LBTQ parents’ needs for support postpartum following a complicated birth: A matter of reproductive justice

Abstract

LBTQ people have increased risks of complications during birth, risks potentially driven by minority stress and increased levels of mental illness and fear of childbirth. With the aim of exploring reproductive injustices in postpartum care for LBTQ people, we analyzed qualitative interviews where 22 LBTQ birth and non-birth parents shared their experiences of support needs during the postpartum period after births where complications had arisen. Results point to the importance of providing an LBTQ safe space, which includes the need to feel safe regarding one’s gender or sexual identity, by avoiding cisheteronormative assumptions and using inclusive language. In the context of recently experiencing birth complications, parents needed a space where they were able to focus on physical and mental healing. The results further show the need for validation of the non-birth parent and inclusive breast/chest-feeding support. Results emphasize the need for more psychosocial support around the birth experience, including better medical support and information during the whole process of childbirth.

Keywords:

• Sexual and gender minority
• LGBTQ
• reproductive health
• birth complications
• reproductive justice

Introduction

High quality postpartum care is an important part of a positive transition to parenthood, as this can facilitate a healthy start for the new family, improving the well-being of both the parents and the child (Tully et al., 2017). Following birth complications, postpartum care becomes even more crucial, given the increased need for medical and psychological support to heal physical injuries, as well as potential trauma (World Health Organization, 2022). High quality postnatal support after a complicated birth is important for increasing the long-term sexual and reproductive health and lowering postnatal fear of childbirth, postpartum depression, and postpartum post-traumatic stress disorder (White et al., 2022). In Sweden, following a broader Western trend, postpartum admission periods have been shortened over the past decades (Petersson et al., 2021). This increases the need for high quality care during the hospital stay, and good continuity to other care units, where follow-ups are being carried out. Deficiencies in postpartum care have been noticed both internationally (World Health Organization, 2022) and in Sweden (Socialstyrelsen, 2022) concerning lack of information, support and continuity of care, both during hospital admission and afterwards. In the present article, Swedish lesbian, bisexual, trans and queer (LBTQ) people’s experiences of postpartum care after complicated childbirths are analyzed. We use the acronym LBTQ, rather than the more common LGBTQ, to avoid falsely implying a focus on cisgender gay men, although we do acknowledge that cisgender women, as well as trans people, may also self-identify as gay. The perspective of reproductive justice (RJ) has guided the interpretation of the results.

RJ has been defined as “the human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities” (SisterSong, n.d.). RJ is a movement and theoretical framework that was developed in the US in the 1990s as a broader alternative to the mainstream feminist reproductive rights advocacy that focused on the abortion debate. Black feminists emphasized how the reproductive lives and choices of black women, indigenous women and women of color (BIPOC) differed from the lives of white women, and how different oppressions and structural inequalities intersect to create the conditions for reproductive health. Therefore, RJ is both an activist movement for social justice and a theoretical intersectional feminist perspective on sexual and reproductive health and rights, focusing on marginalized groups of women and trans people (Davis, 2019; Ross, 2017).

RJ clarifies how structures and oppressions, in addition to gender inequality, affect women’s power and ability to decide over their own bodies and lives, and their choices around reproduction and fertility. RJ asserts that disparities in reproductive health outcomes and access to care are rooted in systematic racism and connected to other intersections of oppression, including classism, sexism, economic marginalization, and LBTQ oppression (Tam, 2021, Yates et al., 2023). Having only legislative rights are not enough to ensure equality and justice, as “there is no choice where there is no access” (SisterSong, n.d.).

The framework of RJ has been utilized to address reproductive perspectives of LBTQ people, for example, to access assisted reproduction treatment (ART) and breast/chest-feeding (Smith, 2018, Tam, 2021). LBTQ prospective parents often use ART, especially as ART has become more available over the past 30 years. However, access to ART continues to be uneven across intersecting social categories of race, gender, sexuality, and class (Tam, 2021). Further, norms and societal barriers make it harder for LBTQ people and their children to access breast/chest-feeding (Smith, 2018).

