(En)Gendering the word ‘midwife’: semantics, etymology and orientations

ABSTRACT

This discussion paper takes as its starting point the marginal existence of men in the seemingly mono-gendered arena of childbearing, both as midwives and as service users. It seeks to explore how their problematic presence can be both accommodated and rejected within the limits of existing language which manifests itself most rigidly in the word ‘midwife’. I argue that ‘midwife’ has multiple meanings which are mobilized in different situations to call upon either a seemingly stable etymological understanding or a more fluid and adaptable semantic meaning. I engage in the heuristic device of ‘orientations’ inspired by the work of Sara Ahmed to illuminate how these multiple meanings serve to exclude people who do not identify as female. Lastly, I illustrate how a recent focus on gender-neutral and additive language to accommodate men into a historically exclusively female discourses has further exposed the limitations of the gendered word ‘midwife’ to be able to include people of all genders and none.

KEYWORDS:

• Midwife
• semantics
• etymology
• transgender
• orientations

Introduction

Definition of ‘Midwife’:

NOUN: A person, typically a woman, who is trained to assist women in childbirth

ORIGIN: Middle English probably from the obsolete preposition mid ‘with’ + wife (in the archaic sense ‘woman’), expressing the sense ‘a woman who is with (the mother’).

(Oxford University Press, 2020. Available at: https://www.lexico.com/definition/midwife?locale=en (Accessed 17 January 2021)

Despite artefacts proving the existence of midwives over 8000 years ago, no word existed in any language to signify a male midwife as it was widely understood as an occupation exclusively performed by women for women (Donnison & Macdonald, 2017, p. 24) until the late 16^th century. The presence of men in the birthing arena was facilitated in the 17^th century by new scientific enquiry into anatomy and surgery which extended to women’s bodies. The male gaze centred almost exclusively on labour with a view to expediting what they regarded as a mechanical and risky process (Pendleton, 2019). Key texts (Cahill, 2001; Donnison, 1988; Wilson, 1995) have argued that this began a process of patriarchy eroding and subjugating the primacy of midwifery skills and experience gained in an apprenticeship model (Donnison & Macdonald, 2017, p. 25) with a focus on pregnancy, childbirth and child rearing as both an important transformative social event and a normal physiological process. Whilst these new male practitioners were widely known as ‘man-midwives’ (Donnison, 1977, p. 11), their scope of practice and focus on pathology and intervention would be recognized today by the modern term ‘obstetrician’, a discrete and separate profession specializing in complications of pregnancy and childbirth. Whilst Obstetrics has developed into a profession which is increasingly dominated by women (Angstmann, Woods, & de Costa, 2019; Royal College of Obstetricians & Gynaecologists, 2018), currently only a vanishingly small percentage of men globally practise as midwives. Data from 77 countries (Sannomiya, Sasagawa, Hikita, Yonezawa, & Haruna, 2019) demonstrate that 19 countries have no men registered as midwives, five countries legally prohibit men from being midwives and, of the 37 countries which produced statistical data, the average proportion of midwives who identified as men was 0.63% of the professional population.

This paper seeks to develop on the existing scholarship focussing on the historic gendered power dynamics that have shaped midwifery knowledge and practice (see Pendleton, 2019) but shift the focus to current and ongoing debates around gender in midwifery. I argue here that these debates are synthesized into the problematic gendered nature of the word ‘midwife’ itself. As a man who is a midwife, I have frequently encountered confusion from service users over the discordance they perceive between my gender and their expectations of what gender a midwife should be. ‘Midwife’ is a term widely recognized outside of the profession as being exclusively a woman who supports other women throughout pregnancy and labour (Madlala, Ngxongo, & Sibiya, 2020). Most obviously, it is also probable that the confusion persists because the word ‘wife’ is universally recognized as signifying a woman, the preposition ‘mid’ rendered obsolete. As evidenced by correspondence on internet chat forums, men who work as midwives frequently experience confusion and being asked, ‘Shouldn’t you be called a Midhusband?’ (see: Jones, n.d.; Pilkenton & Schorn, 2008). A more recent impetus for this paper came when discussing with midwifery academic colleagues – all women – the possibility of using more inclusive language and referring to ‘birthing persons’ rather than ‘women’ in the new midwifery curriculum we were constructing. This was in recognition of the small but growing number of individuals who identify as men, trans masculine or non-binary (Toze, 2018) and are pregnant but prompted one colleague to pose the question, ‘Can we not refer to women anymore? After all, we are midwives and that means “with woman”?’

