Gestational and non-gestational parents: challenging assumptions

‘Maternal health’ is a well-established term, along with related phrasing such as maternal mental health. In reproductive research, participants are commonly referred to using gendered language (e.g. ‘women’, ‘mothers’, ‘men’, ‘fathers’), or gender-neutral terms (e.g. ‘expectant parents’ and ‘new parents’). Rarely are they gender additive (e.g. ‘mothers and other birthing people’). Further nuancing is sometimes given by researchers that either focus exclusively on LGBTQ+ parents, or name LGBTQ+ parents’ involvement, within a wider sample consisting mostly of heterosexual parents. Even here we continue to position the family as one gestational parent and one non-gestational parent, retaining a cisheterosexual nuclear family as the norm. Often, this positioning will be true for an ‘index’ pregnancy or birth that may be the focus of a piece of research.

However, current pregnancies are not experienced in isolation from our perinatal history, whether this is from previous or current relationships. We need – in research, policy and practice – to move away from approaching families as though the current relationship is the only one to have involved a pregnancy, or we will make invisible people’s previous fertility, conception and pregnancy experiences, particularly where those experiences are as a non-gestational parent. Further assumptions include that there is only one person in a family who has pursued pregnancy, that they are a woman, that they are the baby’s genetic, social and legal parent and that they will be the only person potentially breast or chestfeeding the baby.

What can be the implications of these assumptions? In our recent SRIP-funded development workshop, we met with LGBTQ+ expert-by-experience parents to discuss future research priorities. Here, we heard about experiences spanning assisted conception, antenatal care, intrapartum care, postnatal services (including neonatal intensive care, infant feeding, child health), specialist perinatal mental health services and birth registration. Recurring points included anticipated and experienced discriminatory treatment, assumptions about family forms made by services and individual practitioners, and lack of legal and social recognition as a parent; all of which are evident in existing literature (e.g. Abelsohn et al., 2013; Hoffkling et al., 2017). Rarely acknowledged however is 1) that these dynamics may be different with different children, as different choices about genetic and gestational parenthood may alter, as may legal parenthood and 2) the perinatal period may be experienced as beginning earlier, including in planning conception. These points are relevant not only for perinatal mental health but any reproductive psychology, including for example, behaviour change.

Turning to a practice example of how the above assumptions may be problematic, let us consider the new NHS ‘maternal mental health services’. As outlined in the NHS Long Term Plan (NHS, 2019), these are intended to extend existing offers of support and create new ones, for mental health difficulties that are related to maternity experiences. Various models are being implemented and evaluated, with sites varying in their chosen eligibility, structure (e.g. aligning more closely with maternity or perinatal mental health services), and focus (e.g. traumatic birth experiences, perinatal loss, severe fear of childbirth, loss through removal). These new services differ to existing ones in several ways. Firstly, in recognising that untreated childbirth-related PTSD have an enduring impact many years after the traumatic event took place, they are available to people who may have used maternity services many years ago. Secondly, users may not themselves have ever been under the care of maternity services. For example, someone would be eligible for maternal mental health services where a pregnancy loss occurred prior to accessing maternity services. It is also possible that someone may access the service due to primary tokophobia, having either never been pregnant or having never continued with a pregnancy; here, this may be viewed as a ‘pre-conception’ service. Such differences offer opportunities to also think differently about mental health in new, expectant and bereaved parents – and who is in ‘entitled’ to support.

What does this mean for non-gestational parents? The existing policy ambition is that maternal mental health services offer assessment and signposting for partners of those who are accessing these services. However, could they too access these services, independently of there being a gestational parent? What may happen if someone is currently pursuing gestational parenthood but needs support in their capacity as a previous non-gestational parent? Would a non-gestational parent be eligible to receive support from these new services if tokophobia from witnessing their partner’s traumatic birth is impacting upon their current reproductive choices? Can they access these services if they have experienced pregnancy loss or baby loss with a previous partner?

Accompanying this mass expansion of services, there is enormous potential for learning and a need to be evidence-generating. In embarking on this, we need to be aware of and challenge existing approaches in research, policy and practice, which assume that there is one mother, who is the gestational parent, and one father, who is the non-gestational parent. The reality includes that some birthing people are not intended parents, some gestational parents are not women, some non-gestational parents are not men, and that individuals may have held different roles with previous pregnancies in the same or other relationships.