Improving prenatal care for pregnant lesbians.

Introduction

Pregnancy, by nature of its life-changing qualities, makes a huge impact on the childbearing woman and her family (Janssen, 2007). When a woman and her partner choose a prenatal care provider, they are choosing a year-long relationship based on trust, medical expertise and skill. Besides concern about medical expertise, women want to know what kind of care will be received and may question, "Can I trust this midwife or doctor"? For a lesbian woman, trust is more likely to be achieved with a health care provider whose philosophy is to maintain inclusion and cultural sensitivity (Janssen, 2007).

Avoiding Heterosexism

Heterosexism is defined in a variety of ways because it is both hard to recognize and is also so deeply integrated into our social lives (D. Browne, personal communication, January 16, 2011). Yarbar, Sayad, and Strong (2010) define heterosexism or heterosexual bias as "the tendency to see the world in heterosexual terms and to ignore or devalue homosexuality" (p. 572). Heterosexism, as defined by Hyers (2010), seems to combine silent judgment with outright bigotry. In addition to its previous definitions, this author sees heterosexism as hetero-assumptiveness. And being hetero-assumptive is seeing the world without peripheral vision.

Heterosexism is found on so many layers in life. It can be loud and obnoxious or silent and persistent. And, like cancer, it spreads.

Sensitivity to the Needs of Lesbian Patients

Lesbian women are first and foremost women, and should be treated as such. While some healthcare providers are heterosexist and nearly eliminate sexual identity in history taking, other healthcare providers tend to be curious and inquisitive about the childbearing lesbian and give excessive attention to the lesbian relationship (Lee, 2004; Rondahl, 2009). When curiosity takes hold and patients are asked to educate their healthcare provider about their sexual identity, patients are robbed of their prenatal, intrapartum or postpartum experience (Rondahl, 2009). In this circumstance, lesbians are being asked to educate and nurture the very people whose job it is to educate and nurture.

   I'm not there to educate their staff, so a part of me is sitting
   there wishing 'please stop asking me about that' and find out why I
   am having early contractions instead. By all means--acquire the
   knowledge, but not through the patients. I can come and talk about
   it later, but not when I am there to have a baby (Rondahl, 2009, p.
   2341).

Healthcare providers do not ask their heterosexual patients to teach them about their sexual practices nor do they look confused or disgusted when a man and woman present to their office for a new obstetrical visit (NOB). Any woman could feel that her health needs were not being met if her care provider focused only on one aspect of her life. Lee (2004) reiterates this point by asserting that "it is difficult to provide unbiased, woman-centered care if we cannot maintain the focus of the lesbian woman as a person and not simply a sexual orientation" (p. 255).

On the other hand, disclosure is necessary. With decreased disclosure, there is a scarcity of data, which further contributes to the population of lesbian mothers being less visible (Lee, 2004). While it is not known how many lesbian women are reproducing, it is known that between 6 and 14 million children are being cared for by at least one gay or lesbian parent and that having two moms does not negatively impact a child's life (American Academy of Child and Adolescent Psychiatry, 2011; American Academy of Pediatrics, 2012). Despite the findings from a recently published study which suggested that youth from same-sex households were worse off (Regnerus, 2012), research has consistently found that children raised by same-sex parents do not differ, and in some studies fare better, from their opposite-sex parent counterparts in indicators of child well-being (Telingator & Patterson, 2008; Ritenhouse, 2011). Without accurate data exploring the numbers of lesbians procreating, care providers have little evidence upon which to base their care of pregnant women in a lesbian relationship. Lee (2004) states that "if a whole subgroup of the women coming through maternity services are not being adequately acknowledged, then their individual problems, concerns and needs will not be acknowledged either" (p. 354).

Alternative Communication Strategies

According to Lee (2004) and Spidsberg (2007), the current system of maternity care for lesbians is not working. Furthermore, there has not been anyone to test what method of care provision could work better and be more inclusive to alternative families. Studying a new way to talk to patients could focus on the inclusion of all pregnant individuals. Such a semiotic focus might provide a solution to this problem of heterosexism in maternal healthcare.

In order to be more lesbian inclusive, healthcare providers need to change their line of questioning starting with the initial obstetrical visit. They could consider opening the pregnancy dialogue with: "So tell me the story of how you became pregnant." This opening takes provider assumptions out of the equation and allows for a deeper understanding of the patient based on actual facts, rather than on a heterosexist assumption of female reproduction.

