Health inequalities affect many groups of patients in the UK. With regards to maternity care, it is often the case that pregnant people who identify as transgender or non-binary are most in need of healthcare and support and are least able to access the quality care they require (House of Commons and Health Committee, 2003). People in certain protected groups, such as age, ethnicity, gender and sexual orientation, are at increased risk of the negative effects of health inequalities (NHS England, 2021). In 2019, the NHS long term plan set out a vision to reduce health inequalities from within the NHS (2019a). Reducing health inequalities and celebrating diversity is an important value for both midwifery and obstetric care (Royal College of Midwives, 2014; Royal College of Obstetricians and Gynaecologists, 2019).
Gender and health inequalities
The term ‘transgender’ describes people who identify with a gender different to the one assigned to them at birth. Non-binary describes those who identify as both male and female, or neither. Globally it is estimated that up to 2% of the population identifies as transgender (Goodman et al, 2019). Growing numbers of transgender people are becoming gestational parents. With regards to gender identity, a survey of over 100 000 lesbian, gay, bisexual and transgender (LGBT) people in the UK found that 6.9% of respondents identified as non-binary (Government Equalities Office, 2018). It is important to note that some people have a fluid gender identity and some people have no gender at all, but non-binary is often used to encompass the range of groups of people who identify as neither male or female (National Center for Transgender Equality, 2016).
Although there is limited literature comparing the health needs of those who identify as non-binary to those who identify as having a binary gender identity, people in these groups may have greater health needs (Scandurra et al, 2019) and face health inequalities (Berger et al, 2015). Therefore, it is important that healthcare providers reduce potential barriers to accessing healthcare services for this group of patients. Similarly, the findings from a systematic review advised that clinicians and healthcare providers should be educated to reduce the assumption that patients adhere to strict binary gender identities (Scandurra et al, 2019). One way to do this is to address the language that is used to speak about groups of patients in health and care settings, ensuring that the terminology used is gender inclusive (Berger et al, 2015; Hoffkling et al, 2017).
Transgender and non-binary people experience high levels of discrimination, which may limit their access to healthcare (World Health Organization, 2021). The healthcare literature provides many examples of services failing to meet the needs of pregnant transgender and non-binary people. MacLean's (2021) review highlighted the lack of awareness of transgender health issues among clinicians and high levels of discrimination experienced by patients in the USA. Richardson et al (2019) reported transgender men being misgendered in clinical settings.
The NHS is one of England's largest employers (The King's Fund, 2020), and the impact of inequalities within the workforce must be understood and resolved, particularly as these may impact on morale, wellbeing, recruitment and staff retention (The King's Fund, 2019). The NHS LGBT+ Action plan includes an aspiration to ‘challenge hetero-normative and cis-normative culture’ and a focus on ensuring providers are inclusive to both staff and patients (Brady, 2018). A gender-inclusive culture is beneficial for patients, staff and the organisation, and the use of inclusive language can be viewed as an important indicator of the inclusive culture of a provider.
Language guidance for maternity services
With regards to maternity and antenatal services, guidance from the British Medical Association (2016) has advocated for using the term ‘pregnant people’ to ensure that those who do not identify as women are represented in maternity services. However, guidance documentation from Brighton and Sussex University Hospitals NHS Trust advocated for a ‘gender additive’ approach to language, being mindful of the need to represent women (particularly those from ethnic minorities) who are negatively impacted by health inequalities, alongside those from LGBT+ or non-binary backgrounds (Green and Riddington, 2020). This can be done by including terminology such as ‘pregnant women and people’ or ‘breast/chest feeding women and people’ (Green and Riddington, 2020) to represent all groups.
Although it appears that the Brighton and Sussex guidelines have not yet been adopted formally by the Royal College of Midwives, the Royal College of Obstetricians and Gynaecologists, or other NHS Trusts, NHS guidance around the use of inclusive language for digital services has been published. The NHS Digital (2021) content style guide is a set of recommendations used to ensure clarity and reduce variability across online NHS services and providers, and includes information around language for age, disabilities, ethnicity and gender. The style guide for inclusive language states ‘we make content gender neutral as far as possible. In general, we word our content to avoid masculine and feminine pronouns (“he” or “she”). Instead, we use “you” where appropriate and sometimes “they” when we need a gender-neutral pronoun (unless this is confusing).’ (NHS Digital, 2021).
