Vulnerable and strong – lesbian women encountering maternity care

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 ).

LGBTQ+ new and expectant parents' experiences of perinatal services during the UK's first COVID-19 lockdown

BACKGROUND

COVID-19 created specific challenges for new and expectant parents and perinatal services. Services changed rapidly in the United Kingdom (UK), including the withdrawal of home birth services, birth center closures, and restrictions on the number of birth partners allowed in the birth room. The purpose of this study was to examine how these changes affected the experiences of LGBTQ+ parents in the UK.

METHODS

An online survey was conducted in April 2020 to provide real-time data capture of new and expectant families' experiences. It was open to those in the third trimester, or to those who had given birth since the beginning of the first UK lockdown period, and their partners. The survey asked open-ended questions about perinatal experiences. Demographic data were also collected, including sexual orientation and gender. Responses were collected from 1754 participants, including 76 who self-identified as LGBTQ+.

RESULTS

Thematic analysis identified that LGBTQ+ new and expectant parents faced similar issues to cisgendered, heterosexual expectant parents, though additional concerns were also noted relating to support and recognition. Heterocentric policies negatively affect lesbian families. Non-birthing co-mothers feared invalidation as parents. Sexual minority pregnant women were more likely than heterosexual pregnant women to consider additional birth supporters and to consider freebirthing.

DISCUSSION

Service changes introduced in the pandemic were cisheteronormative, creating additional challenges for LGBTQ+ new and expectant parents and compounding existing inequalities. When planning, changing, or evaluating perinatal services, specific consideration is needed to include birthing parents who are not mothers and mothers who did not give birth. If appropriate care is not available, consequences may include impaired perinatal wellbeing and restricted birth choices. Including sexual orientation and gender in data collection enables different perspectives to be considered.

Supporting birth companions for women in labor, the views and experiences of birth companions, women and midwives: A mixed methods systematic review

BACKGROUND

Birth companions can have a positive effect on women's experiences in labor. However, companions can feel unprepared and need professional guidance to help them feel involved and provide effective support.

METHODS

A convergent segregated mixed-methods systematic review was conducted to explore women's, companions', and midwives' experiences of birth companion support and identify ways to improve the experience for women and companions. A thematic synthesis of qualitative data and a narrative summary of quantitative data were conducted followed by integration of the findings.

RESULTS

Companions who cope well in labor reported feeling involved, able to preserve women's internal focus and have a defined role, providing physical or emotional support. LBGTQ+ partners faced barriers to inclusion due to "forefronting" of their sexuality by staff and a lack of recognition in the language and processes used. The experience of birth companions can be enhanced by promoting their role as co-parent, guardian, and coach, provision of timely information and developing a trusting relationship with care providers. Only two papers reported midwives' views on birth companions in labor.

CONCLUSIONS

Women's and companions' satisfaction with birth is increased when companions can support the mother, feel supported themselves, and valued as a co-parent. The midwives' role in information provision and guidance can maximize birth companions' experience and ability to provide positive support. LBGTQ+ families need more support to feel included and recognized.

Homoparenting as a public health issue: a scoping review

OBJECTIVE

To map global scientific production on homoparenting in the field of collective health or public health.

METHODS

In terms of methodological procedures, a scoping review was carried out, guided by the following question: What are the aspects addressed in global scientific production regarding homoparental families in the field of collective or public health? The searches were carried out in seven sources of scientific literature, including 58 studies, involving scientific articles and dissertations. The analytical treatment given to the studies, most of which were qualitative, followed the content analysis technique in the thematic modality.

RESULTS

The results indicate that the perceptions of homosexuals and professionals about the care provided and health services in general was the topic addressed by the largest number of studies (n = 31), followed by heteronormative context of health services (n = 26); disclosure of sexual orientation (n = 20); fertilization (n = 14); educational information and actions (n = 5).

CONCLUSION

Although the issue of same-sex parenthood has been discussed in some health sectors, there is awareness that it is necessary to rely on a consolidated basis through numerous studies when discussing this issue. It is concluded that, among other aspects, the scope of this review is not sufficiently problematized within the scope of health professionals' training and performance.

