Trans and non-binary pregnancy, traumatic birth, and perinatal mental health: a scoping review

A phenomenological exploration of non-carrying mothers in same-gender relationships experiences of a psychologically traumatic birth

AIMS/BACKGROUND

Birth trauma is increasingly recognised in policy and practice, yet remains focused on birthing women, also holding the assumption that families involve only one of these. This research explored psychologically traumatic birth experiences in non-carrying mothers in same-gender relationships, and how they made sense of these experiences.

DESIGN/METHODS

Interviews were conducted with eight participants recruited via social media and charities, analysed using Interpretive Phenomenological Analysis. Sample demographics were homogeneous; all self-identified as Black, lesbian, first-time mothers.

RESULTS AND DISCUSSION

Four themes were developed: 'anticipated and realised threats', 'navigating identities and roles in the transition to motherhood', 'importance of feeling understood and accepted by others' and 'adapting to a new normal'. Participants' reported threat often began during pregnancy, influenced through prior experiences of perinatal loss, trauma, and stressors related to holding minoritised identities, specifically concerning sexuality and race. Challenges were experienced related to navigating dual identities as both a partner and mother, with prevalent feelings of resentment, invisibility, shame, and not being 'good enough'. Most experienced stigma and discrimination, from within and outside their families, and valued spaces where they felt accepted, including through connecting with other LGBTQ+ parents. Implications for subsequent reproductive choices were voiced, typically linked to efforts to prevent repeated trauma.

CONCLUSION

Psychologically traumatic birth may be experienced by any parent, bringing significant impacts for individuals and their relationships. Intersectional approaches that recognise diverse routes to parenthood are needed to inform and evaluate family-focused support provision, which may include facilitating couples' navigation of reproductive choices.

"Saying 'I'm not okay' is extremely risky": Postpartum mental health, delayed help-seeking, and fears of the child welfare system among queer parents

Parent mental health challenges in the postpartum and early parenthood have profound implications for parent, child, and family well-being. Little research has focused on postpartum mental health challenges and barriers to help-seeking among queer birthing people, including members of this community who may be particularly vulnerable to mental health difficulties, such as queer cis women partnered with men, trans/nonbinary parents, and queer parents who are young, low-income, and/or of color. This mixed-methods study of queer parents (n = 99), all of whom were assigned female at birth (AFAB) and gave birth to a child within the past several years, explores parents' postpartum mental health difficulties and perceived barriers to seeking help. Using a structural stigma framework, this study found that participants reported high rates of postpartum mental health difficulties (89%) and reported various barriers to seeking support including fears of discrimination and being deemed "unfit" by providers, which might lead to child welfare system involvement. Young parents and low-income parents were particularly fearful of child welfare system contact and potential child removal. Factors that encouraged help-seeking (e.g., desire to be a good parent; partner pressure to seek help) and implications for family practitioners are discussed.

Mothers' Experiences of Institutional Betrayal During Childbirth and their Postpartum Mental Health Outcomes: Evidence From a Survey of New Mothers in the United States

INTRODUCTION

The purpose of this descriptive study was to explore the relationship between the experience of institutional betrayal (IB) during childbirth and postpartum mental health.

METHODS

Women who had given birth within the last 3 years in the United States as of June 2021 were recruited via Qualtrics to complete an online survey. Participants (N = 588) answered questions about their birth experiences, including adverse medical events and experiences of IB. Multiple logistic regressions examined whether experiencing one or more types of IB was associated with receiving a diagnosis of a postpartum mental health condition, controlling for other theoretically relevant covariates.

RESULTS

More than one-third (39%) of respondents experienced one or more types of IB during childbirth, with a mean (SD) of 1.7 (0.47) and maximum of 2. Experiencing IB increased the odds of a postpartum mental health condition diagnosis by 2.86 (95% CI, 1.63-5.05; P < .001).

DISCUSSION

The findings suggest that experiencing IB may be one mechanism driving negative postpartum mental health outcomes. Health care providers and policymakers should be aware of the role that IB can play in women's birth experiences and consider how strategies to decrease instances of IB during childbirth may improve postpartum mental health.

Canadian Network for Mood and Anxiety Treatments 2024 Clinical Practice Guideline for the Management of Perinatal Mood, Anxiety, and Related Disorders: Guide de pratique 2024 du Canadian Network for Mood and Anxiety Treatments pour le traitement des troubles de l'humeur, des troubles anxieux et des troubles connexes périnatals

BackgroundThe Canadian Network for Mood and Anxiety Treatments (CANMAT) publishes clinical practice guidelines for mood and anxiety disorders. This CANMAT guideline aims to provide comprehensive clinical guidance for the pregnancy and postpartum (perinatal) management of mood, anxiety and related disorders.MethodsCANMAT convened a core editorial group of interdisciplinary academic clinicians and persons with lived experience (PWLE), and 3 advisory panels of PWLE and perinatal health and perinatal mental health clinicians. We searched for systematic reviews of prevention and treatment interventions for perinatal depressive, bipolar, anxiety, obsessive-compulsive and post-traumatic stress disorders (January 2013-October 2023). We prioritized evidence from reviews of randomized controlled trials (RCTs), except for the perinatal safety of medications where reviews of large high-quality observational studies were prioritized due to the absence of RCT data. Targeted searches for individual studies were conducted when systematic reviews were limited or absent. Recommendations were organized by lines of treatment based on CANMAT-defined levels of evidence quality, supplemented by editorial group consensus to balance efficacy, safety, tolerability and feasibility considerations.ResultsThe guideline covers 10 clinical sections in a question-and-answer format that maps onto the patient care journey: case identification; organization and delivery of care; non-pharmacological (lifestyle, psychosocial, psychological), pharmacological, neuromodulation and complementary and alternative medicine interventions; high-risk clinical situations; and mental health of the father or co-parent. Equity, diversity and inclusion considerations are provided.ConclusionsThis guideline's detailed evidence-based recommendations provide clinicians with key information to promote the delivery of effective and safe perinatal mental healthcare. It is hoped that the guideline will serve as a valuable tool for clinicians in Canada and around the world to help optimize clinical outcomes in the area of perinatal mental health.