Baby-making, by nature of the sperm and egg requirement, has been seen as a heterosexual privilege (Access to fertility, 2009). A typical approach in initiating rapport during the new obstetrical visit (NOB) is to inquire whether the pregnancy is planned. By assuming that everyone can become pregnant accidentally, providers are being heterosexist. When healthcare providers assume their patients are heterosexual, lesbian patients are put in a position that requires them to either explain or ignore their life situation.

   The onus is on the healthcare professional to create an environment
   in which the patient feels safe enough to be open about the
   information that is relevant to her healthcare. If we are not clear
   in our own minds about why we ask certain questions, or whether
   these questions are loaded towards heterosexuality (next of kin
   being an important one), then we cannot be sure that lesbian women
   in our care feel safe or trust that the care they receive is
   appropriate. (Lee, 2004, p.356)

Healthcare providers must use inclusive language so that patients don't feel the need to defend their sexual identity but are comfortable including it as part of the fabric of their lives and their reproductive goals. Being hetero-assumptive is being heterosexist (Lee, 2004).

Institutionalized Heterosexism

It is all too easy to be hetero-focused and ignorant of the daily life challenges faced by the Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) community because the majority of individuals seeking prenatal services are heterosexual (Access to fertility, 2009). For example, in order for lesbians to become both pregnant and have legal rights to their child, they need to go through a multiple step process. This process includes insemination of the biological mother and adoption by the non-biological mother. As a result, the couple could incur a large financial responsibility (Access to fertility, 2009). Whereas reproductive healthcare is covered under heterosexual spousal employment benefits, not all jobs extend such benefits to same sex domestic partners. Furthermore, reproductive and fertility coverage within healthcare has restrictive policies to benefit the heterosexual couple trying to conceive (Access to fertility, 2009).

Female couples in need of sperm, ultrasounds, labs and professional expertise are often on their own medically and financially (Access to fertility, 2009; Spidsberg, 2007). This institutionalized discrimination is a not so subtle form of heterosexism. Heterosexuals may have financial assistance in reproducing, but members of sexual minorities often go without medical, government, employer, or societal support. Empathy and awareness of this discrepancy between those who are supported in their reproductive efforts and those who are not is essential when caring for lesbian women trying to conceive (Access to fertility, 2009).

Alternative Care for Alternative Families

Western physicians are trained to see the body's changes as biological or pathological, whereas alternative healthcare providers like Certified Nurse Midwives (CNM), acupuncturists and chiropractors have an existential belief that connects bodily health with the mind and the spirit (Turner, 2004; Kotko-Rivera, 2004). Lundgren (2004) discussed how women need a midwife to be grounded in knowledge while at the same time open to the changing needs of her patients. It is this openness that makes midwifery a good fit for alternative families, and the midwife a good person to begin making change and finding alternatives to hetero-assumptive language. Lesbians, transgender men, single women, and other nontraditional partnerships can all benefit from such an inclusive approach.

Midwifery care attempts to provide an alternative to women seeking a relationship with a healthcare provider who views pregnancy as a state of health, not illness. This is supported by considerable scientific knowledge asserting that pregnancy and childbirth are normal, for most women, and need not be pathologized. Aside from identifying as non-pathologizing, there are several other modes by which midwifery care ought to be delineated from traditional medical practices. Included in this is the effort to maintain inclusion and cultural sensitivity. If midwifery care is going to tout itself as the "alternative" to physician care, then it needs to be less heteroassumptive.

Conclusion

In the interest of building trust and enhancing communication between healthcare providers and patients, it is important to avoid hetero-assumptive dialogue. By utilizing open-ended questions during the NOB visit, the provider allows the patient to comfortably disclose her sexual identity and alternative family construct. Once the patient knows she is in the hands of a capable, caring and nonjudgmental clinician, the lesbian patient is more likely to feel comfortable asking questions and sharing fears related to her health and well-being. Patient disclosure coupled with clinician openness allow for a satisfying healthcare experience.

Summary

To summarize, by not asking questions related to sexual identity, clinicians fail to give pregnant lesbians the opportunity to disclose. Healthcare provider word choice can convey meaning to lesbian patients about their care (Rondahl, 2009). The wrong words used by the healthcare provider can be experienced as heterosexist and can reveal a lack of understanding. Thoughtful word choice by the healthcare provider can demonstrate judgment and openness to alternative family structures (Hyers, 2010). The best possible obstetrical care therefore is lesbian inclusive care. Such care is likely to occur in a trusting environment where patients are free to give their healthcare providers clear and accurate histories and share relevant concerns without the fear of judgment.

