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An expression of love - midwives' experiences in the encounter with lesbian women and their partners

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This paper is a report of a descriptive study of midwives' lived experiences of caring for lesbian women and their partners. A growing body of qualitative studies describes lesbian women's experiences of maternity care. Studies about midwives' caring experiences in the encounter are needed to improve care for lesbian women and their partners. A qualitative study, using a phenomenological-hermeneutical method influenced by Ricoeur was conducted. Eleven midwives were recruited by snowball method. Interviews were conducted in 2009 and participants were encouraged to share events in their midwifery practice encountering lesbian women. The midwives described the lesbian love-relationship as strong and caring, but including elements of difference which could make the couple vulnerable. It was important for midwives to acknowledge their own attitudes and culturally sensitive non-verbal communication; also to consider the co-mother's needs and role as different compared with those of fathers. Although caring for lesbian couples was seen as unproblematic, midwives described experiences of ambivalence or anxiety in the encounter and they had noticed that some couples had had negative experiences with maternity care. Studies are required to map content, consequences and coping strategies regarding the ambivalent or uncertain caring situations and to assess a co-mother's particular role and needs during pregnancy, labour and the postnatal period to provide tailored care for lesbian couples.
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ORIGINAL RESEARCH
An expression of love – midwives’ experiences in the encounter with
lesbian women and their partners
Bente Dahl Spidsberg & Venke Sørlie
Accepted for publication 28 May 2011
Correspondence to B.D. Spidsberg:
e-mail: Bente.Spidsberg@hiak.no
Bente Dahl Spidsberg MNSc RN RM
Assistant professor
Akershus University College,
Lillestrøm, Norway
Venke Sørlie PhD RN RNT
Professor
Lovisenberg Diaconal University College,
Oslo, Norway
SPIDSBERG B.D.SPIDSBERG B.D.
&
SØRLIE V. (2012)SØRLIE V. (2012)
An expression of love –midwives’ experi-
ences in the encounter with lesbian women and their partners. Journal of Advanced
Nursing 68(4), 796–805. doi: 10.1111/j.1365-2648.2011.05780.x
Abstract
Aim. This paper is a report of a descriptive study of midwives’ lived experiences of
caring for lesbian women and their partners.
Background. A growing body of qualitative studies describes lesbian women’s
experiences of maternity care. Studies about midwives’ caring experiences in the
encounter are needed to improve care for lesbian women and their partners.
Method. A qualitative study, using a phenomenological-hermeneutical method
influenced by Ricoeur was conducted. Eleven midwives were recruited by snowball
method. Interviews were conducted in 2009 and participants were encouraged to
share events in their midwifery practice encountering lesbian women.
Findings. The midwives described the lesbian love-relationship as strong and car-
ing, but including elements of difference which could make the couple vulnerable. It
was important for midwives to acknowledge their own attitudes and culturally
sensitive non-verbal communication; also to consider the co-mother’s needs and role
as different compared with those of fathers. Although caring for lesbian couples was
seen as unproblematic, midwives described experiences of ambivalence or anxiety in
the encounter and they had noticed that some couples had had negative experiences
with maternity care.
Conclusion. Studies are required to map content, consequences and coping strat-
egies regarding the ambivalent or uncertain caring situations and to assess a
co-mother’s particular role and needs during pregnancy, labour and the postnatal
period to provide tailored care for lesbian couples.
Keywords: co-mother, lesbian, lesbian motherhood, maternity care, midwifery,
phenomenological-hermeneutical
Introduction
’Being there’ is a well-known key ingredient in the midwife-
woman relationship. It enables midwives to provide individ-
ualized care and create a trusting relationship which is vital for
women’s psychological well-being and the clinical outcome of
labour. However, ‘being there’ includes more than profes-
sional expertise, it involves personal attributes such as
midwives’ attitudes and feelings towards women, meaning
that ‘being good is different than being competent’ (Nicholls &
796 2011 Blackwell Publishing Ltd
JAN JOURNAL OF ADVANCED NURSING
Webb 2006). The International Confederation of Midwives’
(ICM) has a code of ethics for midwives (International
Confederation of Midwives, ICM, 2008). This provides a set
of guidelines regarding moral professional conduct and it
offers a philosophy and model of midwifery care which stresses
the perspective of empowerment and partnership in the
midwife-woman relationship. However, current knowledge
about lesbian couples’ maternity care experiences shows that
not all women receive a caring encounter built on respect and
personalized care (Spidsberg 2007).
Background
Research about experiences in encounters between lesbian
women and maternity care providers may be carried out from
the woman’s perspective or they may take the view of the
healthcare provider. Studies show that lesbian women are
generally satisfied with the care they receive, but they
comment on the need for improved knowledge (Stewart
1999, Buchholz 2000, Wilton & Kaufmann 2001, Renaud
2007, Spidsberg 2007, Larsson & Dykes 2009). They refer to
poor quality care, homophobia and discrimination (Kenney
& Tash 1993, Wilton 1999), over-focusing on sexuality
(Wilton & Kaufmann 2001, Lee 2004, Spidsberg 2007,
Ro
¨ndahl et al. 2009), under-focusing on sexuality (Spidsberg
2007) and assumptions about sexuality (Lee 2004). They also
describe negligence (Wilton & Kaufmann 2001), embarrass-
ment (Ro
¨ndahl et al. 2009), invisibility (Wilton 1996, Wilton
& Kaufmann 2001, Larsson & Dykes 2009) and heteronor-
mative communication (Stewart 1999, Ross et al. 2006,
Renaud 2007, Ro
¨ndahl et al. 2009). Mc. Manus et al. (2006)
conclude that health outcomes for lesbian women and their
infants are affected by healthcare providers’ attitudes and
actions.
