Recruitment and sampling

Author 1 is a midwife who currently works in the NHS. The study was initially advertised using a poster through social and professional networks using a snowball recruitment approach. Professional colleagues were also encouraged to share the study though their social and professional networks. Recruitment commenced 05/01/2024 and closed 01/03/2024 as hypothetical data saturation was reached.

The study was limited to midwives working in the UK within the NHS. The final study sample included nine midwives, and one health visitor who also held a professional qualification as a midwife. All participants identified as a “woman” or “female”; with several clarifying they identified as cisgender women. Professional qualifications, years of experience, area or working, and gender identity are explored in Fig 1.

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Fig 1. Table showing demographic details of interview participants.

https://doi.org/10.1371/journal.pgph.0005684.g001

Data collection methods

Participant information sheets were sent via email prior to interviews with St. George’s Research Ethics Committee consent forms. Consent forms were completed by participants prior to interview. Verbal consent was obtained at the start of each interview and recorded within the transcript. Interviews were informed by a semi-structured interview guide that sought to explore the current evidence base of recommendations for TGNC pregnancy care provision and the feasibility of their integration within NHS care settings. Interviews took between 25 and 80 minutes. The semi-structured interview guide was developed based on a comprehensive literature review of evidence-based recommendations for TGNC care provision.

The literature review was completed in January 2024. A search strategy was designed to select appropriate literature. The search explored the following databases: NCBI PubMed, BioMed Central, Ovid, Cochrane Library, and Hunter Library. Keywords and Boolean terms used included transgender, pregnancy, recommendations, experience, male, birth, gender non-conforming, gender identity, midwifery, obstetrics, transgender AND pregnancy, transgender AND pregnancy AND recommendations. Search terms were used in various combinations. Inclusion and exclusion criteria and rationale for these was developed. The search was limited to literature written in English to ensure correct interpretation of literature. The search was not limited by year of publication, however no relevant articles published prior to 2014 were identified. Articles were excluded due to lack of relevance, such as focussing on contraceptive care, preconception care, pregnancy loss, lactation, non-pregnancy specific care, or not including recommendation for HCPs. Two articles were excluded for repetition. In total, 12 research articles or reports were identified. Full text was accessed for all articles. Four of these articles were excluded for not being specifically relevant to the niche of the topic or for not conducting original research. This left the eight papers that were critically appraised, found to be of high academic standard, and included in the literature review.

An overview of each paper was summarised (S1 Appendix), and all recommendations for care providers were documented (S2 Appendix). Recommendations were categorised by themes: education, language and literature, antenatal care, labour care, postnatal care, documentation and electronic medical records (EMR), environment, and institutional organisation. The recommendations which appeared most frequently were used to create the interview guide (S3 Appendix) for the semi-structured interviews. These recommendations were: training as a part of continued professional development on cultural competency and sexuality and gender diversity, asking service users their pronouns, asking service users their preferred terms for their anatomy and bodily function, gender inclusive EMR systems (allowing sex to differ from gender, allowing male patients admission to labour ward), documentation of correct pronouns, and gender inclusive posters and decoration.

The interviews followed a narrative approach [20] where honesty, sympathy, and respect were paramount to the process. Hypothetical data saturation was set at 10 participants for both feasibility and acceptability within the range proposed by Hennink and Kaiser [21]. Whilst conducting interviews, thematic saturation appeared to be reached by the eighth interview, however a further two were completed to ensure saturation was achieved.

Recommendations were made for midwives, healthcare institutions, policy makers, and for further research. The responsibilities of institutions and organisational bodies are emphasised in lieu of that of individual midwives.

Data analysis

Findings of the interviews were analysed thematically and coded using NVivo using thematic analysis and queer theory. Commonly occurring assertions, experiences, and beliefs created the key themes which were treated as categories for the findings and discussion of the study. Queer theory was utilised to extract meaning from codes “through sociohistorical, contemporary, and self-reflexive lenses” [22]. The aim therefore was to understand participants’ responses within a wider context of a cis- and hetero-normative patriarchal society, and by extension a cis- and hetero-normative patriarchal healthcare system.

To ensure confidentiality and anonymity for participants, recordings of the interviews were stored securely on the university network behind a password protected account. Identifying details were removed from the transcripts.