"Who's the Mom?": Heterosexism in Patient-Provider Interactions of Queer Pregnant Couples

Previous scholarship has discussed how queer individuals experience discrimination in healthcare settings. This study furthers this area of research by exploring how queer pregnant couples encountered heterosexism within patient-provider interactions. Heterosexism is being used as a framework for the study by looking at how healthcare acts as a power system to promote heterosexual identity. Through using a multiadic analysis, I interviewed 16 couples both together and separately, resulting in 46 total interviews. The analysis demonstrated that the couples experienced heterosexism by providers not understanding who the "mom" is, having to explain sexual identity to providers and providers reinforcing heterosexist expectations. The couples also provided advice for healthcare providers to improve their interactions with future queer pregnant couples.

Measuring the attitudes of midwives toward sexual and gender minority clients: Results from a Cross-Sectional survey in Ontario

BACKGROUND

In Canada, Ontario midwives provide care to sexual and gender minority (SGM) people. Published literature shows how midwives' attitudes shape the experiences of lesbians, but research examining midwives' attitudes toward SGM people is lacking. Our study measured the attitudes of Ontario midwives toward SGM clients, hypothesizing that attitudes would be positive overall and that there would be no difference in attitudes across practice settings.

METHODS

Paper surveys (n = 926) with an option to respond online were sent to Ontario midwifery practices. We measured midwives' attitudes toward sexual minorities (11 questions, scores ranged from 11 to 55) and gender minorities (9 questions, scores ranged from 9 to 45), with higher scores indicating more positive attitudes. Overall and subgroup analyses were performed.

RESULTS

The 268 completed surveys indicated that midwives' attitudes were positive toward both sexual (mean score 49.2, maximum possible score of 55, ie, 89.4%) and gender minorities (mean score 38.9, maximum possible score of 45, ie, 86.4%). Analyses showed that attitudes toward SGM were associated with midwives' sexual identity and route of entry into the profession (ie, university-based vs bridging programs), but not practice setting.

CONCLUSIONS

Although attitudes of this subset of midwives toward SGM clients were positive, volunteer bias could account for this finding since 32.6% of respondents identified as sexual minorities. Since the attitudes of midwives who entered the profession through the university-based education program were significantly more positive than those who entered through international bridging programs, future research should examine how SGM-related content is integrated into midwifery education and training curricula.

Nurses' Perceptions of the Quality of Perinatal Care Provided to Lesbian Women

Aim

Based on the Theory of Reasoned Action (TRA), we examined whether attitudes of nurses from different ethnic groups, subjective norms, behavioral intentions, assessments of relationships and communication were associated with their perceptions of the quality of perinatal care provided to lesbian women.

Background

Nurses administer healthcare, provide pertinent information and consultation to lesbians from pregnancy planning through birth.

Introduction

During the past few decades, worldwide, there has been a rise in lesbian-parenting. Despite the changes in Israeli society's public and legal reality, intolerance and discrimination to the homosexual population is still prevalent in Israel's healthcare system.

Methods

A cross-sectional study conducted between 12/2015-4/2016. Of the 270 nurses approached, 184 completed a self-report anonymous questionnaire (a response rate of 74%).

Findings

This is an important and timely study reflecting nurses' perceptions of the quality of perinatal care provided to lesbians. The study findings reflect that attitudes, subjective norms, behavioral intentions, assessments of relationships and communication of nurses from different ethnic groups are associated with their perceptions of the quality of perinatal care provided to the lesbians. The hierarchical regression analysis demonstrated that attitudes, subjective norms, behavioral intentions, assessments of relationships and communication of nurses contributed 56% to the variance of nurses' perception of their own quality of perinatal care.

Discussion

TRA conceptualization predicted the quality of care of nurses from different ethnic groups treating lesbians in a perinatal setting.

Conclusion

TRA provides a useful framework for understanding and predicting the motivational effect of health care personnel with the lesbian population, being at risk for stigmatization and receiving less quality perinatal care.

Implications for nursing and heath policy

Our findings revealed the importance of formulating a recognized policy in the field of LGBT medicine at the national level. Further training of nurses as to the lesbians' unique health needs, might improve the nurses' relationships and communication as well as the quality of perinatal nursing care.