Existing studies about health professionals’ experiences
with lesbian women in general healthcare emphasize need for
knowledge about homosexuality and communication skills
(Arnold et al. 2004, Ro
¨ndahl et al. 2004a, Hinchliff et al.
2005, Bjørkman & Malterud 2009). Barriers to communica-
tion are described, including assumptions about sexuality or
attitudes of being uncomfortable or insensitive (Bonvicini &
Perlin 2003). Attitudes towards homosexuality are influenced
by personal life experiences and education (Ro
¨ndahl et al.
2004a) and some nurses have a neutral attitude in the
encounter that may indicate ambivalence rather than accep-
tance. Cultural and sexual differences in attitudes are
described (Ro
¨ndahl et al. 2004b, Sanchez et al. 2006).
Attention to the importance of addressing both lesbian
women and midwives on their experiences and perceptions in
the encounter to improve care for lesbian women and their
partners is described (Lee 2004, Lee et al. 2011) and in 1996,
Wilton emphasized the need for improved midwifery educa-
tion on lesbian mothering (Wilton 1996). This study is an
extension of previous research about the encounter between
lesbian women and healthcare providers in maternity care
focusing on midwives’ experiences and perspectives.
The study
Aim
The aim of this study was to describe midwives’ lived
experiences of caring for lesbian women and their partners.
Design
We conducted a qualitative study, using a phenomenological
hermeneutical method influenced by Ricoeur (Ricoeur 1976).
This is a method suitable for illuminating lived experience
narrated in texts (Sørlie et al. 2003, Lindseth & Norberg
2004, Torjuul & Sørlie 2006, Spidsberg 2007, Jakobsen &
Sørlie 2010).
Participants
Permission to access two major hospitals was applied for and
granted and four midwives responded to the invitation to
volunteer as study participants. An advertisement in a
midwifery journal resulted in one midwife responding. The
last six respondents were recruited by snowballing method
(Platzer & James 1997, Morse & Richards 2002), with
midwives passing flyers or information by word of mouth to
colleagues they believed would fit the inclusion criteria. This
ensured recruitment of a small, but data-rich sample. The
participants came from different geographical areas, were of
different ages and all had different working experiences that
permitted an in-depth understanding of the lived experience
of being a midwife in the encounter with lesbian couples in
various maternity care settings.
Data collection
The interviews were conducted in 2009. Ten individual
interviews were conducted at the participants’ work site; one
in a private setting. The participants were encouraged to
share experiences from their encounters with lesbian women
and their partners, invited with the initial question: ‘What
have your experiences in the encounter with lesbian women
and their partners in pregnancy, labour and the postnatal
period been like?’
JAN: ORIGINAL RESEARCH An expression of love
2011 Blackwell Publishing Ltd 797
The interviewees were given the opportunity to narrate
freely and were interrupted by the researcher only when
elaboration or clarification was needed (Mishler 1991). The
interviews lasted from 40 to 80 minutes (mean 52 minutes),
they were audio taped and transcribed verbatim by the
researcher. Field notes were taken to comment on situational
aspects, language and interaction (Malterud 2003).
Ethical considerations
The study was conducted according to the Helsinki declara-
tion. Approval was granted by the regional Committee for
Medical Research Ethics and the Norwegian Social Science
Data Service. An information sheet about the study was
distributed to participants and information was repeated
before the interview took place including assurance on
anonymity and confidentiality. All participants gave their
written consent and they were reassured that they had the
right to withdraw from the study at any time.
Data analysis
In the phenomenological hermeneutical method, each inter-
view is looked upon as a text and the interpretation implied a
dialectic movement between the text as a whole and parts of
the text, consisting of three phases. (1) The naı
¨ve reading was
an open-minded superficial reading aimed at gaining an
overall impression of the text, providing access to the lived
experience of the midwives encountering lesbian women in
the maternity care services. (2) In the structural analysis, the
text was divided into meaning units, which in turn were
condensed to themes and sub-themes. The structural analysis
aimed to explain what the text was saying. (3) Finally, a
critical comprehension was developed. The text was read as a
whole, taking into account the authors’ preunderstanding,
naı
¨ve reading and structural analysis, and previous research
and relevant theory (Lindseth & Norberg 2004).
Rigour
A large amount of in-depth information of the meaning of
lived experience was provided. Rigour was enhanced by both
authors separately performing a structural analysis, arriving
at comparable conclusions of the data and agreeing on the
interpretation.
According to Ricoeur (1976), a text may have more than
one possible interpretation and the interpretation presented
here should be looked upon as one possible, but not the only
way of understanding the midwives’ experiences in the
encounter.
Findings
Altogether, a purposive sample (Patton 2002) of eleven
registered midwives, aged 30–59 years (mean 50), working
in four different parts of Norway participated in the study.
They met the inclusion criteria: being professional and
working with lesbian women and their partners in delivery
rooms, maternity units and/or health centres. Their pro-
fessional experience ranged from 4 to 32 years (mean
18 years).
The data analysis revealed three themes; being open, being
different and creating a confidence. The themes and sub-
themes can be seen in Table 1. In the text, citations are used
to illustrate the results.
Being open
Going public as a couple
Lesbian women were described by midwives as strong, well
educated and gifted, and they usually presented themselves as
a couple.
I admire them for having a secure identity as a woman and as a
human being. They have a confidence in themselves that they will
handle the situation; they know that they can offer their children
what they need. It has become a natural part of their lives; they no
longer need to fight for their rights to have a child.
Being anonymous
One midwife performing routine ultrasound examinations
assumed that some couples chose not to involve her in their
situation; another described how lesbian women sometimes
gave the impression of being single mothers.
