Neurodiversity in maternity care: why it is a safety and equity issue, and the reasonable adjustments that help

Consider a woman in her third trimester. She has undiagnosed ADHD. Her booking appointment went well: she prepared carefully, brought notes, and held everything together. But by 32 weeks, she missed two growth scans. Her community midwife documents her as “disengaged from antenatal care”, and safeguarding is being considered. What is not documented is the phone calls she could not make because stress tipped her into paralysis; the appointment letters she could not process quickly enough and misplaced before she could transfer the dates into her calendar; the system she could not navigate without support. Nothing catastrophic has happened yet. But the conditions for harm are quietly gathering.

This is not an unusual story. It is a predictable one. And that is precisely why it matters.

Pregnancy, birth, and the early postnatal period place intense demands on anyone. Bodies change quickly. Sleep is disrupted. Information is constant. Decisions can feel urgent, and the emotional stakes are high. For neurodivergent people, that same system can feel not simply demanding but overwhelming.

Neurodivergence includes, but is not limited to, ADHD, autism, dyslexia, dyspraxia, Tourette syndrome, and sensory processing differences. Neurodivergent people are not a niche group. They are already in every waiting room, clinic, labour ward, theatre, and postnatal bay. Some will have a diagnosis. Many will not. Some will have spent years masking their difficulties, appearing capable right up until the point they can no longer compensate. Others will have previous experiences of being misunderstood, dismissed, or labelled difficult within healthcare settings.

This matters not because neurodivergent parents are inherently harder to care for, but because maternity services are still too often organised around neurotypical assumptions: rapid verbal processing, tolerance of noise and unpredictability, comfort with unfamiliar touch, and the ability to remember, plan, prioritise, self-advocate, and decide under pressure. When a service is built around one way of processing the world, everyone else is forced to adapt. That adaptation has a cost. In maternity care, that cost can appear as missed appointments, misunderstood symptoms, consent that is not fully informed, escalating distress, avoidable trauma, and growing distrust in services. NICE guidance already recognises that both autism and ADHD can significantly affect communication, information processing, organisation, coping with change, and day-to-day functioning. [1,2]

This is why neuroinclusion belongs within the maternity safety agenda. It is also why it belongs within the equity agenda. A neuroinclusive service respects different ways of processing, actively removes barriers, pays attention to language, and works with people rather than expecting them to continually bend themselves around the system. Drawing on Jessica Dark’s 2024 Eight Principles of Neuro-Inclusion, originally proposed as a reflexive framework for inclusive research with autistic communities, it is possible to see how these principles may also be transferred usefully into maternity care. While Dark does not apply them directly to maternity services, her focus on respect, representation, removing barriers, language choices, participation, and actionable outcomes offers a valuable conceptual framework for neuroinclusive practice. [3] This also sits comfortably within the wider maternity safety agenda. The Ockenden Review repeatedly highlighted failures in communication, listening, and individualised care — themes that are highly relevant when considering the needs of neurodivergent parents. [4]

From behaviour to overload

A central shift in neuroinclusive maternity care is moving from a behavioural interpretation of distress to a clinical one.

When distress is read as behaviour, the response becomes moralising or managerial. The person is told they must engage, cooperate, or try harder. If they miss appointments, they are described as chaotic, avoidant, or non-compliant. If they go quiet, they are read as passive. If they become distressed, they are framed as overreacting.

But when distress is understood as overload, the response changes. The clinician slows down, reduces input, offers clarity, adjusts the environment, and documents what helps. The question becomes not “Why is this person so difficult?” but “What in this interaction is making processing harder?”

That distinction matters because overload is common in maternity care. Sensory load, information load, and executive function load often converge at once.

Sensory load is everywhere. Clinics and wards are full of bright lights, alarms, smells, waiting-room noise, scratchy fabrics, repeated touch, loss of privacy, and sudden changes. Pregnancy itself can heighten smell, nausea, pain, fatigue, sound sensitivity, and general sensory reactivity. A once-manageable environment may become intolerable.

Information load is equally significant. Antenatal care involves terminology, screening choices, referrals, medication discussions, monitoring plans, and safety-netting advice, often delivered verbally and quickly. Under stress, many neurodivergent people find it harder to retain, organise, and act on information. That is not a failure of motivation or intelligence. It is a predictable feature of overload.

