Affirming Care for Transgender and Gender-Diverse Youth.

ABSTRACT: Nurses play a critical role in providing gender-affirming care for transgender and gender-diverse youth. With heightened debate about the clinical care for transgender and gender-diverse youth in the national and global spotlight, now more than ever before nurses must equip themselves with the knowledge and the evidence spanning more than 4 decades that support the clinical use of gender-affirming care for youth and young adults. By exploring gender development and gender-affirming care approaches through the lifespan perspective, this review provides an up-to-date discussion about best practices and clinical implications for providing equitable care for transgender and gender-diverse youth from birth to childhood and through adolescence developmental phases. A transgender and gender-diverse youth's future willingness to access health care is dependent on how positive their interactions are with their care team at this sensitive moment in their life. Nurses must not let political rhetoric impede their practice and ethical guidelines to provide competent, skilled, and unbiased care. Knowledgeable, informed, and empowered nurses can provide life-saving care to transgender and gender-diverse youth and their families.

Measuring Fear of Childbirth Among a Diverse Population in the United States: A Revised Wijma Delivery Expectancy/Experience Scale (WDEQ-10).

INTRODUCTION: The current gold standard instrument used to measure fear of childbirth is the Wijma Delivery Expectancy/Experience Questionnaire (WDEQ). However, the existing scale is long, has translational challenges, and lacks data specific to experiences of a diverse population in the United States, making it challenging to assess how fear of childbirth impacts perinatal health care disparities. The objective of this study was to revise the WDEQ and analyze its reliability and validity for use in the United States. METHODS: The questionnaire was revised using qualitative data from a previously published study of fear of childbirth within a racially, ethnically, and economically diverse group of pregnant or postpartum people in the United States. Psychometric properties were analyzed in terms of construct validity, reliability, and factor analysis from a group of 329 participants. RESULTS: The revised and shortened 10 item WDEQ-10 comprises 3 subscales: fear of environmental factors, fear of death or injury, and fear of how they feel. The results indicate that the WDEQ-10 demonstrates good reliability and validity and confirmed the multidimensionality of fear of childbirth through a 3-factor solution. DISCUSSION: The WDEQ-10 is a readable and accessible instrument that will allow health care providers and researchers to accurately measure complex components of how pregnant people experience fear of childbirth.

Minority stress theory applied to conception, pregnancy, and pregnancy loss: A qualitative study examining LGBTQ+ people's experiences.

Many lesbian, gay, bisexual, transgender (trans), queer, and other sexual and gender minority (LGBTQ+) people desire to conceive children. Yet, LGBTQ+ peoples' experiences are scant in reproductive health literature, particularly around pregnancy loss-a stigmatized and distressing pregnancy outcome. Informed by minority stress theory, this qualitative study aimed to explore the experiences of multi-level stigma and resilience among LGBTQ+ people in the context of conception, pregnancy, and loss. Seventeen semi-structured individual interviews (25-70 minutes) were conducted (2019) with a purposive sample of LGBTQ+ people in the United States (U.S.) who had experienced pregnancy loss (n = 14) or in an intimate partnership in which a pregnancy was lost (n = 3) in the last two years. Transcribed interviews were analyzed thematically. Participants described the profound sadness of pregnancy loss due to unique challenges of LGBTQ+ conception. Multiple types of stigma manifested at intrapersonal (e.g., anticipated sexual stigma upon disclosure), interpersonal (e.g., unsolicited advice about conception decisions), and structural levels (e.g., differential requirements to access conception compared to heterosexual/cisgender couples). Resilience was also seen individually (e.g., purposeful disclosure of conception, pregnancy, and loss), relationally (e.g., connecting with other LGBTQ+ community members), and collectively (e.g., creating/engaging in LGBTQ+-specific conception, pregnancy, and loss online spaces). LGBTQ+ people experience minority stressors of multi-level stigmatization throughout the pregnancy process, which limits their access to social support after experiencing pregnancy loss. However, individual, relational, and collective resilience strategies abound in response. Thus, minority stress theory can also be applied to recognize strengths-based and affirming approaches to reproductive healthcare for LGBTQ+ people.

Clinically and Culturally Competent Care for Transgender and Nonbinary People: A Challenge to Providers of Perinatal Care.

Transgender and nonbinary people experience high rates of discrimination and stigma in healthcare settings, which have a deleterious effect on their health and well-being. While the preventative healthcare needs of transgender and gender nonbinary people are slowly starting to make their way into nursing curriculum, there is still a very little guidance on how to appropriately and respectfully care for this population during one of the most vulnerable interactions with the healthcare system, the perinatal period. Without exposure or education, nurses are challenged on how to provide compassionate and culturally competent care to transgender and nonbinary people. The focus of this review is to provide guidance to nurses caring for transgender and gender nonbinary people during the perinatal period. Terminology and respectful language, a discussion around the decision to parent, affirming approaches to physical examination, and care during pregnancy and the postpartum period are all discussed. By increasing the number of nurses who are trained to deliver high-quality and affirming care to transgender and nonbinary patients, challenging health inequities associated with provider discrimination can be mitigated.