In labour, you are naked and vulnerable. In the postnatal ward you
can be just as vulnerable, but it is easier to hide your tears, or hide
your vulnerability and notnot involve us. On the other hand, it
isn’t certain that they want to involve us, and we have to respect that
too.
Table 1 Overview of themes and sub-themes
Being open Going public as a couple
Being anonymous
Being responsible for making
space for communication
Being different Being lovers and friends
Being the other mum
Creating a confidence Overrunning the autopilot
Striking the note
Being a proper midwife
Being guided by instinct
B.D. Spidsberg and V. Sørlie
798 2011 Blackwell Publishing Ltd
Being responsible for making space for communication
Midwives felt they should take responsibility for opening up
the encounter.
I have met couples where I felt certain they were lesbian, but I didn’t
ask them and I regret that I didn’t manage to bring it out into the open.
One midwife thought it was up to the couple to decide if they
wanted a relationship at all, hence she awaited their initiative,
another felt the couple should be allowed to chose who they
wanted to relate to and how much they wanted to share.
However, dialogue was sometimes obstructed.
I don’t know what they think as long as the dialogue is not opened
up. A silence like that can be problematic. A ‘‘quiet silence’’.
The midwife described how her feelings of inadequacy were
replaced by self-confidence when she learned communicative
tools that helped her open up the dialogue. This gave her the
courage she needed to offer the couple an opportunity to
communicate on their terms.
Being different
Being lovers and friends
The midwives commented on the lesbian relationship as
consisting of two dimensions; lover and close friend.
They are happy, may be even more thanI experience this with
heterosexual couples too, definitely. But it’s this mixture of friends
and lovers that makes it differentthan it is with men.
The participants perceived the female friendship in the
lesbian couples to add an extra dimension to the relationship.
They recognized this part of the relationship and found it
practical and strengthening, describing how women would
‘speak the same language’ and have a better understanding of
hormonal and emotional variations, creating a special emo-
tional understanding. They commented that part of the
relationship that involved marriage or partnership was
difficult to recognize, thus it created a feeling of being an
observer to this part of the couples’ lives.
Several midwives commented on the women’s closeness
during labour.
My experience with lesbian women is that they know each other
well. They are good at reading each other and meeting each other’s
needs.
While fathers sometimes would feel uncomfortable during
labour, hiding behind a book, lesbian co-mothers easily
found their place in the birthing room, creating a pleasant or
comfortable setting. Comments on bodily understanding
were frequent.
I remember that it (labour) was very nice, very warm and friendly.
There were no misunderstandings ora feeling thatI don’t know if
it’s correct and it’s an awful thing to say compared to men, but I feel
that the way the woman was cared for, it was so goodco-mother
had an understanding for her woman that was completely different.
There was no need to ask questionsit was justit just was.
Co-mothers, being women, was considered helpful in under-
standing what takes place in the pregnant body during
pregnancy and labour. However, this closeness could also be
challenging.
A man can sometimes be a stronger coach than a woman, but a
woman feel it in her body, the process that her partner is going
through. This can be tougher; in fact some (women) have told me
that it is. It becomes powerful, and it’s probably different in a
feminine constellation because a man is unable to feel it in his body.
Several midwives met couples who expressed a desire to be
treated ‘like everyone else’. However, during labour, acute
situations sometimes would happen.
They expressed that they wanted no fuss whatsoever about
their lesbian orientation. However, when birthmother ended
up undergoing surgery, co-mother became upset when she
was told that she wasn’t allowed to stay in the postnatal
ward, exclaiming that they were a little special after all.
The midwife asked herself how she was supposed to
understand this situation and if the couple really looked upon
themselves as special.
Being the other mum
While some midwives described that they would treat
co-mother like they treated a male partner, others described a
lack of knowledge related to her role.
It’s a little bit like the father. At the same time it is different because
they are women, hence they are different than men. And present in a
slightly different way. There may be questions that I could have asked
co-mother, that I didn’t do. It’s so easy to ask fathers ‘‘How are you,
dad?’’ His role is somewhat more defined.
They asked themselves if co-mother was attached to baby the
same way mother was and if parenting would be different for
her than for a father.
There was a general understanding that co-mothers had a
valuable role being the other mum and it was important to
include her just like dad, but some questions were difficult.
I think about her possibilities to have a child. Her possibility to
become pregnant. This makes the situation unlike that of a father.
Has she given up on something, and am I allowed to ask this
question? Is there some kind of vulnerability in her not being
pregnant?
JAN: ORIGINAL RESEARCH An expression of love
2011 Blackwell Publishing Ltd 799
This situation was easier to handle when co-mother herself
had given birth as they felt this created a balance in the
relation, making it easier to communicate about emotional
concerns related to pregnancy.
Creating a confidence
Overrunning the autopilot
According to the participants, creativity was necessary to
adjust and adapt the needs of lesbian couples regarding lan-
guage and documentation, but they understood this to be
unproblematic for the couples as long as they were met
with respect and their individual needs were attended to. It
was necessary to avoid routines meant for heterosexual
couples.
I need to be aware that I don’t put on my midwifery autopilot and all
of a suddenyou’re so used to relate to mum and dad that you need
to overrun the autopilot to avoid saying dad, or to forget that you
should relate to the actual situation. I think you need to be aware of
that.
Striking the note
It was considered important for midwives to reassure the
couples that they felt comfortable in the encounter.
For my part, I don’t think that this needs to be a theme at all. That
you manage to signal that this is, in a way, natural.
Although they were concerned not to focus on sexuality, they
encountered challenging situations. Teaching antenatal clas-
ses with mixed couples could be stressful because they needed
to mind their language; bereavement groups were even more
demanding. Wherever there would be a mixture of hetero-
sexual and lesbian couples, they felt uncertain if the lesbian
couple felt comfortable in the group.
