Providing evidence-based information to parents throughout the pregnancy, birth and post-partum journey is an essential part of the role of all healthcare professionals working in maternity services. However, evidence suggests in some areas of maternity, such as the highly politicised area of vaginal breech birth, the information provided to parents is biased towards that of what the system supports or the individual healthcare professional providing the counselling prefers. A compelling ethical and legal requirement exists to provide the evidence to parents which they have a right to receive, as discussed by Kotaska et al (2007).
An international qualitative survey by Petrovska et al (2017) surveyed women who had a breech presentation and were seeking support for their choice of mode of birth. Petrovska et al (2017) examines how mothers found inadequate system and clinical support for vaginal breech birth which impeded their access to unbiased information on their options for mode of birth and the care they received. In a paper written by Powell et al (2015) they also found that parents were often given unbalanced information. This lack of balanced information was a motivating factor in developing an information leaflet for parents identified with a breech presentation at or near the end of their pregnancy. The development of an information leaflet is supported by many papers such as that by Guittier et al (2011) and Sloman et al (2016) who also found parents were often provided with biased information. We hope the development and provision of useful, unbiased information material will assist with decision making and enable parents to make an informed choice of their options with a breech presentation.
Clinicians should counsel women in an unbiased way that ensures a proper understanding ofthe absolute as well as relative risks of their different options. [New 2017]
It is alarming that despite this guidance, and in light of more recent evidence which has emerged on the suitability of vaginal breech birth for selective pregnancies, that parents are still not being given all their options and more importantly the impact it is having on their future pregnancies.
The information leaflet has been developed in response to the acknowledged lack of balanced information available to parents. To ensure the information is evidence-based it includes data from the RCOG (2017) guidelines as well as other research sources such as that from Louwen et al (2016) and the NICE Caesarean Section Guideline (2013). The information leaflet was circulated to healthcare professionals of all grades (midwives, SHO’s, Registrars and Consultants) as well as parents who had experienced a breech presentation previously. They were asked to comment via a SurveyMonkey on the information which was provided in the leaflet to ensure it was easy to understand, informative, evidence-based and unbiased. The leaflet is provided below in both PDF leaflet form as well as an MS Word format, so healthcare professionals are able to download and edit for use in their own healthcare organisation.
Providing this readily available resource for parents and healthcare professionals is invaluable for ensuring the correct information is easily accessible and shared to not only support parents in making an informed choice about their options, but also for assisting with the counselling healthcare professionals provide to those in their care. If you have any questions or comments about the information leaflet, please do not hesitate to contact us on the contact form provided below.
My work requires me to be able to speak to many audiences: midwives, obstetricians, paramedics, policy makers, birthing families. Increasingly working across cultural boundaries constantly challenges me to check my assumptions, to learn new ways of communicating. I don’t always get things right. I was recently asked by an education leader in an organisation I had worked with if I would consider eliminating gendered pronouns in my teaching videos. The request was warm, genuine and respectful. And it reflects the policy emerging within some maternity care professional organisations, particularly throughout North America.
I struggled with what I perceived to be a request to eliminate woman and mother in favour of gender-neutral language, and this blog is my attempt to be open and honest about this struggle. Some of my reactions are personal. I am a white cis-female who has given birth and raised my children as their mother. I have been privileged to have a good education and financial security. But my name is Shawn, and about once a week someone asks me how I ended up with a guy’s name, or addresses me via e-mail as Mr Walker, or expresses surprise that I appear to be a woman. It’s annoying, but I get it.
I’ve been using Ms, even when I have to write it in as an option, since I was a teenager. I had to do this yesterday, and the 1970’s have been over for at least 30 years. I have never changed my surname, even after marriage. And now that I know it’s a thing, would probably prefer that e-mailers use Mx rather than assume Mr. Although I have mothered four children (ages 6-16) who are growing up in Norwich, I live mostly 2 hours away in London and travel a lot for work. I am frequently asked who looks after my children when I am gone. No one ever asks their fathers, who are their main carers, when they travel for work. I am also American, but my accent has drifted across the Atlantic enough to be not quite English to English ears and quite English to non-English people. When I visit my parents in the US, people who don’t know me well refer to me as The English Lady. Thankfully, no one has ever referred to me as The English Pregnant Patient. I am enormously privileged and secure by chance and circumstance, but I also find myself in-between at times.
