The targeted words used to assess gender-inclusiveness for this study were largely adapted from the Jennings et al [25] study of gender-inclusive language on National Health Service websites.

The official public-facing obstetric web pages of nonfederal, short-term, acute-care hospitals from Connecticut, New Jersey, and New York were analyzed (n=300). Hospitals without L&D services or web content describing these services were excluded (n=189). Websites were reviewed from late November 2022 to January 2023.

Hospitals were categorized by state, 2013 National Center for Health Statistics Rural-Urban classification, and Healthcare Equality Index (HEI) score. The National Center for Health Statistics Rural-Urban classification is a tool used to identify urban and rural areas of the United States. It was used to analyze any association between urbanization and hospital-based inclusiveness of LGBTQIA+ people. The HEI score is the national LGBTQIA+ benchmarking criterion that assesses health care facilities’ policies and practices regarding equity and inclusion of LGBTQIA+ patients, visitors, and employees. It was also used to identify if there was any association between a hospital’s publicly perceived LGBTQIA+ inclusivity and word choice on the web pages.

For each hospital, at least 1 web page was examined alongside up to 2 additional pages as supplementation for language analysis. The gendered language used was recorded and analyzed by a single reviewer. The complete L&D-related text was analyzed and the types of gendered language used were recorded. (Explicit discussion of related services, such as chestfeeding, within the same site was excluded.) Any non–gender-inclusive descriptors for the name of the building or third-party services were also excluded from analysis, as these are often not controlled by hospital administration.

Each web page was reviewed independently by the chief reviewer to minimize any discrepancies. Each hospital’s L&D web page was rated as “fully inclusive,” “inclusive,” or “noninclusive.” “Fully inclusive” websites explicitly acknowledged LGBTQIA+ or TGNB parents. “Inclusive” websites did not use gendered terminology or pronouns for prospective parents. “Noninclusive” websites used the terms “woman” or “women”; “mom” or “mother”; other terms for women; “father” or “dad”; or she/her pronouns at least once in the text reviewed.

Categories were analyzed using χ² tests presented as frequencies with percentages. P values <.05 were considered statistically significant, and all tests were 2-sided.

Ethics and insitutional review board approval were not required since the study did not include human or animal subjects and all data were collected from publicly available websites.

These results demonstrate that there is a large barrier for TGNB parents to search for and identify potentially inclusive pregnancy care. Out of the 12 inclusive and fully inclusive L&D web pages, 92% were inclusive not because they included gender-additive language or LGBTQIA+ topics but rather because they omitted the pregnant person’s gender altogether by addressing the reader in the second person. The websites may have been inclusive not by intention but by coincidence. In stark contrast, there are multiple private reproductive endocrinology and infertility clinics that specifically target LGBTQIA+ couples using specific gender-inclusive language on their websites [26]. TGNB parents who are accustomed to a purposefully inclusive experience during their fertility journey and early pregnancy may be caught off guard by the sudden invisibility of their identities as they progress further through their pregnancy.

Interestingly, none of the hospitals that are acknowledged for their excellence in LGBTQIA+ care in other specialties discussed serving prospective TGNB parents for L&D care on their websites. This likely reflects a wider societal trend of “repronormativity,” by which society at large does not recognize reproductive sex between TGNB parents as possible or legitimate [27].

The accessibility of websites and web-based platforms is important for TGNB people to find services and connect to similar parents. Our above findings suggest less than 10% of hospitals use gender-inclusive language when representing their services. Thus, TGNB parents who are not connected to a wider LGBTQIA+ community may struggle to find inclusive prenatal care and delivery services due to the lack of representation.

The use of multiple surrogate end points may limit this study. The analyzed web pages, while used as a proxy for the culture in L&D departments, may not fully represent institutional attitudes and practices once parents start using their providers. This is exacerbated by delays between institutional attitude changes and hospital website updates. HEI scores were ineffective in predicting the LGBTQIA+ inclusivity of hospitals’ web pages because HEI scores are determined purely through institutional measures like nondiscrimination policies; they do not directly address subtler, underlying heterosexism that hopeful TGNB parents try to avoid in their health care. Finally, the methodology used in this study makes it impossible to establish a causal link between gendered terminology and the quality of LGBTQIA+ inclusive care.

Additionally, it is important to note that individual TGNB people may feel varying levels of dysphoria around maternal terms; some TGNB parents may not consider the words “mom” or “mother” to be exclusively for women. However, using gender-inclusive language and terminology is an important step towards providing a more welcoming and inclusive environment for TGNB parents, regardless of those individuals’ personal dysphoria triggers.

Using gender-inclusive language and terminology is the first step towards providing a more welcoming and inclusive environment for pregnant TGNB parents. Hospitals that want to be recognized as more inclusive towards LGBTQIA+ people can integrate gender-additive language into their L&D web pages (eg, “mothers and birthing parents”) rather than omit mentions of gender entirely [28]. US hospitals should consider expanding this language to meet the needs of a growing group of people who are having children. Future research should be done including LGBTQIA+ patient advocate groups on the use of inclusive language within health care providers’ obstetrical and gynecology departments, specifically in L&D units and on how this language impacts TGNB parents’ health outcomes and rapport with physicians.