The seemingly mono-gendered nature of the profession can therefore appear problematic when crystallised in the title it confers on its practitioners. For service users being supported by men who are midwives there remains confusion despite men being in the profession for at least 40 years (Speak & Aitken-Swan, 1982). Moreover, the foregrounding and foreclosing of the profession within a title which privileges binary understandings of gender is further problematized with emerging evidence within the United Kingdom that there are more midwives who do not identify with the sex that they were assigned at birth than those who identify as ‘male’ (Nursing & Midwifery Council, 2020). The opportunity to reconsider the role of gender in the relationship between caregivers and service users in the midwifery profession has once again been triggered by the problematic word ‘midwife’. This time the gaze has been reorientated and focussed not solely on those whose gender is incongruent with the majority within the profession, but also outwards towards those whose gender identity is incongruent both with heteronormative assumptions about which bodies can birth babies and which gender midwives can and should serve.

This paper will therefore both deconstruct the word ‘midwife’ to examine its multiple meanings which are both literal and figurative whilst also coupling it with an orientation to examine how this reveals apparently conflicting and conflicted relationships with gender within the profession. In so doing, it is hoped that it will not direct midwives and service users to take up exclusionary or dogmatic positions about how to engage with those of us within and without the profession who are not women based on the limitations of language. Rather, it is intended to serve as the basis for a more reflective critical examination on the possibilities of how – and if – our presence might be acknowledged outside the gender binary discourse in perinatal services. I will start by exploring how its etymological meaning, whilst excluding birthing people who are not female, is rooted in a historical struggle to safeguard the birthing process from patriarchal control and has expanded to incorporate a more politicized semantic meaning. I will then go on to deconstruct the word further by exploring how the discursive practices of some midwives may in fact not reflect either the etymological or semantic meanings but can achieve the undesired effect of objectifying service users. I compare the word ‘midwife’ to both the word ‘obstetrician’ and the word for midwife in other European languages to expose the hidden orientations contained within them and their gendered meanings. Finally, I focus on recent moves within midwifery organizations to use ‘gender neutral’ language to be inclusive to trans-masculine and non-binary birthing people and how this has provoked some groups to insist once again on an essentialist understanding of the etymological roots of ‘midwife’. I conclude by suggesting that calling upon a single interpretation of the word ‘midwife’ serves to reinforce the exclusionary nature of the gender binary; calling upon multiple meanings simultaneously might offer a way of moving beyond the binary and include people of all genders and none.

Semantics, etymology and philosophy

This paper has been inspired by queer linguistics, which uses queer theory as a lens to analyse how language can reinforce or destabilize heteronormative discourses of gender and sexuality (Motschenbacher & Stegu, 2013). As I am seeking to understand the labels given to gendered minorities who give birth, or to those who work with birthing people, but which do not adequately accommodate them, this seems a fitting approach. It allows me to question the seemingly stable nature of the gendered word ‘midwife’ and argue that it has come to create identities that ‘regulate and exclude people who do not fully meet their normative requirements’ (Motschenbacher & Stegu, 2013). Using key linguistics concepts, I have sought throughout to identify ‘midwife’ as having semantic meaning, etymological meaning and philosophical meaning. Semantics in the context of this paper is taken to describe the meaning or ‘language code’ ascribed to words (Brown & Miller, 2013) by those who receive or employ them and is thus shifting and contingent on time and cultural context. The use of etymology, on the other hand, is understood as having an archaeological drive to try and uncover the historical origins of words (Brown & Miller, 2013) and is more positivist in its aspiration to root the word within a definitive and timeless meaning. Finally, I make reference to a ‘philosophical meaning’ which has evolved and is a term more open to evolution and change, based as it is on a discipline that encourages individuals to examine the beliefs and assumptions that have led to our decisions on how to engage and interact with the world around us (Shand, 2014:ix).