Depression in the time of COVID-19: Examination of prenatal and postpartum depression, rurality, and the impact of COVID-19

BACKGROUND

To determine the impact of the COVID-19 pandemic on prenatal and postpartum depressive symptoms in rural versus urban populations.

METHODS

A retrospective cohort study was conducted among 24,227 cisgender women who gave birth from 2010 to 2021 at an academic medical center located in a rural midwestern state. Exclusion criteria were <18 years old, incarcerated, or without a documented zip code. The Patient Health Questionnaire-9 (PHQ-9) was administered during pregnancy and the Edinburgh Postnatal Depression Scale (EPDS) during postpartum. A sub-cohort also completed a COVID-related questionnaire. Rurality was defined as living in a county with <50,000 people. The COVID-19 era was defined as 1/1/2020 to 9/25/2021. Chi-square and Fisher exact tests were used as appropriate. Significance was set at α < 0.05.

RESULTS

Rural participants were more likely (p ≤ 0.001) to exhibit clinical depression symptoms before the pandemic in both the prenatal (8.63 % of rural participants vs. 6.49 % of urban participants) and postpartum periods (11.19 % rural vs. 9.28 % urban). During the pandemic, urban participants had increased postpartum depression. Rural participants endorsed more financial and labor concerns, whereas urban participants expressed support system concerns.

LIMITATIONS

Study data were gathered from participants who gave birth at a single, midwestern hospital. Results may not be widely generalizable given the homogeneity of participants.

CONCLUSIONS

Rural women experienced higher rates of prenatal and postpartum depressive symptoms compared to their urban counterparts. The COVID-19 pandemic was a significant stressor, revealing specific mental health vulnerabilities among birthing people.

A systematic review of the clinical practice guidelines for the assessment, management and treatment of eating disorders during the perinatal period

BACKGROUND

Eating disorders during the perinatal period can pose significant risks to both the mother and the baby. Clinical practice guidelines include statements of expected practice intending to improve effectiveness and quality of care within health care services. This systematic review aimed to identify and synthesise current clinical practice guideline recommendations on the assessment, management and treatment of eating disorders during the perinatal period.

METHODS

Three bibliographic databases and five guideline repository databases were searched alongside the grey literature. Guidelines were screened against eligibility criteria and recommendations for the assessment, management or treatment of eating disorders during the perinatal period were extracted. All included guidelines were assessed for quality using the AGREE-II tool. Recommendations were analysed and summarised using narrative synthesis.

RESULTS

From the 242 records screened, 17 met inclusion criteria. Guideline quality ranged from three out of seven to seven out of seven. Six overall recommendations were formed from the narrative synthesis of data: 1) Early detection: recognising the signs and symptoms, 2) Assessment and screening: a three-pronged approach, 3) Educating and supporting the mother: the importance of knowledge, 4) Cross-system collaboration, 5) Psychological, pharmacological and medical treatment, and 6) Continued monitoring.

CONCLUSION

Perinatal eating disorder guideline recommendations were fairly consistent but showed considerable variability in quality and depth of recommendations. Recommendations require further contextualisation, to allow them to be operationalised and implemented within services. The review findings provide an initial framework for health care professionals responsible for supporting women with eating disorders during the perinatal period, and have several implications for policy, service delivery and health outcomes for women and their families.

Gender-Inclusive Language in Public-Facing Labor and Delivery Web Pages in the New York Tristate Area: Cross-Sectional Study

Background

Transgender and nonbinary (TGNB) individuals are increasingly intentionally becoming pregnant to raise children, and hospital websites should reflect these trends. For prospective TGNB parents, a hospital website is the only way they can assess their safety from discrimination while receiving perinatal care. Cisnormativity enforced by communication gaps between medical institutions and TGNB patients can and has caused delays in receiving urgent care during their pregnancy.

Objective

The aim of this study was to evaluate the current prevalence of gender-inclusive terminology among labor and delivery services in the New York tristate area.

Methods

The labor and delivery web pages of 189 hospitals from New York, New Jersey, and Connecticut were examined for gender-inclusive language. "Fully inclusive" websites explicitly acknowledged lesbian, gay, bisexual, transgender, queer, intersex, and asexual plus other gender- and sexual-oriented (LGBTQIA+) parents, "inclusive" websites did not use gendered terminology for parents, and "noninclusive" websites used gendered terms at least once in the text reviewed. The hospitals' web pages were further stratified by Healthcare Equality Index scores and population classifications defined by the 2013 National Center for Health Statistics Urban-Rural classification given to the county that each hospital was located in.

Results

Of the 300 hospital websites reviewed, only 189 websites met the criteria for inclusion. Overall, only 6.3% (n=12) of labor and delivery web pages were "inclusive" or "fully inclusive." No geographic areas (P=.61) or Healthcare Equality Index scores (P=.81) were associated with inclusive or fully inclusive language.

Conclusions

Hospitals need to use inclusive language to help TGNB people identify hospitals where their existence and needs are acknowledged and thus feel more comfortable in their transition to parenthood.

Embedding LGBTQIA+ health equity in midwifery education: A holistic whole-of-programme approach

Skilled midwifery care for LGBTQIA+ people is a human right, however LGBTQIA+ people have been under-served in perinatal care by the privileging of cisgender heterosexual endosex women as recipients of care. The education of midwives and other professionals to provide LGBTQIA+ inclusive care is a critical component of wider strategies to address LGBTQIA+ discrimination in perinatal care. This paper responds to this challenge by discussing an innovative and holistic approach to introducing and embedding LGBTQIA+ health equity into one midwifery education programme in Aotearoa New Zealand. This approach harnesses opportunities in both the formal and informal curriculum and draws on the conceptual frameworks of cultural safety and humility, intersectionality, and Indigenous justice. These frameworks have informed an on-going process of reflection on, and unlearning of, cis-heteronormativity and other systemic injustices when providing perinatal care to diverse populations, for both midwifery educators and students.