Previous studies show an increased mental illness during and after pregnancy in LBTQ people (Ellis et al., 2015; Flanders et al., 2016; Gonzales et al., 2019). LBTQ people have increased levels of severe fear of childbirth (Hallström et al., 2022), largely related to previous trauma and mental illness (Grundström et al., 2023). In addition, LBTQ people are overrepresented when it comes to obstetrical and neonatal complications (Everett et al., 2019; Leonard et al., 2022). These health disparities between pregnant LBTQ people and heterosexual women indicate unjustified differences in health and unequal access to healthcare, which in turn is connected to reproductive injustice. Sweden is ranked one of the most LBTQ friendly, gender and economically equal countries in the world (Equaldex, 2023; UNDP, 2023), but still has health disparities and unjustified differences in health between groups in society (Folkhälsomyndigheten, 2020). LBTQ people have higher levels of mental illness (Bränström, 2017) and lower sexual and reproductive health (Folkhälsomyndigheten, 2020) in comparison with the general Swedish population, and are one of the prioritized groups in the national strategy for improved sexual and reproductive health.

Although recent studies stress the importance of health care providers (HCPs) treating LBTQ individuals without discrimination, some HCPs still feel uncomfortable or insecure about how to provide care for this group (Medina-Martínez et al., 2021). Cisheteronormativity is prevalent in healthcare due to deeply rooted and socially constructed concepts of gender and sexuality, which can lead to prejudice and ignorance (Enson, 2015). Cisheteronormative assumptions are relatively common amongst midwives and nurses (Stewart & O'Reilly, 2017), also in Sweden (Appelgren Engström et al., 2022, Klittmark et al., 2018). Furthermore, discriminating behavior, such as disrespect of correct pronouns, hurtful language and viewing LBTQ as a pathological disease are approaches from HCPs found in several studies (Medina-Martínez et al., 2021; Stewart & O'Reilly, 2017).

Encountering cisheteronormative behaviors from HCPs greatly affects LBTQ patients’ experienced quality of care, often making them hesitant toward seeking healthcare (Medina-Martínez et al., 2021; Stewart & O'Reilly, 2017). Negative encounters with HCP while seeking reproductive healthcare commonly cause LBTQ people to seek information and alternative healthcare on their own instead of relying on routine clinical care (Carpenter, 2021). Being exposed to discrimination, stigma and lack of support negatively affects pregnancy, birth, and the postpartum period of LBTQ people (Griggs et al., 2021).

Disrespectful treatment and deficiencies in care contribute to negative experiences for LBTQ families during births, and in particular when complications arise (Klittmark et al., 2023). However, little is known about LBTQ parents’ experiences and needs postpartum following a complicated childbirth. Therefore, this study aims to explore LBTQ parents’ experiences and needs for support postpartum following complicated births.

Methods

Design, data collection and recruitment

The current study uses a qualitative cross-sectional interview methodology. In 2022, 22 participants were recruited through advertising in different Facebook groups for LBTQ parents in Sweden (n = 9), emailing participants in an antenatal education program for LGBTQI parents (n = 8), and by snowball recruitment (n = 5). The inclusion criteria were self-identified LBTQ birth or non-birth parents who had experienced obstetrical and/or neonatal complications when their child was born.

Participants received oral and written information about the study and provided their written informed consent to participate. A total of 22 semi-structured individual interviews were held, lasting between 46 and 120 min. The interviews followed a semi-structured interview guide containing questions about the participants’ experiences of pregnancy, birth, and the postpartum period. The interviews were audio recorded and transcribed verbatim except for pseudonyms replacing names of participants.

Participants

Socio-demographic details are shown in Table 1. Among the 22 participants, 12 experienced birth complications as the birth and genetic parent, and ten as the non-birth and non-genetic parent. In five families, both parents participated, although they were interviewed separately. Most participants described the birth of their first child. All participants were married or cohabiting with their co-parent at the time of their child’s birth. A vast majority were born in Sweden, university educated, and had become pregnant through assisted reproduction within public healthcare. The participants resided in different areas of Sweden, with a majority living in major city areas. Participants reported obstetrical and/or neonatal complications (Table 2). Twenty participants were cisgender women who shared parenting with another cisgender woman, self-­identifying as lesbian, bisexual, or queer. Two participants self-identified as nonbinary transgender people and shared parenting with a cisgender person.