Orientations

In order to critically explore the multiple-gendered meanings of the word ‘midwife’ I will focus on the potential of ‘orientations’ as a heuristic device and how the orientations contained with the semantic, etymological and philosophical interpretations of ‘midwife’ have come to be mobilized for political, professional and feminist ends. Ahmed (2006) has elaborated on this device in her work as a means of building on the established philosophy of phenomenology. Phenomenology is a branch of philosophy developed by Husserl concerned with identifying and exploring what has been described as the ‘ignored obviousness’ (Zahavi, 2019, p. 67). Smith et al. (2009, p. 12) suggest that we as human beings have a ‘predilection for order’ and are quick to fit our experiences into pre-existing frameworks and theories. These theories have been developed based on a positivist understanding of knowledge and experience, and this can mask the way we as humans actually experience the world (Crotty, 1998, p. 28). Phenomenologists seek to strip away these constructions and central to Husserl’s philosophy are the concept of intentionality. Langdridge (2007, p. 13) sees this intentionality – ‘the relationship between a person’s consciousness and the world’ or what is experienced and the way it is experienced – as the cardinal quality that defines phenomenological inquiry. The belief is that a person is not simply conscious, but conscious of something and therefore their consciousness is directed outwards towards the world: ‘the focus of phenomenology is on the intersection between mind and world, neither of which can be understood in separation from each other’ (Zahavi, 2019, p. 30). Thus, it is not seeking to find a causal relationship between the two positions (Langdridge, 2007, p. 15) but to explore and expose this relationship in all its complexities.

In Ahmed’s (2006) iteration of phenomenology, she focuses on this orientation – and asks us to look at the thing – or phenomenon – afresh by reorientatating either the thing or ourselves from sedimented and accepted ways of seeing and standing back to see what this exposes. Very often this reorientation is called for when a body arrives in a place normally reserved for others. Ahmed (2006, p. 20) recalls how becoming a lesbian, but remaining in an overwhelmingly heterosexual world was both disorientating – ‘the feelings that gather when we lose our sense of who it is that we are’ – and reorientating – allowing the world to acquire ‘a new shape and makes new impressions’. The disorientation occasioned by the arrival of men – trans or otherwise – into the domain of midwifery as both caregivers and service users exposes how ‘life gets directed in some ways rather than others’ (Ahmed, 2006, p. 21).

Following Ahmed’s (2006) technique of queering the orientations that produce sedimented meanings, I will deconstruct and reorientate the discursive meanings that are contained within the word ‘midwife’, allowing us the possibility of exposing the phenomenon of the gendered world (and word) of midwifery afresh. First, I do this by asking who are we ‘with’ when we are with ‘mid’ (with woman) before considering ‘what [or who?] is put aside when we take sides’ (Ahmed, 2006, p. 89) (disconnected woman). I move on to reflect on how alternative words for birth practitioners contain problematic gendered orientation devices (before woman). Finally, I ask how does being ‘with’ change when one-half of the equation is no longer a woman or ‘wife’ (without woman) and how attempts to engage with and solve these newly visible phenomena (erasing woman) have further provoked questions that are arguably existential in nature to the continuation of the profession in its current form.

A note on terminology

For a paper discussing the meanings and different interpretations ascribed to words and phrases, it is important that I set out my understanding of the words that I choose to use and to use them consistently throughout. For pregnant people accessing midwifery care, I choose the words ‘service users’. This is gender-neutral and does not have the connotations of pathology, suffering and powerlessness implicit in the alternative word patient (Silverton, 2017). There does not appear to be one universally accepted word to encompass all pregnant and birthing people who do not identify as a woman or female. In one qualitative study alone where 10 people were interviewed about their experiences of accessing reproductive services, participants who did not identify as women used at least nine different terms to refer to their gender identity (Hoffkling, Obedin-Maliver, & Sevelius, 2017). For the purposes of this article, I choose ‘trans masculine’ and ‘non-binary’ as the words I have encountered most frequently in my reading. I also acknowledge that the debate around what constitutes gender, sex and identity is beyond the focus of this paper. The words man or male, woman or female can often be used interchangeably but the debate within midwifery centres on whether people take an essentialist or social constructionist stance on what constitutes someone’s identity or being. The essentialist argument holds that gender is innate and biologically determined (Burr, 1998, p. 13; Moskos, 2020). I use the word ‘sex’ in place of ‘gender’ to contain this meaning when referring to the category of male or female assigned to a person based on their reproductive organs and chromosomal make-up as identified at birth (Newton, 2017, p. 6). I take gender to mean the cultural or socially constructed ‘practices that go with being labelled female or male’ (Woodward, 2011, p. x), often used as binary positions to privilege patriarchal legal, economic and cultural institutions and embodied in the words man and woman. I take identity to mean how we see ourselves in relation to others (Pullen & Simpson, 2009).