From the families we choose to the families we find online: media technology and queer family making

Since the mid-2000s, a number of Western countries have witnessed an increase in the number of children born into ‘alternative’ or ‘queer’ families. Parallel with this queer baby boom, online media technologies have become intertwined with most people’s intimate lives. While these two phenomena have appeared simultaneously, their integration has seldom been explored. In an attempt to fill this gap, the present article explores the ways in which contemporary queer reproduction is interwoven with online media practices. Importantly, the article does not understand online media as a technology that simply facilitates queer kinship; rather, it argues that online media technology is a reproductive technology in its own right. Drawing on empirical examples of media practices of kinning, such as online shopping for donor sperm and locating ‘donor siblings’ via online fora such as Facebook, the article analyses the merging and intersection of online media and queer kinship. These analyses serve as a foundation for an exploration of contemporary kinship and the development of a new theoretical framework for contemporary queer reproduction. Empirically, the examples are from single women’s (i.e. solo mothers) and lesbian couples’ family making. Using Weston's work on ‘chosen families’ as a backdrop for discussion, the article describes families of choice in light of new online kinship connections. In particular, the article focuses on online-initiated connections between donor siblings and how such connections can re-inscribe biology as important to queer kinship. Furthermore, it closely examines how media technology guides queer reproduction in particular directions and how technology causes becoming as a family.

Between a Rock and a Hard Place: Considering "Freebirth" During Covid-19

Background: The global coronavirus (Covid-19) pandemic concerns all people, but has a specific effect on those who are expecting a baby during this time. The advice in the UK changed rapidly, with 14 different sets of national guidance issued within 1 month. Individual NHS Trusts released various guidance relating to the withdrawal of homebirth services, the closure of birth centers, restrictions on the number of birth partners (if any) allowed during labor, and whether any visitors were allowed to attend after birth. With the landscape of maternity care changing so rapidly, research was carried out to provide real-time data to capture the lived experiences of expectant families.

Methods: A mixed methods online survey was carried out over 2 weeks between 10th and 24th April 2020. The survey was open to those in the third trimester of pregnancy, those who had given birth since the beginning of the “lockdown” period in the UK, and the partners of pregnant women and people who were in these circumstances. The survey asked questions about how respondents' holistic antenatal experiences had been affected, whether their plans for birth had changed, and the effect of these changes on respondents' emotional wellbeing. Of the 1,700 responses received, 72 mentioned that they had seriously considered “freebirthing” (giving birth without a healthcare professional present).

Findings: An analysis of the respondents' reasons for considering freebirth was conducted, finding that reasons for considering freebirth were complex and multifaceted. Lesbian, bisexual, pansexual, and queer women were more likely to have considered freebirth than heterosexual people (p < 0.001).

Conclusions: Considering giving birth without a healthcare professional present is unusual in the Global North and represents an emerging field of study. The literature examining the reasons that people consider freebirth shows a variety of underlying motivations. A global pandemic represents a new factor in such considerations. The findings from this research can help inform maternity service planning in future crises.

'I know my place'; a meta-ethnographic synthesis of disadvantaged and vulnerable women's negative experiences of maternity care in high-income countries

OBJECTIVE

During pregnancy and childbirth, vulnerable and disadvantaged women have poorer outcomes, have less opportunities,face barriers in accessing care,and are at a greater risk of experiencing a traumatic birth. A recent synthesis of women's negative experiences of maternity care gathered data from predominantly low-income countries. However, these studies did not focus on vulnerable groups, and are not easily transferable into high-income settings due to differences in maternity care provision. The aim of this study was to synthesise existing qualitative literature focused on disadvantaged and vulnerable women's experience of maternity care in high-income countries.

METHODS

A systematic literature search and meta-ethnographic methods were used. Search methods included searches on four databases, author run, and backward and forward chaining. Searches were conducted in March 2016 and updated in May 2020.

FINDINGS

A total of 13,330 articles were identified and following checks against inclusion / exclusion criteria and quality appraisal 20 studies were included. Meta-ethnographic translation analytical methods were used to identify reciprocal and refutational findings, and to undertake a line of argument synthesis. Three third order reciprocal constructs were identified, 'Prejudiced and deindividualized care', 'Interpersonal relationships and interactions' and 'Creating and enhancing insecurities.' A line of argument synthesis entitled 'I know my place' encapsulates the experiences of disadvantaged and vulnerable women across the studies, acknowledging differential care practices, stigma and judgmental attitudes. A refutational translation was conceptualised as 'Being seen, being heard' acknowledging positive aspects of maternity care reported by women.

CONCLUSION

Insights highlight how women's vulnerability was compounded by complex life factors, judgmental and stigmatizing attitudes by health professionals, and differential care provision. Further research is needed to identify suitable care pathways for disadvantaged and vulnerable women and the development of suitable training to highlight negative attitudes towards these women in maternity care settings.

