Attitudes towards homosexuality have transformed considerably in the last 20 years. As recently as 1990, homosexuality was removed from the World Health Organization (WHO) list of diseases, whilst today public acceptance of same-sex families has dramatically increased (Burkholder and Burbank, 2012). Various legislation in UK, for example the Civil Partnership Act (2004), the Equality Act (2010) and most recently, the Marriage (Same Sex Couples) Act (2013) now safeguard the rights of homosexuals and provide legal recognition of their relationships. Technological advances in reproductive science have also enabled same sex couples to contribute to the creation of a baby, causing a shift in the societal paradigms associated with parenthood (Margalit et al, 2013).
The new legislation, advances in fertility technology and lessening societal constraints have all led to a rise in the number of same sex couples becoming parents and therefore requiring maternity care (McMannus et al, 2006). In 2009 there were just 24 births registered to same sex parents in the UK, which rose to 475 in 2010, and 608 in 2011 (Office for National Statistics, 2013). Subsequently, midwives and other health professionals in maternity settings are increasingly encountering same sex couples in their practice (Cherguit et al, 2012). The Nursing and Midwifery Council (NMC) requires that nurses and midwives practice women-centred care which is not discriminatory of sexuality, and to treat partners and families with equal respect (NMC, 2008). Therefore, gay men and lesbian women are entitled to the same non-discriminatory services that are provided to heterosexual women and their families. This literature review will explore how same sex couples perceive their care in the midwifery setting.
Methodology
Relevant literature was collected using a comprehensive search strategy using the following keywords ‘same sex OR lesbian OR gay OR homosexual AND maternity OR birth OR midwife*’, which was applied to general internet search engines as well as CINAHL, Maternity and Infant Care, SAGE and Wiley Online. A date limit of 2004 to the present was used. Although earlier evidence may be useful in providing historical context, societal influences are constantly changing and previous research will not be transferable to today's maternity care provision (Aveyard, 2010). Therefore, it is essential to use contemporaneous evidence within the last 10 years (NMC, 2008).
The studies used in the analysis have not been limited to the UK because noteworthy variances may emerge with differing cultural and legal factors; however, it is imperative to acknowledge the impact of place of publication (Song et al, 2010). The search resulted in 13 studies from around the world. No research was found to include gay men, and so the focus of this literature search is predominantly focused on lesbian mothers. The articles were analysed and their main findings recorded in a theme matrix. Three major themes were identified:
Theme 1: Attitudes of the health professional
Homosexuality can be regarded as a social determinant of health, due to increased associated morbidities, such as substance misuse and mental health disorders, possibly due to social stigma and discrimination (Chakraborty, 2011). Health risk behaviours, for example in relation to sexual health and wellbeing, is also an issue for this group of service users (Coker et al, 2010). These may be exacerbated by the under use of healthcare due to fears of homophobia from health professionals. Negative experiences can affect the decision to disclose sexual orientation in the future or seek medical advice altogether (Weisz, 2009). This review demonstrates an improvement in the attitudes of health professionals, with historically overt homophobia subsiding; lesbian women now seem to encounter overall positive care within maternity, with some areas of more subtle homophobia (Larsson and Dykes, 2007; Spidsberg, 2007; Lee et al, 2011; Dahl et al, 2012; Malmquist and Nelson, 2013).
‘The co-mother's role in pregnancy and childbirth is an integral aspect of both women's journey to parenthood.’
Perceptions of positive attitudes are formed when health professionals exhibit a relaxed disposition, take interest into the unique situation, and give sensitive responses (Dahl et al, 2012). Goldberg et al (2011) show that playful jokes and good humoured dialogue are beneficial in demonstrating comfort from the health professional; however this must be done in the appropriate context. Spidsberg and Sorlie (2011) explored the perspective of the midwife. Midwives may feel tactful in the initial exchange, for fear of unintentionally causing offence, leading to a feeling of awkwardness. However, this preliminary discomfort is often overcome.