With woman

The debate over childbearing terminology could remain relegated to the world of academia, of interest only to those engaging in historical, theoretical and philosophical debates around linguistics. However, midwives themselves in the late 20^th century onwards have held that language matters and have mobilized it for political ends to challenge the increasingly hegemonic obstetric model of facilitating childbirth. I argue that a positivist view of birth has led to a technocratic and biomedical approach which sees the birthing body in mechanistic rather than holistic terms and stems from male dominated scientific enquiry from the 17^th century onwards (Pendleton, 2019). This runs counter to the midwifery profession’s evolution which sees birth as a transformative life event and is based on embodied knowledge, intuition and creating safe spaces to allow birth physiology to happen unhindered from outside interference (International Confederation of Midwives, 2014). The subject – the importance of language used in and about midwifery – has been revisited periodically in midwifery journals to explore the epistemic tensions between the two professions. Zeidenstein (1998) makes reference to the disempowering and objectifying language that the female midwifery profession has inherited and perpetuated in order to be viewed as legitimate by their obstetric colleagues. Hunter’s (2006) article, much quoted in the midwifery literature (see Einion-Waller, 2021; Lichtman, 2013) discusses how the dominant language used in the midwifery world reinforces a patriarchal and biomedical approach to care and argues for the use of language which allows for a more ‘woman-centred paradigm’ to emerge. The authors consistently appear to adopt a social constructionist interpretation of the power of language not to simply describe pre-existing thoughts and beliefs, but to ‘structure our experience of the world and of ourselves’ (Burr, 2003, p. 47). As such, it is argued, words have consequences and can direct action: rather than words describing a hypothetical pre-existing social reality, social constructionism is an epistemology that holds that our choice of language creates the framework within which we can operate and understand the world. The orientation is therefore twofold – to enclose us within a safe space with like-minded people so that we can then direct our gaze outward to other spaces.

It has been established that the etymological meaning of ‘midwife’ is ‘with woman’. It is argued that, despite its appearance, it is an epicene word by virtue of the fact that the meaning of the word centres around the orientation contained within it – the caregiver alongside the service user who is understood in essentialist terms by their sex as always already being female. This orientation has also come to hold a greater significance. Bradfield, Duggan, Hauck, and Kelly (2018) conducted an integrative review on the meaning of ‘with woman’ within the literature largely written by midwifery leaders or from the perspective of women accessing midwifery services. They argue that being ‘with woman’ is not just a literal translation but a concept that is central to the professional identity and work of midwives and sought to analyse the phenomenon across 32 papers. They concluded that ‘midwife’/‘with woman’ has evolved from not only having an etymological meaning but also embracing a ‘philosophical framework’ in the latter part of the 20^th century that serves as an ‘anchoring device’ to ensure that midwives prioritize the needs of the individual who seeks their professional services. This philosophical meaning serves to oppose the alternative position of being ‘with institution’ which has seen birth move from the domestic sphere into hospitals where pregnancy and childbearing have been seen through the lens of a potentially risky and pathological altered state of being. Bradfield et al. (2018) go on to unpack the meaning of this philosophy as being a relationship between midwives and women based on qualities such as ‘inclusiveness’, ‘trust’, ‘empowerment’ and ‘advocacy’ among others and summarize it as follows:

… being with woman [provides] political agency by validating the female experience of childbirth and provides a platform of empowerment.

Their primary research (Bradfield, Hauck, Duggan, & Kelly, 2019) studying midwives’ understanding of being ‘with woman’ concur that these words represent a philosophical construct that emphasizes action and mutuality, building a partnership relationship that privileges agency and empowerment of the individual over the directives of healthcare organizations that privilege efficiency and processes. Thus, it could be concluded that ‘with woman’ has a semantic meaning that is inclusive of all pregnant and birthing persons, regardless of whether they identify as a woman. These two studies do not seek to explore the complexities of being ‘with women’ by including the trans-masculine perspective, nor do they seek to understand the experiences of midwives who are not women, and it would be unfair to critique them for not doing so. However, their research highlights the tension between two positions and competing demands – who do midwives serve? The profession or the individual? Can both be served simultaneously? Or do midwives engage in ‘code-switching’, a theoretical framework which allows speakers to assess and acknowledge the implicit differentials in power hierarchies with their audience and modify their language and tone accordingly (Boulton, 2016)? Choosing either consciously or subconsciously between semantic, etymological or philosophical meanings, midwives may reorientate themselves in response to the situation they find themselves in.