The views and experiences of LGBTQ+ people regarding midwifery care: A systematic review of the international evidence

BACKGROUND

There has been growing attention to addressing the health inequalities and concerns of LGBTQ+ people, with research evidence highlighting areas requiring further attention and development. The distinct concerns of LGBTQ+ people when accessing midwifery care and support is an issue requiring a specific focus to ensure needs are met effectively.

AIM

The aim of this systematic review was to critically appraise and synthesise the best available evidence regarding the views and experiences of LGBTQ+ people in relation to midwifery care and supports.

METHOD

A systematic review was undertaken to identify all relevant studies meeting the inclusion criteria. A total of eleven papers were included in the review, utilising the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) method. Methodological quality was evaluated using the Mixed Methods Assessment Tool (MMAT).

FINDINGS

Following data analysis, the themes that emerged were: (i) Contemplating pregnancy and ante-natal experiences, (ii) pregnancy and labour issues and concerns, and (iii) post-natal ongoing care and supports.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

It has become apparent from this systematic review that LGBTQ+ individuals have variable experiences when accessing midwifery care and support. Midwifery policies and practice guidelines should be reflective of the distinct needs of LGBTQ+ people and their families and friends. Future studies could focus more on the impact and outcomes of their care experiences within midwifery services.

Associations between heteronormative information, parental support and stress among same-sex mothers in Sweden-A web survey

Aim

The aim was to investigate same‐sex mothers’ self‐assessed experiences of forming a family, and the association between heteronormative information, parental support and parenting stress.

Design

A quantitative, cross‐sectional study.

Methods

In a web survey conducted in Sweden in 2019, same‐sex mothers (N = 146) with a child aged 1–3 years answered questions about their experiences of forming a family through assisted reproduction and questions about parenting stress. Descriptive statistics describes the process of forming a family. Pearson's correlation analyses and independent sample t tests were used to test hypotheses about heteronormative information, parental support and parenting stress.

Results

Same‐sex mothers experienced going through assisted reproduction treatment as stressful, and parental groups as not being supportive. Heteronormative information correlated with both lower perceived parental support and higher perceived parenting stress. Non‐birth mothers experienced less acknowledgement and support than birthmothers.

Cultivating awareness of sexual and gender diversity in a midwifery curriculum

OBJECTIVE

To explore the perspectives of student midwives, midwifery educationalists and midwifery clinicians from and connected to one University in order to identify strategies to enhance awareness of sexual and gender diversity in a pre- registration midwifery curriculum.

DESIGN

A mixed method study including an online survey and a series of focus groups Setting: One University in London Participants: 47 survey respondents and 16 focus group participants Findings: Two Inductive themes were developed from the data analysis: Practising Open Mindedness and Cultivating Openness and four sub themes; Making Assumptions, Developing self- awareness, Challenge and Discomfort and Safe spaces. Participants proposed learning strategies that they thought would facilitate cultivating openness and open mindedness.

Include-integrate-involve: Deciphering oral healthcare providers' professional demeanor towards sexual and gender minority cohorts in a metropolitan city of western India

Objectives

The Sexual and Gender Minorities (SGM) have been subject to disparities in healthcare. This study gauges and compares the demeanor of oral health task force in privately-funded and government-funded dental schools of India towards SGM cohorts.

Study design

A descriptive, cross-sectional, point prevalent study was conducted following standard statements of the STROBE guidelines and using the Medical Condition Regard Scale (MCRS). It was conducted among the clinical oral health taskforce hailing from private-funded and government-funded institutes.

Methods

One-way ANOVA test computed differences in mean MCRS scores among the undergraduates, postgraduates and faculty. Independent t-test compared responses of participants from private institutions and government institutions using SPSS version 17 statistical software.

Results

All the respondents were mostly but not completely satisfied to work with SGM patients (MCRS score ​= ​4.55 ​± ​1.114) indicative of some underlying hesitance. Though everyone had a positive regard, undergraduates and those from private institutions felt more compassionate and showed greater willingness to put in extra efforts to help them feel at ease (P-value <0.05). This is interpretive of more receptiveness towards specialized training and policy reforms of these individuals.

Conclusion

The significant differences between institutes and designations highlight disparities in knowledge and training resulting in the underlying hesitation. Health education urgently needs a targeted and focused SGM-related training program to deconstruct these disparities and provide equitable oral and general health for all individuals irrespective of their sexual orientation.

The Polyamorous Childbearing and Birth Experiences Study (POLYBABES): a qualitative study of the health care experiences of polyamorous families during pregnancy and birth

BACKGROUND

As many as 1 in 5 adults practise some type of consensual nonmonogamy such as polyamory; many are married, have children, or both. Polyamorous families face unique challenges when accessing care during pregnancy and birth, and qualitative descriptive studies are needed to understand their experiences and inform health care providers' practice.

