The Truly Oldest Profession: Facing
Future Challenges
Speech by Federal Sex Discrimination
Commissioner Pru Goward at the NSW Midwives Conference, 25
July 2003.
- Thank you Hannah for
inviting me to speak to you today.
- I would like to begin
by acknowledging the traditional owners of the land, the Eora people and all
the wonderful women here who regularly partake in the miracle of delivering
life.
- It must be a source
of great pride to midwives to consider you are part of a profession that reaches
back thousands of years and across all cultures, that has seen its members
reviled and murdered as witches and revered as saints.
- Certainly the patience
of a saint and the powers of a witch are needed today with the challenges
before this ancient and honourable profession.
- I understand from your
association that the difficulty of accessing professional indemnity insurance
is now driving people from your profession as it is from doctoring.
- It is disappointing
that governments have not seen fit to assist midwives with insurance in the
same way they have with doctors, but sadly that is entirely consistent with
the public-life view of women’s work.
- Whether it be mothering,
cleaning, caring for other people’s children or serving them food, traditional
women’s work has never been much valued in the world of work.
- After all, women’s
work is just what women do- there is a strong belief that if women do it well
it is not because of any skill and dedication, it’s just the way women
are. No need to reward it, it comes with the package anyway, it is genetic.
- A quick glance at the
list of issues confronting you and the facts surrounding them (such as the
low numbers of midwives and the lack of indemnity insurance) suggests that
the Association certainly has its lobbying work cut out for it.
- The New Zealand decision
to allow universal access to midwifery from 1990 looks like a good starting
point in making the case for similar change here, but is not an area in which
I would venture an opinion.
- Today I would like to
address two issues of concern to both of us:
- The shortage of midwives
and the rising number of maternal deaths. I am unable and unwilling to make
a direct link between these two outcomes but each of them is of concern in
its own right.
- Let me begin with maternal
deaths. I have drawn my material largely from the authoritative 1994-6 Report
on Maternal Deaths in Australia, the most recent triennial report available.
- The report is compiled
by a distinguished panel of professionals and relies on well respected data
bases, including the State and Territories Confidential Death Enquiries.
- It goes without saying
that the maternal death rate in Australia is low, 13 per one hundred thousand
births. It is low by international standards, although only in the middle
of the range for developed countries.
- We are comparable to
Japan, NZ, western and northern Europe and USA - around 10 (direct deaths)
per 100,000 (live births). Ratios in southern and eastern Europe slightly
higher at about 30 deaths per 100,000 live births. Australia ranked 9th in
1990. Indonesia has the highest rate, Canada, Norway and Switzerland the lowest.
- What is troubling today
is that the maternal death rate in Australia has risen. 13 deaths per 100,000
confinements is an increase. That is according to the last report from the
NHMRC, 1994-96, the latest period for which authoritative data is available.
- We are still awaiting
the report of the most recent triennial, and I have to say it seems to be
very slow in coming. I understood there was some talk of discontinuing with
the report but the NHMRC has advised me that the 1997-1999 Report will be
available next year.
- But we all know the
difference between mortality and morbidity. Mortality is death, morbidity
is ill-health. Epidemiologists link them closely. Where ever there is a climbing
mortality rate, you can be sure there is an increasing morbidity rate and
inevitably morbidity is more prevalent in any given population.
- So, for example, with
every percent increase in the maternal mortality rate, you can expect to find
an increase in the numbers of punctured bladders, torn or permanently damaged
anal muscles, incontinent bladders and uteri, and so on.
- So it is foolish to
pat ourselves on the back and say that a rate of 13 deaths per hundred thousand
confinements is nothing to worry about. It means tragedy for the one hundred
women who died and their families who mourn, any increase in maternal death
rates is disturbing and also suggests an underlying increase in the morbidity
rate which affects far more women
- It is particularly alarming
to think it is going up in an age of improved medical and surgical care
- The obvious points about
the causes of the increasing death rate are made in the Report- increasing
maternal age is a factor, with mothers over the age of thirty five being the
fast growing age group of mothers.
- The authors also point
out that women with complex medical conditions believing modern medicine will
save them are now more willing to take the risk on a pregnancy, some with
tragic results.
- Surely maternal age
is something we can address? Australia does not have a good record in facing
up to issues surrounding sexuality; we have a high teenage abortion rate and
now a high infertility rate among older women, many of whom are shocked to
discover that their age has betrayed them without their knowledge. The truth
is we don’t discuss the higher risks facing women who delay child birth,
such as the risks of death and the risks of not being able to bear a child.
- Interestingly, the Report
finds that once age is standardised the death rate among older mothers (over
forty) has actually declined since 1973 while the age standardised death rate
for women aged 30 -34 has risen alarmingly.