References

Access to fertility treatment by gays, lesbians, and unmarried persons. (2009). Fertility & Sterility, 92(4), 1190-1193. doi:10.1016/j.fertnstert.2009.07.977

American Academy of Pediatrics. (2012). Gay and lesbian parents. Retrieved from http://www.healthychildren.org/English/family-life/family-dynamics/ types-of-families/Pages/Gay-and-Lesbian-Parents.aspx

American Association of Child and Adolescent Psychiatry. (2011). Children with lesbian, gay, bisexual and transgender parents. Retrieved from http:// www.aacap.org/cs/root/facts_for_families/children_with_lesbian_gay_bisexual_and_transgender_parents

Hyers, L. L. (2010). Alternatives to silence in face-to-face encounters with everyday heterosexism: Activism on the interpersonal front. Journal of Homosexuality, 57, 539-565. doi:10.1080/00918361003608749

Janssen, P. A., Ryan, E. M., Etches, D. J., Klein, M. C., & Reime, B. (2007). Outcomes of Planned Hospital Birth attended by Midwives Compared with Physicians in British Columbia. Birth: Issues in Perinatal Care, 34(2), 140-14. doi:10.nn/j.1523-536.2007.00160.x

Hyers, L.(2010). Alternatives to silence in face-to-face encounters with everyday heterosexism: Activism on the interpersonal front. Journal of Homosexuality, 57, 539-565. doi:10.1080/00918361003608749

Koltko-Rivera, M. (2004). The Psychology of Worldviews. Review of General Psychology, 8, 3-58. doi: 10.1037/1089-2680.8.1.3

Larsen, K. S., Reed, M., & Hoffman, S. (1980). Attitudes of heterosexuals toward homosexuality: A Likert-type scale and construct validity. The Journal of Sex Research, 16, 245-257.

Lee, E. (2004). Lesbian users of maternity services: Appropriate care. British Journal of Midwifery, 12(6), 353-358.

Lundgren, Ingela. (2004). Releasing and relieving encounters: Experiences of pregnancy and childbirth. Scandinavian Journal of Caring Sciences, 18(4), 368-375. doi:10.nn/j.i471-6712.2004.00300.x

Patton, M. Q. (2002). Qualitative research & evaluation methods (3rd Ed.). Thousand Oaks, California: Sage Publications, Inc.

Regnerus, M. (2012). How different are the adult children of parents who have same-sex relationships? Findings from the New Family Structures Study. Social Science Research, 41, 752-770. doi:10.1016/j.ssresearch.2012.03.009.

Ritenhouse, D. (2011). What's Orientation Got to Do With It?: The Best Interest of the Child Standard and Legal Bias Against Gay and Lesbian Parents. Journal Of Poverty, 15(3), 309-329. doi:10.1080/10875549.2011.589260

Rondahl, G., Bruhner, E., & Lindhe, J (2009). Heteronormative communication with lesbian families in antenatal care, childbirth and postnatal care. Journal of Advanced Nursing, 65(ii), 2337-2344. doi:10.nn/j.13652648.2009.05092.x

Spidsberg, B. (2007). Vulnerable and strong- lesbian women encountering maternity care. Journal of Advanced Nursing, 60(5), 478-486. doi:10.nn/ j.1365-2648.2007.04439x Telingator, C. J., & Patterson, C. (2008). Children and Adolescents of Lesbian and Gay Parents. Journal of The American Academy of Child & Adolescent Psychiatry, 47(12), 1364-1368. doi:10.1097/CHI.0b013c31818960bc

Turner, P. K. (2004). Mainstreaming alternative medicine: Doing midwifery at the intersection. Qualitative Health Research, 14(5), 644-662. doi:10.1177/1049732304263656

Yarber, W. L., Sayad, B. W., & Strong, B. (2010) Human sexuality: Diversity in contemporary America. (7th ed.). New York, NY: The McGraw-Hill Companies, Inc.

Randi Beth Singer has been practicing as a CNM since 2004 and teaches in the nursing programs at Georgetown University and the University of Pennsylvania. She is currently enrolled in the Human Sexuality Education PhD program at Widener University. She lives in Philadelphia with her husband and three children.

Randi Beth Singer, CNM MSN RN

Article Details

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Author:	Singer, Randi Beth
Publication:	International Journal of Childbirth Education
Date:	Oct 1, 2012
Words:	2262
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Topics:	Lesbians Care and treatment Social aspects Prenatal care Demographic aspects Quality management