Preference for female obstetricians is well-documented, particularly among immigrant women from conservative religious or cultural backgrounds that emphasize modesty.1–3 Whether health systems should respond to requests for a female physician is a matter of debate. In most Western countries, institutions are not legally obliged to meet gender-of-health-care-provider requests. In fact, a patient's refusal of care on the basis of gender-of-health-care-provider has been interpreted as gender discrimination in the United States4–7 and the United Kingdom.8 In Canada, the Society of Obstetricians and Gynaecologists states that, “provision of services cannot and should not ever be based on gender, race, sexual orientation, age, practice patterns or religious affiliations of either the patient or the provider.” [Emphasis added.]9
On the other hand, advocates promoting patient-centered care argue that institutions and individual physicians should do their best to accommodate patients' values, preferences, and expressed needs.2,10 With increasing immigration to the United States, Canada, and western Europe, the issue of meeting gender-of-health-care-provider requests is gaining importance.11–13 Overlooked in this debate is the physicians' perspective of gender-of-health-care-provider requests, their response to such requests, and what might be potential solutions when conflicts emerge. With the objective of informing decisions around addressing requests for female health care providers, the present research sought to investigate obstetricians' values and perspectives related to the importance, effect, and challenges of providing care to immigrant women who request a female obstetrician.
MATERIALS AND METHODS
We conducted a focused ethnography of obstetric health care providers from August 2015 to January 2016 at a large teaching hospital in Edmonton, Alberta, Canada. Whereas ethnography sets about to describe culture broadly, a focused ethnography concentrates on a particular research objective and context to guide decision-making on a particular problem.14,15 The research site was chosen because it has a high immigrant clientele and the issue of gender-based health care provider preference or refusal of obstetric services had been identified as an issue by obstetric health care providers and for which a policy was needed.
Participants were recruited purposively from resident and consultant obstetricians who had experience in working with immigrant women. The study site was characterized by a high proportion of immigrant clientele, predominantly women from North or East Africa, the Middle East, and South Asia. Our eligibility criteria were: 1) obstetricians with at least 1 year of experience working with immigrant women, 2) obstetricians who had provided care to patients who preferred a female physician intrapartum, and 3) for resident physicians specifically, at least 1 year of training. For resident participants, the first author sent an email invitation to all eligible participants (years 2–5: n=28), and all 10 who responded were interviewed. For staff obstetricians, the first author invited, by email, all practicing generalist obstetricians working at the study hospital (n=17), and all six who responded were interviewed. Staff obstetricians who had not responded to the email invitation were approached in person to participate, four of whom agreed.
A total of 10 residents and 10 consultant obstetricians were interviewed after informed consent was obtained. The interviewer met with participants during off-service hours at a mutually agreed location. Interviews were semistructured and followed a piloted guide whose questions included: How has health care provider gender come up as a barrier during labor and delivery? Is this issue discussed with women antenatally? What is your response to this request, and how do you personally feel about it? How do you think we can address this issue?
The first author audio-recorded and transcribed all interviews verbatim. A database of deidentified interview transcripts and observations was created, stored, and managed using Quirkos 1.3 qualitative data analysis software. Data were analyzed using thematic analysis.16 The first author read the interview transcripts to identify recurrent concepts and then coded passages according to topics. The codes were then grouped into similar categories and subcategories and discussed in detail by the research team to arrive at a joint interpretation and set of themes. This process was fluid and iterative and occurred concurrent with data collection. Sample size in qualitative research is not predetermined, but rather sampling continues until saturation, in which no new concepts are emerging in the data.17 In this study, data saturation guided the sample size in that sampling continued until it was achieved.
