked at with such revulsion. We never saw her again, but she tainted the whole experience. It felt like everyone we then came across knew, which is probably crazy to think, but that's how it felt. I don't know what her problem was, we never asked, no one spoke about it, and we didn't complain. We just wanted our baby and to go home. It was heartbreaking to see we still live in that world where homophobia comes before patients’.
The participant confirmed her labour was uncomplicated and the birth assisted via kiwi. There were no other complaints surrounding her care, but the single prejudiced event tarnished the entirety of her experience.
‘It took me a few weeks to get over. It really played on my mind that we had brought our baby into a world where they will still be looked at funny or treated differently for having two mums. I even felt guilt for some time that I'd done that to him. Looking back now, I may have experienced some symptoms of depression’.
The support they received from their wife, friends and family helped them to recover from the event, and they came to view the experience in a different light.
‘My wife was incredible, and our family and friends. After we had told them what had happened, we spoke about it in depth. We've landed in a place where we feel sorry for that midwife, not ourselves. Sorry that she holds onto these outdated views and is incapable of opening her mind. That's why I wanted to do this interview, if we can change the story for just one lesbian couple like us then that's what we should do’.
This participant's experience of perceived homophobic practice was the most distinct report. The remaining nine participants shared concerns regarding use of language, mannerisms and subtle actions, but no other events of refusal to care occurred. There were shared concerns with regards to staffing levels, the commotion of the units and midwives' time to care, but these were not related directly to sexual orientation.
There were no significant accounts of negative experiences in the third stage of labour or immediate postnatal period, and these were generally rated positively (Table 3). All participants confirmed they were supported with their infant feeding choice and skin to skin contact where desired. Largely the postnatal experiences discussed were positive regarding the accommodation of sexual orientation and there were no perceived prejudiced recollections. Four participants re-encountered errors in terminology alongside inappropriate questions, such as ‘will the dad be involved’ or ‘do you know the dad’, together with general misunderstanding. However, these errors were considered to be the result of poor LGBTQ+ education, not purposeful misdemeanour. All women reported postnatal care in their homes was of good standard.
| Variable | Rating, n=10 (%) | |||||
|---|---|---|---|---|---|---|
| Very poor | Poor | Impartial | Good | Very good | ||
| Antenatal care | 0 (0.0) | 0 (0.0) | 2 (20.0) | 4 (40.0) | 4 (40.0) | |
| Labour care | First stage | 1 (10.0) | 2 (20.0) | 0 (0.0) | 4 (40.0) | 3 (30.0) |
| Second stage | 1 (10.0) | 1 (10.0) | 0 (0.0) | 5 (50.0) | 3 (30.0) | |
| Third stage | 0 (0.0) | 0 (0.0) | 1 (10.0) | 7 (70.0) | 2 (20.0) | |
| Overall | 2 (20.0) | 1 (10.0) | 0 (0.0) | 5 (50.0) | 2 (20.0) | |
| Postnatal care | Acute | 0 (0.0) | 0 (0.0) | 1 (10.0) | 8 (80.0) | 2 (20.0) |
| Community | 0 (0.0) | 0 (0.0) | 0 (0.0) | 3 (30.0) | 7 (70.0) | |
Discussion
This study explored lesbian and gay women's experiences of midwifery care across the antenatal, intrapartum and postpartum stages. The participants described a range of experiences, with the majority reviewing their overall care as good. High importance was placed on communication in all formats, predominantly concerning the opportunity for sexual orientation disclosure and the use of correct pronouns (Miller and Smith, 2020).
Disclosing sexuality
Sexuality disclosure in midwifery is an understudied area. The anticipation of a poor reaction is a dated concept in healthcare and society (Puckett et al, 2015), with fear of judgemental prejudices and isolation from treatment being widely documented (Government Equalities Office, 2019; Nava, 2020; Philipps, 2021). Many LGBTQ+ individuals report a fear of exposing their sexuality to healthcare professionals because of previous health encounters, social stigmatisation, peer victimisation or childhood/familial dismissal (Hafeez et al, 2017). Lesbian women may feel vulnerable at the prospect of ‘coming out’, needing to consider the safety of their environment, any alterations in care they may receive and the midwife's response (Lai-Boyd, 2020).