- This age group now has
the highest standardised maternal death rate. It is also the age group most
likely now to begin having children. This suggests to me that women over forty
take their maternal health very seriously (as do their doctors or midwives)
but that women in their early thirties are more likely not to consider their
age a problem.
- When you think women’s
fertility begins to decline from the age of 27, perhaps we should assume there
will be broader health implications by the time they are in their early thirties.
- The high incidence of
mothers, especially first time mothers, in paid work during their pregnancy
may also impact on health outcomes. Busy women are more likely not to see
a doctor early on, or regularly, if they are working.
- I did not work while
bearing either of my first two children, and spent many a happy hour reading
magazines in the doctor’s surgery, waiting to be told how I was doing
and to report any little problems.
- Even when pregnant with
my last child, I lived in Canberra, a city that made it possible for me to
fit a weekly visit to the obstetrician in around my busy schedule as a radio
presenter for the last month of the pregnancy.
- You can be sure however,
that many young women today just can’t get there that often. The forty
minute bus trip across town during a lunch hour is just not on for most young
working expectant mothers.
- It would be no bad thing
if the NSW Midwives Association made it their business to lobby government
to begin public awareness campaigns about the importance of early prenatal
care, of on-going prenatal care and of risk factors associated with maternity
such as ageing mother hood.
- A final reference to
the Triennial Report.
- “Avoidable factors”.
Accidents. Errors. Of the one hundred deaths, one occurred with a midwife.
The others occurred in hospital-medical settings.
- But the Report found
“avoidable factors” (such a euphemism) were possibly or certainly
present in 48 per cent of deaths directly the result of giving birth, and
20 per cent of indirect deaths. This is a doubling in the percentage of avoidable
factor- deaths since the previous report.
- The patient was responsible
for the avoidable factor in two cases, most were doctor and or hospital or
doctor. Only one death involved a doctor and patient avoidable factor. I infer
from the Report that avoidable factors were not involved in the death where
a midwife was present.
- As a consequence, the
Report called for greater scrutiny and surveillance of maternal deaths but
if it’s happened it certainly isn’t public.
- Again, a worthy cause
for the Midwives Association to take up
- Let me turn now to the
shortage of midwives. I understand there is a shortfall of almost two thousand
midwives in Australia. With the average age of nurses now well into their
forties, we have a situation where more people are leaving than entering this
profession.
- The good news, if we
want to be very black-humoured, is that Australia’s birth rate is so
woeful, and projected to fall further, we will need fewer midwives.
- There is no doubt midwives
get bad press. Stories of midwives bungling deliveries and facing litigation
from heart broken parents abound, undoubtedly discouraging mid wife use.
- The facts need to be
put on the table- and advertised- if you, the midwives, want that to change.
I leave that as a challenge for you. It is in the interests of all of us that
this issue is put to rest and who better than this association to take up
the debate.
- It is reminiscent of
an earlier battle your predecessors fought and lost; the mediaeval battle
between church and witches (who were really female doctors and midwives).
- This battle to the
death, which began in 1484 with a papal bull condemning all practices of diabolic
art and led to the deaths of thousands of women by fire or drowning, was not
really about the use of magic and supernatural evil, but about who had power
over life and death, men or women, and who collected the money.
- We must ensure that
this time the battle is not won or lost without a good fight about the facts.
- The declining numbers
taking up nursing careers- and midwifery- is undoubtedly the result of many
social and economic changes.
- A greater range of education
and career choices for women, low wage rates associated with midwifery, the
terrible work hours associated with child birth and the consequent difficulty
in juggling work and family commitments plus the increasing risk of litigation,
all discourage young women from entering the profession or staying in it.
- While midwives working
in hospitals may have better access to family friendly provisions, it is clear
that those engaged in health centres or as home birth midwives work under
very different conditions.
- Paid maternity leave
has long been standard for nurses in public and most private hospitals; not
so outside. Interestingly, there is quite strong evidence that a period of
paid leave after the birth of a child is associated with a reduction in infant
mortality rates.
- It has to be added that
there is not much of a relationship between paid leave and low birth weight
and only a very small reduction in neonatal mortality.
- Child birth deaths are
not related to paid leave- and if almost half our child-birth deaths are the
result of errors, then that’s exactly what we could expect.
- But according to an
American study of European countries offering paid leave, a 10 per cent decrease
in women employed is associated with a 5.5 per cent decrease in post neonatal
mortality.
- Post neonatal babies
are those between a month and a year old. In other words helping mothers to
stay home with their babies is better for the baby’s prospects as well
as the mother’s recovery.
- Health economist Christopher
Rhum from the University of North Carolina, who did the study, estimates a
10-week increase in paid leave reduces infant mortality rates by between 2.5
per cent and 3.4 per cent. A lot of this is due to breast feeding but the
high level of attentiveness mothers give their babies is clearly also important.