The evidence base around the use of gender inclusive language on maternity services websites has not been widely reported. This study assessed the webpages of NHS Trust maternity and antenatal service providers in England, to identify whether they have adequately included gender-inclusive language, as recommended by the NHS Digital (2021) content style guide. Websites were also assessed for whether the language used was fully gender inclusive, either with the use of exclusively gender-neutral language, or in line with the Brighton and Sussex University Hospitals NHS Trust guidance (Green and Riddington, 2020).
Methods
A list of hospital providers (n=133) was taken from the NHS maternity statistics in England (2019–2020) on place of delivery (NHS Digital, 2020). Each provider was given a number (Box 1) and the name of each provider and ‘maternity’ was input into a search engine to locate the NHS maternity services homepage for each service. The first NHS webpage for maternity services and up to two other pages were used to analyse the language, depending on the content of each website (for example, some maternity services homepages were simply a contents page, whereas others included a wealth of detailed information). If more than one page needed to be reviewed, any COVID-19-specific pages were prioritised to be included where possible, as these were deemed the most likely to be recently updated. Specialist antenatal services were also included, where appropriate, if they appeared in the place of delivery list.
Box 1.Maternity services providers included in review
- Aintree University Hospital NHS Foundation Trust
- Airedale NHS Foundation Trust
- Ashford and St Peter's Hospitals NHS Foundation Trust
- Barking, Havering and Redbridge University Hospitals NHS Trust
- Barnsley Hospital NHS Foundation Trust
- Barts Health NHS Trust
- Basildon and Thurrock University Hospitals NHS Foundation Trust
- Bedford Hospital NHS Trust
- Birmingham Women's and Children's NHS Foundation Trust
- Blackpool Teaching Hospitals NHS Foundation Trust
- Bolton NHS Foundation Trust
- Bradford Teaching Hospitals NHS Foundation Trust
- Brighton and Sussex University Hospitals NHS Trust
- Buckinghamshire Healthcare NHS Trust
- Calderdale and Huddersfield NHS Foundation Trust
- Cambridge University Hospitals NHS Foundation Trust
- Chelsea and Westminster Hospital NHS Foundation Trust
- Chesterfield Royal Hospital NHS Foundation Trust
- Countess of Chester Hospital NHS Foundation Trust
- County Durham and Darlington NHS Foundation Trust
- Croydon Health Services NHS Trust
- Cumbria Partnership NHS Foundation Trust
- Dartford and Gravesham NHS Trust
- Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
- Dorset County Hospital NHS Foundation Trust
- East and North Hertfordshire NHS Trust
- East Cheshire NHS Trust
- East Kent Hospitals University NHS Foundation Trust
- East Lancashire Hospitals NHS Trust
- East Suffolk and North Essex NHS Foundation Trust
- East Sussex Healthcare NHS Trust
- Epsom and St Helier University Hospitals NHS Trust
- Frimley Health NHS Foundation Trust
- Gateshead Health NHS Foundation Trust
- George Eliot Hospital NHS Trust
- Gloucestershire Hospitals NHS Foundation Trust
- Great Western Hospitals NHS Foundation Trust
- Guy's and St Thomas' NHS Foundation Trust
- Hampshire Hospitals NHS Foundation Trust
- Harrogate and District NHS Foundation Trust
- Homerton University Hospital NHS Foundation Trust
- Hull and East Yorkshire Hospitals NHS Trust
- Imperial College Healthcare NHS Trust
- Isle of Wight NHS Trust
- James Paget University Hospitals NHS Foundation Trust
- Kettering General Hospital NHS Foundation Trust
- King's College Hospital NHS Foundation Trust
- Kingston Hospital NHS Foundation Trust
- Lancashire Teaching Hospitals NHS Foundation Trust
- Leeds Teaching Hospitals NHS Trust
- Lewisham and Greenwich NHS Trust
- Liverpool Women's NHS Foundation Trust
- London North West University Healthcare NHS Trust
- Luton and Dunstable University Hospital NHS Foundation Trust
- Maidstone and Tunbridge Wells NHS Trust
- Manchester University NHS Foundation Trust
- Medway NHS Foundation Trust
- Mid Cheshire Hospitals NHS Foundation Trust