METHODS

Participants, who self-identified as polyamorous, had given birth in the last 5 years and received at least some prenatal care, were recruited through convenience sampling on social media. Any of the birthing individual's partners were also invited to participate. All participants completed a short demographic questionnaire and participated in a semistructured interview. Interview transcripts were coded using Braun and Clarke's iterative thematic analysis.

RESULTS

A total of 24 participants, 11 who had given birth and 13 partners, were interviewed. Of those who had given birth, 5 received midwifery care only, 4 received obstetric care exclusively and 2 received shared care. Polyamorous families described sharing many common experiences during pregnancy and birth that were affected by their polyamorous identity. Although participants reported both positive and negative experiences with health care providers, when accessing health care all had experienced some form of marginalization that was related to their polyamorous status. One particular challenge for families was with respect to disclosure of polyamorous identity in hospital environments. Participants offered suggestions for improving the health care of polyamorous families during pregnancy and birth, including creating nonjudgmental spaces, accommodating difference through minimizing administrative barriers and allying with patients by providing patient-led care.

INTERPRETATION

Polyamorous families face marginalization when accessing pregnancy and birth care. Care experiences for polyamorous families can be improved by nonjudgmental, open attitudes of health care providers, and modifications to hospital policies to support multiparent families.

Improving the Knowledge, Attitudes, and Behavioral Intentions of Perinatal Care Providers Toward Childbearing Individuals Identifying as LGBTQ: A Quasi-Experimental Study

BACKGROUND

This study explores the impact of gender and sexuality awareness training on perinatal health care providers' (HCPs') knowledge, attitudes, and intended behavior toward childbearing individuals identifying as lesbian, gay, bisexual, transgender, and/or queer (LGBTQ).

METHOD

A nonrandom convenience sample of HCPs (n = 187) comprised an experimental group (n = 99) who attended grand rounds trainings covering gender and sexuality topics and a control group (n = 88) who attended sessions on other unrelated topics. All participants completed a pre-posttraining questionnaire to assess changes in knowledge, attitudes, and intended behavior toward LGBTQ patients.

RESULTS

Participants in the experimental group demonstrated significant improvement in knowledge, misconception, prejudice, sensitive language, and normativity regarding LGBTQ pregnant patients from pretest to posttest.

CONCLUSION

These findings suggest that a 40-minute gender and sexuality training can immediately improve HCPs' knowledge, attitudes, and intended behavior toward LGBTQ childbearing patients. [J Contin Educ Nurs. 2019;50(7):303-312.].

Biological, Psychological, Social, and Legal Aspects of Trans Parenthood Based on a Real Case-A Literature Review

Trans men are people who, based on their genitals, were assigned the status of female at birth. However, their identity and their way of living gender do not correspond to the socially established norms. In this paper, we discuss the different perspectives in relation to transgender people and their desire for parenthood. This review, and the basis of this paper, is inspired by the case of a trans man who desired gestation with his own genetic material. He began the cycle of assisted reproduction when he was a legally recognized woman, but that attempt ended with a miscarriage. From that assisted reproduction cycle, four embryos remained frozen. After the failed experience of gestation, the person completed his transition. Now legally a man, he attempted to gestate using his reproductive organs. This literature review aimed to identify relevant studies describing the relationship between transgender person and biological parenthood. This study comprehensively addresses important aspects one should know when considering a transgender pregnancy. These factors include biological, psychological, social, and legal issues. After reviewing the state-of-the-art information on trans parenthood, the main conclusion is that ‘the desire to have a child is not a male or female desire but a human desire’.

Health Care Experiences of Lesbian Women: A Metasynthesis

Lesbian women experience discrimination within the health care system that leads many to cautiously navigate a heteronormative system. This metasynthesis offers a richer contextual understanding about lesbian health care experiences. The 4 overarching themes that emerged are: (a) sizing up the provider and the environment, (b) to say or not to say: "paradoxes of disclosure," (c) reactions to provider's assumptions, (d) and acknowledging my partner. Lesbian women perceive their health care experiences based on the nature of the relationship with the provider. These women are more likely to seek care from health care providers who acknowledge, affirm, and respect a woman's sexual identity, cultural beliefs, and family structures.