Participants emphasized that it was important that lesbian
couples were treated like everybody else; anything else was
considered prejudiced. Some described being very tactful the
first time they met a lesbian couple in labour because they did
not want the couple to be offended in any way. This
prevented them from having a relaxed attitude, creating
feelings of uncertainty dominating their professional conduct.
I thought about it a lot afterwards, probably because I felt uncertain
about how I should have handledof what my role should have
been.
As time passed they became experienced, thus limits were
moved. They felt more confident and secure and were able to
focus on each couple’s individual needs. It felt easier to ask
the right questions.
I feel that my own limits are moved, and that I dare to approach the
fact that they are two women and in a way can talk openly about this,
the way it is. The challenge isthat you approach it, that you don’t
overlook that it’s there. In a way there is a tiny difference, a tiny
sexual difference, and you should not be afraid to, or you should not
be so afraid that you overlook this, that you move on, avoiding to
approach that theme at all. Regarding this, I think my experience has
made me stronger.
One midwife said it was her responsibility to contribute to
creating a trusting relationship, but to create a good
encounter, all parts must contribute. She described how
lesbian women sometimes used a little more time than
heterosexual women before they felt confident, they used
more time to kind of ‘striking the note’.
Being a proper midwife
Sometimes lesbian motherhood would be a subject for dis-
cussion at work. More often, discussion was replaced by
personal reflection and according to one midwife:
I don’t have time to sit down during my workday and think
abouteverything from morals to my own attitudes or ethical values.
There and then it might run fast through your head, but I am more
concerned about behaving properlyabout being a compassionate
fellow human being.
To her, being a proper midwife meant that the couple did not
have to feel stigmatized or need to defend themselves.
However, they also described how respect sometimes would
be replaced by gossip or offensive comments behind the
couples’ backs.
Anyone can feel uncomfortable in this situation (labour) where you
sort of place your life in somebody’s handsundressedif you are
not met with respect or you experience that someone is making
remarks (about your sexuality) behind your backthat must be a
terrible experience.
Being guided by instinct
The midwives expressed taking a genuine interest in people.
However, when it came to lesbian couples, they needed to
balance their desire to ask questions and the couples assumed
need for privacy to avoid being over-assertive.
It’s always exciting to listen to their story, how they have become
inseminated, you know. But it’s really not my business at all, so I
don’t dare ask them directly.
They described being guided by their professional instinct in
each situation, letting chemistry decide when and what to
ask.
B.D. Spidsberg and V. Sørlie
800 2011 Blackwell Publishing Ltd
Discussion
Study limitations
Recruiting for the study was challenging and most midwives
identified themselves as ‘gay-friendly’ persons. This was
difficult to avoid, as midwives with a negative attitude to
lesbian motherhood were unlikely to volunteer for the study.
This probably influenced the findings.
A qualitative study is not intended for inferences about
incidence in the population; however, the use of purposive
sampling and thick descriptions may permit deep insight into
the studied phenomena and ensure sufficient information for
the reader to determine whether the findings are applicable to
a new situation (Lincoln & Guba 1985), enhancing credibil-
ity. In the interviews, no set questions were used and the
interviewer interfered only when there was a need for
elaboration or clarification. Although the number of partic-
ipants was limited to eleven midwives, the narratives
described a wide range of experiences and repetition of
themes, ensuring saturation of data. However, it is probable
that there exists a greater variety in co-mothers’ perceptions
and reactions to pregnancy and labour. Similarly, observa-
tions of midwife-client interaction and data on midwives’
experiences gathered anonymously, combined with qualita-
tive studies would provide a more extensive perspective
regarding this.
Discussion of findings
Previous studies about lesbian couples’ experiences with
maternity care show that healthcare outcomes are affected
by healthcare providers’ attitudes and outcomes. In this study,
midwives described the lesbian love-relationship as strong and
caring, but including elements of difference which could make
the couple vulnerable. It was important for midwives to
acknowledge their own attitudes and culturally sensitive non-
verbal communication; also to consider the co-mother’s needs
and role as different compared with those of fathers. Although
caring for lesbian couples was seen as unproblematic for the
midwives, they described experiences of ambivalence or
anxiety in the encounter and they had noticed that some
couples had had negative experiences with maternity care.
The epics of love; love is strong and vulnerable
According to Alvsva
˚g, love’s epics are about mediating love’s
nature by the use of narratives. The poetics of love shows us
what compassionate behaviour is all about. Finally, the logics
of love describe love’s way of unfolding or the clinical act of
compassion (Alvsva
˚g 1996, 2010).
It is our emotions that grant us access to our understanding
(Løgstrup 1976). However, being touched and moved by the
other also challenges us to confront the element of strange-
ness in the encounter, to the unknown. Narratives are a
means to understand lived experience; they are intermediary
links of reflection between events and experience (Bjerg
1982). Narratives mediate knowledge and insight and help us
gain a perspective of life, offering new possibilities for acting
(Alvsva
˚g 1996). Often, we describe situations that touch us
or move us, we describe challenging situations where
something is at stake, hence the narrative can never be
morally neutral (Ricoeur 1994).
The midwives spoke warmly and spontaneously of what
they had experienced. The couples were sometimes looked
upon as ‘different’ or vulnerable, but more often the
midwives described the couples’ confidence and strength,
their shared joy and happiness, their mutual physical and
psychological understanding and their intuitive and often
humorous communication. Labour was described as close
and warm, involving bodily sensations, a genuine and
compassionate way of caring and an ability to ‘read’ body
language. Attention was paid to co-mother’s role and
experience, and they asked if being a woman in this situation
made her more vulnerable than a man. The midwives
described being touched by the expression of love and caring
emanating from the encounters and it made them involved
and engaged.