All the present study's participants reported repetitive indirect disclosure with no direct opportunity to discuss personal identity. The assumption of a heterosexual partner was reported at multiple stages, despite previous disclosure of a same-sex relationship. The identification of boundaries related to heteronormative midwifery services are not new concepts (Gregg, 2018; McCann et al, 2021). Ongoing societal norms for family dynamics to consist of heterosexual counterparts (Stewart and O'Reilly, 2017) continue to isolate some lesbian mothers from inclusive midwifery care and greatly influence overall experience.
The initial booking appointment should include discussion of sexual orientation, preferred pronouns and partner details, where relevant. Communication has been recognised previously as an area for improvement (Rypkema, 2020), but there are limited recommendations to amend clinical documentation or implement fixed conversations to facilitate sexual orientation discussions. The documentation of ‘father’ details is repeatedly seen throughout midwifery reference, including the initial pregnancy contact NHS (2018) page. These alterations would enable all professionals to read pertinent information and remove the need for repetitive disclosure. Alterations to official health resources to incorporate inclusive language may assist in reducing initial levels of maternal anxiety when accessing midwifery services (Hayman et al, 2013) and demonstrate progressive changes for equality nationally.
Language and communication
The present study's participants expressed a fear of rejection when accessing antenatal education. Two participants purposefully declined the opportunity to attend group classes because they were apprehensive of being marginalised. Evidence has previously highlighted a heteronormative approach to antenatal education. Engström et al (2018) reported that women perceived the term ‘parents’ to be applied to a mother-father dynamic, which translated into the information provided. They identified a deficiency in psychological support, particularly in relation to conception choices and the use of a donor, alongside an avoidance of identifying the specific needs of lesbian parents. Lesbian women are now offered LGBTQ+ specific antenatal classes in some UK trusts and countries such as Sweden, demonstrating a progressive, culturally sensitive maternity service (Malmquist, 2016).
All participants referred to communication that determined their satisfaction with care. Communication is considered part of the fundamental framework of midwifery (Astrup, 2018), acknowledging the power of words, body language, tone of voice and appropriate use of touch (Gibbon, 2010). Andersen et al (2017) identified a perceived sense of disregard and alienation from clinical staff among lesbian women. The terminology and approach to care reflected a heterosexual society from which women felt isolated. Engström et al (2022) described additional levels of parental stress in correlation with heteronormative information.
This study's findings support globally recognised language barriers faced by lesbian mothers (Brennan and Sell, 2014). The participants described experiences where healthcare professionals assumed pronouns or expected a male parent to be present in acute settings. The use of incorrect pronouns and misgendering is an understudied element of psychological welfare. Reisner et al (2016) discussed the damaging effects of ignorance towards an individual's identity, supported by Karjalainen (2020), highlighting a higher prevalence of poor psychological symptoms and detrimental effects on wellbeing. Correct use of language was considered basic competency and failure to facilitate enabled discriminatory oppression on a systemic level. This has been recognised in both the present study and other research (Stewart and O'Reilly, 2017).
The lack of recognition of participants' sexual orientation further endorsed heteronormative culture. Evidence has suggested midwives may be unaware of the effects of language; a generalised presumption that women treated with kindness and respect will overlook errors in language has been highlighted, although more recent research in this area is limited (Rondahl, 2005; Spidsberg and Sorlie, 2012; RCM, 2022). Perceived alienation, lack of recognition and hostility in response to communication between healthcare professionals, mothers and non-biological parents have previously been highlighted (McKelvey, 2014; RCM, 2022). The present study emphasises the damaging effects of miscommunication and a lack of awareness of LGBTQ+ sensitive language. Although the field of research is limited, midwives are positioned to promote diversity and equality when caring for lesbian families.