Disconnected woman

The ‘with woman’ relationship is further complicated when the ‘anchoring’ or orientation device – ‘mid’ – is removed, inviting an exploration of the meaning of the word ‘woman’ in this context. If a philosophy of midwifery care is predicated on a semantic understanding of the term ‘with woman’ rather than an etymological one; then, it also is predicated on a consistent universal understanding of the word ‘woman’ regardless of whether it is rooted in essentialism or social constructionism. That is to say, it is predicated on an assumption that it is stable in its meaning and used consistently by all who regard themselves as ascribing to the ‘with woman’ philosophy in a respectful or even neutral manner. Pollard (2011) conducted a critical discourse analysis on midwives’ discursive practices and concluded that the terminology used to refer to service users was rarely neutral or consistent but context-bound. Rather than ‘woman’, the word ‘lady’ is commonly used intra- and inter-professionally on the labour ward to refer to birthing persons which Pollard (2011) states sanitises the birth process and assigns birthing persons as ‘genteel’, submissive and ‘restrained’. Pollard also observed that midwives infantilised themselves and their colleagues by using the word ‘girls’ among themselves and in conversations with doctors.

What this appears to highlight is that midwives, when physically separated from the service users can also metaphorically disconnect ‘women’ from the orientating ‘mid’/’with’ and replace them with an alternative gendered signifier. Zeidenstein (1998) provides anecdotal evidence in her editorial of a phenomenon that may be familiar to many midwives still today. She noted that rather than being ‘with woman’, midwives often used words that implied ‘ownership’ (‘my girls’, ‘your lady’) when referring to the women they were caring for in discussions away from the birthing room. Service users become objectified in the inter- and intra-professional shorthand of labour ward parlance in what Zeidenstein (1998) calls a ‘collaboration of convenience’. Babies are ‘delivered’ by the midwife, the service user is described not as a person but in terms of their progress in labour or the complications they are presenting with and the ‘woman’ is lost in the language. Thus, when physical proximity to the birthing person is removed, so too can the stability of both the etymological and semantic meanings of ‘midwife’.

Zeidenstein argues that:

Language is powerful and no matter how philosophically correct midwives’ beliefs may be, their words may reflect an unconscious need to be in control.

She goes further and acknowledges that adopting male medical terminology is part of the evolution towards establishing a respected autonomous profession that must be validated by working in partnership with the obstetric profession which has both power and status. Nevertheless, she also makes the analogy between using these terms which objectify service users and blindly participating in sexist or racist jokes behind the backs of those who are their butt. To change, she argues, requires courage and bravery, but in doing so highlights the capacity and need for those within the profession to be able to change and be reactive to the changing socio-political landscape. Zeidenstein’s (1998) foundational work continues to influence literature calling for language around birth to reject depersonalizing obstetric influences (Hunter, 2006; Mobbs, Williams, & Weeks, 2018; Silverton, 2017). There is complexity still in this call for change – change can be orientated to the future and new ways of acting, but here it is orientated back to pre-obstetric use of ‘woman-centred’ language. This language was created prior to the visibility and acceptability of the trans-masculine pregnant person or the midwife who does not identify as a woman and cannot easily accommodate their presence.

