 Annandoa University in Winchester, Virginia, and she's recently retired from clinical practice in Baltimore. Today's session from Catherine is about midwifery for lesbian couples, and we're really looking forward to hearing what Catherine has to say. Social and legal mores regarding same-sex marriages have undergone rapid change during the past decade in the USA, and 36 states now recognise same-sex marriage. The American College of Nurse Midwives is among the professional organisations whose position statements advocate non-discrimination in healthcare for lesbian women. Globally, the International Confederation of Midwives position statements call for respectful care for all women. However, lesbian women and couples still face misunderstanding and negativity from providers when in the exam room. As more lesbian couples marry and start families, the need for sensitive and caring midwifery services during the antenatal period and at birth increases. Are midwives prepared to meet this need? This presentation will discuss current trends in recognition of lesbian relationships, identify some unique needs of this population, and provide suggestions for midwives to deliver and evaluate sensitive and culturally appropriate care during the childbearing experience. So now it's my great pleasure to hand over to Catherine. Catherine disappeared. Please bear with me, Catherine seems to have lost her connection, so I'll move forward to the first slide. And we'll wait for Catherine to rejoin us. Maybe she was having problems with her sound too. Maybe so, maybe so. Who knows, we'll have to watch out for her coming back in again. Aha, clever colours. Sorry, that was in the private chat box. Do we have an alternative way of getting hold of Catherine? Well, email is the obvious thing, I'll try and email her. Of course, if the reason she's gone is she's lost her internet connection, you won't get an email, but I'll try anyway. I'm seeing if I can find any other contact details. Our next speaker is here, so I guess if she's almost ready, we could go with her. But that really depends if that means that when Catherine comes back in, she needs to do hers. Maybe we should wait a few minutes first. But there is that option. That's a good idea, whoever said that. I think I've still got that, there you go. Please don't evaluate. That'd be fabulous. I think you should come on our committee. Sheila, that was a good idea. I'll take it, that's a no then, Sheila. It's Catherine. She's in Maryland. Not an area that's usually a problem? No, indeed. You had a bit of a short one earlier on. The only contact details have her an email address, and I have emailed her. The solo, that's a possibility. We're just going to give it a couple of minutes to see whether or not Catherine comes back in again. Would you be ready if we wanted you to go ahead? There you go, that's an option in a minute then. How long shall we leave it to call back then? Give her a couple more minutes. Okay. You go to Lou's solo and do whatever else you need to do just in case we're about to pop you. Oh, she's back. See, she's back. Just as we decide to do things, it all changes. I'm going to turn it here. There you go, I've promoted up. Thank you, you beat me to it. My wife, I went out. Can everybody hear me? Yes, we can. I don't know what happened. Just as I was about to come on, all of a sudden, no connection. So I do apologize. Normally it's pretty reliable. Okay, so we might, so now we're running behind, so we might have to scoot a little bit faster through these slides in the discussion. Okay, just dive straight in, Catherine. The recording's on. Okay, great. All right, so I just, Chris mentioned that I had recently retired and I had retired from Chase Brexton Health Care, which is a federally qualified community health center offering full scope services in Baltimore. But their origins were in service to gay men. So part of the mission at Chase Brexton is respectful, inclusive care for members of the LGBT community. At the end of this presentation, the learner will discuss current trends in recognition of lesbian relationships, identify some unique needs to this population, and state ways that midwives can deliver and evaluate sensitive and culturally appropriate care during the childbearing experience. So we just wanted to give you a brief graphic as where same-sex marriage is now legal by state in the United States, and you can see the darker color are states where it is legal. The lighter yellow is where there's a constitutional ban on same-sex marriage, and the lightest, it's a statutory ban. Of course, that may be changing once the Supreme Court, which heard arguments yesterday, makes their decision sometime at the end of June on states' ability to ban. Okay, however, as Chris mentioned in the intro, societal attitudes are definitely changing. There's been a massive seed change over the past 10 years, and these days, many, many people consider that love is genderblind, and we should support marriage equality for all. So in the European Union, under the requirements for marriage, is the right of same-sex marriages, same-sex couples to get married, and you do see a list there of the 11 countries who grant this right. Northern Ireland is excluded for citizens of the United Kingdom. And in the world, Slovenia passes marriage equality legislation and becomes the 21st century, 21st country worldwide to grant marriage equality to all citizens. So the International College Confederation of Midwives has a position statement