Why was removing language about women not erasing them?

The new Scope of Practice for Midwifery.

In a recent article, published on the Spinoff, Cutting through the noise: Why whānau-centred midwifery is not erasing women,(March 1) academics George Parker, Elizabeth Kerekere, Fleur Kelsey and Suzanne Miller wrote about the long-anticipated Midwifery Scope of Practice. The authors claim that they “are watching the fraught passage of this scope with concern” and that opponents to it are “trans exclusionary”.  Perhaps they are referring to the recent petition of midwife Deb Hayes, with 7427 signatories, who protested the proposed removal of the words ‘woman, baby, and mother’, and their replacement with ‘whānau’.  Deb’s campaign has been partially successful.  The new scope was made available to midwives in the first week of March. The profession’s governing body, the Midwifery Council, has made a last minute fix and decided, unexpectedly, that midwifery services are for ‘women /persons and whānau’. An ‘explanatory paragraph’ at the foot of the document explains that:

‘The primary obligation of kāhu pokai | Midwives is to wāhine hapū/pregnant person and pēpē/baby. For the purpose of this Scope of Practice, specified under section 11 of the Health Practitioners Competence Assurance Act 2003, (HPCAA) Whānau refers to the wāhine hapū/pregnant person and, pēpē/baby in their social context, enabling care as it relates to pre-conceptual care, pregnancy, childbirth, and newborn care.‘

Meanwhile despite the Spinoff article the petition said nothing exclusionary, unless you start from same logic that has assessed J.K Rowling as anti-trans. It is a truism of gender theory (which prioritises gender identity over sex) that mentioning women and their sex-based interests is unacceptable.  Clear thinking and a swag of recent academic articles and media about women’s health explain why using language that centres them is important.

These changes could be regarded as a win for those who petitioned against the removal of women, mother and baby. Although, ironically they have not made the scope any clearer. With this explanation the Midwifery Council are trying the have their cake and eat it! By referring to section 11 of the HPCAA as the context for treatment the authors are simply obfuscating. That section provides for a wide leaway in how a Scope of Practice is written but it does not allow health registration bodies to play fast and loose with who the clients of health services are. Claiming it is a woman and baby in a context of a whānau is simply wrong.  It is misinformation! The relevant context is the Code of Health and Disability Services Consumers’ Rights which is precise in indicating that health services are delivered to individual health consumers and this includes their rights to privacy, informed consent, support people of their choice and ‘taking into account the cultural, religious, social, and ethnic groups, including the needs, values, and beliefs of Māori.’  Similarly the Health and Disability Commissioner Act 1994 defines a health consumer as including ‘any person on or in respect of whom any health care procedure is carried out’ and elsewhere in the Act that the Code of Consumer Rights must contain ‘the duties of health care providers and disability services providers to provide services in a manner that respects the dignity and independence of the individual’.(Emphasis added).

There was no stated intention by the Midwifery Council to defer to gender theory. Neither does the Scope of Practice address the specific needs of people with gender identities, or indeed ANY group of mothers. But in feedback to the consultation some submitters – both critical and supportive – spotted the coded signs. Those who watch this issue closely know that removing words about women could signal opening the door to gender theory.  So thank you to the Spinoff, for the confirmation that changes to the Scope of Practice were indeed a Trojan Horse for gender theory’s backdoor entry into midwifery, with cover for this conveniently provided by treaty obligations.

There are other serious concerns about the scope, that were raised in the consultation, but were overlooked by the Spinoff article. As feedback to the process showed parts of it were opposed by all but one of the Midwifery Organisations who made submissions.The Collaborative Reference Group who oversaw the project claimed that their work was evidence-based. But no research evidence was provided to midwives, and other submitters, to support the proposed changes, including to demonstrate how women, including Māori and Pasifika women, and babies, would benefit from having care delivered to meet the needs, not of the mother herself, but of her whānau. To make whānau a subject of the treatment relationship in midwifery, will also break the bond with New Zealand’s 75 year framework of individual human rights protections. If women and babies are treated in the context of whānau, this will happen whether or not this is the woman’s choice. How does that benefit any woman, let alone those who are part of a whānau that is not safe for them?  Who are the whānau to mothers in cases of surrogacy, and should their priorities be pre-eminent?  If whānau have primacy in pregnancy and birth, rather than the pregnant women, then aren’t the arguments in favour of women having autonomy in employment, choice of partner or in accessing education weakened immeasurably? Similar arguments could easily be mounted about the ‘benefits to whānau’ of restricting women’s agency in all manner of ways.