- Child fatalities go
down by between 3.3-3.5 per cent with an extra ten weeks of paid leave. Again,
you can expect the morbidity effects to be even greater.
- Yet despite this- and
an overwhelming body of other evidence to suggest the health and welfare benefits
to Australian families would be enormous- Australia remains one of only two
OECD countries in the world without a nationally mandated scheme.
- No wonder countries
like Canada, where they offer 50 weeks of paid leave at 55 per cent of earnings,
are poaching our nurses and teachers and anyone else they can get their hands
on.
- Forty thousand Australians
left Australia last year- the highest number ever- and if we want them to
come back here when it is time for them to start their families, we need to
see we are in competition with other countries that welcome working parenthood
and support it.
- My proposal for paid
maternity leave, which I submitted to the Government last December, proposed
a government funded scheme for women who had been in paid work for 40 of the
past 52 weeks.
- They could be part time,
casual, full time, self employed, bosses or contract workers. They just have
to have worked regularly enough to demonstrate a reliance on income.
- Eligible women would
receive up to the minimum wage for a period up to 14 weeks. They would not
be eligible for some other government benefits during that period, nor the
Maternity Allowance nor the first twelve months of the Baby Bonus. If they
went back to work before that, they did not receive the benefit.
- The net cost of the
scheme was estimated to be $213million a year. Cheaper than any other family
support programme, including the maternity allowance. Certainly very affordable
and modest, hardly a burden for the Australian tax payer, especially when
compared with the $17 billion the Australian Government currently spends supporting
our families.
- Never let it be said
that having a child is a personal choice and tax payers need not be involved.
Australian tax payers have been involved since the introduction of the first
maternity benefit in 1912- a benefit paid to married and unmarried mothers.
We support families to ensure all our children get a decent start.
- Paid maternity leave
is no different- it ensures all Australian children get off to a decent start,
meaning they are able to be breast fed, to feel loved and needed, to have
their developmental needs supported and enhanced by the full time love and
care of a parent.
- Midwives, like other
Australian women, are caught up in the nightmare of combining work and family.
While 57 per cent of mothers work part time, 43 per cent work full time.
- Forty three percent
of mothers do the crazy mother juggle five days a week. The other 57 per cent
do it two or three days a week. The so called very flexible family friendly
workers- some might say they are the lucky ones- who work shorter hours each
day are the casuals and part timers least likely to enjoy paid leave entitlements
like paid maternity leave or sick leave.
- The Australian Institute
of Family Studies estimates that 40 per cent of Australian mothers work without
access to paid benefits, including paid maternity leave.
- In fact it comes as
something as a shock to people to discover that Australia is the sort of place
that gives you paid sick leave if you break your leg playing football on Saturday
and need time off work but doesn’t give you a day’s paid leave
if you have a Caesarian section.
- Perhaps there are also
some contradictions in a so called family friendly country like Australia
paying child care subsidies to women who return to work and leave their child
in someone else’s care but nothing to the woman who wants to do the
caring herself for the first three months.
- With an ageing society
of course, it is not just children women are looking after. Ageing relatives
also have demands.
- With the determined
reduction in the numbers in institutionalised care, it is increasingly families
who are caring for parents post operatively, sorting out dad’s phone
bill, taking mum shopping and doing their washing. That mostly means women
doing the caring.
- I sometimes wonder how
women have time to work- they do ¾ of the unpaid child care and 2/3
of housework.
- Working mothers sleep
less than others and spend even less time on personal grooming than men do.
- It is no wonder that
the Australian birth rate has dropped to 1.73 children on average, per woman.
That old saying that if men had babies there might be a first child but there
wouldn’t be a second is now proving true for women too.
- The enormous difficulties
women encounter should they wish to combine work and family means many really
don’t want to do it a second time. Perhaps this explains why the birth
rate has dropped.
- While there are more
women ending their lives without having children at all, women also have fewer
children. The number of only-child families has risen from one in five families
in 1980 to one in three families today.
- There are primary schools
in Melbourne and Sydney where half the class is made up of only children.
It’s also clear, listening to women describe their decision-making,
that return to work is a big issue.
- Most women want as much
time off work as possible, but it needs to be paid. Couples save up for babies.
They save up her annual leave for a couple of years, they pay the mortgage
off in advance, they stop going on holidays or out for a meal.
- With all that, they
can afford to take maybe six months off work. If they have employers who offer
paid maternity leave, they will take longer.
- A recent Queensland
survey showed that one in three women who took maternity leave was back at
work by the time the baby was six months old. Since no more than 40 per cent
of mothers in the workforce have access to paid maternity leave, this is understandable.
- Now a family will do
that the first time, for the first child. But there just aren’t the
resources and time squirreling possibilities there to do it again, for the
second child. So increasingly they don’t.