on ethical and human rights approach to healthcare in all settings, respecting culture, religion, ethnicity, gender, and individual choices, although without support for actions that result in harm. And as far as education, we will promote the inclusion of the principles of ethics and human rights within the midwifery curriculum worldwide. The AC&M, American College of Nurse-Midwives, believe that every person has the right to healthcare that respects human dignity, individuality, and diversity within groups. And that midwives in their professional practice will act without discrimination, and you see among the list of possible variables they specifically address sexual orientation. The Midwives' Alliance of North America also has a statement of values and ethics, which again addresses sexual orientation and gender identification specifically in terms of giving care without prejudice. Now, I'm going to start in with a case study, and this is not a real person or a real couple, but a composite of women and couples that I have cared for in my practice at Chase Brexton and previously. So let's just say that Nina S. Nina S. is a 36-year-old Caucasian woman. She's a G2P0010, who presents for a new OB visit at 10 weeks' gestation based on last menstrual period. Her past medical history is unremarkable. She's taking daily vitamin. Her GYN history, she's onset of menses at age 12, regular cycle of 28 days for four days of bleeding. She has no history of abnormal pap smears or sexually transmitted disease. Her last pap was a year ago. Her OB history in 2001, she had an uncomplicated first trimester termination. Her genetic history, she does present with advanced maternal age. Her social history, she's a nonsmoker. She drank wine on the weekends prior to pregnancy. Denies any recreational drug use. She's an accountant with a college degree and no religious affiliation. Oh, the parody, no term births, no preterm births, one termination and no living children. Not for the weeks, it's for the outcomes of pregnancy. Okay, so her sexual history, she reports that she was abused by her stepfather when she was between the ages of 10 and 14. Among the family history, significant for mother with a bipolar disorder. The objective data, normal vital signs, normal BMI, normal general physical exam, and her bimanual exam, the uterus is 10 weeks size. So our assessment would be intrauterine pregnancy at 10 weeks, size equals dates, advanced maternal age, and a history of sexual abuse. So our plan, routine new OB labs, gonorrhea, chlamydia, she was offered genetic counseling because of her advanced maternal age and first trimester screening for aneuploidies. She used to continue her daily vitamin. I oriented her to the practice, reviewed warning signs, diet, exercise, how to reach the midwife, and to schedule her return OB appointment in four weeks. So what is missing? And here I would like some responses from the audience. So, you know, either you can be given a microphone by the host if you'd like to respond verbally or type in the chat window, and I'll take a look there. Okay, question about the partner. No partner details. Okay, partner status. Support person, Mexican family support. Great, anything else? Claudia, I see. Lifestyle, well, we did sort of address lifestyle in her, you know, in her social history in terms of occupation, religion, habits, paternal. Okay, where is she planning to birth? Okay, family origin, counseling, plan. What is important? Okay, those are all very pertinent comments. What I was kind of looking for was a question or an exploration of her sexual orientation. So usually the way we ask that would be, do you have sex with men, women, or both? Because we have made an assumption here that this is a heterosexual relationship. So now we're getting into the partner, which several of you have asked about. So she's accompanied by Suzanne, who's a quiet, well-grown woman who appears to be in her early 40s. Suzanne listens attentively to the interview, requests to be present for the physical and pelvic exam, and asks appropriate questions in regards to genetic risks to the fetus. So my question's again for you, and again, chat window or mic. Would you ask what is their relationship? Would you assume that they would tell you if they wanted you to know? And how comfortable are you with care for the lesbian couple? So we'll take a couple minutes here for audience response. I see there's a lot of typing going on. You would ask. Okay. All right. So a lot of people are responding that they would have established that relationship at the very beginning of the visit, and Claudia once is commenting on more in-depth understanding about prospective pregnancy, parenthood, et cetera. Shabuzy would assume they won't tell me if I don't ask. Okay. At least it's not concerned. Okay. All right. So very good. It seems like most people would be very direct. All right. And it gets to the point that we really must begin with ourselves, and the foundation for ethical care is understanding yourself, including your cultural and value biases. And some of us do have cultural and value biases to overcome based on our upbringing. All of us do, of course. Okay. So 20 years ago, interviews revealed that women's healthcare for lesbians lack sensitivity, care providers are not knowledgeable, assumptions of heterosexuality predominate, and assumptions of STD risk are inaccurate. And there's a high distrust of the healthcare system, as well as lack of confidentiality. Recognizing that this was