Table 1. Socio-demographic data of the participants.

	Total sample n = 22	Birth parent n = 12	Non-birth parent n = 10
Age in years at time of interview mean (range)	34.2 (28-40)	34.8 (31-40)	33.5 (28-39)
Age in years at time of birth experience mean (range)	32.5 (28-37)	33.5 (30-37)	31.3 (28-38)
Time since childbirth in years mean (range)	1.7 (0-11)	1.4 (0-7)	2.2 (0-11)
Family constellation at time of birth n (%)
Cisgender woman in same-sex relation	20 (90.9)	11	9
Nonbinary person in relation with cisgender partner	2 (9.1)	1	1
Childbirth history n (%)
Couple’s first childbirth	17 (77.2)	9	8
Couple’s second childbirth, participant’s first time giving birth	2 (9.0)	2	–
Couple’s second childbirth, participant given birth once	1 (4.5)	–	1
Couple’s third childbirth, participant given birth twice	2 (9.0)	1	1
Conception method n (%)
Assisted reproduction in healthcare	20 (90.9)	11	9
Self-insemination	1 (4.5)	0	1
Intercourse	1 (4.5)	1	0
Gender identity n (%)
Cisgender woman	20 (90.9)	11	9
Nonbinary transgender person	2 (9.1)	1	1
Sexual identity n (%)
Lesbian	12 (54.5)	6	6
Bisexual/Pansexual	4 (18.2)	3	1
Queer or undefined	6 (27.3)	3	3
Country of birth n (%)
Sweden	20 (90.9)	11	9
Other	2 (9.1)	1	1
Education n (%)
High School	3 (13.6)	1	2
University degree/ University student	18 (81.8)	10	8
Unknown	1 (4.5)	1	0
Residence in Sweden n (%)
Major City	12 (54.5)	6	6
Middle-sized city	6 (27.2)	3	3
Small city	4 (18.1)	3	1

Table 2. Obstetrical and/or neonatal complications experienced at birth.

	Total sample n = 22	Birth parent n = 12	Non-birth parent n = 10
Birth complications n (%)
Emergency cesarean	8 (36.4)	5 (41.7)	3 (30.0)
Surgery after vaginal birth	8 (36.4)	4 (33.3)	4 (40.0)
Complicated tear	5 (22.7)	2 (16.7)	3 (30.0)
Vacuum extraction	5 (22.7)	3 (25.0)	4 (20.0)
Major hemorrhage	4 (9.1)	2 (16.7)	2 (20.0)
Advanced neonatal care n (%)
Of premature child	2 (9.1)	1 (8.3)	1 (10.0)
Of full-term born child	2 (9.1)	1 (8.3)	1 (10.0)

Data analysis

The authors used Systematic Text Condensation [STC] by Malterud (2012) to organize, interpret and summarize the data. STC uses four steps to identify units in the text that make up categories which are used to reorganize the text in a meaningful and transparent way. In step 1, the authors read through the transcripts of the 22 interviews to achieve a “helicopter” view of the data. Preliminary themes were then identified. Data related to care needs during pregnancy and birth were not included into the analysis, as this study focuses on the period after birth. In step 2, the meaningful units in the text were extracted and organized under possible themes, called coding. Some large themes were split into smaller themes and new preliminary sub-themes emerged. In the condensation phase (3), the authors abstracted the knowledge received from the second stage and rearranged these meaning bearing units to systematically form context and significance. Every code-group was divided into subgroups by relevance. In step 4, the subgroups were finalized and synthesized, and the final themes were formed to summarize the essence of all the code-groups, and these themes formed the headings in the result, with no additional subgroups left.

Ethical considerations

The research project has been approved by the Swedish Ethical Review Board (2021-05801-01). The first author worked as a midwife in a parental support program for LGBTQI prospective parents and had cared for some of the participants. These participants were interviewed by other researchers.

Results

Three themes encompassed the experiences and support needs of LBTQ parents during the postpartum period following complicated births. The first theme, “An LBTQ safe space postpartum,” explored the importance of LBTQ parents feeling safe in healthcare settings regarding their sexual or gender minority identity. The second theme, “Support during the early transition to parenthood,” addressed the needs of LBTQ people as new parents. The third theme, “Healing after a complicated birth,” highlighted the physical and psychological support needs of LBTQ parents following complicated births.