So why does gender neutral language in maternity care not feel obviously right to me? Certainly, referring to a group attending antenatal classes as parents rather than mums and dads feels right, because many combinations of parents make up families these days. But I feel a sense of loss as I contemplate dropping women and/or mothers completely from the way I teach and talk about my work.
Certainly, some of it is cultural. I am aware of advocacy for recognition of non-binary sex, gender and sexuality in the UK, and many things have changed for the better. But in general the midwifery profession still sees itself collectively as aspiring to woman-centred care, certainly in the UK and internationally if the collaborative Lancet Series in Midwifery is anything to go by. The etymology of “midwife” is “with woman.” Midwifery has a natural affinity with feminism in its aspirations to reduce inequalities, and this inherently involves recognising women as a class of people who are exposed to unequal and sometimes actively oppressive cultural and health care dynamics. In 2015, Glosswitch suggested, “Gender-neutral language around reproduction creates the illusion of dismantling a hierarchy – when what you really end up doing is ignoring it.” Elephant Circle, responding to MANA’s decision to shift to gender-inclusive language, made it clear that they are “committed to promoting the additive use of gender-neutral language in traditionally woman-centric movements.” I agree that use of exclusively gender-neutral language has at least potential to harm through erasure, but its additive use has clear potential to promote compassion and inclusion.
But I do question why it is so uncomfortable to have traditionally female-associated language transition into catch-all terms. When I was training, during a placement on the Intensive Care Unit, the senior nurse on the ward was a man. Senior nurses and midwives in the UK are often called Sister. Once, about to call him Sister, I caught myself and asked, “What should I call you?” Without hesitation, he said, “Call me Sister.” Then he told me off for wearing my jumper on the ward. My hesitation bothered me. But his professionalism and completely unthreatened acceptance of Sister as the gender-neutral term in the profession he had chosen impressed me. Male midwives have always done this. They are midwives.
What doesn’t impress me is when someone refers to a group containing both women and men as guys. This came up in a social media group for mothers who work in academia. Despite feedback from students voicing that it makes them uncomfortable, many people answered that guys is gender-neutral and, essentially, there are more important problems that require addressing so they were not going to go to the bother of changing their language. Guys will be gender neutral when it feels equally comfortable to refer to the same group or a group of men as gals. When taxi drivers no longer ask me if Shawn isn’t usually a guy’s name. Men was definitely neither gender- nor colour-neutral when the words “all men are created equal” sparked a revolution, and it still isn’t.
But it is very common, especially among male doctors, to refer to a group of midwives as girls, as in, “The girls will look after you …” It is incredibly tricky to challenge this language without being dismissed as an over-sensitive ranty feminist, the one with the problem, the one whose political correctness gets in the way of co-operating on more important problems. Yet if I do not change my own language in referring to birthing people primarily (but not exclusively) as mothers and women, I fear I will simultaneously be regarded as insensitive and possibly transphobic.
Some of my frustration also comes from years of being an ally in a different minority struggle. I would like every health care professional using predominantly gender neutral language in their practice to also normalise breech presentation. Every time you demonstrate the mechanisms of labour, do it with the baby coming out both ways. Always say, “Babies are born head-first or bottom-, knee- or foot-first.” Because they are, or they could be. I can’t tell you the number of times that people have said they would like to support breech birth, but it requires too much time and effort (see the “more important problems” excuse above).
Many professionals who hold the power to change things have even suggested that spending the extra time and/or resources it would require to ensure women who want to birth breech babies vaginally are attended by skilled, experienced professionals would be an unequal and thus unfair application of resources for such a small number of people (1:25-30 mothers at term carry a breech baby). Other rarer conditions, especially those which require expensive fancy-pants technology rather than more people-time, don’t seem to be affected by such arguments. In our over-stretched and over-aware maternity services, giving more to one seems to come at the cost of another.