The findings do not aim to add to the “great deal of ‘midwives should’ writing” [23] by creating prescriptive lists of solutions unachievable within an understaffed, underfunded NHS perinatal care setting. The interpretations of the data were informed by the authors positionality. Both authors identify as queer, with the first author working as a healthcare provider and thus as an “in-out-sider” [24] as both a queer person, and a healthcare practitioner.

Sixteen codes were generated from transcript analysis (Fig 2). Some elements of interviews aligned with multiple themes, however each theme was notable and justified separate analysis. Codes with the most references are viewed as the key themes. The themes are distinct, but overlap between other codes, referenced from this point forward as sub-themes, which will be explored within each key themes.

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Fig 2. List of codes generated from participant interviews.

https://doi.org/10.1371/journal.pgph.0005684.g002

The code “trauma informed care” was only mentioned by two participants. Despite this, the code remained included due to its importance as a framework for care provision [25,26]. This is included with the acknowledgement that trauma informed care was not explicitly explored by all midwives.

The code “practical integration ideas” was explored separately as these did not contain the same depth of emotional exploration from interview participants. Practical integration ideas encompassed four categories: pronouns and language, gender inclusion, education for staff, and education for TGNC service users (S4 Appendix). Excluding practical integration ideas, 14 distinct codes for analysis were generated from interviews.

Ethical Approval was granted by St. George’s University of London under REC reference 2023.0242.

External and institutional barriers

“What’s the need and where does that come on the massive list of priorities that we’ve got and is that the most appropriate way to spend our money and time and effort or whatever it is?”

Participant 6

Prior to discussion of the findings of the literature review, participants were asked about their backgrounds, experience, and philosophies of care. Following this, participants were asked to imagine there were no constraints on their practice, and to describe how this would change their philosophy and care provision. A common limitation to care provision was time. The viewing of philosophy of care as constant rather than situational was consistent across all participants, and significant in demonstrating their commitment to their care provision.

“I don’t think it would be different, but I think I’d have more time to be able to treat people the way that I would want them to be treated… And so, I’d say, although my philosophy would probably be similar. I would be able to do it better.”

Participant 1

Pressures of time, staffing, and funding are well-documented in NHS services, and in particular perinatal care services [27–29]. These provide notable context as to why care needs of vulnerable patient groups may not be appropriately prioritised. In particular this is an important consideration as due to their minority status within healthcare settings, TGNC service users may be affected by these constraints on care in addition to more specific shortcomings in care provision. There is therefore a compounded burden on TGNC service users: to advocate for themselves as birthing people in addition to advocating for themselves as TGNC birthing people.

External barriers overlapped with many themes perceived by participants as negatively impacting care provision and relationship building in addition to institutional barriers. Namely, outdated medical systems, and medicalisation of birth. External barriers additionally overlapped with internal barriers, and in particular exoticisation or othering of TGNC service users and fears around erasure of women. Lack of training and experience was commonly cited as affecting participants’ confidence in providing care for TGNC service users. Multidisciplinary team (MDT) working was discussed in both positive and negative aspects by participants. Ineffective MDT working was discussed in relation to external barriers to care provision, whilst effective MDT working was discussed in relation to ensuring service user safety.

An external limiting factor for midwives in providing appropriate care for TGNC was the EMR systems in place. There is no standard EMR system for perinatal care services across NHS settings, and a variety of systems are utilised. Despite this, participants who reported using different EMR systems reported similar limitations. These included: inability to record gender separately to sex assigned at birth, inability to add a pregnancy record to service users recorded as male, and inability to register admittance of a male service user to “female” inpatient wards, such as an antenatal ward. This led to a variety of non-standardised “solutions” which varied significantly between institutions. Solutions included changing service users’ sex to female, adding a separate record with different record numbers which was connected to their medical records, or utilising only handwritten notes. None of these solutions were deemed satisfactory or feasible by participants, who reported these EMR limitations were often not investigated in advance of appointments or admittance of TGNC to inpatient areas. They reported EMR limitations as taking clinical staff away from providing care as they attempted to find ad-hoc solutions in addition to being “embarrassing” and a “clinical risk” (participant 5). Limitations of tools and technologies can be understood to impact safety and ability of midwives to provide care through a human factors framework [30]. Participants did not feel there was a clear solution to these challenges however, they did highlight the role of digital midwives and the administrators of EMR systems to develop solutions.

“We created the same name with a different MRN number, connected to the male record was a female record with the pregnancy added to it. So, we added any documentation for the pregnancy on female record, but he actually had a different MRN which was his male record that was used, you know, if he had to go into hospital for anything else, that would be his record. So, I can just see that this is gonna cause problems in the future as well.”