- We have made the choice
of having children just too hard for all but the unemployed, the wealthy and
the very children-committed. I suspect if that had been the reality during
our parents’ day, many of us would not be here today.
- It should not be that
people have to be very poor or very rich or are especially keen on having
children in order to do so.
- We are not alone. All
OECD countries are dealing with birth rates below replacement level. Only
the United States and ourselves do not have pro natal policies to address
this. Only the United States and ourselves do not have paid maternity leave.
- Some countries, like
France, believe the increase in their birth rate is the result of family friendly
policies like six months paid maternity leave. The Scandinavian countries
certainly enjoy higher birth rates than those parts of Europe without family-friendly
work policies.
- Paid maternity leave
alone cannot fix the problem, although there is some evidence in America that
women in companies which offer paid maternity leave have slightly higher fertility
rates than those working in companies who do not.
- But there is no country
in the world trying to address its fertility problem, including traditional
family values countries like Portugal, which got down to a birth rate of 1.1
children per woman, that does not include paid maternity leave in its suite
of measures. For the obvious reason that women will be reluctant to have children
if they cannot afford to stay home to recover from the birth.
- Most people don’t
take three months off to have a holiday without using paid leave either, and
child rearing is no holiday!
- There has been a strong
moralistic dimension to the debate about paid maternity leave to which I have
objected. It was not a moral objection raised by the Churches- both the Catholic
Archbishop of Sydney, George Pell, and the head of the Central Mission, Gordon
Moyes, support paid maternity leave, but there was the view that it was immoral
for women to work with children and that paid maternity leave would reward
this immorality- that somehow it would make them go back to work and legitimise
their sin.
- This ignores the fact
that existing industrial paid maternity leave arrangements do exactly that-
almost always the woman has to return to work before she receives the balance
of the leave monies owing, often forcing her back to work earlier than she
would have liked.
- Upon reflection, I
too believe there is a moral dimension to the paid maternity leave debate.
I believe it is immoral to turn our backs on women and babies at the most
vulnerable stages of their lives and tolerate a situation where all our bar
maids and hotel workers are estimated to be back at work within three months,
where half our car factory and assembly line workers come back to work as
soon as their six weeks leave are up, and where the number of women returning
to work within a year of the birth grows every year.
- The proportion of mothers
of children under one in paid work has doubled from 17 per cent in 1976 to
36 per cent in 2001 (the space of a single generation).
- That is immoral. And
it is no longer happening in other western countries.
- Women have come as far
as they can alone. The super mum syndrome is as prevalent today as it has
been since mothers began to stay in the workforce and the pay gap has hit
a ceiling at 85 cents in the male dollar for those in full time work. If we
include part time and casual workers, the gender pay gap stretches to 63 cents
in the male dollar. We have hit a ceiling.
- Until we get more men-
and in particular more fathers- engaged in equal sharing of family responsibilities,
female-dominated professions like midwifery will struggle to retain skilled
and experienced workers.
- Women will continue
to enter and leave the workforce at great expense to employers and the economy.
All that investment in the education and training of young women will be seen
as less productive than investment in the education and training of young
men.
- So how do we do it?
- Practical change one
– the introduction of paid parental leave. While we recommended the
first fourteen weeks of paid leave be maternity leave only, and available
to non birth parents only in very limited circumstances, any longer period
of paid leave should be shared between parents.
- This is the standard
practice across Europe.
- In Denmark for example
28 weeks of paid maternity leave is provided to mothers, the last 10 of which
may be taken by the father.
- Turning to more long
term measures - flexible working arrangements, including part time work should
be available to all parents.
- It can be argued that
currently they are. The year of unpaid parental leave is available to either
mothers or fathers.
- In theory there is nothing
stopping men from accessing part time working arrangements or flexible work
hours.
- In reality, we do not
live in a society which tolerates or venerates men who do part time work or
leave work early to pick up a sick child from school.
- Our culture is such
that these men are more likely to be seen as uncommitted to their careers
to an even greater extent than women who allow their family life to intrude
into their working life.
- The tariff for being
involved in the unpaid caring work of their families is very high for men.
- So most of them don’t
do it.
- And as long as men continue
to earn more than women it usually makes more sense for the women to change
her paid work arrangements to factor in child care.
- The discrimination is
self perpetuating.
- The reality is then
that we can implement as many ‘family’ friendly practices or policies
as we like, however unless they are coupled with a genuine attitude that either
parent can access these measures they will be for ‘women only’.
- Averting the work/life
balance collision and replacing it with a genuine work life is both the key
issue and key challenge facing women today. It is also the key issue and challenge
facing men and the workforce overall.
- The time has come for
us to see this challenge in this holistic manner. It is the only way we will
ever achieve more progress, bridge that remaining gender pay gap.
- It is the only way there
will be equality of choice for men and women.
- Thankyou
Last
updated 25 August 2003.