Homophobia
Homophobia in midwifery is based on factors that influence human behaviour in response to female homosexuality. Historically, in medical and social literature, homosexuality has been depicted as a disorder or crime (Wyatt-Nichol, 2014) and remained on the World Health Organization list of diseases until 1990 (Drescher, 2015).
Although many women reported positive experiences, all women identified limited LGBTQ+ awareness during their care. Cultural competency is an essential aspect of global midwifery and remains an area for improvement in the UK (RCM, 2021). Participants described apparent discomfort portrayed by several clinicians, although no obvious conclusion as to the cause. Spidsberg and Sorlie (2012) previously identified anxiety or ambivalence among midwives caring for lesbian women because of uncertainty surrounding individual needs and associated health disparities. Although these apprehensions were innocent in origin, they caused disturbances in the woman-midwife relationship and on occasion were interpreted as indirect intolerance.
Cuncic (2021) documented that the leading motivations for LGBTQ+ aversion include religious teachings, cultural philosophy, repressed desire and institutional dominance. The relationship between religion and homosexuality is complex and controversial. Many religions hold teachings on sexuality, and an individual's interpretation of these teachings may influence their acceptance and behaviours towards LGBTQ+ parents. Additionally, lesbian women may have their own pre-conceived ideas of a religious person's views. With the historical denouncement of homosexuality throughout religion, women may perceive their midwife to be intolerant of their orientation based on their faith rather than their actions, leading to a misinterpretation of behaviour and an expectation of homophobia (Zuckerman, 2017).
One participant reported that a midwife refused to care for them during their birth, an event that significantly impacted their experience of care. The NMC (2021b) code allows midwives to conscientiously object to caring for women undergoing a termination of pregnancy and technological conception of pregnancies; however, there is no guidance for those who object to lesbian motherhood. The moral obligation to deliver kind, compassionate care and remain true to one's faith, which may hold negative views of LGBTQ+ parents, may prevent acceptance and directly impact quality of care (Audi, 2011). Under the protective characteristics in UK law, it is illegal to refuse care to a patient based on sexuality, regardless of one's personal belief system (Equality Act, 2010). The impact of religious influences on the care of lesbian and gay women requires independent investigation; however, institutions must remain aware of LGBTQ+ global marginalisation throughout orthodox practice (Tamim, 2019) and how care could be directed by faith.
Social stigmatism of lesbian parents remains a common challenge and may include psychological taunting, social exclusion or even extreme physical hate crime (Mijatovic, 2021). As the midwifery workforce originates from many backgrounds, women are likely to meet practitioners with varying levels of societal acceptance and influence. The inclusion of LGBTQ+ curricula in higher education may reduce intolerance among students who will go on to become midwives (Stonewall, 2019). A full examination of cultural influences on homophobia in midwifery is outside the scope of this discussion. However, it is imperative that healthcare professionals consider the implications of societal views surrounding same-sex relations and parenting, to understand the vulnerabilities faced by lesbian women. Demographic details may directly impact the care provided and the interpretation of care received (Snively et al, 2008).
Desire for normality
Many participants in this study placed importance on being considered ‘normal’. Lacaillade (2018) described the perception of normal as the interpretation of an individual on oneself or others. The term ‘normal’ has proven problematic in midwifery and healthcare in many remits, from the description of normal birth (Ewers, 2018) to the association of normal behavioural characteristics (Neuman, 2013). However, midwives should be aware of the depiction of normal and features that may lead mothers to feel excluded. The desire to be ‘normal’ may even be the result of internalised homophobia or previous direct/indirect discrimination (Ong et al, 2021). As midwifery moves away from abnormal/normal terminology in practice, midwives must promote inclusion and reject the concept of orientation abnormality.