Ensuring rigor in research is imperative, and although means to evaluate rigor in quantitative research methods are well understood, there is debate in qualitative research as to how rigor can be achieved, ensured, and evaluated. Terminology for rigor is widely varied, but to bridge qualitative and quantitative readership, adapting the terminology from quantitative methods applied specifically to qualitative research has been advocated. As such, we used the concepts of validity, reliability, and generalizability, as described by Morse et al,18 as the framework for ensuring rigor of the study. Here validity refers to ensuring conclusions are congruent with the data, reliability refers to ensuring data saturation, and generalizability refers to adequate sampling, ensuring the phenomenon exists in a range of experiences.14 Ensuring rigor is not a matter of adhering to a set of post hoc standards that are evaluated, but rather is integral to the design of the study, requiring responsiveness and verification throughout the process. Responsiveness was ensured through the use of a reflexive journal to track process, challenges, thoughts, and changes. The first and second authors met regularly to assess coding and to discuss emerging concepts and directions as data analysis proceeded. The minutes of these meetings in addition to the reflexive journal and field notes formed an audit trail. Verification was ensured through purposive sampling and the iterative process of data collection and analysis. Interviews were transcribed by the first author within 2 weeks of the initial interview, and analysis occurred concurrent with data collection. When new concepts were identified, they were followed up in subsequent interviews with participants.
Ethics approval was obtained through the University of Alberta Human Research Ethics Board (panel B) and operational approval through the Northern Alberta Clinical Trials and Research Centre.
See Table 1 for respondent demographics. Our analysis revealed two main themes: 1) physicians recognize the validity of, and sympathize with, immigrant women's preference for female health care providers; and 2) physicians are resistant to the idea of accommodating patient requests for female health care providers.
All respondents described patient-centered care as the epitome of best practice. They recognized the importance of honoring individual patients' requests, even if the requests differed from recommendations. Physicians alluded to many examples of requests that are accommodated in obstetrics, likening the request for a female health care provider to a whole host of other patient preferences.
We respect a patient's desires to use or not use pain medication, and we respect patient desires to use natural-you know-oh I don't know, natural birthing, versus whatever. And so I think that this is just another patient preference that is important for us to consider.
—Obstetrics resident, female
However, because the preference immigrant women had for a female health care provider was influenced, at least in part, by the patient's cultural, religious, and social context, physicians also described the requests somewhat differently. They expressed sympathy for immigrant patients requesting a female health care provider, acknowledged the values present within these contexts, and recognized that multiple factors from the surrounding community could influence the patient.
I can understand where they are coming from, especially when I am also from an Asian background, and Asian people have that tendency of “I just want a female,” because it's very private parts that they are going to be touching, so I do understand that.
—Obstetrics resident, female
Physicians also emphasized that it was not possible to know every factor influencing a particular patient's request for a female health care provider and noted that many women may have come from war-torn countries where sexual violence was a systematic form of abuse. One physician described her experience with a patient who had been a victim of sexual abuse from a health care provider. This physician recognized that care from a male health care provider would replicate the trauma of these past experiences. For the physicians, the priority was on being respectful and providing the best care for each individual while keeping in mind that they might never know how important having a female health care provider is to specific patients or what their reasons are.
Like I think in general I am kind of pro-patient request, because like you never know where someone is coming from and why they have a certain preference one way or the other.
—Obstetrics resident, female
Despite this sympathy, none of our respondents supported always accommodating requests for a female health care provider intrapartum. Some physicians reported offense on a personal level when women requested a female physician, viewing it as a form of gender discrimination. Both female and male respondents said that, although respecting patient requests was important, the need to protect principles of gender equity within society and medicine took priority. Some argued that such gender discrimination would not be tolerated in other spheres of society, yet was tolerated in labor and delivery and, at times, encouraged.
I think it's pretty ridiculous that this preference for a female health care provider is condoned at our institution. I think that it's been couched as an issue of cultural sensitivity, but I also think that in Canada—we—in general—and this doesn't always happen in practice certainly—but in general, [I] feel that discrimination by sex or gender is not acceptable, but in this case, we are allowing blatant discrimination by sex. And, or I guess I should say by gender—whatever…I don't really know if I agree that it's an issue of cultural sensitivity. I think these people are now interacting with the healthcare system in Canada, and that may or may not be by choice, depending on their circumstance, but um I think like their ability and their freedom to express their cultural norms, or their cultural milieu within Canada should not kind of supersede our policy of non-discrimination.
