If gender matters in maternity care, does it matter in maternity care research?

While still heavily stigmatised and underreported by women to maternity services, it can be argued there is a rising understanding of the impact of postnatal depression in western societies. Although encouraging, there remains the difficulty of communicating to women, healthcare staff and researchers that many of the antecedents of these depressive symptoms manifest in the antenatal period or prior to conception. However, there is increasing awareness of indicators of potential mental health issues in the postpartum and this is reflected in screening procedures in routine care (National Institute for Health and Care Excellence, 2014). Of course, while maternal mental health is crucial it is important to recognise that the perinatal period is a challenging time for both parents. As editors, we have observed a growing number of submissions over the past year that address issues specific to fathers’ experiences or which examine the dyadic relationship of couples in their analyses. Unlike the initial focus on the postnatal period in research on mothers’ mental health, recent papers we have received have addressed fathers’ needs and concerns across the wider scope of parenthood; with papers exploring the perspectives of males pre-conception (Hanna & Gough, 2017; Santos, Sobral, & Martins, 2016), during pregnancy (Pinto, Figueiredo, Pinheiro, & Canário, 2016) and the early years of parenting (Eskandari, Simbar, Vedadhir, & Baghestani, 2016). This trend is encouraging as the expanding literature on fathers’ perspectives across reproduction, pregnancy and infancy suggests that current research is not replicating the early mistakes of research into women’s mental health; whereby postnatal mental health is focused on at the expense of the antenatal period (Brockington, Macdonald, & Wainscott, 2006).

Irrespective of whether pre-conception, during pregnancy or after childbirth, emerging studies consistently conclude that (i) positive paternal mental health bolsters the overall health of the family unit, and (ii) that there is a need for more resources for fathers providing information and support tailored to their needs. Criticisms are increasingly made that maternity services are primarily geared towards the mothers’ needs despite both parents preparing for parenthood. The recognition of fathers’ needs raises the question of who is best to deliver services to fathers. Although fathers might feel more comfortable having men deliver such services, increasing number of male health professionals in maternal health services brings its own challenges. From a logistical perspective, the proportion of male nurses and midwives varies internationally but within reproductive health the numbers have remained very low; within the UK, the proportion of males on nursing degrees was 9.5% last year (UCAS, 2016). UCAS does not provide the proportions for specifically midwifery courses but it can only be assumed the numbers will be even smaller. From a more socio-cultural perspective, women may actively refuse to be seen by a male midwife for reasons ranging from religious and cultural beliefs, past history of abuse or trauma or personal embarrassment (Pilkenton & Schorn, 2008). Given the sensitive and emotional experience for many women, these preferences need to be acknowledged which may impact on staffing resources in a profession that is renowned for staff pressures (RCM, 2012). However, a controversial counter-argument is that male maternity care staff provide unique qualities as it is inevitable that many women will question the reproductive history of the midwife. For example, does she have children? If so, what were her decisions on childbirth plans? What changes in behaviour did she adopt when pregnant? How was her experience of childbirth? Do her views align with mine? A woman’s interpretation of her care providers’ own reproductive history may ultimately affect the information she provides. Being male may provide a neutral perspective where women feel more comfortable to divulge information as they believe males have less pre-conceived beliefs on how to behave while pregnant or what birth choices should be made; having not been pregnant themselves (Pilkenton & Schorn, 2008). In contrast, many women may want to talk with a female member of staff because they may be able to directly emphasise with the physical and emotional experience of pregnancy and motherhood.

If the gender of maternity care staff has a direct impact on parents’ willingness to share personal information, we need to consider how the gender of researchers may influence research findings in the field of reproductive psychology. While midwifery is a predominantly female workforce, the same could be said of psychology. The same degree figures mentioned previously showed that only 18.3% of psychology degree applications are by males (UCAS, 2015). If the mental healthcare needs of mothers are primarily provided by women, and traditionally researched by women, then how may the conduct of research be impacted when reproductive health services and its research take an increase in focus on fathers? Howard and colleagues (2016) recently commented on how gender is not acknowledged enough in planning and analysing outcome data but it is important to be considerate of how gender may influence the collection of findings. Good researchers have learnt to separate their own beliefs and attitudes when conducting and interpreting research findings, but even better researchers appreciate how unconscious biases may influence those findings. To neglect the potential confounders of the gender dynamics when designing studies could lead to a fundamental oversight as many of the studies we have reviewed highlighted a common message that many fathers feel uncomfortable discussing their concerns to midwifery staff as they believe the mother should be the focus. However, the presence of male midwives has been reassuring to fathers-to-be and has made them feel more open about their concerns (Kennedy, Erickson-Owens, & Davis, 2006; Pilkenton & Schorn, 2008). If these studies show that fathers respond differently in light of the gender of the healthcare provider, it has to considered that they may react differently to a male or female interviewer for study data collection purposes. These dynamics may become further complex in same-sex relationships where the traditional ‘father’s role’ is another woman. Does this facilitate discussions with midwives or provide a further barrier that alienates the partner of the pregnant woman further? Same sex families are increasing in prevalence globally, and yet same sex partnerships are often considered exclusion criteria rather than seen as an opportunity to further understand the role of gender in reproductive healthcare (Egleston, Dunbrack, & Hall, 2010).

As a male researcher within perinatal research I feel it would be remiss not to provide my own perspective. Even prior to initiating studies I have encountered scepticism from gatekeepers within maternity healthcare settings as to whether women are likely to respond to a male researcher when recruiting. Consequently, when recruitment for a study is slow it is difficult to determine whether this is due to a problem with the study design or an indirect effect of being a male researcher. As male midwives are trained to accept that there are times when a male midwife may not be best for the woman (Kennedy et al., 2006), I similarly have had to learn when being male is an genuine obstacle to recruiting to certain studies. Conversely, I am frequently asked by patients and healthcare providers what drew me into this female-dominated field as they’ll comment on how it is not typical to see many men doing research. I think this has given me a ‘gateway’ in the conversation to explain why I think a particular study is important and I can imagine that female researchers are not as frequently asked through concern that the sensitive topics often discussed in research projects (e.g. miscarriage, stillbirth, pregnancy-specific mental health problems) may have been experienced personally by a female researcher. There have also been logistical advantages in that when I approach mothers to take part in studies, potential study participants can more easily differentiate that taking part in a research study would not necessarily impact on the standard of care simply because as, with fewer men in maternity care, I am not usually seen as part of their healthcare team.

I am hoping this editorial provokes more consideration in planning, conducting and designing studies rather than provoking controversy. Whereas the gender and personal characteristics of the researcher or participant should not dictate how the research is conducted, the influence of gender cannot be ignored in the dynamics that take place in perinatal research - where gender underpins so many issues. We would like to reiterate a call by Howard and colleagues (2016) in that researchers should refer to the SAGER guidelines when reporting their findings as these are a comprehensive procedure for reporting of sex and gender information in study design, data analysis, results and interpretations of findings (Heidari, Babor, De Castro, Tort, & Curno, 2016). Ultimately, it is important that neither reproductive healthcare nor research is seen as the domain of a specific gender. To do so devalues the professions and furthermore limits valuable opportunities to gain perspectives and insights that had not been considered.

J. J. Newham
Research Associate, Institute of Health & Society, Newcastle University, UK
[email protected]
F. Alderdice
Chair in Perinatal Health and Well-being, School of Nursing and Midwifery, Queens University Belfast, UK
[email protected]