Treatment and counselling preferences of postpartum women with and without symptoms of (childbirth-related) PTSD: findings of the cross-sectional study INVITE

BACKGROUND

Post-traumatic stress disorder (PTSD) in the postpartum period is a prevalent yet under-researched mental health condition. To date, many women who suffer from postpartum PTSD remain unrecognized and untreated. To enhance the accessibility of help for these women, it is crucial to offer tailored treatment and counselling services that align with their needs. This study aimed to understand how support preferences differ between women with and without postpartum PTSD, considering the two subgroups of postpartum PTSD: childbirth-related PTSD (CB-PTSD) and general PTSD (gPTSD).

METHODS

This study used data from the cross-sectional INVITE study, comprising telephone interviews with N = 3,874 women conducted six weeks to six months after childbirth. The City Birth Trauma Scale (City BiTS) was used to assess CB-PTSD, while the Primary Care Posttraumatic Stress Disorder Screen for DSM-5 (PC-PTSD-5) was used to assess gPTSD. Service preferences and preferred modes of service provision were measured with self-developed questionnaires. Analyses of variance were used to identify differences between groups.

RESULTS

The support services (family-)midwives and family, friends, or colleagues and the service provision mode as in person communication were preferred most by women across groups. The analyses revealed that women with CB-PTSD had lower overall preferences for services compared to women without postpartum PTSD. Women with CB-PTSD also showed less preference for psychotherapeutic services (e.g. outpatient treatment, inpatient clinics) compared to women without postpartum PTSD. Regarding modes of service provision, women with gPTSD had a higher preference for all service modes compared to women with CB-PTSD and those without postpartum PTSD, with a stronger preference for both direct (e.g. in person, video conference) and delayed communication (e.g. chat, e-mail).

CONCLUSION

This study was the first to explore the support preferences of women experiencing symptoms of postpartum PTSD. Findings suggest that women differ in their preferences, contingent upon the subgroup of postpartum PTSD. According to women's overall preferences, the expansion and further training of (family-)midwife services is recommended. By tailoring support services accordingly to women's preferences, it may be possible to bridge the treatment gap for postpartum PTSD and to improve the well-being of affected women and their families.

Anesthesiologists' Role in Recognition, Prevention, and Treatment of Childbirth-Related Posttraumatic Stress Disorder

Childbirth-related posttraumatic stress disorder (CB-PTSD) is increasingly common and consequential for pregnant patients. Throughout the labor experience and beyond, anesthesiologists are central to creating a psychological safe space for patients and play an essential role in preventing, recognizing, and treating CB-PTSD. This narrative review summarizes the current literature surrounding risk factors for CB-PTSD that are relevant to anesthesiologists; patients' symptoms or signs anesthesiologists should look out for; and ways anesthesiologists may be involved in preventing and treating this condition.

Transsexual men's experiences of childbirth and postpartum in the light of transcultural care

to unveil the experiences of transsexual men during childbirth and postpartum in the light of the Theory of Diversity and Universality of Cultural Care.

a qualitative and descriptive study using the multiple case study method. Data was collected using an intentional sample of five transsexual men, selected on the basis of convenience and availability. The interviews were transcribed in full and the results were organized and adapted to the Sunrise Model.

the majority of the participants were «primiparous» and had given birth by cesarean section. In adapting the Sunrise Model, we observed the encouragement of medicalization and mechanistic management of childbirth; fear of natural childbirth; violence perpetrated against transsexual men resulting from the difficulty of access to information by the pregnant man, and obstetric care not qualified to meet the needs of the public, resulting in fragile care, with dissatisfaction with the health service.

the experiences of transsexual men during childbirth and the postpartum period are a mixture of experiences that generate damage, especially when linked to situations of transphobic violence and violation of rights.

Non-binary patients in ART: new challenges and considerations

OBJECTIVES

To discuss the increasing visibility of non-binary individuals and inclusive policies and practices in assisted reproductive technologies (ART).

METHODS

Comparison between traditional ART approach designed for binary genders and propose approach in non-binary individuals.

RESULTS

Traditional ART services, designed for binary genders, must adapt to address the unique fertility needs of non-binary patients. This includes using gender-neutral language, providing comprehensive fertility assessments, and offering hormone therapy and fertility preservation options. Children of non-binary parents benefit from open communication about gender diversity, enhancing psychological well-being. Positive societal attitudes and inclusive environments in schools are crucial for preventing discrimination and promoting mental health. A systemic approach is required to make ART inclusive. This involves training staff, adjusting facilities, updating documentation, and advocating for supportive legislation. Addressing the reproductive needs of non-binary individuals ensures equitable access to care and supports their family-building goals.

CONCLUSIONS

Ensuring the well-being of children in non-binary families requires psychological support, inclusive healthcare, legal recognition, social support, and comprehensive education.

Mapping the scientific literature on obstetric and perinatal health among sexual and gender minoritized (SGM) childbearing people and their infants: a scoping review

BACKGROUND

Evidence suggests sexual and gender minoritized (SGM) childbearing individuals and their infants experience more adverse obstetric and perinatal outcomes compared to their cisgender, heterosexual counterparts. This study aimed to comprehensively map obstetric and perinatal physical health literature among SGM populations and their infants and identify knowledge gaps.

METHODS

PubMed, Embase, CINAHL, and Web of Science Core Collection were systematically searched to identify published studies reporting obstetric and perinatal outcomes in SGM individuals or their infants. Study characteristics, sample characteristics, and outcome findings were systematically extracted and analyzed.