Participant 5

Whilst there was a deep appreciation for the role of the MDT expressed by the participants, the MDT was seen as a potential area where miscommunications could occur. In particular, emergency situations where members of the MDT attending had been unaware of the service user’s history and used incorrect pronouns for them (participant 7). Participants grappled with ensuring that all members of the MDT were appropriately informed and creating an unnecessary and unwanted focus on a service user’s gender. In addition, participants could not clearly identify who the appropriate care provider to refer to would be when caring for TGNC service users. Participants reported examples of care being led by teams aimed to care for those with complex social histories or mental health diagnoses, and examples of care being led by complex medicines teams, both of which were appropriate for the case in question but recognised as not appropriate for all TGNC service users. Additionally, participants often felt they did not have the resources or knowledge to address specific concerns or considerations of TGNC service users, such as how having a caesarean birth would affect phalloplasty in the future (participant 5) and additional precautions in the cases of testosterone use at conception or prior to pregnancy (participant 9). This aligns strongly with areas where TGNC service users have attempted to seek further information from midwives and found insufficient knowledge, highlighting the importance of providers “differentiat[ing] between ‘I don’t know’ and ‘science doesn’t know’.” [31]. Therefore, lack of clear pathways for TGNC service users led to inequities with service provision, with appropriate care provision depending on the knowledge of individual midwives, unsupported by institutional policies or training. Participants highlighted many perceived aspects of caring for TGNC service users as outside their sphere of competency. Whilst understandable for individual practitioners, this is unacceptable for care institutions as a whole, who have a responsibility to provide comprehensive and equitable care to all, as outlined within the NHS Constitution [3].

“Making sure that I am giving the care that they are expecting and also kind of making sure that as a team, we are providing the care that they are expecting because I’m very much aware that I am one member of a big team.”

Participant 9

“It’s just in terms of making people more likely to access care and making sure that staff are providing the same quality of care to everybody because as much as we would like to say that everybody would provide the same level of care, you know that staff in some situations find when they’re uncomfortable or not confident, they’re less likely to.”

Participant 1

Labour and birth were highlighted as a time where inappropriate language and pronouns may be used, due to being at higher likelihood of exposure to multiple midwives and a higher chance of needing wider MDT involvement in comparison to the antenatal and postnatal period. Labour and birth were also viewed by participants as a time where it may not be appropriate to ask questions about preferred language, and where utilising preferred language in lieu of “medical” language may cause miscommunication between HCPs. Therefore, the importance of birth planning and continuity of carer were highlighted by some participants to minimise disruptions in birthing environments and allow midwives to advocate for TGNC service users. Participants were aware of these barriers however did not always envision clear solutions to overcoming them, especially when they seemed outside of their control. Participants were aware of their own sphere of practice and the individual impacts they could achieve, and acknowledged the importance of these. However, external barriers were seen as affecting relationship building, service user experience, and in some cases, service users’ safety.

“Pelvic opening might not necessarily be seen as a medical term for it. It is more of a preferred term, same as breast and you have breast tissue, not chest tissue, but obviously so I think probably like in terms of medical things to clarify what you’re talking about, it would be hard to integrate that.”

Participant 4

Safety

Safety was viewed by participants as multifaceted, with importance placed on service users’ physical safety in tandem with their psychological safety. Participants recognised their role in contributing to a multitude of safeties, however felt that their institutions focused more on physical safety than psychological safety. Participants argued however that there was a strong link between types of safety. In particular, participants voiced concerns that if TGNC did not feel supported and psychologically safe within healthcare institutions, they may choose to limit access to them or not access care entirely. Participants felt therefore that without psychological safety, positive relationships could not be built, and care provision would be affected, which in turn would affect physical safety. This is in line with the findings of the ITEMS report [7], in which 30% of respondents reported they did not access NHS or private healthcare support during their pregnancies. Only 20% of respondents within the ITEMS survey “reported feeling comfortable accessing maternity services” (page 30). Conceptualising psychological safety as affecting physical safety additionally aligns with research within broader perinatal care services. From Better Births: “Women told us how important it was for them to know and form a relationship with the professionals caring for them… It was felt that this could provide better support for women, and enable midwives to better meet their needs, identify problems and provide a safer service” [32]. Therefore, whilst evidence applying prioritisation of relationship building to TGNC perinatal care is limited, with continuity of carer recommended in only two of the papers within the literature review, we can infer importance as with any person accessing perinatal care.