An LBTQ safe space postpartum

Most participants encountered cisheteronormative assumptions around their same-sex family constellations and/or transgender identity during postpartum care. These assumptions were present in both individual interactions with HCPs and in the structures and routines of care. For example, they received written information directed at heterosexual cisgender couples and were encouraged to fill in forms that did not fit their family constellations or parent labels. Participants found it challenging to deal with cisheteronormativity during this vulnerable time after having a complicated childbirth. Some participants expressed that they were unable to protect themselves from cisheteronormativity as they could not use the coping strategies they usually did due to being in a vulnerable state. They expressed a need for an LBTQ safe place where they could focus on healing after the complicated birth and on the transition to parenthood.

An essential aspect of an LBTQ safe space involved inclusive language and respect for pronouns and parental labels. Addressing non-birthing parents as parents, rather than as partners was fundamental, as parent denotes a relationship to the child, while partner denotes only a connection to the birthing person. Nonbinary participants emphasized the importance of having their correct pronouns respected. Participants wanted healthcare to have better routines for transferring information on family constellations and gender identities. However, some of the participants also experienced HCPs that were professional and open-minded.

Most participants expressed the need to avoid separation from their partner and/or child during aftercare, as it led to cisheteronormative assumptions and confusion about parental roles. Kim, a nonbinary non-birth parent, provided a positive example of a HCP who handled this situation well by asking inclusive and gender-neutral questions:

[the doctor] asked “Yeah but are you the parent of [child’s name]?” and I was like […] "Yeah but it is my partner who has given birth to her" and they said "Yeah, I thought so, it said here that [birthing parent] had a c-section, you were very alert otherwise" (laughter). That was like… it was like, a good way to ask. Kim, non-birth parent

Some participants faced covert homophobia from HCPs, making them feel insecure or unwelcome in the postnatal wards. Monica, a non-birth mother, experienced negative reactions when she showed physical closeness with her partner:

I was very active in helping [birth parent], partly because she was bedridden, but I, well, I helped [the child] latch the breast, and being very physical in that, and then I felt, well, it could be something internalized, but I felt, well, that they didn’t see this as very natural. Monica, non-birth mother

Monica felt that HCPs did not view her intimacy with her partner as natural, but she also acknowledged that her discomfort with touching her partner’s breast in front of HCPs could come from internalized stigma. Another couple received a dismissive response when asking about starting having sex postpartum:

We got the feeling that she (the midwife) meant “How do you actually have sex if you’re not having penetrating sex” (–-) we realized quite quickly that there is not… there is not enough knowledge for us to be able to seek advice here. Frida, non-birth mother

Some participants described that HCPs were excessively focused on their LBTQ identity, such as being overly positive about families with two mothers. Participants found it stressful when HCPs asked irrelevant questions about their sexual identity or how they became pregnant as an LBTQ couple, questions they did not have the energy to deal with after a complicated birth.

Support during the early transition to parenthood

Participants emphasized the importance of HCPs being equally inclusive of both parents to facilitate the transition to parenthood. However, they frequently encountered more attention to the parental role of the birth parent, neglecting the non-birth parent. In contrast, when both women in same-sex couples were referred to as mothers, they generally experienced this as validating. Linda expressed how being recognized as parents helped her and her partner realize their parental role amidst the challenging circumstances of becoming mothers to a premature child in need of neonatal care:

I think that the good thing that many (HCPs) do is precisely that they have a very inclusive approach and especially when you have been involved in something that you are so unprepared for, (–-) then it feels good to hear every time that, like this, “Here are the mothers,” like this, “Now you can go to your mother,” and they can mean any one of us, and they distinguish us, like, by saying “Who has been pregnant?”. Linda, birth mother

Non-birthing parents faced the dual challenge of defending their parental role to HCPs and educating them about LBTQ families, while at the same time struggling internally with insecurities in their role as a non-genetic parent to their newborn child.