Before woman

If we take the word ‘midwife’ to represent an identity as well as a philosophy; then, it needs to be understood in how it is positioned or orientated in relationship to others. The gendered and sexed nature of language surrounding birth practitioners resides not just with midwives but also with obstetricians. An obstetrician can be defined as a doctor who specializes in complications of pregnancy and childbirth. Unlike the word ‘midwife’ which has its first recorded use in the 14^th century (Merriam-Webster, 2021), the term obstetrician is a relatively new invention. It has been argued that the word ‘obstetrician’ was created in 1847 to distinguish male intervention in birth physiology from the role of the female midwife (Donnison & Macdonald, 2017) and derives from the Latin word ‘obstetrix’. The word ‘obstetrix’ when translated back into English means midwife (Cameron, 2001). Thus, the male techno-rational model of facilitating childbirth appropriated an ancient word for female practitioners. It was created in the 19^th century to elevate the status of medical men involved in childbirth and distinguish them from the unregulated and seemingly unskilled female practitioners. And so, a word that sought to divide and reinforce the binary-opposites of male technocratic medicine from female tradition in fact etymologically unites the two gendered professions and should therefore logically reorientate the care of parturient service users back towards a female-centric practice. But importantly for this discussion, what continues to separate them is the orientation of the practitioner to the service user. ‘Midwife’ places the practitioner alongside – ‘with’ – the birthing woman and describes the ambition of a horizontal, non-hierarchical relationship between two equals. The word ‘obstetrician’, however, also contains an orientation but one that the modern ‘mid’wife has rejected. Etymologically, obstetrician is derived from the verb ‘obstare’ meaning ‘to stand before’ and indicates the orientation of the caregiver in relation to the service user. This reinforced the new positioning of service users lying supine or ‘confined’ on their beds for the convenience of the male accoucheur but which in fact impedes birth physiology by, among other things, reducing the diameters of the pelvic outlet. This can lead to prolonged labour, increase in pain and the need for interventions as well as poorer outcomes for service user and their baby (Walsh, 2017, p. 605). The orientation of the caregiver contained within the word does indeed have hidden consequences.

In languages, other than English the focus shifts and changes from being ‘with’ and standing ‘before’ the woman to orientate the caregiver towards the child. German (‘hebamme’) and Italian (‘levatrice’) words for midwife refer to the female caregiver who lifts the baby up (Jahr, 2012) and thus erases the birthing person completely. In French (‘sage-femme’) and Dutch (‘vroedvrouw’) any orientation is lost, the words simply meaning ‘wise or knowledgeable woman’ untethered to either caregiver or receiver. The reluctance by the midwifery profession to confront how the word ‘midwife’ is problematic in relation to gender and who it excludes can best be understood when juxtaposed with the inclusion of alternative orientation devices in the relatively newly adopted word for the allied male professional. Words can and do evolve – the Italian ‘levatrice’ is replaced in the 21^st century by ‘ostetrica’ – but the gendered division between midwifery and obstetric practices (Pendleton, 2019) can be understood as being both ontic and epistemic, whether the caregiver is orientated physically and philosophically with or before the service user and enshrined in the language used to describe the professions. Using Ahmed’s (2006, p. 7) theory in this context can encourage us to think of the orientation hidden with these words as not only directing us towards our choice of profession, but also, once adopted, explaining how we ‘come to feel at home’ within it.

Without woman

Arguably, the turn towards its etymological roots removes the need for many midwives who are female to consider how men and non-binary people who are midwives feel about their professional title. Certainly, there is anecdotal and journalistic evidence that men who are midwives align themselves with the powerful philosophical meaning of being ‘with woman’ (McEwan, 2014) and this may negate any fleeting dysphoria they might experience at hearing themselves called ‘midwife’. Ahmed (2006, p. 15) recalls Butler (1997) and suggests that we become ‘a subject’ when ‘hearing oneself as the subject of an address’. The action of turning towards the person who is calling us can be disorientating – we can both ‘misrecognize’ ourselves in the service user’s address whilst simultaneously becoming a midwife by responding to their call. There is a semantic disconnect between the gendered meaning service users outside the profession ascribe to the word ‘midwife’ and how those within the profession understand it. The arrival of the pregnant body, which does not identify as female; however, further problematizes the orientation device ‘with’ and removes the security and stability that can be mobilized by pointing to the etymological meaning of ‘midwife’.

Historically, the practice of negative eugenics sought to render infertile those considered deviant to normative notions of sex, gender and sexuality (Lowik, 2018). This pernicious medical approach to managing difference may have a lingering legacy in current practices. Many countries either explicitly require or implicitly coerce individuals to relinquish their reproductive capacity in order to achieve legal gender recognition (Toze, 2018). This may also be based on the assumption that a pregnant body is the apotheosis of femininity (Malmquist, Wikström, Jonsson, & Nieminen, 2021) and therefore a pregnant person should want to identify as a woman. Consequently, a person who has rejected their identity as a woman must logically reject their bodily autonomy over their reproductive rights. This has resulted in a lack of historic visibility of pregnant and birthing transmasculine and non-binary persons. This invisibility, however, is gradually diminishing with representations of pregnant transmasculine bodies in the media (Toze, 2018), often sensationalist in nature, reflecting the fascination with such an apparently incongruent state of being. Pregnancy for transmasculine people can be seen as a dysphoric experience and their experiences of pregnancy and interactions with care providers are reported to enhance feelings of exclusion, isolation (Charter, Ussher, Perz, & Robinson, 2018), erasure and experiences of microaggressions (Besse, Lampe, & Mann, 2020). Whilst not a universal experience and not representative of all midwives, it is worrying that these experiences are the polar opposite of the philosophical and semantic interpretation of the word ‘midwife. If midwife is not etymologically relevant, what is then left when semantic meanings are also not valid?

