Aotearoa perinatal care is slowly becoming more inclusive, but some trans, non-binary and gender-diverse Kiwis are still facing discrimination. Katie Harris looks into the quiet shift and what experts say still needs to change.
"Pregnant people should discuss the timing of their booster with their midwife.
"The health and wellbeing of pregnant people and their babies is of paramount importance.
"Evidence shows that pregnant people and newborn babies are at greater risk of poor outcomes if infected with Covid-19."
For many, these statements on the Ministry of Health website's fact sheet on Covid-19 during pregnancy, which only uses the word "women" once, might not feel important, but for gender-diverse Kiwis, the change in terminology can make a world of difference.
Although the ministry says there's been no directive that's gone out to staff about what language they use, the agency has made a clear move toward being more inclusive in its messaging when it comes to pregnancy care.
Across Aotearoa, some midwives are changing terms like mother to pregnant person, others say chestfeeding instead of breastfeeding and charity The Period Place uses phrases like "people who get periods".
Te Aho o Te Kahu (the Cancer Control Agency) is more explicit: "Uterine cancer affects people with a uterus: women, trans-men, non-binary people assigned female at birth and some intersex people," it says on their website.
Although these changes have been welcomed by many in the space, some see them only as a first step, believing they should also incorporate greater education for health workers.
Women are not being erased
Heated discussion overseas surrounding perinatal terminology is not new but as research emerges showing the benefits of language inclusivity, more health care providers globally are making the switch.
Dr George Parker, a health services lecturer at Victoria University of Wellington, says there is no short answer as to why inclusive language isn't already in use or why people may be opposed to the language, but one challenge they say is the persistence of gender essentialism in our models of care.
"Gender essentialism is a framework of ideas that conflate sex assigned at birth with gender when in reality these are two distinct things."
Parker says conflating the distinction between sex assigned at birth and gender helps us understand that pregnant and birthing people may have a gender distinct from their assigned sex at birth.
Despite how gender essentialist ideas harm trans and non-binary people, Parker says they continue in perinatal care.
"Another factor is the Terf [trans exclusionary radical feminist] backlash we are seeing and some misinformed ideas that embracing trans and non-binary inclusion will lead to the invisibility of ciswomen and feminist goals of equality for women. This is an idea propagated by Terfs and is more based on fears than actualities."
Parker is the lead investigator on the Trans Pregnancy Care Project, a $180,000 government-funded research project looking to understand the need for inclusive perinatal care in Aotearoa and ways to achieve it.
Parker says that although positive changes are being made, the system as a whole is "not delivering" for trans, non-binary and gender-diverse people.
Even though society may be moving away from overt transphobia, they say there are still structural norms that can infer pregnancy care isn't for gender-diverse people.
To the best of Parker's knowledge, there's not information currently being collected on the number of gender-diverse Kiwis needing pregnancy care, but they say it's needed and they would love to see it happen.
The research has two phases, the first involves speaking to gender-diverse whānau about their experience getting fertility and pregnancy care. Then surveying the perinatal workforce about their knowledge and beliefs, and what education they need to be able to provide the best care.
Parker points to the day-to-day stress research participants reported experiencing, such as feeling invisible or that their perinatal care is not for them, and being misgendered.
"That has an incredibly accumulative toll on the mental health and wellbeing on our families during their pregnancy and birth.
"It's not a nice start for their parenting journey."
Through their research, they heard examples of individual midwives or doctors who were providing great gender-affirming care, but it was not universal.
"When our participants go beyond those trusted providers and into general services whether that's a post-natal ward or a delivery unit they are encountering not inclusive care."
When language is not inclusive, communities don't trust their healthcare providers and aren't able to get the care they need, Parker says.
Inclusive language is not a "nicety" and it can not be extracted by real everyday experience, Parker explained, noting how participants reported the harmful effects that exclusive language and practices have had on their health and wellbeing.
"This isn't just a debate on Twitter, this is a real everyday set of practices that are harmful to our families when we don't get it right."
Some change is afoot and Parker says some workers are shifting to gender-neutral words or gender-additive language, like women and people, instead of just women.
A Te Whatu Ora Health New Zealand spokesperson says Parker's project was a joint funding initiative between the Ministry of Health and the Health Research Council of New Zealand.
"The study, understanding the need for trans and non-binary-inclusive maternity care, aims to help achieve equitable maternal and infant health outcomes in Aotearoa New Zealand."
They say the ministry is working with districts to consider how to improve access to services, including services for gender diverse and non-binary people.
This year's Budget also committed $2.182 million to support primary and community health providers to improve the responsiveness of the health workforce to gender-diverse people.
Around the world, the use of inclusive pregnancy language by government agencies is more divisive.
In 2021 in the UK, Brighton NHS trust introduced language guidelines to support trans and non-binary birthing people, which included terms like "mothers and birthing parents", they faced backlash online with some claiming it was "eradicating women".
However, it was also celebrated by many, and research published in the British Journal of Midwifery this year showed 71 per cent of all NHS services websites used inclusive language.
The study's conclusion said language inclusivity in maternity services may help to reduce discrimination experienced by transgender and non-binary patients and contribute to a more diverse workforce.