Participants stressed the importance of HCPs supporting breast/chest-feeding, including having knowledge and positive attitudes toward co-nursing and induced lactation for non-birth parents. Some birth parents expressed satisfaction with the breast/chest-feeding support from HCPs, which they found to be a positive aspect contributing to their postpartum healing. However, most participants described negative experiences related to feeding, including a lack of support, contradictory advice, outdated information, lacking knowledge around induced lactation and co-nursing, and HCPs providing formula without parental consent.

Several non-birth parents were asked about their breast/chest-feeding intentions at the postnatal or neonatal ward. Despite being asked about their intentions, participants described a lack of knowledge and practical support for co-nursing. Sandra sat with their newborn baby while her partner was in the operating ward and wanted to know if it would be okay for her to breastfeed the baby while waiting. In contrast, Frida, another non-birth mother, described a validating experience when a midwife took the initiative to ask if she wanted to breastfeed the baby. This occurred when the birth mother was unavailable due to receiving sutures for her birth injuries. This act made the non-birth mother feel validated in her role as a mother.

Need for healing after a complicated birth

All birth parents had medical and physical care needs postpartum, but most of them did not have their needs met. They expressed a lack of information from HCPs regarding their physical health and the expected recovery process. Many participants understood the lack of support as being due to HCPs having a stressful work situation. Veronica, a birth mother, suffered from a complicated tear and expected negative effects on her sex life due to the injury. She did not receive any help from HCPs and wished for more support to look at her genitalia to overcome her fear. Another birth mother, Alma, also sought assistance from HCPs to address her birth injuries, but was faced with skepticism when she expressed a desire for a vaginal examination. Instead she was directed to read about her injuries in her medical chart.

The majority of participants expressed dissatisfaction with the lack of adequate psychological support provided by HCPs following their complicated births. Participants desired supportive conversations with HCPs regarding their birth experiences, as well as an opportunity to ask questions about the birth process and decisions made. Empathic responses and acknowledgement of their feelings were crucial for the participants to feel safe.

Participants described an absence of systematic mental health follow-up both before discharge and after returning home. They experienced a lack of established routines, such as pathways for referrals to access additional support. Many emphasized the importance of a follow-up meeting, as their stress reactions emerged later in the postpartum period. Lo, a birth mother who experienced birth trauma, experienced hostility from a HCP who had pre-checked the “no” box on a form for post-birth follow-up without Lo’s consent:

She just (said) “Well yeah, but everyone who had a vacuum extraction is still contacted afterwards.” Well, okay, I didn’t think to question anything, I just felt really small and useless, and thought “That’s how they do it,” it was strange. But no one ever called (---), it’s clear that she didn’t want to be scrutinized for what happened. Lo, birth mother

Some participants expressed struggling for months to obtain a follow-up regarding the birth trauma or that they had to arrange their own support. Lack of support made recovery from birth trauma challenging and some perceived this neglect from healthcare as a prolonged birth trauma.

Birth parents received more psychological support by HCPs compared to non-birth parents. Many non-birth parents chose to prioritize the needs of their partner and suppressed their own emotions. Their own birth experiences were rarely addressed or acknowledged by HCPs.

Non-birth parents expressed a sense of insignificance, which was reinforced when they were overlooked in postnatal care. This was particularly challenging if they were left alone with their baby while the birth parent underwent procedures for complications in the operating ward. During this time, they did not receive sufficient information and updates regarding the well-being of their partner. Some non-birth parents had been promised someone to talk to, to get a sandwich, or to receive instructions about infant rearing, but they did not receive anything. Monica’s partner needed surgery due to heavy bleeding, leaving Monica alone with their newborn baby:

I would have wished that maybe I could get, at least for like 15 minutes, maybe someone could sit there and be with me for that moment, but that, it wasn’t like that. There was always someone on the run there, and when they entered the room, they were always standing up while talking to me. Monica, non-birth mother

Monica developed a fear of childbirth following the experience of her partner giving birth. She expressed a desire for more personalized support, considering her unique position as a potential birth mother in the future. All non-birth parents in this study had childbearing capacity; some had experiences of previously giving birth or planned to give birth in the future. Many of them found the experience of being present during the complicated birth, while also having the potential to give birth themselves, to be a complex and traumatic experience. They expressed that HCPs lacked awareness and understanding of their situation, resulting in insufficient emotional support.