While the majority of care provision was reported to be positive, homophobia can be perceived, for example, through lack of eye contact (Larsson and Dykes, 2009; Dahl et al, 2012; Goldberg et al, 2013). Lesbian women and their partners reported feeling disempowered when health professionals were unable to maintain eye contact—a basic communication skill (Dahl et al, 2012). Inappropriate questions can also be interpreted as homophobia (Spidsberg, 2007; Erlandsson et al, 2010; Lee et al, 2011; Spidsberg and Sorlie, 2011; Chapman et al, 2012; Dahl et al, 2012; Hayman, 2013). Although taking an interest in the woman's lifestyle can positively impact the midwife-mother relationship, the midwife must avoid asking questions that only serve to satisfy her curiosity. Insensitive questions and an over-focus on sexual orientation may cause the woman to feel that the legitimacy of their relationship is doubted. The women may also feel like their roles have become reversed and they are now the educators of the health professional (Dahl et al, 2012).
Women who experience negative attitudes find it difficult to differentiate between homophobia and professional incompetence. Dahl et al (2012) suggest that women believe that the health professionals may be ‘having a bad day’ or have general poor communication skills, rather than acting with deliberate homophobia. In contrast, Lee et al (2011) believe that women who make these judgements are simply rationalising their poor care in order to protect themselves. Their article suggests that the new legislation has not eradicated homophobic practices, but is instead hiding them (Lee et al, 2011). However, it is impossible to judge conclusively whether the women in the studies experienced true homophobia, as unspoken prejudices are not measurable.
Theme two: Involvement of the co-mother
The co-mother's role in pregnancy and childbirth is an integral aspect of both women's journey to parenthood. Women find that recognition of the ‘two-mum’ family is essential in confirming their parental identities (Erlandsson et al, 2010). Homosexual parents still face negative stereotypes about their families, such as they will raise homosexual children, or have children who are bullied at school (Dahl et al, 2012). Midwives must not reinforce these stereotypes, but instead should actively celebrate the uniqueness of the family unit (Spidsberg and Sorlie, 2011).
Studies report that co-mothers appreciate doing ‘dad things’ (Erlandsson et al, 2010; Dahl et al, 2010). By encouraging them to ‘cut the cord’ or stay overnight in the postnatal ward, comothers feel that midwives value their support as much as that of a father (Erlandsson et al, 2010). Goldberg et al (2012) also recommend asking what their child will call the two mothers. This may demonstrate acceptance of both women as legitimate parents and allows midwives to use these names in the same way as they say ‘Mum and Dad’ to a heterosexual couple (Goldberg et al, 2011).
Larsson and Dykes (2009) suggest that antenatal education was the strongest criticism of care provision. In some cases, non-birthing mothers were asked not to attend, to avoid other parents feeling uncomfortable (Dibley, 2009). This refusal of care directly contradicts the NMC Code (2008) which states that midwives must provide care to all women, regardless of sexual orientation. Some midwives also divide antenatal classes into ‘mother’ and ‘father’ groups, putting the co-mother in an uncomfortable position (Erlandsson et al, 2010). Non-birthing mothers often find themselves identifying with both mother and father roles in their parental identity, and asking them chose which group they belong to can evoke uneasy emotions (Padavic and Butterfield, 2011).
In the study from Goldberg et al (2011), nurses commented that they would not provide care to a lesbian couple in a different way to heterosexual parents. On the surface, this may seem to indicate a lack of discrimination. However, lesbian parents, particularly the co-mother, have very different needs and emotions to their heterosexual counterparts (Cherguit et al, 2012). Some co-mothers fear that they will not bond with the newborn; this is different from the transition to fatherhood for men, as they are likely to not be biologically related (Hargreaves, 2006). Pregnancy and labour may also evoke jealousy for a co-mother who wishes to carry the baby (Rapheal-Leff, 2011). Awareness of the emotions faced by the co-mother are essential in order to facilitate a nurturing environment. Therefore midwives must not treat lesbian mothers ‘like any other’ mother, but should instead recognise the differing pressures on these mothers (Goldberg et al, 2011). A resounding conclusion from most women was the need to be treated the same as others but with special consideration given to their unique situation (Larsson and Dykes, 2009; Erlandsson et al, 2010; Dahl et al, 2012; Malmquist and Nelson, 2013).