—Obstetrics resident, female
This was particularly important to physicians within the context of historical gender inequalities in the field of medicine. Obstetrics and medicine in general was historically closed to women, a memory that respondents said should not be repeated in the reverse.
(sighs)—I suppose I defend either gender equally. It's not my issue…I've defended both, and I just—I don't see that marginalizing our male residents or male medical students—demanding that they not see them is necessarily in society's or our best interests. That's how I see it. I mean I've lived through where women weren't allowed in medicine, so I'm not going to go there. It's not my—I don't think it's right, I've never thought it's right, so I'm not going to be part and parcel of it.
—Staff obstetrician, female
Respondents argued that gender discrimination was still a reality in the medical profession. Some female physicians shared experiences of gender discrimination by both patients and allied health professionals. They argued that accommodating gender-of-health-care-provider requests would further propagate gender inequalities within medicine, even if it was in reverse. They went as far as stating that prioritizing requests for female obstetricians could lead to a slippery slope of accommodating a host of preferences that could threaten the very values of equality within society.
So—I think it's a fine line, but I think the other thing is that once you start to make exceptions then you set a precedent.
—Staff obstetrician, female
Closely related to the physicians' support for gender equity, another reason for their resistance was their experience that often the decision to request a female health care provider was not made by the women themselves but their male partners or other family members. This made our respondent physicians, male and female, uneasy because they perceived it as a denial of a woman's right to make decisions and a form of oppression. Informed consent was considered a central pillar of patient-centered care, which became imperative when patient requests differed from health care provider recommendations and had potentially negative implications.
Yeah, I've been in that situation, where you walk in and the husband, or like the father or grandfather, you know it's a very male—unfortunately—and that's pretty sad. I don't care for that at all. If it's the woman's choice then so be it, but the husband, or the boyfriend…
—Obstetrics resident, male
…the mother doesn't have any rights! I just—IT JUST PUTS THE BACK OF MY HAIR ON MY NECK UP.
—Staff obstetrician, female
The physicians also cited a number of practical reasons for their expressed resistance. Key among these was the cost of making health system changes required to meet patients' requests. In Canada's publicly funded health care system, an on-call obstetrician provides after-hours and weekend care. This means patients presenting to a hospital are seen by any of the consulting obstetricians (both male and female) with hospital privileges. Our respondents argued that this system enabled provision of safe care and judicious use of resources. They also acknowledged that it served the interest of health care providers, enabling them to protect their time outside of working hours and maintain a more sustainable work–life balance.
Because it's a huge drain on the system, it's a huge use of resources, and I'm not sure that it has anything to do with quality of care, and these people aren't denied care. They have choices, but I think they have to understand…that we may be able to accommodate their requests, but we're not going to guarantee that.
—Staff obstetrician, female
Another reason our respondents identified for not accommodating patient requests for female health care providers was the detrimental effect it would have on the training of the next generation of obstetricians. Accommodating such requests meant that only female residents could attend the birth. For male residents and medical students, this exclusion meant lost learning opportunities and for female residents a potentially overwhelming burden of care.
I think that's a huge barrier to not only care, but also from—when you're coming to a learning hospital, I think it's a huge barrier to our trainees, and them getting the experience and the exposure that they deserve too.
—Staff obstetrician, female
Exclusion of male teaching staff from the labor room was also considered detrimental given that direct supervision is an essential element of training.
…from an education point of view, we have to be supervising people, and then to be deliberately not supervising people because of their choice of the sex I don't think should be done and I think is wrong.
—Staff obstetrician, male
In discussing all this, physicians argued in favor of establishing a clearcut guideline to address patients' requests for a female health care provider. They wanted a policy that would both protect patients by providing more guidance on their rights and support physicians on ways to address the issue. However, respondents mainly argued that such guidelines would guard against ambiguity and provide physicians with a framework within which they could decline the request.