- Mid Essex Hospital Services NHS Trust
- Mid Yorkshire Hospitals NHS Trust
- Milton Keynes University Hospital NHS Foundation Trust
- Norfolk and Norwich University Hospitals NHS Foundation Trust
- North Bristol NHS Trust
- North Middlesex University Hospital NHS Trust
- North Tees and Hartlepool NHS Foundation Trust
- North West Anglia NHS Foundation Trust
- Northampton General Hospital NHS Trust
- Northern Devon Healthcare NHS Trust
- Northern Lincolnshire and Goole NHS Foundation Trust
- Northumbria Healthcare NHS Foundation Trust
- Nottingham University Hospitals NHS Trust
- Oxford University Hospitals NHS Foundation Trust
- Pennine Acute Hospitals NHS Trust
- Poole Hospital NHS Foundation Trust
- Portsmouth Hospitals NHS Trust
- Royal Berkshire NHS Foundation Trust
- Royal Brompton & Harefield NHS Foundation Trust
- Royal Cornwall Hospitals NHS Trust
- Royal Devon and Exeter NHS Foundation Trust
- Royal Free London NHS Foundation Trust
- Royal Papworth Hospital NHS Foundation Trust
- Royal Surrey County Hospital NHS Foundation Trust
- Royal United Hospitals Bath NHS Foundation Trust
- Salisbury NHS Foundation Trust
- Sandwell and West Birmingham Hospitals NHS Trust
- Savernake Community Hospital
- Sheffield Teaching Hospitals NHS Foundation Trust
- Sherwood Forest Hospitals NHS Foundation Trust
- Shrewsbury and Telford Hospital NHS Trust
- South Tees Hospitals NHS Foundation Trust
- South Tyneside and Sunderland NHS Foundation Trust
- South Warwickshire NHS Foundation Trust
- Southend University Hospital NHS Foundation Trust
- Southport and Ormskirk Hospital NHS Trust
- St George's University Hospitals NHS Foundation Trust
- St Helens and Knowsley Hospital Services NHS Trust
- Stockport NHS Foundation Trust
- Surrey and Sussex Healthcare NHS Trust
- Tameside and Glossop Integrated Care NHS Foundation Trust
- Taunton and Somerset NHS Foundation Trust
- The Dudley Group NHS Foundation Trust
- The Hillingdon Hospitals NHS Foundation Trust
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust
- The Princess Alexandra Hospital NHS Trust
- The Queen Elizabeth Hospital, King's Lynn, NHS Foundation Trust
- The Rotherham NHS Foundation Trust
- The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust
- The Royal Wolverhampton NHS Trust
- Torbay and South Devon NHS Foundation Trust
- United Lincolnshire Hospitals NHS Trust
- University College London Hospitals NHS Foundation Trust
- University Hospital Southampton NHS Foundation Trust
- University Hospitals Birmingham NHS Foundation Trust
- University Hospitals Bristol NHS Foundation Trust
- University Hospitals Coventry and Warwickshire NHS Trust
- University Hospitals of Derby and Burton NHS Foundation Trust
- University Hospitals of Leicester NHS Trust
- University Hospitals of Morecambe Bay NHS Foundation Trust
- University Hospitals of North Midlands NHS Trust
- University Hospitals Plymouth NHS Trust
- Walsall Healthcare NHS Trust
- Warrington and Halton Hospitals NHS Foundation Trust
- West Hertfordshire Hospitals NHS Trust
- West Suffolk NHS Foundation Trust
- Western Sussex Hospitals NHS Foundation Trust
- Weston Area Health NHS Trust
- Whittington Health NHS Trust
- Wirral University Teaching Hospital NHS Foundation Trust
- Worcestershire Acute Hospitals NHS Trust
- Wrightington, Wigan and Leigh NHS Foundation Trust
- Wye Valley NHS Trust
- Yeovil District Hospital NHS Foundation Trust
- York Teaching Hospital NHS Foundation Trust
For each website, the entire text was assessed and examples of type of language used recorded, with particular focus on examples of how pregnant patients and midwives were referred to, the use of any she/her or he/his pronouns and references to support partners and family units. Data collection and analysis was undertaken by all three authors. The website of each provider was reviewed independently by at least two authors to increase the validity of the findings. Disagreements were resolved by consensus discussion and additional review by the third author. The websites were reviewed from August to October 2021. Data collation and analysis was completed by the lead author, using Microsoft Excel for Mac v16.49.