Another major concern is that the Scope of Practice as published is unsuitable for its regulated purpose.  It is first and foremost a legal document, not an aspirational one, and it requires precise language. Midwives must be able to be assessed against it for registration, to prosecute breaches and address complaints. Midwifery standards and competence and midwifery education is based on it too. As well as the woman/person/whānau confusion, other elements are unworkable. The scope refers to the need for midwives to work with ‘other ways of knowing’. If unspecified non-medical criteria can override medical ones, how can the council deal with a midwife who says she has aligned her practice with other ways of knowing? What are midwives to do if clients demand such practices be used? Cultural sensitivity is very important of course, but the proposed words leave the door open to poor practice.

The Spinoff article also outlined the results of the recently completed, $180,000, Trans Pregnancy Care Project. It apparently showed what ‘pregnant and birthing whānau wanted’. The authors did not mention they had to radically alter the criteria for participation , to find an adequate number of interviewees. The initial project proposed to interview 15 to 20 transgender and non-binary people who had been pregnant. To achieve this the time period since pregnancy was doubled from three to six years. It appears that at least one interviewee also had a advisory role within the project team, raising concerns about proper process.* Transgender people who were trying to get pregnant and transgender women (who can never be pregnant) were also interviewed although though neither group were eligible in the published scope. In all only eleven women who fitted the original criteria took part.

The journal article describing this research adopted extreme language, rather than convincing argument, to make the case for change. Midwifery was ‘eugenic’ towards trans people, who were also ‘strangers’ to the system and were ‘totally erased’ by it in New Zealand. Participants used their own ‘lived experience’ which was then parsed through the ‘emerging field of transgender epistemology’ – meaning the world as viewed by transgender people.  The danger that, with transgender participants and researchers, and a transgender framing, the results would lack balance and perspective were not addressed. Meanwhile the article was silent on the actual health impacts for transgender mothers and their babies such as the effect of having had mastectomies on feeding and nurturing infants.  The project’s final report makes recommendations that would see women and sex-based language completely excised from midwifery practice. Meanwhile every woman would have to be asked about her gender identity and preferred pronouns, and have to endure the humiliation of being called a ‘pregnancy’ or a ‘person with a uterus’.

The project could not even find the modest number of candidates it had assessed as necessary for the research to take place. How strong are its claims to override the interests of the almost 60,000 New Zealand women who give birth each year and for whom such changes are disadvantageous? The New Zealand Health Research Council are convinced of the need. They have made a further  $1.2 million grant from the for ‘building system readiness for trans inclusive perinatal mental health services’ to run over three years. It may not prove popular with the sector. A similar project was recently defunded in the UK when it was found to be unworkable and it faced strong opposition from midwives.

This is not to say that intending mothers, no matter how they identify, should not be dealt with respectfully by their Lead Maternity Carers. We should expect that sensitivity in individual interactions, and referring to pregnant transgender people as men, if that is what they believe will support them in their perinatal journey, should be a consideration in midwifery care. Such 1:1 support might be construed as equivalent to the considerations that allow midwives to meet the specific needs of other groups of mothers. Providing professional empathy though does not, and cannot, demand that people believe in gender theory. Society at large, and its professions and policy makers, must not be enjoined into dogma that deviates from both science and from truth.

Overall it seems that the Midwifery Council lost its way, including making these last minute changes.  What were they thinking? To get to this messy conclusion the Collaborative Reference Group were ‘on a journey’ but they manifestly failed to bring their colleagues with them. Thirteen of fourteen midwifery organisations were listed in feedback as having concerns about the proposed scope. Midwives reported feeling ‘done to’ and their legitimate concerns, such as that ‘the role of midwifery was being undermined’, or that the process was ‘causing unrest in already difficult times’, were ignored. A full year elapsed between the closure of the last round of consultation and the November 2023 newsletter announcing that the Scope of Practice would be implemented. In the same newsletter an announcement of additional training that will ‘improve access for whānau to early ultrasound’ demonstrated, in miniature, the actual effects if the scope is deployed as planned.  There are more issues than can be addressed in a short article but the whole process has been divisive for the profession. The proposed Scope of Practice does not have the clarity to fulfill its purpose of governing the profession and the Midwifery Council should go back to the drawing board.
*I wrote to the lead author with a number of questions, including whether any members of the research team had also been interviewees. My questions were not answered.