RESULTS

Our search yielded 8,740 records; 55 studies (1981-2023) were included. Sexual orientation was measured by self-identification (72%), behavior (55%), and attraction (9%). Only one study captured all three dimensions. Inconsistent measures of sexual orientation and gender identity (SOGI) were common, and 68% conflated sex and gender. Most (85%) focused on sexual minorities, while 31% addressed gender minorities. Demographic measures employed varied widely and were inconsistent; 35% lacked race/ethnicity data, and 44% lacked socioeconomic data. Most studies (78%) examined outcomes among SGM individuals, primarily focusing on morbidity and pregnancy outcomes. Pregnancy termination was most frequently studied, while pregnancy and childbirth complications (e.g., gestational hypertension, postpartum hemorrhage) were rarely examined. Evidence of disparities were mixed. Infant outcomes were investigated in 60% of the studies, focusing on preterm birth and low birthweight. Disparities were noted among different sexual orientation and racial/ethnic groups. Qualitative insights highlighted how stigma and discriminatory care settings can lead to adverse pregnancy and birth outcomes.

CONCLUSIONS

Frequent conflation of sex and gender and a lack of standardized SOGI measures hinder the comparison and synthesis of existing evidence. Nuanced sociodemographic data should be collected to understand the implications of intersecting identities. Findings on perinatal health disparities were mixed, highlighting the need for standardized SOGI measures and comprehensive sociodemographic data. The impact of stigma and discriminatory care on adverse outcomes underscores the need for inclusive healthcare environments. Future research should address these gaps; research on SGM perinatal outcomes remains urgently lacking.

TRIAL REGISTRATION

The review protocol was developed a priori in February 2023, registered on Open Science Framework ( https://doi.org/10.17605/OSF.IO/5DQV4 ) and published in BMJ Open ( https://bmjopen.bmj.com/content/13/11/e075443 ).

Models of care: Opportunities and challenges

Perinatal mental health models can broadly be described by scope and structure. Within these two broad domains lies an array of diverse methodologies that have attempted to increase access and coordination of care. These efforts have uncovered many opportunities that, if addressed, may improve our current parent and infant outcomes within our healthcare system and community. Furthermore, there are several opportunities that, if addressed, will result in more equitable, inclusive care. These include being attentive to the unique needs of vulnerable populations, emphasizing community efforts, and closing the current gaps in legislation.

Experiences of menopause among non-binary and trans people

Background

Conventional categorizations of menopause can be difficult to apply to trans, gender non-conforming and non-binary (TGNB) populations. Menopause has biological, psychological and social meanings that may be hard to clearly apply within a context of diverse experiences of sex and gender. Nonetheless, some TGNB people do experience menopause, and their experiences may be different from those of other groups due to those diverse biopsychosocial understandings and experiences.

Method

This paper thematically analyses the responses of 15 TGNB respondents who responded to a larger survey about LGBTQ+ experiences of menopause.

Results

Two key themes were identified: Menopause and embodied identities, and Navigating gender normativity and gender binarism. The first of these contains two sub-themes, shifting and (un)settled gender identities, and embodied dis/connections with femaleness.

Conclusions

These findings appear to be comparatively novel within the published academic literature but potentially have some parallels with prior observations regarding interactions between puberty and gender identity, and also regarding TGNB people's experiences of challenges in navigating other health and life experiences normatively understood as female. These explorations raise a number of potentially sensitive questions, given the current debate and controversies around gender, sex and identity. Nonetheless, they point to a need for further research and practice into menopause that is inclusive and supportive of a range of gender and sexual identities.

Subjective Experiences of Pregnancy, Delivery, and Nursing in Transgender Men and Non-Binary Individuals: A Qualitative Analysis of Gender and Mental Health Concerns

Studies of how gender-diverse individuals experience pregnancy, childbirth, and nursing remain few, mainly focus on the US and contain scarce information about mental health concerns peri-partum. This hinders informed reproductive health decisions and counseling. We used in-depth interviews to examine how gestational gender-diverse individuals in Sweden experience the process of planning and undergoing pregnancy, delivery, and nursing. In total, 12 participants, identifying on the masculine side of the gender spectrum or as non-binary, who had attended Swedish antenatal care and delivered a live birth, were included in the study. Data were analyzed using qualitative thematic content analysis. The analysis resulted in one overarching theme: sustaining gender congruence during pregnancy and three main categories: (1) considering pregnancy; (2) undergoing pregnancy and childbirth; and (3) postnatal reflections. The association between childbearing and being regarded as female permeated narratives. Participants renegotiated the feminine connotations of pregnancy, accessed gender-affirming treatment, and concealed their pregnancy to safeguard their gender congruence. Mis-gendering and breast enlargement triggered gender dysphoria. Social judgment, loneliness, information shortages, hormonal influence and cessation of testosterone increased gender dysphoria and strained their mental health. Depression exacerbated gender dysphoria and made it harder to claim one's gender identity. Dissociation was used to handle a feminized body, vaginal delivery, and nursing. Pregnancy was easier to envision and handle after masculinizing gender-affirming treatments. The results deepen the understanding of gender dysphoria and may be used to inform reproductive counseling and healthcare development. Research outcomes on mental health concerns provide a basis for further research.

Trauma-Informed Care Education Initiative Explores Impact on Perinatal Nurse Secondary Traumatic Stress and Workforce Challenges

BACKGROUND

Psychological trauma refers to long-lasting adverse effects on well-being precipitated by the experience of a distressing event or a combination of events. High rates of psychological birth trauma in patients contribute to secondary traumatic stress (STS) in perinatal nurses, creating workplace challenges and resulting in dissatisfaction, apathy, and attrition. Perinatal nurses experience high rates of STS, and researchers have called for a universal standard of trauma-informed care (TIC). However, there is a lack of published results on effectively creating TIC education in this nurse population.