Each provider was rated by each reviewer as ‘fully inclusive’, ‘inclusive’ or ‘not inclusive’. The definitions of each category were agreed during the pilot phase of the study, where a sample of 40 websites were reviewed. Websites that were categorised as fully inclusive either did not use any gender-specific pronouns or terminology, or consistently used a gender additive approach as identified in the guidance by Green and Riddington (2020). Those that were identified as inclusive did not use gendered terminology or pronouns for either patients or staff, but may have used woman/women or mothers/mums to describe their patients at least once in the text reviewed. Providers that were identified as not inclusive were those that may have used gender-specific terms, such as she/her pronouns, ladies or fathers. Some websites referred to smartphone applications, such as ‘DadPad’ or ‘Mum & Baby’ but these were not included in the overall rating, as the name of third-party applications is not under the control of the individual Trust.
As agreed by the University of Manchester research ethics team, ethical approval was not required for this evaluation of publicly available websites.
Results
From the 133 websites reviewed, three NHS Trusts did not have a maternity or antenatal services website and so were excluded from further analysis.
From the remaining 130 websites analysed, 90 websites (69.2%) included generally inclusive language, as per the NHS Digital (2021) style guide. This included phrases such as ‘pregnant women’, ‘partners and family’, and/or ‘your pregnancy’, and the content was written without she/her pronouns. Of these websites, 51 (56.7%) included references to mothers/mums, and 86 (95.6%) included women/woman. One website referred to dads, but this was phrased as part of a generic sentence that could be applicable to a variety of types of family units, so this website was still deemed to be inclusive.
Three websites (2.3%) had language that was fully inclusive. In addition to meeting the criteria for being inclusive, they also either consistently used the Brighton and Sussex gender-additive language guidance for birthing people (Green and Riddington, 2020) or did not use any gendered references at all throughout the website. One website included an inclusivity statement at the bottom of the page, which advised that the provider was happy to use the correct pronouns for patients who do not identify as a woman.
The remaining 37 websites (28.5%) used language that was not inclusive. These web pages identified either patients (n=22) or maternity staff (n=17) using she/her pronouns. Some websites also referred to patients as lady/ladies, and one also referred to dad. A summary of the results is shown in Table 1.
Table 1. NHS maternity and antenatal service provider websites that used each type of language
| Fully inclusive (%) | Inclusive (%) | Not inclusive (%) | Total (%) | |
|---|---|---|---|---|
| Websites | 3 (2.3) | 90 (69.2) | 37 (28.5) | 130 (100) |
| Language used | ||||
| Woman/women | 0 (0) | 86 (95.6) | 35 (94.6) | 121 (93.1) |
| Mother/mum | 0 (0) | 51 (56.7) | 24 (64.9) | 75 (57.7) |
| She/her (patients) | 0 (0) | 0 (0) | 22 (59.5) | 22 (16.9) |
| She/her (staff) | 0 (0) | 0 (0) | 17 (46.0) | 17 (13.1) |
| Other | 0 (0) | 1 (1.1) | 8 (21.6) | 9 (6.9) |
Discussion
The majority (69.2%, n=90) of the websites included language that was in line with the NHS Digital (2021) content guide for gender inclusive language. This included the use of they/their or you/your pronouns (in place of the more gendered pronouns, such as she/her or he/his). They also did not assign gender to partners, families or birth support partners in the pages reviewed.
Most websites referred to pregnant patients as women and mothers or mums. In line with the guidance from Brighton and Sussex, a gender-additive approach could be applied to re-write these as ‘women and pregnant people’ and ‘mothers and birthing parents’ to enable the content to be more inclusive to trans and non-binary patients (Green and Riddington, 2020). However, it is worth noting that this guidance was written recently, and may not have yet been adapted for use more widely across other NHS Trusts. Therefore, in the current study, those who referred to women or mums but used no other gender-specific terminology were categorised as inclusive, as it is in line with NHS Digital (2021) guidance. It is important to recognise that there are changes that could be made so that these pages are accessible and relevant to a wider range of pregnant people.