Theme three: Invisibility of the lesbian client due to heteronormativity
Heteronormativity refers to the ideology that a valid relationship must consist of a man and a woman, with heterosexuality being the ‘norm’ (Cronin, 2005). In healthcare, the assumption that pregnant women are heterosexual is a detrimental but common occurrence (Hayman et al, 2013). The literature highlights obvious heteronormativity in the terminology that midwives use (Porter 2005; Rondahl et al, 2009; Erlandsson et al, 2010; Spidsberg and Sorlie, 2011; Cherguit et al, 2012). Erlandsson et al (2010) highlight the inappropriate use of the word ‘father’ in antenatal care. Women suggest the need for gender neutral language, for example partner or couple, which is inclusive of all sexual orientations and family structures (Rondahl et al, 2009). The midwives in the study conducted by Spidsberg and Sorlie (2011) state that it is essential to ‘turn off autopilot’ and be creative in the use of language for example in antenatal classes, in order to accommodate all couples.
Heteronormativity may be negatively reinforced in written communication as well as verbal dialogue. Hospital forms are often standardised and stereotyped, for example asking for the father's details, leaving lesbian couples embarrassed and confused about how to fill them in (Rondahl et al, 2009). Although it may be important to ascertain health details about the biological mother, it should also be acknowledged in a non-judgemental way that these details are not always available (Rondahl et al, 2009). This is additionally apparent in journals and health care research, which often overlook homosexuals, potentially reinforcing ideologies of heteronormativity for the health professionals that read them (Burkholder and Burbank, 2012).
In addition, hospital policies and guidelines often overlook the needs of lesbian, gay, bisexual and transgender (LGBT) patients, leading to further social exclusion of these minority groups (Fish, 2010). Guidelines have been issued by the Royal College of Nurses (RCN) about the appropriate care of LGBT patients, which provides advice on communication in a positive way (RCN, 2003). However, in terms of maternity care, there is a significant lack of national guidance, with limited publications from the National Institute of Health and Care Excellence (NICE) or the Royal College of Midwives (RCM) that specifically focus on lesbian mothers. The RCM has guidance specifically targeting fathers, including publications under the campaign to ‘involve fathers in maternity care’, (RCM, 2011), but has no equivalent for lesbian women or gay men.
Another form of heteronormativity is the assumption of heterosexuality (Goldberg et al, 2011). As highlighted by Porter (2005), the booking appointment is often an uncomfortable exchange for lesbian women, who must decide whether to disclose sexual identity, and if so, how. Disclosure is important for lesbian women, to enable them to discuss their concerns or family stresses, and ensure involvement of the co-mother (Singer, 2012). However, disclosure relies on a trusting relationship with the midwife, which may be damaged when the assumption of heterosexuality is made (Dibley, 2009). When lesbian women are faced by continual heteronormative assumptions with different health professionals, they may feel the need to ‘come out’ again and again, causing detrimental emotions on a regular basis (Dahl et al, 2012). As explained by Hayman et al (2013), heteronormativity, on both an individual and organisational level, further marginalises a vulnerable group in society, and health professionals must strive to make changes.
‘Midwives' knowledge increases with experience, and so they must find the courage to challenge themselves in unfamiliar situations.’
Discussion
All three themes that arose from the literature search highlight areas in which changes can be made to improve lesbian women's experiences of maternity care (Lee et al, 2011; Cherguit et al, 2012; Dahl et al, 2012). Various authors have recommended increased training in midwifery education (Rondahl et al, 2009; Spidsberg and Sorlie, 2011; Malmquist and Nelson, 2013). There is a significant gap in the training of midwives, where the needs of minority groups such as LGBT individuals must be addressed, including their complex needs and the diversity of family structures. Rondahl et al (2009) also call for specific training on the appropriate questions to ask and the need for gender-neutral language. In this way, the negative experiences raised in the three themes can be challenged for future practice, and midwives would therefore feel more comfortable in providing empowering care.