“I think it’s just first impressions, relationship building, creating a trusting relationship where someone feels able to access care again. This is quite major when it comes to whether they’re likely to receive antenatal care, if they attend hospital in labour, or, you know, access support if they think something’s not going right. So, I think, yeah, first impressions count, so if we don’t meet their needs at the beginning, then we could possibly… They’re not going to access care at all.”

Participant 8

In parallel to relationship building, individualised care provision was highlighted by participants as important to ensure physical and psychological safety. Many methods of facilitating individualised care provision were proposed by participants, as outlined within the practical integration section. Individualised care included using TGNC service users’ preferred language, discussing mode of birth and mode of feeding, and listening to the needs and priorities of the service users. Additionally, to ensure psychological safety, the importance of appropriate dissemination of this information between HCPs was highlighted, in particular with members of the MDT and at handovers. This was linked to planning and dissemination ahead of birth and ahead of HCPs interacting with TGNC service users. Individualised care was felt by participants to rely on communication between the service user and midwife in addition to communication between individual midwives and the wider MDT.

“It could be quite confronting to go into labour and birth and have to, you know, talk about body parts, or maybe didn’t want to talk about and be asked a lot of personal questions. It’s probably quite a big thing, so I’d definitely say that planning aspect would be quite important.”

Participant 3

Although only framed as such by two participants, the concept of safety is a key principle of trauma informed care, which “aims to promote feelings of psychological safety, choice, and control” [26, page 13]. Whilst this term was not commonly presented as a utilised framework, many aspects of a trauma informed care framework were used in participants’ responses. Further research into trauma informed care provision for TGNC perinatal service users could provide evidence into its acceptability.

Eagerness to learn

All participants expressed a desire, and in some cases a perceived need, for additional training for midwives focused on TGNC healthcare and perinatal care provision. Training was perceived as feasible by most participants, however one participant highlighted “the massive impact to our service provision and the cost” of training (participant 6). This is a valid critique somewhat overlooked within the research. Within an NHS context, the Core Competency Framework [33] outlines the training institutions should provide perinatal care staff. Therefore, in order to provide additional training or training not covered by this framework, institutions may incur additional expenses in funding the training itself, paying midwives to attend the training, and paying other midwives to work clinically whilst midwives attend training. Therefore, to fund appropriate training, policy must view TGNC service users as a priority.

“So, as a simple like suggestion, recommendation from a piece of evidence, yeah, it totally is like your goal, number one, that you just write down. We’ll provide training, lovely. Everyone says it like a tick box thing, done. Like the realities are really hard in terms of who delivers the training, what does the training… what does the training mean? What’s going to be backed up behind the training? What do we need to support that to make it a real part of our organisational culture and knowledge base?”

Participant 6

Midwives’ attitude of normalising or othering TGNC service users fluctuated throughout their interviews, seemingly by how confident they felt with the care provision described. This awareness of personal limitations in terms of knowledge and care provision also featured prominently in responses. Awareness of one’s own competency, role within the MDT and when further resources and training are important factors in ensuring the safety of care provision [9]. Therefore, whilst this personal awareness and reflection on practice demonstrates consideration on the part of midwives interviewed, it also demonstrates the need for training, policies, and support to care for TGNC service users to ensure safe care provision.

Different methods of training were discussed, including in-person and e-learning packages. Participants reported increased value of in-person training led by “skilled facilitators” (participant 10). Participants did not feel that facilitators necessarily needed to have a clinical background, but instead would be able to foster healthy discussion, educate with room for discomfort, and address misconceptions. Examples of appropriate facilitators for this training were those with experience of TGNC healthcare, people who identified as TGNC, or TGNC midwives. Facilitators would ideally by “experts by experience” (participant 10). Participants felt that education on “the basics” (participant 8) including language and pronouns would be most helpful, alongside case studies.

Participants also stressed the importance of any training being within the MDT, which aligns with recommendations from Better Births [32]. Notably, MDT training programmes such as PROMPT report improvements in physical safety, reducing hypoxic brain injury and maternal death [34]. Further research would be needed to demonstrate the impact of MDT training on psychological safety. Recognising the importance of MDT training denotes the participants’ awareness of themselves within an MDT and healthcare institution. Training and education were viewed by participants as a starting point from which other positive changes to care for TGNC service users could flourish. Framing the importance of training in tandem with MDT training allowed participants to envision a difference in organisational culture and norms. Viewed through a more pessimistic lens, this could also be interpreted as participants seeing a strong need for education for their colleagues and perhaps witnessing or being involved in inappropriate care provision for TGNC service users.