METHODS

A pre/posttest design evaluated an online pilot evidence-based practice project addressing a perinatal nurse education initiative on STS and its correlation with nurse attitudes toward TIC. Participants include perinatal nurses in the United States (n = 29). Two scales measured the program's effect on nurses: the Secondary Traumatic Stress Scale (STSS) and the Attitudes Related to Trauma-Informed Care (ARTIC) scale.

RESULTS

A paired t test evaluating pre- and postprogram levels of the STSS showed a decrease in STS (t28 = -3.28, P = .003, Cohen's d = 0.609), the ARTIC scale results showed an increased receptiveness to TIC (t28 = 3.8, P < .001, Cohen's d = 0.706], and a not significant correlation was found between pretest STS and ARTIC scores (Spearman' ρ = -0.248, P = .194).

CONCLUSION

This program supported a significant reduction in nurses' identification of STS. Future perinatal nurse education can expand to build a standard of TIC that is patient-centered and reduces nurse STS.

Experiences of postpartum anxiety during the COVID-19 pandemic: A mixed methods study and demographic analysis

INTRODUCTION

The first wave of the COVID-19 pandemic saw the reconfiguration of perinatal and maternity services, national lockdowns, and social distancing measures which affected the perinatal experiences of new and expectant parents. This study aimed to explore the occurrence of postpartum anxieties in people who gave birth during the pandemic.

METHODS

An exploratory concurrent mixed-methods design was chosen to collect and analyse the quantitative and qualitative data of an online survey during the first UK lockdown. The survey included the Postpartum Specific Anxiety Scale-Research Short Form-for use in global Crises [PSAS-RSF-C] psychometric tool, and open-ended questions in relation to changes in birth plans and feelings about those changes and giving birth in a pandemic. Differences in measured scores were analysed for the participant's ethnicity, sexual orientation and disability using independent Student's t-tests, and for age, the analysis was completed using Pearson's correlation. Qualitative data from open-ended questions were analysed using a template analysis.

RESULTS

A total of 1,754 new and expectant parents completed the survey between 10th and 24th April 2020, and 381 eligible postnatal women completed the psychometric test. We found 52.5% of participants reported symptoms consistent with a diagnosis of postnatal anxiety-significantly higher than the rates usually reported. Younger women and sexual minority women were more likely to score highly on the PSAS-RSF-C than their older or heterosexual counterparts (p<0.001). Younger participants reported anxieties in the 'infant safety and welfare' category, whilst lesbian, gay, bisexual, and pansexual participants scored highly in the 'psychosocial adjustment to motherhood' category.

DISCUSSION

Postpartum anxiety is under-reported, and demographic differences in the rates of postpartum anxiety are under-researched. This research demonstrates for the first time a difference in postpartum anxiety rates amongst sexual minority women.

The intersection of traumatic childbirth and obstetric racism: A qualitative study

BACKGROUND

Traumatic childbirth experiences are common in the United States - affecting a third to a fourth of mothers - with significant negative impacts on maternal health. Yet most research on traumatic childbirth focuses on white mothers' experiences. Drawing on a racially and ethnically diverse sample of mothers who experienced traumatic childbirth, this exploratory qualitative study examined Black, Latina, and Asian mothers' traumatic birth experiences and the role of obstetric racism in shaping these experiences.

METHODS

In-depth, semi-structured interviews were conducted in 2019-2020 with 30 mothers who identified as women of color (37% Black, 40% Latina, and 23% Asian) who gave birth in the US and self-identified as having experienced a traumatic childbirth. Data were analyzed using qualitative content analysis.

RESULTS

Mothers reported obstetric racism as core to their traumatic birth experiences. This racism manifested through practitioners' use of gendered and racialized stereotypes, denying and delegitimizing mothers' needs. Mothers shared key consequences of the obstetric racism they experienced, including postpartum anxiety and depression, increased medical mistrust, and decreased desire for future children.

CONCLUSIONS

Mothers' reports suggest that obstetric racism played a role in their traumatic birth experiences. Particularly, practitioners' deployment of gendered and racialized stereotypes influenced mothers' treatment during birth. These findings point to opportunities to address obstetric racism during childbirth and improve patients' experiences through enhancing their agency and empowerment. The findings, in addition, highlight the need for increased practitioner training in anti-racist practice and cultural humility.

Women's experience of post-traumatic growth following a traumatic birth: an interpretive phenomenological analysis

BACKGROUND

Approximately 3-5% of women experience post-traumatic stress disorder following birth; positive experiences that can follow traumatic birth are under-researched.

AIMS AND OBJECTIVES

To explore how women experience post-traumatic growth following a traumatic birth.

METHODS

Interpretative Phenomenological Analysis was used to explore experiences of women who self-identified as having found positive benefits through coping with a traumatic birth. Eight women who had birthed in the past five years in the UK were recruited online and interviewed face-to-face.

RESULTS

Three superordinate themes were developed: 'The total opposite to what I'd expected' (participants' struggle to understand and integrate their birth experience in the postnatal period); 'I see it a bit differently now' (processes experienced in coming to a place of growth); and 'A much better place' (experienced growth 'outcomes').

DISCUSSION

Faced with shattered assumptions whereby their birth experiences contrasted with their expectations, participants felt their identities as women and mothers were challenged. In overcoming these challenges, participants described actively striving to cope and make sense of their experience. Multiple factors facilitated this, notably partner support, telling their birth story, acknowledging the impact and developing a compassionate narrative. Although growth was experienced in ways commonly reported by survivors of challenging life events, some aspects appeared pertinent to birth trauma.

CONCLUSIONS

Widening our understanding of the range of experiences following traumatic birth and making these narratives public may offer hope for some women and families and inform health professionals' education and practice. Further research would be needed before advocating interventions to foster post-traumatic growth.

Conceptual framework on barriers and facilitators to implementing perinatal mental health care and treatment for women: the MATRIx evidence synthesis

Background

Perinatal mental health difficulties can occur during pregnancy or after birth and mental illness is a leading cause of maternal death. It is therefore important to identify the barriers and facilitators to implementing and accessing perinatal mental health care.