The poetics of love; shaping the other’s world by being and
attitude
To trust someone is to lay oneself open, hoping to be
accepted. It is the nerve in communication and it implies a
vulnerable self-surrender (Martinsen 2003a). Human rela-
tions always include elements of power and self-surrender.
This we can use to recognize or offend the other, hence our
vulnerability. According to Løgstrup (1997), life itself has an
anonymous and unarticulated demand to take care of the life
that trust has placed in our hands. This appeal to take care
does not emanate from a personal determination (Vetlesen &
Nortvedt 2000), but from the life utterances, such as trust,
speaking freely and love. Løgstrup draws our attention to
Lipps’ phenomenological analysis of attitude in which
addressing the other implies that a note is struck, ‘in which
we, as it were, step out of ourselves in order to exist in the
speech relationship’ (Løgstrup 1997, p. 15). Being human
means that we actively relate to the world, that we give form
to our lives. This will appear in our attitude, involving ges-
ture, facial expressions and way of speech, including the tone
we use to address the other. Striking the note implies an
expectation that the other accepts and receives the note
JAN: ORIGINAL RESEARCH An expression of love
2011 Blackwell Publishing Ltd 801
(Andersen 1998), thus the note cannot be neutral. The
midwives felt that they were challenged to strike a note in the
encounter, creating a confidence. This implied a need to find
a way to be open and at the same time respect the couples’
need for privacy. Speaking freely implies being open. How-
ever, openness can only be looked upon as a genuine open-
ness if it is united with the zone of untouchability, respecting
the other’s autonomy (Andersen 1998, Martinsen 2003a). In
general, the couples were open about their sexuality to the
midwives. If they felt that the couple wanted the encounter
to be anonymous, this was respected; however, it was
important that anonymity was self-imposed and not a result
of discriminative actions. Some midwives commented that
lesbian couples needed more time than heterosexual couples
before they felt confident and thought this was a result of
previous experiences caused by an abuse of trust. Although
openness was considered essential and it was their respon-
sibility to open up the dialogue, they sometimes found this
difficult.
In several studies, lesbian women describe documentation
forms, journals and the use of heteronormative language to
be a problem (Stewart 1999, Ross et al. 2006, Bjørkman &
Malterud 2007, Renaud 2007, Ro
¨ndahl et al. 2009). In our
study, both midwives and couples shared a joint irritation
directed towards the authorities not addressing the problem.
When it came to using gender neutral words, the midwives
felt this to be a challenge when teaching antenatal classes, but
they experienced that lesbian couples rarely felt offended by a
slip of the tongue if the encounter otherwise went well.
Attitude was considered more important than finding the
proper words and studies about quality of midwifery care
confirm that caregiver’s attitude and behaviour have power-
ful influences on women’s satisfaction with intrapartum care
and quality of relationship (Hunter et al. 2008).
The logics of love; reaching out to the other is to make
oneself vulnerable
Trust, dialogue, supporting uniqueness and creation of
meaning are considered essential concepts in labour
(Lundgren & Berg 2007). In our study, midwives described
that they wanted the encounter to be natural, meaning that
they would care for lesbian couples like any other couple.
However, our findings also describe experiences of ambiva-
lence and anxiety. A similar ambivalence is described by
lesbian women (Spidsberg 2007, Lee et al. 2011).
The midwives described that there was a fine line between
being taking an interest in the couples’ lives and being over-
assertive. Regarding this, they found professional experience
to be helpful and some described how their professional
attitude had changed from being too tactful to feeling
confident and responsible, thus being able to focus on the
couples’ individual needs. At this point, they also described
being able not to overlook the ‘tiny sexual difference’, instead
they were able to bring it up when it felt natural. To obtain
this confidence, striking the note in the encounter was
essential.
Lesbian couples ask if negative experiences are a result of
healthcare providers’ personalities rather than deliberate
action (Spidsberg 2007, Lee et al. 2011). In our study,
midwives asked if lesbian couples sometimes consider
What is already known about this topic
Attitudes towards homosexuality among healthcare
providers are shown to be influenced by personal life
experiences and education.
Existing studies about healthcare providers’ experiences
with lesbian women emphasize the need for knowledge
of homosexuality and specific, culturally sensitive
communication skills.
Both lesbian women and midwives should be
questioned about their experiences and perceptions in
the encounter in order to improve maternity care.
What this paper adds
Acknowledging attitudes and culturally sensitive non-
verbal communication was considered more important
than finding gender neutral words in the encounters.
Co-mothers needs and role was considered to be
different compared with those of fathers.
Caring for lesbian couples was described as
unproblematic by midwives, but some of them
presented experiences of ambivalence or anxiety in the
encounter.
Implications for practice and/or policy
Further knowledge on a co-mother’s particular role and
needs during pregnancy, labour and the postnatal
period is required to provide tailored care for lesbian
couples.
Ambivalence and uncertainty in the caring situation is
described by women and midwives. Further research
should be carried out to map content, consequences and
coping strategies.
Caring for lesbian women is at stake if midwives
practice ‘neutral caring’ rather than finding courage to
stand in unfamiliar situations.
B.D. Spidsberg and V. Sørlie
802 2011 Blackwell Publishing Ltd
ambivalent situations to be homophobic when healthcare
providers simply had ‘a bad day’ and they believed this was a
result of the couples’ previous negative encounters with
healthcare providers. However, several midwives were aware
that some of their colleagues would find it difficult to care for
lesbian couples because of their religious belief. A Swedish
study showed nurses to be negative or ambivalent towards
homosexuality, describing that they would refrain from
nursing homosexuals if possible (Ro
¨ndahl et al. 2004b).
They also said they could care for people in a ‘neutral way’,
without personal attitudes affecting the caring relationship.