Implications for practice
To improve clinical confidence when caring for lesbian women, additional education is required. Further training in LGBTQ+ cultural awareness has been suggested previously at all levels of education. Idnani (2021) discussed the positive impact of LGBTQ+ curricula being added to the education standards of all age groups at school. Levels of homophobia in UK schools are increasing at exponential rates (Soteriou, 2021), supporting the demand for additional educational resources from school age to pre- and post-registration. Resources can be delivered both face-to-face and via e-learning to accommodate all learning styles, time restraints and distance learning. With the changing demands of lesbian mothers and growing LGBTQ+ network (Gabb, 2017), the importance of up-to-date, accurate guidance is essential to facilitate inclusive, individualised care. The level of LGBTQ+ awareness has not readily been assessed among the midwifery workforce; however, the evidence surrounding acceptance in healthcare and education encourages the recommendation for additional training.
Despite vast improvements in cultural acceptance and implementation of LGBTQ+ awareness (NMC, 2019), the participants' accounts of intolerance demonstrate the continued need for improvement. Multiple influences may lead a practitioner to demonstrate LGBTQ+ discrimination, including religious, cultural and societal norms. Further research is required to explore these influences in midwifery.
To reduce direct homophobia, it is vital that trusts implement a zero-tolerance philosophy at an institutional level. ‘Standing against homophobia’ was the first NHS campaign to tackle homophobia in healthcare (NHS Greater Glasgow and Clyde, 2012), highlighting that discrimination based on sexuality by patients, staff or visitors would be treated as seriously as sexism, racism or any other form of bigotry. Additional campaigns may assist in bringing this topic to the forefront of conversation. It is essential for progression in acceptance that homophobia remains part of a dialogue for improvement.
NHS England hosted the second virtual Pride week to demonstrate equality, promote education and increase awareness for both staff and patients (NHS Devon Partnership NHS Trust, 2021). The NHS rainbow badge initiative also displays similar concepts of LGBTQ+ equality and diversity (De Santos, 2021). Despite these steps at a systemic level in the NHS, further improvement is required to continue working towards eliminating homosexuality discrimination. To further increase the comfort and confidence of lesbian and gay mothers, health trusts may consider appointing specialised teams, which have proven beneficial among many groups of individuals where additional needs have been identified (RCM, 2016; Global Pre-Meds, 2016). Dedicated teams allow specific practitioners to develop advanced knowledge related to the needs of LGBTQ+ parents. These practitioners would be able to advance trust awareness and deliver teaching to their colleagues. In response to the Better Births report and the implementation of carer continuity (NHS, 2017), these teams may develop and assist in leading patient caseloads to improve outcomes and experiences at a national level.
Limitations
As with all research, this study has limitations (Ross and Zaidi, 2019), primarily as a result of the single researcher approach, which influenced the design, pace and evolution of the study, ethical approval, social distancing measures at the time of completion and the limited availability of pre-existing literature.
Women without social media access were excluded from the sample, representing a limitation of the recruitment methods. Additionally, consideration should be given to the quality of rapport obtained virtually and the time constraints of the single researcher. Responses should be interpreted with caution, as participants may only represent extreme positive and negative practice. Furthermore, there was no representation of mothers under 25 years old or above 35 years old and ethnic diversity was limited. An increased need for research and awareness has been identified through available literature relating to health disparities of Black and minority ethnic groups (RCM, 2020). However, combined features of LGBTQ+ and minority ethnic groups are outside of this study's remit.
Conclusions
Supplementary research is required to explore clinical staff experiences and the wider LGBTQ+ community in maternity services. The recommendations made based on the present study's findings support ongoing work for LGBTQ+ equality in midwifery and the psychological wellbeing of lesbian and gay mothers. Increased occurrence of mental health concerns and associated disruptive coping mechanisms continue to be recognised in relation to lesbian and gay women. Individualised pathways of care may further influence psychological wellbeing. Through additional education, embedded institutional acceptance and specialised teams, the holistic health of lesbian and gay mothers can be improved.