Desistance, Self-treatment, or Substitution: Decisions about Cannabis Use During Pregnancy.

Cannabis is the most commonly used drug during pregnancy in the United States and Canada, and the American College of Obstetricians and Gynecologists recommends that all pregnant individuals be screened for cannabis use and counseled regarding potential adverse health impacts of use. However, those considering or using cannabis during pregnancy report experiencing stigma and lack of information from health care providers and, thus, frequently rely on friends, family, and the internet for information. This article describes 3 types of decisions individuals may be making about cannabis use during pregnancy and suggests approaches health care providers may take to minimize judgment and provide optimal support for informed cannabis use decisions among pregnant individuals. Desistance decisions involve consideration of whether and how to reduce or stop using during pregnancy. Self-treatment decisions are made by those exploring cannabis to help alleviate troublesome symptoms such as nausea or anxiety. Substitution decisions entail weighing whether to use cannabis instead of another substance with greater perceived harms. Health care providers should be able to recognize the various types of cannabis use decisions that are being made in pregnancy and be ready to have a supportive conversation to provide current and evidence-based information to individuals making desistance, self-treatment, and substitution decisions. Individuals making desistance decisions may require support with potential adverse consequences such as withdrawal or return of symptoms for which cannabis was being used, as well as potentially navigating social situations during which cannabis use is expected. Those making self-treatment decisions should be helped to fully explore treatment options for their symptoms, including evidence on risks and benefits. Regarding substitution decisions, health care providers should endeavor to help pregnant individuals understand the available evidence regarding risks and benefits of available options and be open to revisiting the topic over time.

Understanding fear of childbirth among underrepresented populations in the United States.

The purpose of this study was to expand our understanding of fear of childbirth (FOC) by examining the interplay between individual, provider, identity, and culture among women historically underrepresented in FOC research to develop a deeper understanding of FOC. Purposive sampling was used to recruit 22 participants into three different focus groups, each with a unique demographic makeup. The results provide evidence that people's birth experiences and their experiences with fear surrounding childbirth are affected by many other social mechanisms, including relationships with providers, birth setting, race, class, gender, sexual orientation, and ethnicity.

Relational Decision-Making in the Context of Life-Limiting Fetal Anomalies: Two Cases of Anencephaly Diagnosis.

Life-limiting fetal diagnoses such as anencephaly require families to make decisions in which no options offered will lead to the desired outcome of a healthy newborn. Although informed choice and shared decision-making are important aspects of ethics regarding care choices, they have limitations. In this article, 2 cases of anencephaly diagnosis are presented, and a relational decision-making model of care is proposed as an alternative for aiding pregnant people and their families in making challenging choices in the context of perinatal care.

Determinants of postnatal care utilization in Tigray, Northern Ethiopia: A community based cross-sectional study.

INTRODUCTION: Globally, 289,000 women die from complications related to pregnancy, childbirth, or the postnatal period every year. Two-thirds of all maternal deaths occur during the first six weeks following birth and more than two thirds of newborn deaths occur during the first week of life, These statistics underscore the importance of postnatal care, an often neglected service according to the World Health Organization (WHO). The purpose of this study was to assess the factors associated with postnatal service utilization in the Tigray region of Ethiopia. METHODS: The study was a community-based, cross-sectional study. A multi-stage sampling method was used to select study districts randomly from the entire region. A total of 1,690 participants were selected using systematic random sampling. Participants were 18-49 years old, had given birth within the last six months, and were residents of the district for at least six months. Using SPSS version 20 means, frequencies, and percentages were calculated for the sub-group of participants who did attend postnatal care. Barriers to non-attendance of postatal care were analyzed using descriptive statistics. Bivariate analysis was undertaken to assess the association between demographic, obstetric, and knowledge regarding PNC and attendance at antenatal care. Variables with a P value, <0.05 were included in the multivariate logistic regression analysis to identify the determinant factors of postnatal care utilization. RESULT: Of the women surveyed, 132 (8%) obtained postnatal care. Women who did not receive postnatal care reported lack of awareness of the services (n = 1110, 73.3%). Most mothers who received postnatal care reported that they were aware of the service prior to the birth of their child (n = 101, 76.5%). Women were more likely to receive postnatal services if they lived in an urban area (odds ratio 1.96, 95% confidence interval 1.07, 3.59), had greater than a secondary education (OR 3.60, 95% CI 1.32,9.83), delivered by cesarean section (OR 2.88 95% CI 1.32,6.29), had four or more antenatal visits (OR 4.84, 95% CI 1.57,14.9), or had a planned pregnancy (OR 6.47, 95% CI 2.04,20.5). CONCLUSION: Postnatal care service utilization is very low in Tigray region. Interventions targeted at increasing women's awareness of the importance of postnatal services and improving accessibility, particularly in rural areas, is needed.

Achieving competency in vaginal examinations: The challenge of balancing student learning needs with best practice in maternity care.