Some women suggest that the barriers mentioned in the three themes could be avoided if they were cared for by gay or lesbian practitioners, who could relate to their emotions and unique situation (Spidsberg, 2007). However, this recommendation could be challenged as it may be equally perceived as a form of prejudice which reinforces the over-emphasis on sexual orientation. It also may not be achievable due to the restraints regarding disclosure for LGBT practitioners themselves (Mander and Page, 2012). Spidberg and Sorlie (2011) would also challenge this, as all midwives must gain experience in caring for lesbian women. Midwives' knowledge increases with experience, and so they must find the courage to challenge themselves in unfamiliar situations. In doing so, midwives can increase their knowledge of diverse family arrangements, and facilitate a more relaxed and open environment (Lee et al, 2011).
Antenatal education classes may be a particularly negative experience for same-sex parents, where heteronormative language can exclude co-mothers. Various studies recommend developing specialised classes for same sex couples (Rondahl et al, 2009; Erlandsson et al, 2011). It is suggested that groups for same sex parents could focus more on the unique challenges for lesbian mothers, and would address the complexity of transition to parenthood for both women (Erlandsson et al, 2011). This conclusion could be critiqued in terms of its application to healthcare in England. It is questionable how feasible this is in the UK, considering the limited financial resources facing the NHS, and the well-documented shortage of midwives (National Audit Office, 2013). There is an added issue of the potentially small numbers of same-sex parents in a particular area at one time. The theory of ‘othering’ which argues that excluding a minority group can create a barrier of ‘them and us’ should also be reflected on and the implications for practice (Wies, 1995). Differentiating LGBT individuals into their own class may cause further social exclusion for this vulnerable group (Johnson et al, 2004).
Instead of developing specialist classes, or specially trained staff, all midwives should make changes to their individual practices (Dahl et al, 2012). On a personal level, there are many possible improvements that have been highlighted in the literature, for example the use of gender neutral language, eye contact, appropriate questioning, involvement of the co-mother and challenging heteronormative care (Lee et al, 2011; Cherguit et al, 2012; Dahl et al, 2012). The only way that these changes can be made, is if they are implemented in conjunction with the personal reflection of the individual midwifery practitioner, which correlates to professional growth (Forshee, 2012). Midwives must explore their own attitudes, values and beliefs in order to provide truly holistic care (Chapman et al, 2012). It is imperative that midwives address their views to ensure they do not impart prejudicial behaviours, and in doing so will be able to challenge heteronormative rituals (Lee et al, 2011). Further research into the topic is essential.
Limitations
The literature in this search has been sufficient to draw generalised themes and conclusions; however, there are restrictions to the data (Dahl et al, 2012). There were various limitations to the studies included in the literature review, for example the majority sampled were mainly white, middle-class, educated women who were happy to disclose their sexual orientation (Lee et al, 2011; Cherguit et al, 2012; Dahl et al, 2012). It is imperative to conduct further research and analyse the experiences of other sub-groups of lesbian women (Cherguit et al, 2012). There is also a significant lack of research into the perspective of the midwife in the exchange, making it difficult to ascertain the relationships that are formed with this group of women (Spidsberg and Sorlie, 2011). The search resulted in no research that discussed the experiences of gay men seeking maternity care, highlighting a major gap in the literature (Norton et al, 2013). Rabun and Oswald (2009) state that there is disproportionate research focusing on gay men, and we must consider that this group also have particular needs to be considered. Bisexual and transgender individuals also have specific needs that should be investigated in the future (Burkholder and Burbank, 2012).
Conclusions
Most lesbian mothers encounter positive care provision; however, areas of perceived homophobia still exist (Dahl et al, 2012). Attitudes of midwives, involvement with the co-mother and heteronormativity can all influence the experiences of maternity care for same-sex couples. Awareness of the needs of same-sex couples must be increased, with further research needed particularly in relation to gay men. Education and experience is imperative for midwives, to ensure that negative care and homophobia are eradicated. Gender-neutral journals and guidelines for the care of LGBT individuals should also be developed on local, national and international levels. Instead of focussing on same-sex specific care, all midwives must critically explore their own attitudes and reflect upon the care they give (Erlandsson et al, 2011). The resounding conclusion from women in a same sex relationship is that they wish to be treated the same as others, but with special consideration to their unique situation.