Gender Diversity and Inclusion in Midwifery

Midwifery is a profession that is composed almost entirely of women. Diversification of the profession with regard to race and ethnicity has received increasing attention,1, 2 but gender diversity within midwifery has not been well explored. Given the current workforce shortage of perinatal and gynecologic care providers,3 why are midwives not actively focusing on encouraging gender diversification of the profession as one option for expanding the workforce? The study by Bly et al4 in this issue of the Journal of Midwifery & Women's Health, the first of its kind, has several important messages for midwives about gender diversity within the profession. These researchers surveyed members of the American College of Nurse-Midwives (ACNM) with the goal of identifying attitudes toward male midwives. The participants were asked about their experiences working with or precepting male midwives. Additional questions explored perceptions about the effect of men in the profession and the effect of gender on patient care. The questionnaire was sent to all ACNM members, and the analysis was based on results from 864 individuals (12% of ACNM membership). The participants reflected the current gender distribution of the profession in that 97.4% identified as female, 2.5% as male, and 0.1% as other. The results of this study are both striking and concerning. First, although the majority of the respondents stated that they thought men belong in the profession (71.4%), a substantial percentage were unsure (18.7%) or stated they did not think men belong in midwifery (9.9%). When asked if a midwife's gender affects the quality of care they render, 74% stated that midwife gender does not impact the quality of care offered. However, 12.4% stated that gender does impact quality of care, and 13.6% were unsure. The respondents were more positive that male midwives would be good preceptors for midwifery students (86.2% agreed). Why do this many midwives today feel unsure about or not comfortable with men being midwives? Bly et al's qualitative analysis revealed a fascinating set of dichotomies that illustrate the duality of midwives' attitudes toward men in the profession. The authors identified 3 themes of beliefs about which the participants felt positive, negative, or conflicted. There was often a tension between what the study participants thought is ethically correct versus what they felt. For example, participants expressed an internal conflict between believing diversity is needed but feeling more comfortable with midwifery as a female profession. Some participants articulated a variety of concerns about having men in the profession. These included fearing the power of patriarchy could lead to negative effects for female midwives, suspecting the motives of men in the profession, and equating male gender with favoring a medical model of care. In contrast, other participants held equally strong positive beliefs about having men in the profession. A number of participants articulated mixed opinions, such as recognizing the benefits men bring to the profession while acknowledging that some of those benefits may be secondary to negative influences such as patriarchal privileges men have. Tension between socially constructed binary gender roles and professional roles in health care has a long history. Studies have documented that female obstetricians and male nurses have experienced gender discrimination.5, 6 A host of stereotypes have accompanied the clear demarcation of genders throughout the history of perinatal care. Examples include beliefs that women prefer female perinatal care providers, or men cannot provide empathy because they cannot become pregnant and give birth. It is hard to escape bias and typecasting that has centuries of weight. Furthermore, belief that gender should define or dictate one's role is pervasive and deep in our society overall. Bly's study is an exemplar of the effect of gender bias stereotypes. When one's core beliefs or implicit biases are challenged, an initial classic response is to protect the bias with discrimination against the person challenging the belief. The attitude that only women can best care for women was identified in the Bly study, yet what is the evidence for this belief? Is it really a fact or is it a bias? Another response to bias is to add more bias to strengthen the wall around the initial bias. This is reflected by participants in Bly et al's study who expressed concern that male midwives will act as junior obstetricians. Gender-based stereotypes fuel the process of building territorial walls between coworkers. The higher the wall, the less reality you see. And when you do not get input from others, you create an echo chamber that perpetuates the original stereotypes and misconceptions. Biases can be overcome with recognition and new exposures. Bly et al found evidence of this in that participants who had experience with male midwives were more likely to think men belong in the midwifery profession than midwives who did not have experience with male midwives (77.6% vs 66.2%; P = .001), and more likely to think midwife gender does not affect the quality of care that individual offers patients (80.6% vs 68.2%; P < .001). These findings are congruent with studies that have shown obstetric and midwifery interprofessional collaborative models are highly rated by midwives and obstetricians who work in such practice models.7, 8 Familiarity improves acceptance, support, and ultimately, patient care. The findings of the Bly study have important implications for clinical practice. Midwives have a unique placement in the health care system. Our scope of practice overlaps with several other health professionals including physicians, nurses, social workers, and doulas. As such, interprofessional relationships and teams with colleagues from partner professions are a defining aspect of our professional role. This is a critical placement because it gives us the ideal position from which to recognize and then avoid the pitfalls of territorial boundaries, many of which have deep roots in gender bias. Midwives can use our unique position among health care professions to build strength for our profession and better care for our patients by welcoming all who practice midwifery, or we can use it to support territorial, gender-based boundaries that will ultimately impede our work. Although it is easy to focus on the negative attitudes identified in the Bly study and argue why they are not helpful, the conflicting beliefs articulated by many of the participants are perhaps more important in today's health care arena. This tension in beliefs reveals a growing awareness that stereotypes of gender roles in the midwifery profession are in transition, which is an opportunity to effect change. There is currently both a workforce shortage in perinatal and gynecologic health care and a need for more diversity in the health care workforce in the United States. If having more male, transgender, and nonbinary midwives could address both of those problems, why should women discriminate against men and transgender and nonbinary people entering midwifery? As midwives finally start to publicly acknowledge the fluidness of individual gender identities among our patients, ourselves, and society at large,9-11 why do we cling to traditional binary gender roles as clinicians? Aren't a midwife's skills, philosophy, and provision of care more important than their gender? Midwives can be role models for the health care professions in welcoming and valuing gender diversity among our current and future midwives. Bly et al's findings are important for every midwife to consider as we work to create a future for our profession that promotes diversity and inclusion within our workforce.

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