at the onset of the AIDS epidemic, and there was a lot of fear of same-sex relationships, particularly gay men. Okay. So are we doing any better today? Many providers are aware to ask about sexual orientation. Sometimes your medical history form or the electronic medical records address sexual orientation. But the comfort level of the providers still varies. So this is a sample of the electronic medical record from Chase Brexton, which, as you recall, I mentioned earlier, has a specific mission of care for individuals for the LGBT population. And if you look, FOB stands for Father of Baby, and there is an assumption that they're either a husband or involved, or a male partner who has fathered the child. Okay, we're getting to that, Fiona. We're getting to that. Okay, so Nina and Suzanne tell you they've been together for five years. They married when same-sex marriage became legal in their state six months ago. They've wanted to have a baby together for a long time. So who will be the biological mother and who the co-parent? I just want to interject here very briefly. Not regarding this particular couple, but I did care for a couple who came in in the first trimester for a new OB visit. And the woman who was pregnant had a terrible OB history of recurrent first trimester miscarriages and then one preterm delivery that was just at the verge of the age of viability that that baby didn't survive. And then the pregnancy that she had enrolled for care with me, she also had another first trimester miscarriage. So in that situation, I really wanted to explore with them why she was the one who they had agreed to be the biological mother because the partner had had one previous pregnancy that was an uncomplicated one. So, you know, it's just, we don't want to impose our own, you know, attitudes and belief system, but I think that is an issue that comes up when we discuss roles as how was the decision made as to biological mother. Okay, yes, I see that. Okay, so the process of conception can involve either intercourse with a willing known male, a fertility center, or home insemination. So Nina tells you that because of the expense of going through a fertility clinic, they chose to involve a family friend, and they used his sperm and did the insemination of home with successful conception after three cycles. So pros and cons, home clinic versus home self. Basically, in the clinic, they take care of it all. The couple can choose the donor sperm based on desired characteristics, screening for medical history and STDs is done by clinic personnel, paternity is anonymous and has been revoked by the donor. The cons of the clinic is that the process was specifically developed for infertility treatment of heterosexual couples to allow conception, and therefore, staff might not be sensitive to the needs of same-sex couples, and the cost that's out of pocket in most cases and may need several cycles of insemination. The pros of home self are affordability, known donor and privacy, but known donor can also be a con because the couple needs to negotiate the extent of the involvement. It's a sensitive discussion in terms of testing for STDs. There's logistical issues with obtaining, storing and using sperm, and the huge issue of the legal paternity rights of the donor. I see there's a discussion going on about, you know, how to take the history and what's on the chart. So that's good. So has anyone ever been involved as a midwife to participate in the process? We can do this as a little poll up there with the man raising their hand. Can people just raise, click, agree or disagree if they've been asked to participate? Okay. Can you see the raised hands all right, Catherine? I only see... I see a raise, a couple, and I see a couple of greens and a red. Yeah. At least you can see what people are doing. That's good. How many of the participants have been involved? Is it consistent with midwifery standards of practice? So among the AC&M core competencies, it does apply in a general sense. However, there is one practice that I came across in my literature review in Seattle that offers a basic fertility package where they have consultations, a plan, timing, chart reviews of their fertility records and early pregnancy visits. The International Confederation of Midwives also refers to pre-pregnancy care and family planning, although without specifying, you know, gender orientation. Now, the legal issues of paternity are a huge... can be a huge barrier or consequence of conceiving a child, especially with a known donor, as we discussed a little bit earlier. And this is a quote from the Maryland law that, as long as the parents are married, the offspring is considered to be the legitimate child of both, including a child by artificial insemination of a married woman with consent of her husband, and one could assume partner, and the consent of the husband is presumed. However, the National Center for Lesbian Rights Backsheet advises the couple to do a second parent adoption in case they relocate to another state where same-sex marriage is not recognized. Okay, I see Claudia has commented that this Maya midwifery practice in Seattle has online classes as well. And yes, there is a link to their website a little bit later in the presentation if people want to explore that further. All right, so again, this is from the Maya midwifery in Seattle, and they have developed a set of contracts which can be very useful for the couple who is approaching a known donor, and they also have a questionnaire which