[It] would make people more empowered to say that we aren't sexist here, and we have support not to be sexist, because we're all having the same opinion about that. And so I think if we work together as a group about that, it would be a lot easier for everybody, and you would never feel like you are discriminating, or not providing patient-centered care.
—Obstetrics resident, female
Physicians in our study expressed strong values around gender equity and felt accommodating requests for female health care providers violated these principles. These responses can be understood both in the history of gender-based exclusion within the medical profession and in the fragility of successes in a medical system that, “feminized incompletely and unevenly.”19 Currently, female physicians are still unequally distributed across medical specialties and face discrimination, including receiving less pay than men for equivalent hours and being underrepresented in research and leadership positions.19,20 Full gender equality remains aspirational rather than a realized goal. Although it would be easy to exclude male physicians from delivery rooms, our respondents, including the women, rejected this route. Instead they chose to follow the principle that personal preference or cultural norms do not constitute legitimate grounds for excluding any physician.
However, articulating these values within the hospital context remained a problem for our respondents. They chose to frame their concerns in terms of practical issues such as scheduling difficulties, increased costs, and difficulties in providing appropriate supervision of learners, loss of learning opportunities for male learners, and an increased workload for female learners. We postulate our respondents' avoidance of discussion of their own values reflects two social pressures. First, people from powerful groups such as physicians working within the medical system often avoid emphasizing their own authority when dealing with people from relatively marginal or vulnerable populations. Second, medical authority is based on impersonal scientific evidence and its pragmatic application in clinical practice, which discourages physicians from treating their own values as legitimate grounds for decisions. The appeal by physicians in this study for the establishment of formal guidelines on gender-of-health-care-provider requests follows that pattern. Such guidelines would excuse them from having to make value judgments about the legitimacy of each request and would allow them to focus on the clinical aspects of the case.
These findings concur with studies from Ireland and Finland where physicians were also found to be resistant to accommodating immigrant patients' requests.12,13 However, these quantitative studies focused on issues such as communication difficulties, different cultural traditions, and patients' religious beliefs as reasons underlying physician resistance. None of these studies explored in greater depth the reasons behind physician resistance. This study adds the insight that physicians' responses to immigrant women's gender-of-health-care-provider requests are not simply a matter of workload or medical risks; they are also entwined with physicians' personal and professional values, particularly around gender equity.
Fortunately, there is emerging evidence that immigrant women largely accept male health care providers. In one study, more than half of the women surveyed had no preference about the gender of the obstetrician and, among those with a preference for a female health care provider, only a small proportion cited religious values as the reason.8 Similarly, in Finland, although physicians reported problems with communication and cultural expectations, they also reported reaching tentative mutual understandings with the immigrant women in their care.13
There are a number of limitations of the study. The findings presented here are based on interviews with a sample of physicians working at one hospital and are subject to the limitations inherent in any qualitative study.14 Although the intent is not to generalize these findings to all physicians, they nevertheless provide new insights into how physicians in this setting respond to accommodating gender-of-health-care-provider requests by immigrant women. Another possible limitation is the interviews are based on 20 physicians who agreed to participate. However, a key feature of a “good” respondent is willingness and availability to talk to researchers,21 which can only be assured when respondents willingly participate in time-consuming, in-depth interviews. Moreover, the sample of 20 was obtained from a universe of 45 physicians. In qualitative research, saturation of data drives sample size and according to Guest,17 a sample of 12 respondents is sufficient to obtain saturation.
In conclusion, our research provides evidence for the basis of Society of Obstetricians and Gynaecologists' current policy that requests for female health care providers is a violation of physician rights and should not be met. We advise additional in-depth research be carried out before making any changes to existing policies around accommodating specific health care provider gender requests. For example, a first step would be to broadly survey obstetric health care providers to explore how common these physician perceptions are for patients’ requests for female health care providers. There is also a need to document the prevalence of gender-based requests intrapartum and the degree to which this affects patient outcomes before making policy changes.
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