Assessment of labor progress through vaginal digital examination (VE) remains one of the most challenging skills for midwifery students. As VE during labor has become a less frequent occurrence there are less opportunities for student midwives to gain mastery of the skill. Best practices for teaching and evaluating VE involve a step-wise, multi modal approach. More research is needed on how to standardize teaching for this essential skill.

Immediate Postpartum Contraception: A Survey Needs Assessment of a National Sample of Midwives.

INTRODUCTION: Immediate postpartum long-acting, reversible contraception (LARC)-providing intrauterine devices (IUDs) and contraceptive implants immediately following birth-is an effective strategy to prevent unintended pregnancies and improve birth spacing. We measured US certified nurse-midwives' (CNMs') and certified midwives' (CMs') knowledge, training needs, current practice, and perceived barriers to providing immediate postpartum LARC. METHODS: We invited currently practicing CNM and CM members of the American College of Nurse-Midwives to complete an online survey about their knowledge and experience with the use of LARC and analyzed eligible questionnaires using descriptive statistics. RESULTS: Of 4609 eligible midwives, 794 responded (17% response rate). Most were female (99.5%) and non-Hispanic white (92.1%), with 45.0% attending births in urban settings. Responses revealed multiple knowledge gaps related to IUD expulsion rates and appropriateness of immediate postpartum LARC in certain clinical scenarios. Only 10.1% of respondents reported feeling confident to insert an immediate postpartum IUD and 43.3% an implant. Many reported desiring additional training in immediate postpartum IUD (63.5%) and implant (22.8%) insertion; few reported access to such training (IUD, 19.9%; implant, 15.2%). Most respondents had never inserted an immediate postpartum IUD (90.7%) or implant (86.8%). The most commonly cited barriers to immediate postpartum LARC provision were that it is not standard practice (IUD, 40.9%; implant, 39.0%) or is not available (IUD, 27.8%; implant, 34.8%) at one's institution and feeling inadequately trained (IUD, 26.5%; implant, 10.7%). DISCUSSION: Nine in 10 midwife respondents have never inserted an IUD or implant immediately postpartum, but more than half indicated they would like the opportunity to provide these services. Our findings highlight opportunities to enhance the immediate postpartum LARC-related knowledge and skills of the midwife workforce. They also suggest that logistic and institutional barriers to immediate postpartum LARC access must be removed in order to make this evidence-based reproductive health service available to all women who desire it.

Exploring Fear of Childbirth in the United States Through a Qualitative Assessment of the Wijma Delivery Expectancy Questionnaire.

OBJECTIVE: To explore women's experiences while completing the Wijma Delivery Expectancy Questionnaire (W-DEQ), an instrument used to measure fear of childbirth, and to analyze the readability and applicability of the instrument within a diverse population of women in the United States. DESIGN: Qualitative descriptive study using focus groups with women who were pregnant or had given birth in the last 5 years. SETTING: Urban health center in the Detroit metropolitan area. PARTICIPANTS: Participants included 22 women who participated in three focus groups. METHODS: Focus groups were used to collect data, which were analyzed using content analysis. The Fry Readability Graph, in computer form, was used to rate the readability of the instrument. RESULTS: Women in the focus groups identified many themes that were consistent with previous research. However, the women indicated many new factors that contributed to their fear that were previously unidentified by the W-DEQ, including fear of abandonment by their clinicians and fear of how the structure of the maternity care system affects care during childbirth. CONCLUSION: The findings from the focus groups challenge the utility and appropriateness of the W-DEQ for use as a screening tool to identify women who are pregnant and experiencing FOC in a U.S.

Retrospective Review of Nurse-Midwifery Care at a Large University Health System.

The purpose of the study is to characterize practice trends, outcomes, and changes over time of a full-scope midwifery service over the past 30 years from 1983 to 2013. The types of clients served and the evolution of the services provided and resulting outcomes are described as an exemplar of the changing nature of providing midwifery services in a tertiary care hospital setting. The overall data reveal that despite small increases in intervention practices, such as epidurals, inductions, and cesarean births, midwives have a commitment to providing safe, evidenced-based, woman-centered care within a collaborative practice model at a tertiary care center. The role of midwives as leaders in supporting physiologic birth in this setting and encouraging opportunities for interprofessional education and collaborative is demonstrated.

Psychometric assessment of the Health Care Alliance Questionnaire with women in prenatal care.

The current study assessed the reliability and validity of the Health Care Alliance Questionnaire, which was developed using a Delphi process and embedded in an ongoing perinatal outcomes study. The Health Care Alliance Questionnaire exhibited content and face validity and high reliability. Results indicated concurrent validity in relation to satisfaction with practitioner and discriminant validity in relation to interpersonal sensitivity and posttraumatic stress disorder. The Health Care Alliance Questionnaire demonstrated predictive validity in relation to perceptions of practitioner's care during labor and postpartum depression. Overall, results suggest that alliance may be an important factor in maternity care processes and outcomes. Further psychometric work is warranted.