The debate around terminology when it comes to women's health was also thrown into the public consciousness in July following the US Supreme Court's decision to overturn Roe v Wade, the 1973 landmark ruling that guaranteed a constitutional right to abortion.
In Australia, the trial of a medical form using the term "birthing parent" was halted last month by Services Minister Bill Shorten following criticism from Sall Grover, the founder of a female social network that excludes trans women.
Grover has been accused of alleged transphobia and multiple recent tweets seen by the Herald on Sunday show Grover misgendering trans people.
Grover told the Herald on Sunday she rejects the notion that her refusing to call a trans woman "she" or "her" makes her transphobic.
"The concept that birthing parent, uterus havers, cervix owners or any other similar terms are inclusive is simply incorrect. Not only do many of these terms have the potential to confuse and exclude people who have a limited understanding of English or a limited medical vocabulary, anyone who opposes the terms is immediately labeled a transphobe or a bigot in an attempt to exclude us from civil society.
"Furthermore, more conversations need to be had about how some women can, apparently, cope with pregnancy despite suffering from gender dysphoria but, apparently, cannot cope with the words 'pregnant woman' or 'mother'. If they want to be given an alternative title, it is between them and their midwife or doctor. It is not something everyone else should have to deal with."
The decision to scrap the trial was met with frustration from reality star Angie Kent, who said on the Two Girls One Podcast show that stopping it was a "waste of time and money".
Greens LGBTQ+ spokesperson Stephen Bates wrote on Twitter that it was "disappointing" to see one of Shorten's first acts in the job was to remove inclusive language.
"Inclusion of all does not come at the exclusion of anyone else," Bates tweeted.
Being a trans healthcare consumer
Frankie, a non-binary trans-gay man, is in the process of trying to have a child with their husband Rāwā.
They told the Herald on Sunday they felt uncomfortable being in pregnancy and birthing spaces because words like mother are everywhere.
"Being a bearded cis-passing trans person, the people in the waiting room look at me like 'what is he doing here?'"
That being said, when they have seen a registrar or a consultant Frankie says they have typically been very respectful, used the correct pronouns and made sure that they used inclusive language.
They say they feel like an imposter even though they can carry their own child, which is something they are actively trying to do.
Frankie, who works as a human-rights advocate specialising in intersectional equity issues, pointed to "femininely suggestive" decor, for example, certain posters and artwork, as something that was heteronormative and female-focused.
"The focus is on sex and the fact that [only] 'women have children', that is simply untrue. Trans and non-binary people have been having children for a long time."
Only of late has this become a "sexy topic" of discussion, Frankie says, and even recent coverage has been done "salacious and scandalously" to dehumanise the pregnant person.
Frankie believes that if these clinics were more inclusive it would mean more trans and non-binary people would feel comfortable in considering whether or not they want to carry their own child.
"Often the dysphoria is triggered by the unnecessary injection of femininity into the space. We know through telling our story of at least three other couples who would have never otherwise considered travelling the path we are on."
They say inclusivity promotes informed decisions and bodily autonomy, which is important for all people, but particularly meaningful for trans, non-binary people and women.
"This must happen at the clinical level but also in the non-clinical support spaces if change is to be enduring and meaningful."
Pregnancy care for everyone
When midwife Arlene Oram was working for a public hospital within the Auckland DHB, she felt she was having to "constantly" come out as queer to her colleagues at work and act as a "bodyguard" for her clients so they didn't have to deal with internalised homophobia.
She says she saw firsthand the "limited understanding" many had on how to care for pregnant people in the rainbow community.
After witnessing negative comments towards LGBTQI+ people in the tea room and being given an unwanted moniker by staff ("queer midwife") she felt the need to act fast.
"Changing policies and education and stuff like that is really important but it's also a really long-term goal - you can't change people's preconceived ideas or judgments overnight."
That's when Oram launched EMPWR, which she describes is a holistic pregnancy health practice dedicated to providing compassionate care to Auckland's queer community.
"I felt validated seeing these really glorious rainbow families just living their lives and doing their thing and being quite happy, so that was an unexpected outcome for me.
"People feel safe to be themselves, particularly within the birthing space."
In a Facebook video posted for Aotearoa Patient Safety Day, a couple who Arlene helped through their pregnancy shared how Oram had supported them throughout the process.
"It was so good having her there," they said, "When your trusting someone with bringing someone into this world, someone that you've waited so long for and just can't wait to meet, in order for that to go well, whether it goes quickly or not, there has to be a level of trust both for you with them but also for them with you."
Included in her offering is a resource she created for pregnant people, similar to what is available through Health NZ, but with diverse images and language because traditional resources surrounding pregnancy and birthing in New Zealand have been cis-centred.
Also important to Oram was finding a clinic for EMPWR that wasn't in a maternity clinic, which again is gendered. Initially, she set up shop in the Tonic Room in Kingsland but now practises in her own home.
"Going into that [traditional] space to see their midwife particularly if their body is changing and it's making them feel big feelings about their gender or identity anyway then going into a space that is very cis and het will be triggering for them.
"I don't think you have to be a queer midwife to provide queer inclusive pregnancy care, but you have to have done a lot of work and be a really good ally."