So-called ‘neutral caring’ implies professional detachment
and task orientation rather than emotional involvement in the
caring situation. Midwives’ interaction with women during
childbirth has a major impact on women’s experiences and
well-being. We therefore do not find neutral care an option,
rather we think upon it as a contradiction in terms, as caring,
according to Watson (2005), is transpersonal, mutual,
intersubjective and reciprocal.
Conclusion
According to Watson (2005, p. 182) ‘it is our humanity that
wounds us and heals us and those whom we serve; in the end,
it is only love that matters’. She refers to Løgstrup’s hand
metaphor ‘holding another person’s life in one’s hand’,
describing how health professionals, in the caring moment,
have the power to determine the direction of something in the
other person’s life by their very gaze, their attitude. In a
transpersonal caring encounter, an act of genuine engagement
in the other takes place, recognizing differences and similar-
ities, allowing for individualized woman-centred care. Caring
is an act of love (Watson 2005). The fact that the midwives
were touched by the expression of love in the encounter
indicates the presence of engagement and involvement. This
is not surprising as several midwives had lesbian or gay
friends and personal knowledge has a positive effect on
personal attitudes (Anderssen 2002).
We find the ambivalent encounters challenging. The ethical
demand to care challenges our professional judgment and
holds us responsible for giving care; however, it does not
come with specified directions for caring but demands that
we use reflection, imagination and professional knowledge,
that we use professional judgment (Martinsen 2003b).
Reaching out to the other is to make oneself vulnerable in
the caring moment (Watson 2005). This implies that we find
the courage to ‘be there’ for lesbian couples despite uncer-
tainty and ambivalence. However, discussion of the sexuality
of childbirth is not an issue in mainstream midwifery
literature and providing emotional support in situations that
contain elements of sexuality may prove difficult for some
(Hunter 2001). Studies are required to map content, conse-
quences and coping strategies regarding the ambivalent or
uncertain caring situations.
A lack of knowledge concerning co-mothers role and needs
was also described, resulting in midwives holding back
questions related to their situation in fear of asking ‘the
wrong question’. In accordance with Watson, the caring
situation should be a welcoming of the vulnerable other, and
related to receptivity and openness (Watson 2005). Our
study shows that there are several stones yet to be turned
before we are able to tailor maternity care needs for lesbian
couples.
Acknowledgements
The authors thank the midwives who participated in the
study, Professor Kirsti Malterud for valuable comments and
Midwife Andrina Donald Svindland for revising the lan-
guage.
Funding
This work was partially funded by The Norwegian Women’s
Public Health Association.
Conflict of interest
No conflict of interest has been declared by the authors.
Author contributions
BDS & VS were responsible for the study conception and
design. BDS performed the data collection. BDS & VS
performed the data analysis. BDS was responsible for the
drafting of the manuscript. VS made critical revisions to the
paper for important intellectual content. BDS obtained
funding. VS supervised the study.
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... Five relevant primary studies were identified and reviewed; all were qualitative studies employing interview methodology (Table 2 ). [20][21][22][23][24] Four of these studies examined the experiences of lesbians* with their midwives or with groups of care providers including midwives, and addressed the midwives' attitudes. [20][21][22][23] The remaining study directly explored midwives' perceptions of their own attitudes towards lesbians and their partners. ...
... [20][21][22][23] The remaining study directly explored midwives' perceptions of their own attitudes towards lesbians and their partners. 24 Although the purpose of this review was to examine literature about midwives' attitudes towards all SGMs, there were no eligible studies that examined sexual minorities (such as bisexual, pansexual, or queer people) or gender minorities (such as trans or nonbinary people). Two review articles were identified as possibly relevant to this review. ...
... Midwives felt that in order to provide inclusive care to lesbians, they had to avoid heteronormative routines, such as not assuming that clients were heterosexual or assuming that the clients' partners would be men. 24 In this regard, midwives felt that creativity was necessary to adapt to the needs of a lesbian couple and that midwives needed to think "outside the heteronormative box" to provide individualized care, which they felt was important to lesbians who present for care. 24 These thoughts match the experiences of lesbians in the studies, who reported feeling embarrassed, insecure, and vulnerable when midwives didn't recognize their individual needs or provide inclusive care. ...
Article
Full-text available
Midwives are positioned to play a crucial role in the health experiences of sexual and gender minority people (SGM), who often avoid accessing care due to previous, or anticipated, negative health encounters. Canadian provincial, territorial, and national regulatory entities hold midwives accountable to the provision of inclusive and safe midwifery care to all. A broad, systematic search of literature examining midwives’ attitudes towards SGM and published from 2005 to 2020 included Medline, Embase, PsychInfo, CINAHL, Sociological Abstracts, Sexual Diversity Studies, PubMed, Scopus, Web of Science, PsychLit, and Cochrane. English language studies that were relevant to midwives’ attitudes towards SGM were eligible for inclusion. Of 623 articles retrieved, five primary studies met inclusion criteria but examined midwives’ attitudes exclusively towards lesbians. Positive and caring midwives’ attitudes contributed to creating a safe and supportive space for lesbians, even if the midwives didn’t have specific training or education regarding how to care for them. Midwives’ negative attitudes contributed to lesbians’ experiences of homophobia and heterosexism. Further research on midwives’ attitudes towards all sexual and gender minorities is needed, especially in the Canadian context, demonstrated by the importance midwives’ attitudes have in shaping the experiences of lesbians in midwifery care.
... Therefore, the understanding of the experiences of maternity care of lesbian couples demonstrates that many women do not receive individual and respect-based care. The attitudes of health professionals related to homosexuality are motivated by frustrated and personal academic experiences with little empathy 15 . ...