Erasing woman

In recent years, there has been evidence of explicitly addressing the gendered meaning of midwifery language in general, centring around whether language can be additive to include all birthing persons, or whether this signals the beginning of erasure of women from the birthing discourse. The Midwives Alliance of North America (MANA) did acknowledge the problematic nature of the gendered use of language in general within the profession and altered the wording within its educational standards for midwifery education to ‘better reflect the diversity of midwives and clients they serve’ (Midwives Alliance of North America [MANA],n.d.). The word ‘midwife’, however, remains intact and unchanged, the semantic and etymological significance not addressed but ‘gender neutral’ language is used to refer to service users. They refer to the ‘client’ and ‘childbearing family’ and thus reaffirm the importance of the etymological orientation device of ‘mid’ but ascribe semantic meaning to ‘wife’ in an attempt to include birthing people who do not identify as women within the birthing community. In their words:

As long as a single client is excluded from the midwifery community, all clients are potentially vulnerable to discriminatory treatment.

There was a ‘firestorm’ (Reis, 2020) in response to their use of the replacement ‘gender-neutral’ language to refer to service users rather than as additive to ‘mothers’ or ‘women’ resulting in an open letter posted by a group seemingly newly created to challenge and contest the MANA vision. ‘Woman-centred midwifery’ describe themselves as a group of ‘gender-critical’ people with an understanding of humans ‘as a sexually dimorphic species’ (Woman-Centered Midwifery, n.d.) and that, when it comes to pregnancy and accessing healthcare professionals, their ability to give birth defines someone as a woman regardless of the gender that person identifies with. MANA calls upon semantic meaning, Woman-Centred Midwifery upon semantic and etymology. When the word ‘midwife’ is firmly orientated towards the service user, the gendered meaning of the word has a powerful capacity to expose ideological divisions within the profession. Equally, the direction of being incorporated in the etymological interpretation of ‘midwife’ could be queered and redirected back to the caregiver so that it is the service user who is with ‘wife’ or woman, given that the profession is almost exclusively inhabited by women. It would preserve the service user from having a gender imposed on them, contrary to the philosophy of empowerment understood by midwives, but in so doing it redirects the debate back to who is included in the profession.

The trans-masculine perspective on the word ‘midwife’ is difficult to find in the academic literature. In providing guidance for midwives, a trans midwife in the United Kingdom states that words are powerful and asserts that misgendering – the repeated use of incorrect pronouns and language – is dehumanizing, causes ‘deep psychological stress’ and impacts on mental wellbeing (Welch, 2020). In an earlier blog interview (The Midwife Diaries, 2019) they do acknowledge the fact that the etymological meaning of the word midwife excludes trans people. They go on to highlight the socio-political significance of the word ‘midwife’ that represents the role they have had in supporting childbearing women within the context of a patriarchal world, and state that trans people ‘ought not seek to take away or threaten this deep truth’. Anecdotal evidence from one person cannot and should not be used to generalize this as representing the views of many trans people. It does, however, serve to highlight the conflict between the power of words to create visibility but also raising the fear of their power to erase or minimize another population’s experience and need for visibility. Silver (2019) asserts that using inclusive language in maternity services should be additive and expansive rather than replacing or erasing the word woman, a sentiment shared by Brighton and Sussex NHS Trust when it published its first guidance in the UK on gender inclusive language in perinatal services (Green & Riddington, 2020). It advocates for a ‘gender-additive approach’ to language to ‘ensure that everyone is represented and included’ but again does not address the gendered nature of the word midwife, suggesting it sits at the limitations of what the word can do to emphasize or erase gender.