Internal barriers

Although participants had a detailed understanding of external barriers affecting care provision and could answer confidently and coherently, participants were more hesitant when discussing perceived internal barriers. This was explained by participants as internal barriers being more difficult to untangle, or not something they had thought about before. One outlier to this response was a participant who spoke in detail about the importance of recognising “unconscious bias”. This phrase allowed the participant to use an introspective analysis of their own experiences, however this phrase was not used by any other participants.

Some participants referenced their age as a limiting factor for providing care for TGNC clients. This was also referenced by midwives who did not self-identify as being “older” but saw “older” midwives as more likely to struggle with providing inclusive care. A potential consideration for viewing of gender variation and inclusion as more acceptable for younger generations and therefore younger midwives is the framing of gender inclusive practice as (1) exclusionary for older midwives and (2) a passive process which does not require active participation from the HCP or their institution. This grouping by generation could be harmful to older persons who have worked to be advocates and allies, and harmful for younger persons who may not be viewed as requiring training on gender inclusion. This framing also excludes older persons who are TGNC. Therefore, whilst an interesting theme across interviews, this perspective requires critique to ensure it does not influence policy makers to assume improved care will occur spontaneously over time without input or training. In addition to this, whilst a midwife’s personal experience may inform their practice, this cannot be used as a rationale not to provide appropriate care. It is standard for practice to evolve with time and in line with evidence and therefore care for TGNC service users must align with this.

“I think it’s something that’s very unfamiliar to me because I haven’t grown up with this”.

Participant 2

“I would possibly say older generations have a more negative view.”

Participant 3

Internal barriers were often spoken about in relation to external barriers, or participants referenced internal barriers they perceived in other staff members or the general population. An unexpected finding of this was, even when not referenced by name, participants held a strong awareness of trans-exclusionary ideologies present within feminist and birthing education and advocacy spheres. Although participants separated themselves from this ideology, several participants referenced their fear over the removal of the word “woman” from perinatal care and spaces. The topic created malaise within participants as they grappled between a perceived erasure of women, evoking the phantasm of “gender ideology” described by Butler [35], in conjunction with the importance of ensuring inclusion. Although not expressed as such by all participants, this can be understood as participants’ valuing their own gender identity and wanting to ensure this is included, respected, and represented. This is of course an important consideration as the majority of service users seeking perinatal care do identify as cisgender women and are equally entitled to affirming and inclusive care provision. Participants interviewed were able to recognise the importance of these inclusive languages in tandem.

“Thinking about conversations I’ve heard, I think, if I’m being really honest, I think trans people are one of the few groups of people that people still think is socially acceptable to ridicule.”

Participant 8

“I’ve only heard amongst midwives; I’ve only really heard… A few sort of overheard conversations. Almost. And with some midwives feeling kind of disgruntled about. Changing language generally, but particularly that the fear that the word woman’s going to get taken away.”

Participant 10

However, participants also referenced the opinions and fears of other midwives they knew which were more critical of TGNC service users, and reported midwives vocalised these concerns within care settings. The fears and opinions expressed by participants when a discussing phantasmic erasure of women is insightful into a wider political climate of conceptions of “gender”. The abjection of TGNC people allows an individual choosing to become a biological parent to become a wider political and cultural issue subject to scrutiny. Additionally, fears surrounding erasure of women invoke semblance to replacement theory, discussed by Butler [35]. This is most certainly an area requiring further research and discussion which cannot be adequately discussed within this research. However, it is mentioned to highlight participants’ awareness of the pathologisation of individual service users as representations of a perceived agenda. This directly contradicts many of the priorities reported by participants, in particular ensuring care is individualised and person-centred. Whilst every individual is entitled to their own opinions, the importance of providing fair and non-discriminatory care is enshrined within the NMC [9] and GMC [36]. Therefore, this is concerning when considering the midwives they reference are likely providing care for TGNC service users and are not behaving in line with their professions guiding principles.