... With regard to this specific public, during the pregnancypuerperal cycle, understanding the relevance of the non-biological mother and recognizing her particular needs is fundamental 15 . In the context of lesbian motherhood, co-mothers or non-biological mothers feel excluded and invisible, both in the lack of shared terminology in health services and for situations in which they seek the "true mother", because they do not consider the existence of two legitimate mothers. ...
... Thus, the need for knowledge about homosexuality is perceived, especially regarding the approach of inclusive communication 15 . Sensitivity and knowledge about lesbian sexuality and female gender are important aspects to be considered for an improvement in the quality of pregnancy-puerperal cycle care 18 . ...
Article
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Parental practices refer to the process of becoming pregnant, in addition to the care, training and follow-up of children during their lives 1. Thus, lesbian, gay, bisexual, transvestite and transsexual (LGBT) couples, when choosing to become parents, have the fear of their children suffering any kind of discrimination, causing us negative feelings that can lead to psychological implications such as: anxiety, anguish, depression and even the use/abuse of alcohol and other drugs 2,3. In addition, the process of trying to become pregnant can generate difficult decisions 4 , such as: whether they will make insemination or adoption, how to conceive, who will be the donor, titles that parents will have on the child, child's surname, legal provisions and how it will be with health systems throughout their lives 5,6. With regard to women, a study conducted in Australia with 20 families of lesbian women showed that they report delay and even avoid health care due to fear of suffering some kind of homophobia due to their sexuality 7. In such a way, there are still few studies on the transition to motherhood process of women who relate to women 8. Thus, seeking information and treatments about sexual health in primary care becomes a challenge when there is self-declaration of homosexuality and this reflects throughout the pregnancy-puerperal cycle, due to the poor perceptions printed in these women in relation to care 9. In this sense, a Norwegian study showed that young lesbian women are more depressed and have more suicidal thoughts than a corresponding population sample. Such situations may have as a cause related to social heterosexism, which directly influences health care and keeps homosexual women invisible to the care of health
... Logo, a compreensão sobre as experiências de cuidados da maternidade de casais lésbicos demonstra que muitas mulheres não recebem uma assistência individual e baseada no respeito. As atitudes dos profissionais de saúde relacionadas à homossexualidade são motivadas por experiências acadêmicas frustradas e pessoais com pouca empatia 15 . ...
... No que se refere a este público específico, durante o ciclo gravídico-puerperal entender a relevância da mãe não biológica e reconhecer suas necessidades particulares é fundamental 15 . No âmbito da maternidade lésbica, as co-mães ou mães não biológicas, se sentem excluídas e invisíveis, tanto na falta de terminologia compartilhada nos serviços de saúde quanto por situações em que buscam a "mãe verdadeira", por não considerarem a existência de duas mães legítimas. ...
... Desse modo, percebe-se a necessidade do conhecimento sobre homossexualidade, principalmente quanto à abordagem da comunicação includente 15 . Sensibilidade e conhecimento sobre sexualidade lésbica e gênero feminino são aspectos importantes a serem considerados para uma melhoria na qualidade do atendimento ao ciclo gravídico-puerperal 18 . ...
Article
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As práticas parentais se referem ao processo de engravidar, além do cuidado, a formação e acompanhamento dos filhos durante sua vida 1. Assim, os casais de lésbicas, gays, bissexuais, travestis e transexuais (LGBT), ao escolherem se tornarem genitores, possuem o medo dos seus filhos sofrerem qualquer tipo de discriminação, ocasionando-nos sentimentos negativos que podem acarretar implicações psicológicas tais como: ansiedade, angústia, depressão e até o uso/abuso de álcool e outras drogas 2,3. Além disso, o processo de tentar engravidar pode gerar a tomada de difíceis decisões 4 , tais como: se farão inseminação ou adoção, como conceber, quem será o doador, títulos que os pais terão sobre a criança, sobrenome da criança, disposições legais e como será com os sistemas de saúde ao longo de suas vidas 5,6. No que tange às mulheres, um estudo realizado na Austrália com 20 famílias de mulheres lésbicas, evidenciou que elas relatam atraso e até evitam os cuidados à saúde devido ao medo de sofrerem algum tipo de homofobia em razão de sua sexualidade 7. De tal forma, ainda existem poucos estudos sobre o processo de transição para a maternidade de mulheres que se relacionam com mulheres 8. Dessa maneira, buscar informações e tratamentos sobre saúde sexual na atenção primária se torna um desafio quando se há a autodeclaração da homossexualidade e isso reflete em todo o ciclo gravídico-puerperal, devido às más percepções impressas nessas mulheres diante do atendimento 9. Nesse sentido, um estudo norueguês mostrou que mulheres lésbicas jovens se encontram mais deprimidas e possuem mais pensamentos suicidas do que uma amostra populacional correspondente.
... The finding that midwives' attitudes are generally positive toward sexual minority clients is consistent with qualitative research exploring midwives' perceptions of their own attitudes toward lesbians and their partners, wherein midwives described positive attitudes toward lesbian clients. 27 However, our findings are not consistent with qualitative studies that center the experiences of lesbian midwifery clients, in which participants described how their midwives' negative attitudes shaped their experiences. [27][28][29][30][31] There are possible explanations for why our study did not show this. ...
... 27 However, our findings are not consistent with qualitative studies that center the experiences of lesbian midwifery clients, in which participants described how their midwives' negative attitudes shaped their experiences. [27][28][29][30][31] There are possible explanations for why our study did not show this. First, volunteer bias could account for the findings of positive attitudes, since sexual minority midwives may have been more compelled to participate and had higher attitudinal scores than heterosexual midwives; heterosexual midwives with positive attitudes and/ or who have worked with SGM people may have similarly been more motivated to participate. ...