Then there is executive function load. Maternity care places heavy demands on initiating tasks, planning, switching attention, organising information, regulating emotions, and following a sequence through to completion. Making appointments, remembering advice, arranging transport, filling in forms, tracking symptoms, and advocating repeatedly to different professionals all require executive capacity. This is particularly relevant for people with ADHD, where executive function difficulties are central, but it is also relevant for many autistic people who may experience difficulties with processing, flexibility, sensory overload, and coping with change. [1,2]

When these forms of load converge, distress may present as going quiet, going blank, missing appointments, shutting down, becoming tearful, appearing abrupt, or leaving care altogether. It is easy to misread this as a refusal. Often, it is overwhelm.

Why respect matters

Dark places respect first in her neuro-inclusion framework, and rightly so. She argues that genuinely inclusive practice starts with respecting autonomy, perceptual differences, and lived experience. [3] In maternity care, that means recognising that neurodivergent people may experience the same environment, conversation, or procedure very differently from the clinician in front of them. Their distress is not evidence that they are wrong. It may be evidence that the care environment is inaccessible.

Respect also means not requiring people to prove their needs repeatedly. Many neurodivergent adults have long histories of being told they are too sensitive, too disorganised, too intense, or too much. If maternity services respond in the same way, they do not simply fail to help. They actively reproduce harm.

A respectful approach sounds like this: what helps you process information? what makes appointments harder? what helps you feel safe? what should we know before examining you? These are small questions, but they can fundamentally change the quality of care.

Removing barriers, not blaming people

Another of Dark’s principles is barrier removal: reflecting on the social, procedural, and environmental barriers that prevent participation, and then actively reducing them. [3] This principle translates powerfully into maternity care.

Many so-called engagement problems are in fact access problems. The letter arrived too late. The person forgot because the appointment was only given verbally. The clinic was too noisy to tolerate. The route was unfamiliar. The instructions were split across multiple leaflets. The patient was expected to make a phone call during working hours, but was labelled disengaged when she did not.

Reasonable adjustments in this context are often simple and low-cost. Confirm appointments in writing in the person’s preferred format. Offer one clear, sequenced plan rather than multiple competing instructions. Give written summaries after appointments. Allow extra processing time. Ask before touching. Explain what will happen next. Offer a quiet place to wait where possible. Permit sensory aids without requiring justification. Welcome a support person as a note-taker or “spare brain”. Read the notes before asking someone to repeat their history yet again.

These are not luxuries. They are access measures. Under the Equality Act 2010, service providers have a duty to make reasonable adjustments for disabled people. In healthcare, this means that adapting communication, information, and the care environment is not an optional extra but part of equitable access. [5,6] NHS England’s Reasonable Adjustment Digital Flag is intended to support this by allowing key adjustment needs to be recorded and shared across services, reducing the burden on patients to explain themselves repeatedly. [7]

Language is a clinical issue

Dark’s work also emphasises that language choices matter: words do not merely describe a person, they shape how that person is understood. [3] In maternity care, language can either open understanding or shut it down.

Terms such as non-compliant, poor historian, anxious, overreacting, or disengaged often flatten complex realities into judgements. Once written, they can influence the tone of every later interaction. By contrast, language that describes context is more clinically useful: finds telephone contact difficult when overwhelmed; needs written information to process decisions; becomes less verbal under stress; benefits from reduced sensory input; needs additional time for consent conversations.

This is not about being polite for the sake of it. It is about writing notes that increase safety rather than reproducing stigma.selves repeatedly. [7]

Language also matters in conversations with patients. Plain language, one question at a time, clear signposting, and regular pauses all improve accessibility. A rushed explanation in jargon-heavy language may technically count as information-giving, but it does not necessarily amount to informed consent. These principles also align with the Accessible Information Standard, which requires NHS services to identify, record, share, and meet people’s information and communication needs. [8]

Representation and participation

Dark argues that inclusion requires better representation and meaningful participation, especially of groups whose experiences are frequently overlooked. [3] These matters in maternity care too. Neurodivergent experiences are not uniform. The needs of an autistic parent with high sensory sensitivity may differ from those of a dyslexic parent who struggles with written information, or someone with ADHD who cannot hold multiple instructions in working memory under stress. Those differences are further shaped by trauma, poverty, race, language, disability, and immigration status.

That means neuroinclusive maternity care cannot be one-size-fits-all. It must be person-led. The most useful question is often the simplest one: what helps you feel safe enough to understand what is happening?
Participation also matters at service level. If services want to improve, neurodivergent parents and neurodivergent staff need to be part of the conversation. Adjustments designed without them are often based on assumption. Adjustments shaped with them are more likely to work.

High-impact moments

Some points in the maternity pathway carry particularly high overload risk.

Triage is noisy, bright, time-pressured, and unpredictable. It is often one of the hardest environments in the whole pathway. A single lead communicator, a clear explanation of what is happening, and acceptance of brief or written responses can reduce distress significantly.