“It feels like a really difficult push pull for me on this one, because then the other part of me goes I do understand the whole thing around not getting to the point where we have… like we’ve… we’re afraid or we don’t… We don’t, we don’t talk about women. And I have that. I do... I understand that and I relate to that as a woman, and where I don’t even think we have… And this again is the same thing though, because we don’t even have what we need and want as women in society or in our lives.

And then so I’m acknowledging that as true. And then I’m also acknowledging the fact that then that therefore means that people who identify as male but can have babies and do want to have babies and things and have to do that process to become parents, they’re going to be feeling that on a whole other level.

So, it’s like I can hold all of these truths as reality, and it gets really muddied as to what the best way forward is then.

But I’m very aware of… I’m very aware of the need to listen and to value and to respect everyone’s experience as an individual and for that on both sides, not to diminish the other or the others specific issues or terminology or wording, so I would like to get to a place where it can all be held as OK.”

Participant 6

Implications for practice

Many of the responses and recommendations made by participants provide further clarity on how findings of the literature review can be appropriately integrated into an NHS setting. Several ideas aligned with the literature review findings despite not being mentioned by the researcher at interview. These include non-gendered options for cot cards, appropriate handovers, and antenatal classes and information aimed at TGNC service users. Although some suggestions made may be problematic and may require further clarification or discussion, such as pronouns above beds creating a potential stigma or disclosing private information to others on a ward. These integration ideas would benefit from review and consultation with key stakeholders including TGNC service users to ensure acceptability. Participants ideas for practical integration could also be considered in other high income country healthcare settings with review and consultation with local healthcare workers and stakeholders.

Participants recommended appropriate referral systems and pathways. These were mentioned in the literature review in relation to mental health following birth, but not in relation to perinatal care as a whole. The importance of policies and pathways was also highlighted by participants within research by Pezaro et al. [37]. This may be due to the positionality of the participants of the research within the literature review in relation to the participants of this research and Pezaro et al.’s research. Service users may be less likely to have an awareness of hospital guiding policy in comparison to midwives who use these documents to frame their practice. Alternatively, this could be viewed as a pathologisation of TGNC service users by participants due to the assumption their care will need specialist input or oversight unlike that of a cisgender service user.

Overall, responses and practical integration ideas made by participants of this research were appropriate and highlighted areas of additional resources, knowledge, and guiding policy for participants. Perceptions of feasibility differed between recommendations, with many areas of change perceived as outside their control as midwives. This included changes to ward signage, colour schemes, ward names, and service user information (e.g., patient leaflets). Ideas based on discussions with service users such as asking for correct pronouns and preferred language was seen as more feasible than broader changes to institutional structure. This may also reflect the priority vocalised by participants to ensure their care provision is individualised. Eight out of the 10 participants suggested asking for pronouns at the “booking appointment”, which is usually the first point of contact with an HCP during a service users’ pregnancy. One participant reported that asking a person’s pronouns at booking was a standard practice within their institution. Asking a person’s pronouns was viewed by participants as something which may cause offense to a minority but ultimately was no more invasive than other questions routinely asked. It is interesting that participants tended to externalise discussion of pronouns. Several mentioned the use of pronouns in email signatures becoming more frequent, however no staff recommended implementing pronouns on staff name badges or introducing themselves with their pronouns. Perhaps this can be understood as an assumption their pronouns are known due to external presentations of gender identity. As use of pronoun badges for staff is recommended in the ITEMS report [7], it would be useful to ask for HCP feedback on this recommendation specifically.

“And we’re asking them demographic questions, and I know this is an identity question as well. But we’re it’s, you know, you’re asking them “do you… do you go by other titles?” You know there’s a whole range of questions that are completely valid and. And yeah, I think that’s fine.”

Participant 10

When discussing recommendations and their integration, participants had an awareness of their ability as an individual within a larger institution and placed value on their role to affect individual encounters and experiences. Additionally, there was an awareness of the time, resources, and funding required for larger or more institution-wide changes to occur. Participants tended to externalise recommendations as information or resources they could be provided with to better facilitate gender affirming care. Practical integration ideas were in general limited to horizontal interventions rather than vertical interventions. Horizontal integrations have shown in some cases to incur lower costs for institutions in addition to increasing efficiency [48]. Vertical integration “involves patient pathways to treat named medical conditions that transcend organisational boundaries” [49]. Therefore, vertical integration and creation of policies to support TGNC perinatal care service users could create a greater shift in institutional norms with greater support and resources between organisations. Further research involving policy makers may provide further integration ideas which extend the realms of individual patient interactions.