... For example, Abdessamad et al 25 found no significant difference in the attitudes of obstetriciangynecologists toward lesbian patients between rural and urban settings. 25 Previous studies examining midwives' attitudes toward lesbian women took place within urban settings, and the association between attitudes and geographical setting was not examined [27][28][29][30][31] ; thus, our study makes an important contribution in this regard. ...
Article
Full-text available
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.
... Heteronormative context of health services [15][16][17][18]21,24,26,29,30,32,34,[39][40][41][42][43]48,51,54,56,57,59,[65][66][67][68]72 Compromised standard of healthcare of homosexual couples due to the hegemony of heterosexuality Inadequate forms and information systems for same-sex couples Discrimination against non-biological mothers or fathers ...
... Controversies about the fact that lesbians are mothers Not reducing parenting to blood ties Disclosure of sexual orientation 19,[21][22][23][24][25]31,34,38,41,43,[47][48][49][50]51,52,60,64,65,69,71 Couples' positions on non-disclosure because they do not consider it important ...
Article
Full-text available
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.
... Consequently, these women undergo fertility treatments and receive perinatal health care at women's health centers in the community. Nurses usually accompany the lesbian patients from the pregnancy planning stage through birth and the postpartum period and are available for consultation (Spidsberg, 2007;Spidsberg and Sorlie, 2012). ...
Article
Full-text available
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.
Article
Full-text available
Background: The widespread availability of reproductive technology and family planning services has led to an increase in the number of available pathways to parenthood for LGBTIQA+ people. However, emerging research indicates that significant healthcare inequities have been documented among LGBTIQA+ people and attributed to the pervasiveness of structural and systemic discrimination that extends to preconception and pregnancy care. Aim: The aim of this systematic review was to synthesise qualitative research that has explored the experiences of LGBTIQA+ people in navigating preconception and pregnancy care services to inform healthcare quality improvement. Method: Six databases were searched for relevant research published between 2012 and 2023. The findings of all included studies underwent a secondary thematic synthesis, and methodological quality was assessed using the Joanna Briggs Institute Checklist for Qualitative Research. Findings: A total of 37 studies were eligible for inclusion. Four major themes were constructed through thematic synthesis: (1) unavailability of information, services, and support; (2) clinical competencies of healthcare staff; (3) hetero- and cis-sexist care experiences; and (4) discrimination and traumatisation. Conclusions and implications for practice: The findings of this review indicate that LGBTIQA+ people experience significant challenges during the journey towards parenthood, marked predominantly by the pervasiveness of inequity, and defined by discriminatory healthcare processes. This review has led to several recommendations for future healthcare quality improvement through an investment in policies, procedures, and interactions that are sensitive to the needs of LGBTIQA+ people. Importantly, future research must be co-designed and led by LGBTIQA+ community input.
Article
Background: In Sweden, antenatal and child health care are offered free of charge to all expectant and new parents. Professionals in antenatal and child health care play an important role in supporting parents. Previous research shows that same-sex mothers face heteronormative assumptions and insufficient support during their transition to parenthood. Objective: To explore professionals' experiences of supporting two-mother families in antenatal and child health care. Method: A qualitative method with focus group discussions was used. An interview guide was followed, and the discussions were held online. The data was analysed according to inductive content analysis. Settings and participants: The participants were midwives (n = 8) and nurses (n = 5) in antenatal and child health care from different parts of Sweden. Participants were recruited through the coordinating midwives and child health care nurses in the different regions. Findings: One main category was identified: Striving to be open-minded in supporting same-sex mothers. Health care professionals described meeting well-prepared mothers, with an equal commitment between each other, and mothers on guard against heteronormative views. Professionals provided support through empowerment by creating a safe environment and aiming at providing equal support to all parents or tailored support to same-sex mothers. Mothers described handling challenges, as a balancing act to acknowledge both mothers. Struggling with documents and communication and a lack of information were other challenges to be handled. Professionals reflected on their own professional competence and expressed that knowledge acquired through education, experience and personal interest all contributed to their competence. Conclusions: Forms and documentation need to be updated to be gender neutral to be including to a variety of family constelleations. Health care professionals need time to reflect on norms and challenges to better support both mothers in a two-mother family.
Article
Lesbians constitute a significant proportion of users of maternity services. However, their existence is poorly acknowledged and, therefore, their needs may not be adequately assessed. Treating all women in the same way denies the existence of problems and stresses specific to this client group. Provision of women-centred care which recognizes the imperative to remove assumptions regarding sexuality may provide the key to better understanding. It may also result in maternity services within which lesbian mothers feel safe enough to express their individuality. Failure by midwives to provide this safe environment is a failure to be ‘with woman'. The author proposes a constructive rethinking of institutional heterosexist factors which render lesbian mothers largely invisible and unacknowledged.
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The HIV/AIDS pandemic has revealed the extent to which a deeply ingrained homophobia permeates the health and caring professions. Midwifery is no exception, and prejudice may compromise the service which lesbian clients receive. Yet AIDS has also stimulated efforts to combat homophobia, and lesbian and gay community networks may offer additional support in developing truly egalitarian midwifery practice.
Article
This qualitative study set out to ask whether the maternity services are meeting the needs of lesbian parents. Women who have had babies within a lesbian relationship were interviewed using semi-structured in-depth interviews. The data was analysed using a phenomenological approach. Six common themes emerged from the material analysed, namely: communication; choice, continuity and control; support; being accepted; assumptions and stereotyping and, finally, homophobia. Some of these themes are common to previous work that has been done, examining the needs of women as users of the maternity services. Some of these themes, however, are related to the participants' sexuality. There is, at present, an assumption by the maternity services that all women are heterosexual and the language, culture and philosophy of care further reinforce that assumption. In order to provide a system of care that is truly woman-centred there is a need to challenge assumptions of heterosexuality, and to acknowledge the existence and unique needs of lesbian parents.