Exploring the attitudes, knowledge and beliefs of nurses and midwives of the healthcare needs of the LGBTQ population: An integrative review

OBJECTIVES

To explore current literature surrounding the knowledge, beliefs and attitudes of nurses and midwives of the healthcare needs of Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ) patients and their influence on equal and non-discriminatory care for LGBTQ individuals.

DESIGN

Systematic integrative review.

DATA SOURCES

CINAHL, MEDLINE, PubMed, InterNurse.

REVIEW METHODS

This integrative review used Wakefield's (2014) framework to establish the knowledge, beliefs and attitudes of nurses and midwives of the healthcare needs of LGBTQ patients. Qualitative, quantitative and mixed methods primary studies carried out between 2006 and 2015 from 7 countries were included. Four databases were searched and 98 studies were screened for eligibility by two researchers. Level of evidence was assessed by the Scottish Intercollegiate Guidelines Network (SIGN, 2010) criteria and quality was assessed by a screening tool adapted from Noyes and Popay (2007) for qualitative papers and Quality Assessment Tool for Quantitative Studies adapted from the Effective Public Health Practice Project (EPHPP, 2010). Following PRISMA guidelines, this integrative review analysed and synthesised evidence using thematic analysis to generate themes.

RESULTS

24 papers were included in the final synthesis which revealed four primary themes: Heteronormativity across Healthcare; Queerphobia; Rainbow of Attitudes; Learning Diversity.

CONCLUSIONS

Nurses and midwives possess a wide spectrum of attitudes, knowledge and beliefs which impact the care received by LGBTQ patients. Many issues of inadequate care appear to be due to a culture of heteronormativity and a lack of education on LGBTQ health. Further research is needed on interventions which could facilitate disclosure of sexual orientation and interrupt heteronormative assumptions by staff. It is recommended that LGBTQ issues be included within undergraduate nursing and midwifery education or as part of continued professional development.

The Invisible Work of Closeting: A Qualitative Study About Strategies Used by Lesbian and Gay Persons to Conceal Their Sexual Orientation

The last decades have offered substantial improvement regarding human rights for lesbian and gay (LG) persons. Yet LG persons are often in the closet, concealing their sexual orientation. We present a qualitative study based on 182 histories submitted from 161 LG individuals to a Web site. The aim was to explore experiences of closeting among LG persons in Norway. A broad range of strategies was used for closeting, even among individuals who generally considered themselves to be out of the closet. Concealment was enacted by blunt denial, clever avoidance, or subtle vagueness. Other strategies included changing or eliminating the pronoun or name of the partner in ongoing conversations. Context-dependent concealment, differentiating between persons, situations, or arenas, was repeatedly applied for security or convenience. We propose a shift from "being in the closet" to "situated concealment of sexual orientation."

Factors Related to Homophobia Among Nursing Students

A convenience sample of 90 nursing students participated in an online survey measuring homophobia or sexual prejudice. Significantly higher scores were seen among those who endorsed the belief that being gay was a matter of personal choice, did not have a friend or family member who was gay or lesbian, and endorsed religiosity. A significantly higher level of sexual prejudice was seen among those who identified as non-Catholic Christians when compared to other religions. Asian/Pacific Islanders showed significantly higher scores on the scales compared to non-Hispanic Caucasian students. Nursing education should focus on those aspects of homophobia amenable to change.

Building healthcare workers' confidence to work with same-sex parented families

This article reports on a qualitative study of barriers and access to healthcare for same-sex attracted parents and their children. Focus groups were held with same-sex attracted parents to explore their experiences with healthcare providers and identify barriers and facilitators to access. Parents reported experiencing uncomfortable or anxiety-provoking encounters with healthcare workers who struggled to adopt inclusive or appropriate language to engage their family. Parents valued healthcare workers who were able to be open and honest and comfortably ask questions about their relationships and family. A separate set of focus groups were held with mainstream healthcare workers to identity their experiences and concerns about delivering equitable and quality care for same-sex parented families. Healthcare workers reported lacking confidence to actively engage with same-sex attracted parents and their children. This lack of confidence related to workers' unfamiliarity with same-sex parents, or lesbian, gay and bisexual culture, and limited opportunities to gain information or training in this area. Workers were seeking training and resources that offered information about appropriate language and terminology as well as concrete strategies for engaging with same-sex parented families. For instance, workers suggested they would find it useful to have a set of 'door opening' questions they could utilize to ask clients about their sexuality, relationship status or family make-up. This article outlines a set of guidelines for healthcare providers for working with same-sex parented families which was a key outcome of this study.