Objectives

Our research objective was to develop a conceptual framework of barriers and facilitators to perinatal mental health care (defined as identification, assessment, care and treatment) to inform perinatal mental health services.

Methods

Two systematic reviews were conducted to synthesise the evidence on: Review 1 barriers and facilitators to implementing perinatal mental health care; and Review 2 barriers to women accessing perinatal mental health care. Results were used to develop a conceptual framework which was then refined through consultations with stakeholders.

Data sources

Pre-planned searches were conducted on MEDLINE, EMBASE, PsychInfo and CINAHL. Review 2 also included Scopus and the Cochrane Database of Systematic Reviews.

Review methods

In Review 1, studies were included if they examined barriers or facilitators to implementing perinatal mental health care. In Review 2, systematic reviews were included if they examined barriers and facilitators to women seeking help, accessing help and engaging in perinatal mental health care; and they used systematic search strategies. Only qualitative papers were identified from the searches. Results were analysed using thematic synthesis and themes were mapped on to a theoretically informed multi-level model then grouped to reflect different stages of the care pathway.

Results

Review 1 included 46 studies. Most were carried out in higher income countries and evaluated as good quality with low risk of bias. Review 2 included 32 systematic reviews. Most were carried out in higher income countries and evaluated as having low confidence in the results. Barriers and facilitators to perinatal mental health care were identified at seven levels: Individual (e.g. beliefs about mental illness); Health professional (e.g. confidence addressing perinatal mental illness); Interpersonal (e.g. relationship between women and health professionals); Organisational (e.g. continuity of carer); Commissioner (e.g. referral pathways); Political (e.g. women's economic status); and Societal (e.g. stigma). These factors impacted on perinatal mental health care at different stages of the care pathway. Results from reviews were synthesised to develop two MATRIx conceptual frameworks of the (1) barriers and (2) facilitators to perinatal mental health care. These provide pictorial representations of 66 barriers and 39 facilitators that intersect across the care pathway and at different levels.

Limitations

In Review 1 only 10% of abstracts were double screened and 10% of included papers methodologically appraised by two reviewers. The majority of reviews included in Review 2 were evaluated as having low (n = 14) or critically low (n = 5) confidence in their results. Both reviews only included papers published in academic journals and written in English.

Conclusions

The MATRIx frameworks highlight the complex interplay of individual and system level factors across different stages of the care pathway that influence women accessing perinatal mental health care and effective implementation of perinatal mental health services.

Recommendations for health policy and practice

These include using the conceptual frameworks to inform comprehensive, strategic and evidence-based approaches to perinatal mental health care; ensuring care is easy to access and flexible; providing culturally sensitive care; adequate funding of services; and quality training for health professionals with protected time to do it.

Future work

Further research is needed to examine access to perinatal mental health care for specific groups, such as fathers, immigrants or those in lower income countries.

Trial registration

This trial is registered as PROSPERO: (R1) CRD42019142854; (R2) CRD42020193107.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR 128068) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 2. See the NIHR Funding and Awards website for further award information.

Mapping the scientific literature on obstetrical and perinatal health among sexual and gender minoritised (SGM) childbearing people and their infants: a scoping review protocol

INTRODUCTION

Sexual and gender minoritised (SGM) populations are disproportionately impacted by multilevel risk factors for obstetrical and perinatal outcomes, including structural (eg, stigma, discrimination, access to care) and individual risk factors (eg, partner violence, poor mental health, substance use). Emerging evidence shows SGM childbearing people have worse obstetrical outcomes and their infants have worse perinatal outcomes, when compared with their cisgender and heterosexual counterparts; this emerging evidence necessitates a comprehensive examination of existing literature on obstetrical and perinatal health among SGM people. The goal of this scoping review is to comprehensively map the extent, range and nature of scientific literature on obstetrical and perinatal physical health outcomes among SGM populations and their infants. We aim to summarise findings from existing literature, potentially informing clinical guidelines on perinatal care, as well as highlighting knowledge gaps and providing directions for future research.

METHODS AND ANALYSIS

We will follow the Joanna Briggs Institute (JBI) scoping review framework and report findings according to the PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines. We will conduct a broad systematic search in Medline/PubMed, Embase, CINAHL and Web of Science Core Collection. Eligible studies will include peer-reviewed, empirical, English-language publications pertaining to obstetrical and perinatal physical health outcomes of SGM people or their infants. No temporal or geographical limitations will be applied to the search. Studies conducted in all settings will be considered. Records will be managed, screened and extracted by two independent reviewers. Study characteristics, key findings and research gaps will be presented in tables and summarised narratively.

ETHICS AND DISSEMINATION

Ethical approval is not required as primary data will not be collected. The findings of this scoping review will be disseminated through a peer-reviewed journal and conference presentations.

PROTOCOL REGISTRATION

Open Science Framework https://osf.io/6fg4a/.

When complications arise during birth: LBTQ people's experiences of care

OBJECTIVE

To explore the care experiences of lesbian, bisexual, transgender, and queer (LBTQ) people during births where complications have arisen.

DESIGN

Data were collected through semi-structured interviews with self-identified LBTQ people who had experienced obstetrical and/or neonatal complications.

SETTING

Interviews were conducted in Sweden.

PARTICIPANTS

A total of 22 self-identified LBTQ people participated. 12 had experienced birth complications as the birth parent and ten as the non-birth parent.

FINDINGS

Most participants had felt invalidated as an LBTQ family. Separation of the family due to complications elevated the number of hetero/cisnormative assumptions, as new encounters with healthcare professionals increased. Dealing with normative assumptions was particularly difficult in stressful and vulnerable situations. A majority of the birth parents experienced disrespectful treatment from healthcare professionals that violated their bodily integrity. Most participants experienced lack of vital information and emotional support, and expressed that the LBTQ identity made it harder to ask for help.