can be reviewed by the couple and the midwife. They also have parenting agreements for biological and nonbiological parents. Both mothers' names can be placed on the birth certificate in Australia. Good. All right, so if anybody is interested in seeing those full documents available and learning more about their classes, as Claudia mentioned, the link is here on the slide. Okay, so Nina works as an accountant. She's got health insurance coverage through her job, but assisted reproductive technology for the same... Lost your sand. Oh, I was afraid that was happening. Just lost Catherine. So we'll probably have to wait three or four minutes for Catherine to rejoin us, but we'll just have time, hopefully, to finish off the remainder of her slides. What about the speaker, Chris? I'm afraid she's just lost her connection and it's happened right at the beginning. No, she's just completely dropped out. That is the facilitator. I'm sorry? There is another one here. Who's shoulder is the next speaker? She's speaking in session 17. Sorry to interrupt. That's okay. It's Catherine Salem, and she dropped at the beginning as well. She said her Wi-Fi just disappeared. It might be worth people just sharing what they know about this current slide. So across your different countries, where is the same sex conception covered either by insurance or a national health system if you have one? Claudia, have you raised your hand? What can we do for you? Nothing other than a mic? Put your hand down again. Anybody would like to take a mic? Feel free, just let us know. Welcome back, Catherine. Yes, this is just... I'm not even connected with the USB cable, so because the wireless was connecting. But it still went out. I don't know. Of all days, right? Exactly, exactly. How many minutes left, so you probably ought to pick the most important slides of what you've got left so that I can move on to the final bit. So just basically, you know, some concerns about, you know, ask partners how they would like to be addressed. Do they refer to each other as my wife, my husband, or more generally, spouse? Clarification of the roles, respect for the decision and sexual orientation recorded in the medical record. Again, this was article that discussed this was about five years old, so there might have been some changes since then. But definitely, it's part of Medwifery's standard of practice to be familiar with treatment avenues and appropriate referral and support. Medical record should reflect the inclusive sexual history, non-discrimination policies should be publicly posted. So Nina gets to term healthy pregnancy. She comes in in labor. She's going to be admitted. So again, with the admission database to labor and delivery, be it a hospital or birth center facility, again, some of the issues apply as to taking history. And generally in our hospitals, it's the labor nurse who is taking the most comprehensive database. Should the midwife talk to her? Should she leave it up to the couple? But that we need to recognize that both women are parents and allow time and space for intimacy as desired and make sure there's round-the-clock access for the spouse before and after the birth. So how do we evaluate care? One method is through patient satisfaction questionnaires, which can include questions on whether care was given with respect regardless of sexual orientation. We can use the hospital or clinic comment cards. We can get personal feedback from clients. And of course the best feedback of all is the intent to return for follow-up care, both their postpartum and their GYN care. So of course with any pregnancy, we want the outcome of a healthy baby. Then the references are available for anyone who would like to do more reading or research on this. Katyn, thank you very much and thank you very much for battling through, wrestling through the technology issues. I'm sorry about that. You know, this is the... Well, as you say, today of all days. More comments or feedback in the chat window for anything that's been covered. I see Claudia is commenting on issues of breastfeeding with trans families. It's an issue to listen to carefully. You know, definitely agree on that. Okay. Well, thank you very much. I'll just give it a minute or two more before I turn off the recording. In the meantime, if any of you here have any photos of yourself or your friends taking part in this year's conference, please do take a photo and email them to us at admin.vidm.org. We'd love to see them. We're developing a slideshow that will show at the end of the conference. And those of you who have attended in previous years may well remember us doing that. We will be making recordings available via our website and our Facebook page. We have a YouTube channel now that we can use and that's where they'll end up. Don't forget to download the certificate of attendance for your portfolio. Linda's just posted the link to our online feedback survey. Please do go and fill that in. The only way we can work out what to do better next year from what we hope is already a good conference is for you to tell us, so please, please do so. Don't forget also, this year for the first time, we're running a student café and that's just posted the link for that. So that'll be running at the same time as session 21, so in about four or five hours time. So we really look forward to seeing students there. I'm now going to stop the recording and Catherine, thank you once again for your really, really interesting presentation. Great, you're quite welcome.