Midwives as Partners in Inclusive Primary Care

May 15/2017

DLSPH Student Blog

Jen Goldberg

By: Jen Goldberg RM, MPH (Family Community Medicine) student

With the unfolding of spring, midwives are recognizing International Day of the Midwife (May 5) and queer and trans people are readying themselves for International Day Against Homophobia, Transphobia and Biphobia (May 17). As a queer midwife and MPH student, I spend a lot of time reading and listening to stories about the health care experiences of queer and trans people. How, I am trying to discover, is midwifery inclusive of queer and trans people, how is it not, and what can be done to improve health outcomes?

Rooted in principles of feminism and social justice, the tenets of midwifery care provide a foundation for safe, quality care for queer and trans people in theory. Midwives provide informed choice: the client is the primary decision maker about all aspects of their care experience. Often invisible in health care settings, queer and trans people can be empowered by the opportunity to make informed decisions about what is right for them and be in control.

Midwives offer choice of birth place: at home, in hospital, or at a midwife-led birth centre. The option to receive care at an alternative, inclusive health care setting is often welcomed by queer and trans people, who may avoid accessing medical care after previous homophobic or transphobic experiences in mainstream care settings. Midwives also provide care in small teams and are on call 24/7. This continuity of care ensures queer and trans people have the time and space required to grow trusting, respectful relationships with their team of midwives. Creating safe spaces in midwifery care means queer and trans people are free to share their stories and their identities, if they so choose. Ensuring that care is individualized and inclusive means queer and trans people have access to safe, quality care during their experience of becoming new — or new again — parents.

Inclusivity means queer and trans people are not just recognized, but celebrated, even within heteronormative and cisnormative health care spaces. The rainbow flag, a broadly recognized symbol of sexual and gender diversity, can signify a positive or inclusive space. Queer and trans people need to see recognizable images of themselves in those spaces, like the cheerfully designed poster featuring queer and trans families from the Association of Ontario Midwives and the Sherboune Health Centre.

Midwifery clinics can also provide access to all-gender bathrooms. This simple act of inclusivity can reassure a trans or non-binary person that their needs are seen, and they are valued. From websites to client information handouts, language can easily be rewritten to be inclusive, and professional midwifery entities are recommending it. Examples of inclusive language include: “mothers and birth parents,” “pregnant people,” and “breast and chestfeeding.”

Like any person seeking midwifery care, a queer or trans person might be asked to complete an intake form. A person who cannot see any part of their experience or identity reflected at the point of entry into care might simply not proceed, or might proceed out of necessity with a sense of dread. Midwives decide about the language used on these forms, and can take care to avoid heteronormative/cisnormative assumptions about a client — not all of them will be heterosexual cisgender women partnered to heterosexual cisgender men, and everything about the practice starting with the website and intake form should reflect an understanding of that.

The Ontario Antenatal Record, which guides prenatal care, does not currently guide the care provider to ask about sexual or gender identity. The decision to disclose or ‘come out’ about one’s sexual and gender identity is personal and individual, involving a multitude of factors. Inviting disclosure can make queer and trans people present in health care spaces, and might, for some, be an affirming experience. It is also true that queer and trans people might, for a variety of reasons, not choose to disclose, and that’s also equally valid. Should midwives invite clients to self-identify their gender and sexuality? This is an area ready to be explored by research. In fact, a Canadian pilot study showed women whose sexual histories included more than one gender (bisexual, for example) but were currently partnered with men, might be at higher risk for postpartum depression.

Rainbow flags, gender-inclusive forms, feminist midwifery tenets and the endorsements of professional entities are all integral to enabling the provision of inclusive, quality midwifery care. But do midwives uniformly demonstrate positive and caring attitudes towards queer or trans people? There is one published study that specifically explores the attitudes of midwives towards a subset of LGBTQ people, in this case, lesbian women and their partners in Norway.

The study shows that midwives’ attitudes do influence the experiences of lesbian clients and their partners. Midwives — really, any health care provider — can begin to consider their own positionality within a heteronormative and cisnormative health system. For example, from the beginning of pregnancy, there are assumptions about how babies are made:  a sperm comes from a cisgender man and impregnates the ovum of a cisgender woman.

But there are many ways to create a baby, and many different types of bodies and identities. Consider a transgender man who is pregnant and will be the birth parent and father, partnered to a transgender woman who will become the mother of their child. Assumptions and expectations abound, some misguided and some actively harmful. Will they be cared for in a competent and appropriate way?

Midwives also have the opportunity to interrupt cisnormativity in a variety of ways. There’s an ongoing issue of conflation of sex and gender when ultrasound results report the baby’s ‘gender’ instead of what could actually be visualized – an indication of the baby’s sex. Midwives can gently remind parents that sex is assigned at birth based on visualization of genitalia, and includes intersex, and that gender comes later, when a baby grows into a person and shows or tells you their gender identity. Gently declaring, “it’s a baby!” at the birth helps parents and other care providers see there are possibilities beyond the girl/boy binary.

Sexuality and gender are determinants of health. Public health professionals can take the lead and model inclusive language and develop strategies to reduce the invisibilizing or erasure of queer and trans people in a heteronormative and cisnormative health system. As primary care providers, midwives play an integral role in reducing health inequities of queer and trans people. As such, they are well positioned to be effective partners in public health initiatives to reduce the disparities in health of queer and trans people.

Photo courtesy of the Association of Ontario Midwives.