The majority of participants, regardless of their role as birth or non-birth parents, expressed symptoms of postpartum mental illness, e.g. depression and/or PTSD, and many expressed a fear of childbirth following the birth experience. Participants expressed a need for psychological support to process their experience before considering another birth, regardless of who would carry their next child. Some birth and non-birth parents expressed a hesitation to carry a child after their current birth experience.

Discussion

While several previous studies have addressed the challenges faced by LBTQ people in reproductive healthcare, this study makes a unique contribution by specifically focusing on the postpartum support needs of LBTQ people after birth complications. The findings highlight the need for LBTQ competent and trauma-informed care during the postpartum period. Trauma-informed care is rooted in an understanding of how trauma exposure impacts a person’s neurological, biological and social functioning (Harris & Fallot, 2001). Previous trauma exposure, as well as perpetuated trauma experience, are risk factors for long term physical and psychological effects postpartum (Raja et al., 2015). These risk factors are increased among LBTQ people (Roberts et al., 2010), who therefore can be considered a risk group for postpartum ill health when birth complications have arised.

Postpartum care has been underprioritized for many years, and numerous patients have expressed dissatisfaction (Wiklund et al., 2018). Several structural changes have been proposed to promote a more equal, accessible and family-centered care. Improvements in knowledge and education for HCPs about breast/chestfeeding, vaginal tears and mental health issues occurring after birth, adequate postnatal follow-up and improved continuity are among these proposed changes (Socialstyrelsen, 2022; World Health Organization, 2022). In addition to the overall shortcomings in postpartum care, the findings of this study demonstrate that the likelihood of LBTQ people receiving appropriate postpartum support is low when care is provided in a cisheteronormative environment.

From an RJ perspective, it is important to ensure that all people have access to the reproductive services they need (Yates et al., 2023). The findings revealed a dissatisfaction among LBTQ parents regarding the insufficient provision of psychological support. While the postpartum period is a sensitive time for most families, it is crucial to recognize that LBTQ families may require additional psychological support due to the added minority stress (Malmquist et al., 2019; Ross et al., 2012). Following birth complications, LBTQ people need an LBTQ safe space postnatally to ensure optimal conditions for physical and psychological healing, and to facilitate a healthy transition to parenthood.

The deficiencies experienced by LBTQ people during this critical phase of reproductive healthcare highlight systemic and structural deficiencies that result in differential treatment and limited access to appropriate support, thereby indicating a presence of reproductive injustice in the postpartum care provided to LBTQ people. Postpartum care must be organized to reach all parents irrespective of sexual or gender identity and family constellation. An RJ perspective on postpartum care acknowledges that healthcare’s language and perspectives, as well as structural norms, will affect who can actually access care, as well as the quality of the care received (Ross, 2017). The Swedish National Board of Health and Welfare states in their national guidelines for postpartum care that they see inequalities in the distribution of postpartum care: patients born outside the Nordic countries attend less postpartum care, at the same time as that group has higher risks of experiencing postpartum complications (Socialstyrelsen, 2022) which reveals reproductive injustice in relation to race/ethnicity.

Postpartum support encompasses conversations about intimate parts of the body, intimacy and sexual activities within queer relations, as well as physical examinations of the genitalia. These areas are often at the center of homophobic or transphobic attitudes, and some participants in this study reported encountering prejudice from HCPs when seeking help. The results show that negative attitudes and lack of knowledge created barriers to care for the participants. In accordance, Carpenter (2021) found that negative encounters with HCPs, while seeking reproductive healthcare, led LBTQ people to develop strategies to seek information and alternative healthcare independently, rather than relying on HCPs. Therefore, it is crucial to ensure that HCPs possess adequate knowledge and are not being left unchallenged if they hold negative attitudes toward LBTQ people’s bodies, intimacy and sexual activities.

