Background: Evidence suggests that transgender and gender‐expansive people are more likely to have suboptimal pregnancy outcomes compared with cisgender people. The aim of this study was to gain a deeper understanding of the role of midwifery in these inequities by analyzing the pregnancy experiences of transgender and gender‐expansive people from a critical midwifery perspective.Methods: We conducted a systematic scoping review. We included 15 papers published since 2010 that reported on pregnancy experiences of people who had experienced gestational pregnancy at least once, and were transgender, nonbinary, or had other gender‐expansive identities.Results: Three themes emerged from our analysis: “Navigating identity during pregnancy,” “Experiences with mental health and wellbeing,” and “Encounters in the maternal and newborn care system.” Although across studies respondents reported positive experiences, both within healthcare and social settings, access to gender‐affirmative (midwifery) care and daily social realities were often shaped by trans‐negativity and transphobia.Discussion: To improve care outcomes of transgender and gender‐expansive people, it is necessary to counter anti‐trans ideologies by “fixing the knowledge” of midwifery curricula. This requires challenging dominant cultural norms and images around pregnancy, reconsidering the way in which the relationship among “sex,” “gender,” and “pregnancy” is understood and given meaning to in midwifery, and applying an intersectional lens to investigate the relationship between gender inequality and reproductive inequity of people with multiple, intersecting marginalized identities who may experience the accumulated impacts of racism, ageism, and classism. Future research should identify pedagogical frameworks that are suitable for guiding implementation efforts.

Midwives’ position in maternal and newborn care (MNC) in the Netherlands is unique: unlike many other countries, they have retained the authority over risk assessment and referral. We studied why and how midwives formally gained their position as gatekeepers, a role formally granted in 1987 by the Study Group for the Revision of the Kloosterman List (SGKL), a group of representatives from all professions and organisations involved in Dutch MNC. We analysed the minutes of the SGKL’s meetings and conducted interviews with eight key-informants who were involved in the SGKL’s decision process. We used theories of professional boundary work and cultural theories of risk to analyse the negotiations regarding the authority over risk assessment and referral in MNC that occurred between the representatives of midwives, general practitioners, and obstetricians in the SGKL. Our study offers new insights into professional boundary demarcation and the contest for control of risk management that occur at the political level of MNC. We show that beliefs regarding risks associated with childbirth and concern with the protection of professional interests can differ not only between but also within professions that seek to police and extend their boundaries. Negotiations are shaped by a dynamic interaction between these beliefs and interests, creating the possibility for otherwise unexpected transprofessional coalitions and redefining boundaries in unexpected ways. Our findings offer the possibility to view disputes in MNC as occurring between beliefs and interests, instead of between professional groups. These insights can reframe policy discussions in MNC and point to the need for further analysis of the boundary work that occurs in political and regulatory arenas.

Globally, millions of women and their children suffer due to preventable morbidity and mortality, associated with both underuse and overuse of maternal and newborn care. An effective system of risk selection that differentiates between what care should be provided and who should provide it is a global necessity to ensure women and children receive appropriate care, at the right place and the right time. Poor conceptualization of risk selection impedes evaluation and comparison of models of risk selection across various settings, which is necessary to improve maternal and newborn care. We conducted a scoping review to enhance the understanding of risk selection in maternal and newborn care. We included 210 papers, published over the past four decades, originating from 24 countries. Using inductive thematic analysis, we identified three main dimensions of risk selection: (1) risk selection as an organisational measure to optimally align women’s and children’s needs and resources, (2) risk selection as a practice to detect and assess risk and to make decisions about the delivery of care, and (3) risk selection as a tool to ensure safe care. We found that these three dimensions have three themes in common: risk selection (1) is viewed as both requiring and providing regulation, (2) has a provider centred focus and (3) aims to avoid underuse of care. Due to the methodological challenges of contextual diversity, the concept of risk selection needs clear indicators that capture the complexity of care to make cross-setting evaluation and comparison of risk selection possible. Moreover, a comprehensive understanding of risk selection needs to consider access disparity, women’s needs, and unnecessary medicalization.

Background Studies indicate unwarranted variation in a wide range of neonatal care practices, contributing to preventable morbidity and mortality. Unwarranted variation is the result of complex interactions and multiple determinants. One of the determinants contributing to unwarranted variation in care may be variation in local hospital protocols. The purpose of this study was to examine variation in the content of obstetric and neonatal protocols for six common indications for neonatal referral to the pediatrician: large for gestational age/macrosomia, small for gestational age/fetal growth restriction, meconium-stained amniotic fluid, vacuum extraction, forceps extraction, and cesarean birth. Methods We conducted a nationwide cross-sectional study examining protocols for neonatal referral to the pediatrician in the obstetric and neonatal departments of all Dutch hospitals. Variation in protocols was analyzed between regions, between neonatal and obstetrics departments located in the same hospital, and within neonatal and obstetrics departments. Results There was considerable variation in protocols between regions, between neonatal and obstetrics departments, and within neonatal and obstetrics departments. The results of this study showed considerable variation in recommendations for type of referral, admission, screening/diagnostic tests, treatment, and discharge. Furthermore, results generally showed lower referral thresholds in neonatal departments compared with obstetric departments, and higher referral thresholds in the eastern region of the Netherlands. We also found variation in local hospital protocols, which could not be explained by population characteristics but which may be explained by varying recommendations in existing national and international guidelines and/or lack of adherence to these guidelines. Conclusions To reduce unwarranted variation in local protocols, evidence-based, multidisciplinary guidelines should be developed in the Netherlands. Further research addressing knowledge gaps is needed to inform these guidelines. Attention should be paid to the implementation of evidence, and only where evidence is lacking or inconclusive should agreements be based on multidisciplinary consensus. Where protocols deviate from evidence-based guidelines because of specific local circumstances, clearer, more transparent justifications should be made. Uniformity in guidance will offer clear standards for care evaluation and provide opportunities to reduce inappropriate care.