Imagining parenthood: the possibilities and experiences of parenthood among transgender people

This paper reports on a qualitative study exploring the ways in which transgender adults imagine a place for parenthood in their lives, and/or the ways they have negotiated parenthood with their transgender identity. A total of 13 transgender adults (including parents and non-parents) were interviewed with respect to their thoughts and experiences about family, relationships and parenting. The study sought to understand the possibilities for parenthood that transgender people create, despite barriers imposed by restrictive laws, medical practices and cultural attitudes. Interview data showed how normative assumptions about gender and parenthood shape the way people imagined and desired parenthood. It also showed how participants re-appropriated and resisted normative cultural scripts by either re-imagining parenthood in different terms (such as step-parenthood) or by creating different family forms, such as co-parented families. Participants reported a variety of experiences with healthcare providers when it came to conversations about fertility preservation and family building.

Diversity in midwifery care: working toward social justice

As midwifery moved from lay practice to a regulated health-care profession in Ontario toward the end of the twentieth century, it brought with it many of its social movement goals and aspirations. Among these was the desire to attend to diversity and equity in the provision of birthing care. Drawing on interviews with currently practicing Ontario midwives, this paper focuses on midwives' conceptualizations of diversity and explores their everyday work to support and strengthen diversity among those using and those providing midwifery care. We argue that midwifery's recent relocation within state structured health care means neither that the social change projects of midwifery are complete nor that midwifery has abandoned its movement-based commitment to social change. Responses to social diversity in health care range from efforts to simply improve access to care to analyses of the role of social justice in recognizing the needs of diverse populations. The social justice aspiration to "create a better world" continues to animate the work of midwives postregulation. This paper explores the legacy of midwifery as a social movement, addressing the connections between diversity, social justice and midwifery care.

LGB-parent families: the current state of the research and directions for the future

Over the past several decades, lesbian, gay, and bisexual (LGB) parenting has grown more visible. Alongside this enhanced visibility, research on the experiences of LGB parents and their children has proliferated. The current chapter addresses this research, focusing on several main content areas: family building by LGB people, the transition to parenthood for LGB parents, and functioning and experiences of LGB parents and their children. In the context of discussing what we know about LGB-parent families, we highlight gaps in our knowledge and point to key areas that future research should aim to answer, including how race, ethnicity, social class, and geographic factors shape the experiences of LGB-parent families.

[The lesbian population in health studies: contributions for a critical reflection]

For decades, lesbian sexuality was associated with pathology in the attitudes to and practices of health sciences and psychology. During the twentieth century that position changed gradually. This article analyzes these changes in a theoretical reflection on the domain of lesbian health, dominated by heteronormative and heterosexist concepts and practices both in research and in health care. By means of a critical contextualization of the literature, specific health needs of lesbians were identified and the interventions of health care professionals and services were questioned. Specific concrete actions are proposed in the fields of health promotion and in the eradication of discrimination and inequality in health care.

The other mother: a narrative analysis of the postpartum experiences of nonbirth lesbian mothers

The purpose of this study was to develop a metastory of nonbiological lesbian mothers' postpartum experiences utilizing Riessman's structural approach to thematic analysis. Ten nonbirth lesbian mothers were interviewed. Each shared a unique story of her first year of motherhood. Themes were individually analyzed within each story. The metastory of the postpartum experiences of nonbirth lesbian mothers revealed 6 themes including the following: At the mercy of health care providers, Nursing is the major difference between us, Defined by who I am not, Fighting for every piece of motherhood: The world can take them away, What's in a name?, and Epilogue: The new normal.

Efforts to maintain a ‘just great’ story: Lesbian parents’ talk about encounters with professionals in fertility clinics and maternal and child healthcare services

After lesbian couples have decided to become parents, their family-making journey entails a wide range of encounters with professionals in fertility clinics and/or in maternal and child healthcare services. The article presents the results of an analysis of 96 lesbian mothers’ interview talk about such encounters. In their stories and accounts, the interviewees draw on two separate and contradictory interpretative repertoires, the ‘just great’ repertoire and the ‘heteronormative issues’ repertoire. Throughout the interviews, the ‘just great’ repertoire strongly predominates, while the ‘heteronormative issues’ repertoire is rhetorically minimized. The recurrent accounts of health services as ‘just great’, and the mitigation of problems, are meaningful in relation to a broader discursive context. In a society where different-sex parents are the norm, the credibility of other kinds of parenthood is at stake. The ‘just great’ repertoire has a normalizing function for lesbian mothers, while the ‘heteronormative issues’ repertoire resists normative demands for adaptation.