Labour, birth, and inpatient care involve uncertainty, repeated delays, changing plans, and severe sleep disruption. People benefit from being told what is known, what is not yet known, what the next checkpoint will be, and what changes in plan might mean.

Theatre and operative birth combine bright lights, multiple voices, immobility, physical exposure, unfamiliar sensations, and reduced personal control. Here, explicit communication becomes critical: who will speak, whether the person wants narration or minimal input, what sensations to expect, and when touch is about to happen.

The postnatal ward is often the most overlooked environment of all. It is noisy, interrupted, sleep-depriving, and cognitively demanding at the precise moment when people are physically depleted and emotionally raw. For neurodivergent parents, this may be the point at which coping strategies collapse. What presents as not coping may in fact be sensory overload, executive fatigue, pain, fear, or shutdown. There is also a plausible neurobiological dimension to this. Hormonal transition periods affect neurotransmitter systems, including dopamine, and emerging evidence suggests that hormonal shifts across the reproductive lifespan may influence ADHD symptom expression in females. [9,10]

Actionable outcomes

Dark’s final principles emphasise actionable outcomes and dissemination: inclusive work should not stop at insight but lead to practical change that people can use. [3] That is a powerful challenge for maternity services.

Neuroinclusion does not need to remain a good idea discussed in training rooms. It can be translated into booking templates that ask about communication and sensory needs. It can be embedded in care plans, handover language, triage protocols, consent practice, birth planning, ward routines, and debrief processes. It can be carried across the pathway through clear documentation of what helps. It is also consistent with the NHS Three-Year Delivery Plan for Maternity and Neonatal Services, which emphasises safer, more personalised, and more equitable care. [11]

It also matters how information is shared. If a service develops a neuroinclusive pathway, parent-facing resources should be accessible too: clear, plain-language, multi-format, and usable when someone is exhausted or overwhelmed. A beautifully written policy that never reaches the people it is meant to help is not enough.

Conclusion

Neurodivergent parents do not need to be fixed to fit maternity services. Maternity services need to become flexible enough to meet people where they are, especially during pregnancy, birth, and the early postnatal period, when vulnerability is heightened, and the consequences of poor communication can be significant and lasting.

Crucially, this is not rocket science. It is not about building an entirely separate system, nor is it about waiting until somebody arrives with a diagnosis neatly wrapped up in a bow. Many people do not discover their neurodivergence until adulthood, sometimes not until pregnancy, parenthood, or even later. Many more will never have a formal diagnosis at all, but will still experience real barriers around communication, sensory overload, executive function, uncertainty, and self-advocacy. If we only adjust for those who can name and prove their needs in the “right” way, we will continue to miss many of the people who most need support.

That is why these improvements matter universally. When clinicians reduce unnecessary sensory load, communicate clearly, allow processing time, remove barriers, and document what helps, they do more than make care feel kinder for a small subgroup. They make maternity services safer, more accessible, and more humane for everyone who uses them.

That is not an optional extra. It is good individualised maternity care.

References:

1. National Institute for Health and Care Excellence. Autism spectrum disorder in adults: diagnosis and management. Clinical guideline CG142. London: NICE; 2012. Updated 2021.
2. National Institute for Health and Care Excellence. Attention deficit hyperactivity disorder: diagnosis and management. NICE guideline NG87. London: NICE; 2018. Last reviewed 2025.
3. Dark J. Eight principles of neuro-inclusion; an autistic perspective on innovating inclusive research methods. Front Psychol. 2024;15:1326536. doi:10.3389/fpsyg.2024.1326536.
4. Ockenden D. Findings, conclusions and essential actions from the Independent Review of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust. London: HMSO; 2022.
5. Equality Act 2010. UK Public General Acts. London: The Stationery Office; 2010. Available from legislation.gov.uk.
6. NHS England. Reasonable adjustments. NHS England; accessed March 2026.
7. NHS England. The reasonable adjustment digital flag action checklist. NHS England; accessed March 2026.
8. NHS England. Accessible Information Standard (DAPB1605). NHS England; 2025.
9. Barth C, Villringer A, Sacher J. Sex hormones affect neurotransmitters and shape the adult female brain during hormonal transition periods. Front Neurosci. 2015;9:37. doi:10.3389/fnins.2015.00037.
10. Osianlis E, Thomas EHX, Bisset M, Rossell SL. ADHD and sex hormones in females: a systematic review. J Atten Disord. 2025;29(9):706-723. doi:10.1177/10870547251332319.
11. NHS England. Three year delivery plan for maternity and neonatal services. London: NHS England; 2023.