CONCLUSIONS

Disrespectful treatment and deficiencies in care contributed to negative experiences when complications arose during birth. Trusting care relationships are important to protect the birth experience in case of complications. Validation of the LBTQ identity and access to emotional support for both birth and non-birth parents are crucial for preventing negative birth experiences.

IMPLICATIONS FOR PRACTICE

To reduce minority stress and create conditions for a trusting relationship, healthcare professionals should specifically validate the LBTQ identity, strive for continuity of carer and zero separation of the LBTQ family. Healthcare professionals should make extensive efforts to transfer LBTQ related information between wards.

Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 4

PURPOSE

To review evidence on the current understanding of mental health conditions in pregnancy and postpartum, with a focus on mood and anxiety disorders, and to outline guidelines for screening and diagnosis that are consistent with best available scientific evidence. The conditions or symptoms reviewed include depression, anxiety and anxiety-related disorders, bipolar disorder, suicidality, and postpartum psychosis. For information on psychopharmacologic treatment and management, refer to American College of Obstetricians and Gynecologists (ACOG) Clinical Practice Guideline Number 5, "Treatment and Management of Mental Health Conditions During Pregnancy and Postpartum" (1).

TARGET POPULATION

Pregnant or postpartum individuals with mental health conditions. Onset of these conditions may have predated the perinatal period or may have occurred for the first time in pregnancy or the first year postpartum or may have been exacerbated in that time.

METHODS

This guideline was developed using an a priori protocol in conjunction with a writing team consisting of one specialist in obstetrics and gynecology and one maternal-fetal medicine subspecialist appointed by the ACOG Committee on Clinical Practice Guidelines-Obstetrics and two external subject matter experts. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements.

RECOMMENDATIONS

This Clinical Practice Guideline includes recommendations on the screening and diagnosis of perinatal mental health conditions including depression, anxiety, bipolar disorder, acute postpartum psychosis, and the symptom of suicidality. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.

The effectiveness of psychological interventions for anxiety in the perinatal period: A systematic review and meta-analysis

PURPOSE

Anxiety disorders are relatively common during pregnancy and the postnatal period. Despite their potential acceptability to users, psychological interventions research for this population is still in its infancy. The meta-analysis aimed to comprehensively evaluate the evidence of the effectiveness of psychological interventions for reducing perinatal anxiety.

METHOD

The review followed PRISMA guidelines. A total of 26 studies published between 2004 and 2022 fulfilled inclusion criteria of which 22 were included in the meta-analysis.

RESULTS

Results indicated that psychological interventions were more effective than control conditions in reducing symptoms of perinatal anxiety (equivalent to a medium post treatment effect size). Effect sizes were robust for cognitive, behavioural and mindfulness-based interventions. Targeting anxiety also appeared to impact on depression symptoms. There was substantial evidence of methodological heterogeneity.

CONCLUSIONS

This review demonstrates that psychological interventions are effective in reducing symptoms of both anxiety and comorbid anxiety and depression in both the antenatal and postnatal periods. Further research on longer-term effects, infant outcomes, treatment approach and modality are required.

Childbearing at the margins: A systematic metasynthesis of sexual and gender diverse childbearing experiences

BACKGROUND

The reproductive and perinatal health of sexual and gender-diverse (SGD) individuals is a research priority area for the National Institutes of Health. Over the past decade, this childbearing population has been the focus of several qualitative studies providing the opportunity to evaluate and synthesize the qualitative literature on SGD childbearing experiences in a metasynthesis.

METHODS

We conducted a literature search of four databases to identify original research published from January 2011 through June 2021. These results were augmented by forward and backward searching strategies. Two authors independently screened studies. All qualitative studies of the childbearing experience were eligible. Data were extracted and inductively coded using conventional content analysis, and studies underwent a quality appraisal by two authors.

RESULTS

From 2396 articles, 127 full-text articles were screened, and 25 were included in this synthesis. Three overarching themes were identified: (a) Systematic Invisibility; (b) Creating Personhood Through Parenthood; and (c) Resilient Narratives of Childbearing.

CONCLUSIONS

Relative to heterosexual and cisgender parents, SGD childbearing parents experience unique structural and interpersonal challenges and employ critically important resilience strategies and coping techniques to manage an overwhelming heterocisnormative experience. These findings provide an important target for health care organizations and professionals to improve SGD perinatal health. In addition, this metasynthesis identified persistent gaps in our understanding of this marginalized childbearing population, which have important implications for reducing health disparities that SGD parents experience.

Addressing inequalities in the identification and management of perinatal mental health difficulties: The perspectives of minoritised women, healthcare practitioners and the voluntary sector

Background

Perinatal mental health (PMH) difficulties affect approximately one in five birthing women. If not identified and managed appropriately, these PMH difficulties can carry impacts across generations, affecting mental health and relationship outcomes. There are known inequalities in identification and management across the healthcare pathway. Whilst barriers and facilitators have been identified there is a lack of clarity about how these relate to the avoidable and unfair inequalities experienced by various groups of women. Further research is required to understand how to address inequalities in PMH.

Aim

To understand the key factors that enable and hinder access to PMH care for women from minoritised groups across the PMH care pathway, and how these have been affected by the COVID-19 pandemic.

Methods

A sequential mixed-methods approach gathered views and experiences from stakeholders in one region in northern England. This included an online survey with 145 NHS healthcare practitioners and semi-structured interviews with 19 women from ethnic minority and/or socio-economically deprived backgrounds who had experienced PMH difficulties, and 12 key informants from the voluntary and community sector workforce. Quantitative data were analysed using descriptive statistics and framework analysis was applied to qualitative data.