Lesbian women's experiences with healthcare providers in the birthing context: a meta-ethnography

OBJECTIVE

to explore research knowledge about lesbian women's experiences with health-care providers in the birthing context.

METHOD

a systematic search for relevant qualitative studies in selected databases identified 13 articles of sufficient quality. The findings were synthesized using a meta-ethnographic approach as described by Noblit and Hare. SYNTHESIS AND FINDINGS: issues related to covert or overt homophobia and prejudice were demonstrated and were sometimes mediated by subtle mechanisms that were difficult to understand and to manage. On the other hand, small gestures of support were described to make a huge difference. A lack of knowledge was demonstrated, contrasted by staff showing a positive and informed attitude. Disclosure was an important issue, but due to the risk involved the women demonstrated a need to be in control. Finally, being acknowledged, both as individuals and as family were considered vital. In this regard, it was essential to recognize and include co-mother as equal parent and to look upon lesbian sexuality as normal and natural.

KEY CONCLUSIONS

midwives' emotional involvement in the situation is significant for moral perception of the women's intimate citizenship, even when they are distressed by lesbian sexuality.

IMPLICATIONS FOR PRACTICE

our findings reveal the importance of including sexuality as an issue deserving reflection in maternity wards, whether or not this might cause unrest in midwives who do not feel comfortable with intimate citizenships beyond mainstream.

Nursing's silence on lesbian, gay, bisexual, and transgender issues: the need for emancipatory efforts

The purpose of this study was to selectively review the nursing literature for publications related to lesbian, gay, bisexual, and transgender health, using (1) a key word search of CINAHL, the database of nursing and allied health publications; (2) from the top-10 nursing journals by 5-year impact factor from 2005 to 2009, counting articles about lesbian, gay, bisexual, and transgender issues; and (3) content analysis of the articles found in those journals. Only 0.16% of articles focused on lesbian, gay, bisexual, and transgender health (8 of nearly 5000 articles) and were biased toward authors outside of the United States. We discuss the impact of this silence.

Birthing ethics: what mothers, families, childbirth educators, nurses, and physicians should know about the ethics of childbirth

This article discusses current ethical issues associated with childbirth in the United States. It provides a review of moral problems and ethical choices made by parents and health-care professionals during the prenatal, intrapartum, and postpartum periods. Ethical issues are identified and framed through a "naturalized bioethics" approach, as recommended by Margaret Walker and her colleagues, Hilde Lindemann and Marian Verkerk. This approach critiques traditional bioethics and gives attention to everyday ethics and the social, economic, and political context within which ethical problems exist. This approach provides the reader with the tools needed to critically assess the way ethical problems are defined and resolved.

Lesbian women's experiences with health care: a qualitative study

BACKGROUND

Although the social situation for gay, lesbian, and bisexual people has improved over the last decades, lesbian women still face unique challenges when seeking healthcare services.

OBJECTIVES

To explore lesbian women's healthcare experiences specifically related to sexual orientation to achieve knowledge which can contribute to increased quality of healthcare for lesbian women.

METHODS

Qualitative study based on written stories, with recruitment, information, and data sampling over the internet. Data consisted of 128 anonymously written answers to a web-based, open-ended questionnaire from a convenience sample of self-identified lesbian women. Data were analysed with systematic text condensation. Interpretation of findings was supported by theories of heteronormativity. Main outcome measures. Patients' histories of experiences where a lesbian orientation was significant, when seeing a doctor or another healthcare professional.

RESULTS

Analysis presented three different aspects of healthcare professionals' abilities, regarded as essential by our lesbian participants. First, the perspective of awareness was addressed--is the healthcare professional able to think of and facilitate the disclosure of a lesbian orientation? Second, histories pointed to the attitudes towards homosexuality--does the healthcare professional acknowledge and respect the lesbian orientation? Third, the impact of specific and adequate medical knowledge was emphasized--does the healthcare professional know enough about the specific health concerns of lesbian women?

CONCLUSION

To obtain quality care for lesbian women, the healthcare professional needs a persistent awareness that not all patients are heterosexual, an open attitude towards a lesbian orientation, and specific knowledge of lesbian health issues. The dimensions of awareness, attitude, and knowledge are interconnected, and a positive direction on all three dimensions appears to be a necessary prerequisite.