A small proportion (16.9%, n=22) of providers did not use gender-neutral pronouns and used she/her to describe the pregnant patient. Five providers also referred to pregnant patients as ladies. This use of gender-specific information, coding processes and paperwork in maternity settings has been described as ‘institutional erasure’ of trans and non-binary people (Bauer et al, 2009), and incorrect pronoun usage and references to the patients as ladies may contribute towards services users feeling less comfortable accessing maternity services as their authentic selves (Hoffkling et al, 2017).
Providers who fully adhered to the Brighton and Sussex guidance (Green and Riddington, 2020) or used no gender-specific language at all were categorised as fully inclusive, and deemed to be the most accessible to those at risk of gender-related health inequalities. This applied to only a small number of providers reviewed (2.8%, n=3). It is also important to note that language changes frequently, and the language used by services should be frequently reviewed to ensure inclusivity (Green and Riddington, 2020), with the input of service users, trans and non-binary advocates and equality and diversity champions (Beere et al, 2019).
Non-binary people also have been found to have lower levels of familial support than gender binary people (Reisner and Hughto, 2019), particularly in the context of pregnancy loss (Riggs et al, 2020), emphasising the need for neutral language around birth support partners, who may not be a family member or relative. The vast majority of websites reviewed included non-gender-specific references to birth support partners, with only one website mentioning fathers specifically. Another provider mentioned dads as part of a broader list of potential support partners, so was still deemed to be inclusive.
The needs of LGBT+ NHS staff are also mentioned in the retention of workforce section of the NHS long term plan, based on the findings from the NHS (2019b) staff survey. Although most of the websites reviewed did not contain gender-specific pronouns for staff, 13.1% (n=17) of providers referred to midwives by she/her pronouns, potentially alienating male members of the midwifery workforce, as well as non-binary staff members (Kantrowitz-Gordon et al, 2014).
It is important to note that all guidelines are designed to guide, rather than be viewed as inflexible policies, and it is also important to note that trans and non-binary service users and staff are a diverse group and may feel comfortable with a range of different terminology (Hoffkling et al, 2017). However, as a result of the barriers that many trans and non-binary people face, it is important to ensure that they feel able to access services freely and as their authentic selves, to reduce the impact of these health inequalities going forwards. Using language that is inclusive to as many people as possible, while still being clear and easy to understand, should be implemented more widely across NHS maternity and antenatal services.
Strengths and limitations
This was an observational study investigating the use of gender-inclusive language on NHS maternity websites. The strengths of this study include the breadth of websites reviewed (n=133), and that each website was reviewed by at least two authors, to reduce any missed information or recording bias.
The limitations include the number of webpages reviewed (a maximum of three for each website by each reviewer), and that the results are limited to NHS providers based in one country. This study is also limited by the lack of direct input and editorship from trans and non-binary communities.
Future work
The NHS Trusts identified as not inclusive have been sent a link to the NHS Digital (2021) content style guidance together with the findings of this study. Future research could qualitatively review the impact of inclusive and non-inclusive gender language on those who are affected by it, in particular trans and non-binary pregnant people, and staff in maternity settings, and how these findings can be implemented across maternity settings.
Conclusions
The majority of NHS maternity websites use language that is in line with the NHS Digital content guide for gender inclusivity. However, a substantial proportion use non-inclusive language, such as she/her pronouns to refer to patients or staff. It is essential to update the language used on maternity websites to be as inclusive and accessible as possible, to reduce the health inequalities faced by trans and non-binary people and to ensure a fulfilled and diverse workforce. Future work could seek to understand the views of trans and non-binary people in maternity settings around the language used and how inclusivity can be implemented.
Key points
- People who are trans or non-binary may be at increased risk of health inequalities.
- There is current guidance around the type of gender inclusive language that should be used on NHS websites.
- This study assessed the language used on NHS maternity websites in England to investigate whether it is inclusive to people of all genders.
- The majority of webpages reviewed included language which was in line with the NHS Digital content guide for gender inclusive language, but 28.5% (n=37) of websites used non-inclusive language, such as she/her pronouns to describe groups of patients and staff.
- Improving language to be more inclusive may help to improve accessibility and reduce inequalities for trans and non-binary people, and help contribute to a more diverse maternity workforce.
CPD reflective questions
- Do you have strong beliefs about how maternity patients should be referred to? If so, why?
- Does the way you speak about patients apply to all patients?
- Could you make your clinical practice more accessible to people who are trans or non-binary?
- Thinking more widely than gender, what is the role of your profession in reducing health inequalities?