Findings

Barriers and facilitators were mapped using a socio-technical framework to understand the role of (i) processes, (ii) people (organised as women, practitioners and others), (iii) technology, and (iv) the system as a whole in deepening or alleviating inequalities. Influences that were identified as pertinent to inequalities in identification and management included provision of interpreters, digital exclusion, stigma, disempowerment, distrust of services, practitioner attitudes, data capture, representation in the workforce, narrow rules of engagement and partnership working. Stakeholder groups expressed that several barriers were further compounded by the COVID-19 pandemic.

Discussion

The findings highlight the need for change at the system level to tackle inequalities across the PMH care pathway. Four inter-connected recommendations were developed to enable this systems change: building emotional safety between professionals and women; making PMH a part of core healthcare business; increasing cultural competency specific to PMH; and enhanced partnership working.

The role of specialist perinatal psychiatrists in modern medicine

The perinatal period, from the beginning of pregnancy to one year after birth, is a time of considerable physiological and emotional change, where women face a significant risk of development or relapse of mental health disorders. Mental health disorders are one of the most common conditions faced in the perinatal period, but often go unrecognised. There are several barriers to accessing and delivering care, such as instances of structural bias, cultural diversity, stigma, lack of resources and the additional challenge brought by the coronavirus pandemic. Perinatal psychiatry is a dynamic and evolving field, which spans gender, age, ethnicity, socioeconomic background and many other characteristics, to care for people at a vulnerable time in their lives. This article explores the role of perinatal psychiatrists in today's society, as well as the challenges faced in the field.

Minority Stress and Positive Identity Aspects in Members of LGBTQ+ Parent Families: Literature Review and a Study Protocol for a Mixed-Methods Evidence Synthesis

BACKGROUND

Parents and children in LGBTQ+ parent families face unique stressors (i.e., minority stress), but also possess unique resources (i.e., positive identity aspects) related to their family identity. Empirical evidence and theory suggest that these minority stressors and positive identity aspects are situated on the individual, couple, and family level and may be associated with key outcomes, including parent and child health, family functioning, and school-related outcomes. A systematic evidence synthesis and a theoretical placement are currently lacking. The aims of the systematic review outlined in this protocol are thus to (1) map minority stressors and positive identity aspects according to multiple levels in the family system, and (2) to synthesize evidence on their associations with key outcomes.

METHODS

We will conduct a PRISMA-conform mixed-methods systematic review. Studies will be retrieved using a multi-tiered search strategy, including database searches (PsycInfo, PubMed, Scopus, Web of Science), cited literature searches, authors' publication lists, and study requests. The mixed-methods synthesis will follow a parallel-results convergent synthesis design, where quantitative results will be synthesized via meta-analysis and qualitative results via thematic synthesis.

CONCLUSIONS

Our proposed systematic review may add to the theoretical understanding of LGBTQ+ parent family functioning and advance social inclusion of LGBTQ+ parent families.

"Mom and dad = cis woman + cis man" and the stigmatization of trans parents: an empirical test of norm-centered stigma theory

Background: Empirical research on transgender individuals and their families is growing but investigations of attitudes toward trans parents are sparse. This gap is especially important to address because transgender parents face unique strains due to their violations of hetero-cis-normativity and the "Mom and Dad = Cis Woman + Cis Man" stereotype. Methods: Using a sample of adults aged 18-64 stratified by U.S. census categories of age, gender, race/ethnicity and census region collected from online panelists (N = 2,948), this study provides an intersectional investigation of Norm-Centered Stigma Theory (NCST) with hetero-cis-normativity (a system of norms, privilege, and oppression that situates heterosexual cisgender people above all others) as the centralized overarching concept that helps us to understand negativity directed toward transgender parents. Specifically, social power axes including gender identity (cisgender woman, cisgender man, nonbinary; trans people were excluded from the current study), sexual identity (heterosexual, lesbian, gay, bisexual), and interactions among these axes of social power are investigated. Results: Findings indicate that hetero-cis-normativity is strongly related to negativity toward trans mothers and fathers and that there is overall greater stigma toward trans dads when compared to trans moms. In addition, gender, sexual identity, and interactions among these experiences of social power have complex relationships with the stigmatization of trans parents. Conclusion: Results provide support for the use of Norm-Centered Stigma Theory to help us best understand the constellation of hostilities directed toward trans people and their families.

Improving Medical Student Comfort and Competence in Performing Gynecological Exams: A Systematic Review

PURPOSE

Performing a gynecological exam is an essential skill for physicians. While interventions have been implemented to optimize how this skill is taught in medical school, it remains an area of concern and anxiety for many medical students. To date, a comprehensive assessment of these interventions has not been done. The authors conducted a systematic review of the literature on interventions that aim to improve medical student education on gynecological exams.

METHOD

The authors searched 6 databases (Ovid MEDLINE, Ovid EMBASE, EBSCO CINAHL Plus, Scopus, Web of Science Core Collection, and ERIC [Proquest]) from inception to August 4, 2020. Studies were included if they met the following criteria: focus on medical students, intervention with the purpose of teaching students to better perform gynecological exams, and reported outcomes/evaluation. Extracted data included study location, study design, sample size, details of the intervention and evaluation, and context of the pelvic exam. All outcomes were summarized descriptively; key outcomes were coded as subjective or objective assessments.

RESULTS

The search identified 5,792 studies; 50 met the inclusion criteria. The interventions described were diverse, with many controlled studies evaluating multiple methods of instruction. Gynecological teaching associates (GTAs), or professional patients, were the most common method of education. GTA-led teaching resulted in improvements in student confidence, competence, and communication skills. Physical adjuncts, or anatomic models and simulators, were the second most common category of intervention. Less resource-intensive interventions, such as self-directed learning packages, online training modules, and video clips, also demonstrated positive results in student comfort and competence. All studies highlighted the need for improved education on gynecological exams.

CONCLUSIONS

The literature included evaluations of numerous interventions for improving medical student comfort and competence in performing gynecological exams. GTA-led teaching may be the most impactful educational tool described, though less resource-intensive interventions can also be effective.