Conclusion

This paper argues that the statistically insignificant number of both midwives and pregnant people who do not identify as women has made the midwife-service user dyad a mono-gendered relationship gazing in both directions. Over time, this has come to be uncontested in its ‘ignored obviousness’ (Zahavi, 2019, p. 67) and manifests itself in an understanding that ‘midwife’ encompasses only women who provide care for other women throughout pregnancy and childbirth. This paper has been guided by the heuristic device of orientations introduced by Ahmed’s (2006) work rooted in the philosophy of phenomenology to peel away this sedimented meaning that has accumulated around the word midwife and redirects etymological and semantic meanings to problematize its gendered meanings when disrupted by the presence of men as both midwives and service users.

The paper has taken the word ‘midwife’ and dissected it not just as an academic exercise, but because the midwifery profession itself has long held that words are powerful and hold political and philosophical capital central to the profession and the work that midwives do. The profession has argued at different times that the word has semantic, philosophical and etymological meanings. I have shown how the choice of meaning is deployed either consciously or subconsciously depending on the context and the audience but, in the context of gender, only in the service of those within the profession rather than those they serve. The experiences of men, trans-masculine and non-binary service users suggest that semantic meaning still does not universally orientate itself towards them and service users do not recognize the etymological meaning as being orientated towards them when encountering men who are midwives. This has yet to be explored empirically and qualitatively in the academic literature.

The paper has also offered an example of when ‘gender neutral’ language has been incorporated into official midwifery standards and in exposing the debate has also exposed the fact that language is anything but neutral when it comes to the gendered profession of midwifery. To try to neutralize the gendered nature of the word by describing it as merely representing a ‘profession’ both ignores the fact that professional roles have ‘gender value’ (Porter, Crozier, Sinclair, & Kernohan, 2007) independent of how the person inhabiting the role identifies their gender and also reinforces the binary and hierarchical nature of professional status which privileges institutions along gendered lines.

Gendered discourses in the childbearing arena appears to lock stakeholders in a cyclical debate, requiring people to take sides. The act of doing so exposes ‘what is put aside when we take sides’ (Ahmed, 2006, p. 89) and in turn reignites the debate. The word ‘midwife’ – whether etymological or semantic in its orientated meaning – immediately creates a space which signifies to some bodies that they are misaligned and ‘othered’ (Vitry, 2020) by setting up a gendered binary division between who can be a midwife and those who midwives can serve. It is argued by Vitry (2020) that Ahmed’s (2006) queer phenomenology is a useful theoretical device to highlight how bodies are ‘assumed to be governable’ and ‘gendered’ by attempting to orientate them into alignment within the pre-existing spaces that have not been constructed to accommodate them. I, in turn, have argued that the effect of a body out of place – either as a midwife or a service user who is not a woman – can be disorientating for all involved and that this manifests itself most problematically in the word ‘midwife’ itself.

Ahmed (2006, p. 41) cautions against simply facing the phenomenon head on without also turning back to face the historical context of how it has arrived at the point in which we can contemplate it:

What passes through history is not only the work done by generations, but the ‘sedimentation’ of that work is the condition of arrival for future generations.

The important work of midwives throughout history to maintain safe spaces for birth physiology to occur is at the core of the semantic, etymological and philosophical meanings of the word midwife and must be disseminated to those outside the profession. When arguing for the use of more holistic language in childbirth to counter obstetric language, Hunter (2006) cites Walton (1995) to argue that ‘words only remain in use if they are useful to a culture and symbolically valid’. As culture comprises individuals, words need to be re-examined periodically to assess their continuing validity. This paper does not call for a rejection or replacement of the word ‘midwife’ or to ‘de’gender it for to do so would be to reorientate ourselves to the present and in so doing erase the past. But when asked how orientating the word ‘en’genders it opens up the possibility for a multiplicity of intersecting meanings which can co-exist alongside each other and can move the debate beyond reactionary binary divisions to a more inclusive understanding of the role of gender in midwifery and midwives.

Acknowledgments

With thanks to Dr Evangelia Prokopiou, Dr Steve O’Brien, Dr Aura Lehtonen and Dr Sebastian Bartos for their support, critical review and comments. I would also like to thank the three peer reviewers for their constructive feedback.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

John Pendleton

John Pendleton is a Registered Midwife, a Senior Lecturer in Midwifery and a PhD research student conducting an IPA study on the experiences of men who work as midwives.