Our study showed that participants were hesitant to seek help and be open with their support needs. They often remained silent regarding mental health and traumatic birth experiences despite having needs for support. This can be understood as a consequence of earlier negative experiences or a feeling of being unsafe, where participants were trying to protect themselves by not being open. Encountering cisheteronormative behaviors from HCPs can make LBTQ people hesitant toward seeking healthcare (Medina-Martínez et al., 2021; Stewart & O'Reilly, 2017). In postpartum care, this silence could hinder access to postpartum depression treatment, trauma care, and support during early parenthood, and can be seen as a patient security risk, following a complicated birth.

The silence from LBTQ people regarding support needs as new parents need to be understood from a historical context where LBTQ people have been considered unsuitable for parenthood (Malmquist, 2015). The pressure to maintain a facade of everything being “just great” can contribute to LBTQ people feeling hesitant to seek help for postpartum mental illness or parenting support, as shown in this study and previous research (Malmquist & Zetterqvist Nelson, 2014). Using an RJ perspective, historical oppression must be taken into account when considering a patient’s “choice” to reveal or not reveal mental health problems. A lack of adequate questions targeting mental health from HCPs, combined with the reluctance to seek care lead to an increased risk of postpartum mental illness remaining untreated. The establishment of an LBTQ safe space is necessary for ensuring genuine access to postpartum support. To create an LBTQ postpartum safe space, it is imperative to reduce cisheteronormative structures.

To support new LBTQ parents, HCPs should provide tailored LBTQ-specific information and resources regarding the transition to parenthood for LBTQ families, including non-birth parents. All LBTQ parents may not desire an overt focus on their sexual or gender identities, especially as this could tip into exotification, but it is important that information and care are provided in a way that is inclusive. It is crucially important to acknowledge non-birth parents as equal parents by involving them in the care of the newborn baby and addressing them as parents of the child, rather than solely the partner of the birth parent.

Organizing postpartum care to reach a higher continuity of HCPs could possibly create improved conditions for providing good care by creating the possibility of feeling safe and being open with needs and preferences. Moreover, maintaining continuity of carer reduces the number of HPCs to whom the LBTQ person must come out during the stressful situation of experiencing recent birth complications.

Our findings showed a neglect of psychological support to non-birthing parents, a finding consistent with previous studies (Appelgren Engström et al., 2021; Klittmark et al., 2023; Malmquist & Nieminen, 2021; Vallin et al., 2019; Wells & Lang, 2016). It is of particular importance to recognize the significant need for support among non-birth parents who have witnessed their partner’s complicated birth, especially considering that they may have future plans of giving birth themselves. Policy changes are needed at a structural level to enable the follow-up of non-birth parents, as they also require and benefit from clinical support. However, by not having a medical record, non-birth parents are not considered patients/clients in the eyes of HCPs, and therefore, their psycho-social problems are often unsupported. Both birth and non-birth parents with traumatic birth experiences require access to emotional support following a complicated birth, and they should both be screened for postpartum depression and offered treatment, if needed.

The findings showed that participants experienced that HCPs had a lack of knowledge and awareness regarding induced lactation and co-nursing, resulting in lack of information and support. These results align with other studies, reporting a limited understanding and awareness among HCPs concerning induced lactation and co-nursing (Ferri et al., 2020; Juntereal & Spatz, 2020). In their conceptualization of social justice around breastfeeding, Smith (2018) describes how gendered language, as well as existing practices and policies reinforce breastfeeding as being for some but not others, and that HCPs need to expand their perspective on who is capable of and/or desires to breastfeed. There is a need for increased awareness within reproductive healthcare regarding the possibility of induced lactation and co-lactation for non-birthing parents and also specific breast/chest-feeding support to trans people (MacDonald, 2019). By enhancing awareness and knowledge, induced lactation and co-nursing can become more accessible for LBTQ parents. By HCPs demonstrating knowledge and positive attitudes toward LBTQ breast/chest-feeding, breast/chest-feeding can become more accessible for LBTQ parents.

Conclusion

LBTQ people experience exclusion in postpartum care due to HCPs’ attitudes and the presence of cisheteronormative routines and perspectives. Changes are necessary in postpartum care to ensure reproductive justice for LBTQ people and to achieve the goals of equal support, care and treatment to all new parents irrespective of their sexual or gender identity. HCPs in postpartum care need to receive education and training in order to implement LBTQ competent and trauma-informed care.