I am genuinely grappling with the implications of the language I use, involving my family and colleagues in conversations, changing bits which feel right and remaining open to how my language may continue to change. I don’t feel there are “more important problems.” But I am not yet convinced that using exclusively gender-neutral language to ensure that a (non-woman) minority will not feel uncomfortable, will not mask another invisible injustice towards women. Inclusivity has to be both gender-acknowledging AND gender-neutral, rather than exclusively gender-neutral, until we know that losing gender specificity will do no harm to women. I am convinced by the research suggesting health professionals need to use more inclusive language and communicate with LGBTQIA+ families more sensitively and competently. I’ve seen no research assuring me that removing all gendered pronouns from the language around maternity care will do no harm to women. Until I am assured, I will continue to take an additive approach rather than an exclusively gender-neutral one.
For me, for now: More inclusive language is welcome, and in my work I will strive to include gender-neutral language alongside the gendered language that is embraced by the majority. I recognise that not everyone who gives birth is a woman, and I’m going to consciously use alternatives more often, just like I am consciously using people and folks where others are still using guys. When I do use women, especially in a group of parents, I am going to try to include other descriptors to acknowledge both women who want or need me to see the way their gender influences their experience, and people who need to know that I welcome them, and want to include and care for them, whatever their gender or lack of it.
And I hope that when inclusive birth professionals describe normal birth, they refer to the physiological birth of a baby who emerges spontaneously at term, head, bottom, feet or knees first, so that people who are pregnant with breech babies no longer feel they are abnormal or a freak for wanting to birth their breech babies. Just imagine what will happen when the families you teach attend their appointments expecting that they will give birth normally like everyone else, unless a genuine problem emerges! When I describe a person’s birth video, I am going to continue to describe them using the pronouns they use to describe themselves.
But I have a practical problem: I spend a lot of time talking about the way two pelvises interact with each other during a breech birth. I need to distinguish between the fetal/baby’s pelvis and the birthing person’s pelvis, and how they operate together as what the professionals in my research called the Mother-Baby Unit. Birther-Baby unit doesn’t feel right; it feels like I’ve separated the birthing body from the loving carer and sustenance-giver. Birthing is the ultimate reproductive act; but it is also a major bit of parenting. A time of being and becoming. Merriam-Webster‘s on-line dictionary tells me that the verb mother means “to give birth,” “to give rise to,” or “to care for or protect like a mother.” It feels right (to me) that mother itself has the potential to transition to gender-neutral. Not all of those who mother a child are women, nor do all women mother a child. (And not all people who father a child are men, nor do all men father a child.) I am asking those who wish for a more inclusive language to consider whether mother could be the mother of all inclusive terms. Such a concept may be just as radical as shifting gendered pronouns out of maternity services.
Folks, I am asking you to consider my use of mothering as a gender-neutral verb for giving birth, and to see such acceptance of maternal descriptors for the birth act as a radical act of solidarity with the women around you who remain a second sex. Women who have had to live with male descriptors being used as gender-neutral, but almost never vice versa, their entire lives. Women in every country of the world whose genders and embodied existences are immutably determined by others’ sexual (ab)use of them, women who are made to birth children against their will. Because no one should have to mother against their will. Mothering should always be a role one chooses, during pregnancy, birth and sometimes after. I’m remaining open to new possibilities as our language and culture shift. But for the moment, I ask you to be with me in considering the radicalism in mother-centred care, the importance of understanding women as a class of people despite infinite diversity within that group, and the need to explore and challenge the discomfort arising when descriptors historically associated with the female sex are used as gender-neutral terms in our brave new world. I in turn will recognise your radical acceptance and compromise, while I continue to check my inclusion of gender-neutral language.
I have shared my thoughts in good faith, wanting to do well by all I work with. I welcome you to comment here in order to help me and others continue learning and growing, but please as always, practice compassionate understanding in your response.
P.S. I am a Unitarian. But I love unisex-named medieval mystics, especially when they are mother enough to be challengingly gender-fluid the 14th century without a position statement, awesome enough to be the first woman to have her book published in the English language, and their own self enough to depict Jesus as the bad-ass Mother that he was, inclusive of caesarean section imagery (how did she know how important this would be?) Go Jules!