Limitations and further research

This study presents valuable and new knowledge about LBTQ people’s postpartum needs, which can be used to inform HCPs and guide changes toward a more inclusive and equal postpartum care. One limitation is that the participants had similar socio-cultural backgrounds. The recruitment methods attracted mostly white middle-class cisgender women in same-sex relations. This sample could be mirroring who feels safe (enough) to participate in a research study about LBTQ parenting, openly showing struggles with trauma, mental health and/or parenting. In future research, reaching a more diverse sample is important to analyze postpartum care access and needs.

Disclosure of interest statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Additional information

Funding

This work has been funded by The Royal Swedish Academy of Science (AM2023-009).

Notes on contributors

Sofia Klittmark

Sofia Klittmark is a midwife (RNRM) working clinically at a Midwifery clinic in Region Stockholm, Sweden. Klittmark is specialized in supporting LGBTQ parents and wrote her master’s thesis in Midwifery about LGBTQ parents’ experiences of reproductive healthcare. Klittmark worked for three years in a parental support program within RFSL, the Swedish Federation for Lesbian, Gay, Bisexual, Transgender, Queer and Intersex Rights. Within the project, she developed and held parental support groups online for prospective LGBTQ parents from all over Sweden. She developed information material on LGBTQ issues for midwives, and support material online for LGBTQ prospective and new parents, including how to support induced lactation and co-nursing.

Jaqueline K. P. Niit

Jaqueline K. P. Niit is a midwife working at the Gynecological Clinic at Norra Älvsborgs Sjukhus in Trollhättan, Sweden. She received her Bachelor of Arts in Nursing and Nursing degree from the University of Gothenburg and her Degree of Masters in Midwifery from the Karolinska Institute of Stockholm. She wrote her candidate thesis during her studies at the Karolinska Institute of Stockholm focusing on LBTQ's parents’ needs after a difficult birthing experience. She is interested in LGBTQ+ rights, women’s rights and sexual health.

Emilia Nerström

Emilia Nerström is a midwife working at the delivery ward at Nya Karolinska Solna in Stockholm, Sweden. She received her Bachelor of Arts in Nursing and Nursing degree from Sophiahemmet University in Stockholm. She later received her Degree of Masters in Midwifery from the Karolinska Institute of Stockholm, writing her candidate thesis during her studies focusing on LBTQ's parents’ needs after a difficult birthing experience.

Hanna Grundström

Hanna Grundström is a midwife and associate professor (senior lecturer) of reproductive, perinatal, and sexual health at Linköping University, Sweden. She has expertise as a researcher in the fields of birth experiences and postnatal support. She is experienced in several qualitative and quantitative research methods and has worked with interview studies, cross-sectional designs, longitudinal data, and register data. Additionally, she has a long clinical experience as a midwife working in peri-and postnatal care.

Katri Nieminen

Katri Nieminen is a senior consultant, specialist in obstetrics and gynecology with expertise in research on fear of childbirth, traumatic birth and postpartum experiences. Her thesis Clinical aspects on childbirth-related anxiety included studies on internet therapy of fear of childbirth and traumatic birth as well as health economic analysis on how fear of childbirth influence the ordinary health care. She is experienced in working with health-related questionnaires and quantitative analysis. The last years co-operation in the research group with Ass. Professor Malmquist and Dr Grundström has dealt with questions about childbirth anxiety and traumatic birth experience in the LBTQ context, using both qualitative and quantitative methods.

Michael B. Wells

Dr. Michael B. Wells is a Docent and Associate Professor in Women’s and Children’s Health at Karolinska Institutet. He is the research group leader for his group called Global Reproductive Outreach and Wellness (GROW), where his research focuses on reproductive health and rights around the world.

Anna Malmquist

Anna Malmquist is associate professor and senior lecturer in social psychology at Linköping University, Sweden. She has expertise as a researcher in the field of queer psychology, with a main focus on family formation and reproductive health among LGBTQ people. She has a specific interest in fear of childbirth, birth complications and birth trauma in this group. Among her publications are the first Swedish textbook in LGBTQ psychology as well as one book on lesbian mother families and another on gay father families.