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Table 2 The gender ethics protocol

From: The advancement of a gender ethics protocol to uncover gender ethical dilemmas in midwifery: a preliminary theory model

Article 1

Article 2

1. Ethical dilemmas presented in the article

Overarching ethical dilemma: Whether the fetus shows sign of life after termination of pregnancy

Underlying ethical dilemma: The increasing influence of other professions, especially physicians, becomes apparent in the counselling of pregnant women/couples after diagnosis of fetal abnormalities

1. Ethical dilemmas presented in the article

Overarching ethical dilemma: That Japanese midwives are obliged to assist women with abortion and/or that they are poorly educated to take on this task

Underlying ethical dilemma: Midwives cannot decline abortion care

Abortion and deliveries are carried out in the same institutional framework

2. Context of the study

Midwives in Denmark working with late termination of pregnancy (TOP)

Danish TOP practices

2. Context of the study

Abortion care education programs in nurse and midwifery schools in Japan. Abortion is legal up to week 21 for reasons such as rape, the physical health of the mother, or socioeconomic hardship

Most of the abortions are performed before gestational week 12

Medical abortions using drugs are rare in Japan. Surgical methods such as dilatation and curettage are used

3. Method (e.g., qualitative/quantitative/observation/document analyses)

Qualitative interviews with ten midwives

3. Method (e.g., qualitative/quantitative/observation/document analyses)

A descriptive study to determine the extent of abortion care education programs and the respondents’ perceptions of abortion care education

  (a) Who is researching what

The researchers from the unit of women and gender research in medicine, Department of Public Health

(a) Who is researching what

A researcher from the Division of Health Care Science, Kanazawa University, Japan

  (b) Empirical material (data)

Interview transcripts with midwives

(b) Empirical material (data)

A questionnaire was developed based on ten topics identified form an analysis of 220 textbooks about reproductive health

  (c) Preunderstanding of the researchers

No preunderstanding is stated

   (c) Preunderstanding of the researchers

No preunderstanding is stated

4. Theory? (e.g., feminist analysis, content analysis, grounded theory)

Grounded theory (Corbin and Strauss), Theories of professions (Brante and Eriksen)

4. Theory? (e.g., feminist analysis, content analysis, grounded theory)

None

5. The article’s conclusion about the ethical dilemmas

The personification of the fetus is driven by the changing guidelines at hospitals

The views of the professionals, the wishes of the women/couples, and the influence of other professionals. (gynecologists/obstetrics) in “nagging” the freedom for midwives in their work with women/couples

5. The article’s conclusion about the ethical dilemmas

Education and practice guidelines should be developed

Abortion care education and training for nurses and midwives in Japan have deficits. Abortion care must be incorporated

Abortion care education and training are lacking in education and training programs

The skills in reproductive health such as family planning and abortion care should be in the curricula for midwives as the midwives are required to treat women in a professional manner (the code of conduct)

6. Gender

Women/couples. Midwives = predominantly women

How is gender conceptualized?

Gender = “sex” (men and women)

Gender as a social category (how they act and react)

Gender as a power relationship (e.g., disagreement between pregnant women, physicians, or midwives/obstetricians)

Different positions in the hierarchy where physicians influence midwives

Gender and power: If physicians do not order enough medication during the abortion, midwives will be alone and responsible for taking care of the dying fetus when parents refrain refuse

Midwives disagreed with how physicians counselled the women/couples after prenatal “diagnosis.”

Further research is needed to secure the best possible working conditions for midwives and how to optimize the care for women/couples

The institutional setting is highly influenced by other professionals (physicians)

6. Gender

93% of responders were women

How is gender conceptualized?

Gender = “sex” (men and women)

Gender as a social category (how they act and react)

Gender as a power relationship (e.g., disagreement between pregnant women, physicians, or midwives/obstetricians)

Disagreement concerning abortion care. The author indicates that in the US and in many EU countries health care providers can decide if they want to take part in the abortion

Male pressure (disagreement?) on a woman to undergo an abortion has a negative impact on women’s mental health

The obstetrician/gynecologist’s power to decide the abortion method and choose a more harmful method instead of a modern method for abortion (mifepristone)

Imbalanced power in decision making between obstetricians and midwives

The lack of mandate for midwives in relation to abortion care is a serious shortcoming

  (a) Gender as invisible

Gender/power is visible in the article. The structure of the organization indicates that doctors are making decisions rather than midwives

(a) Gender as invisible

Gender is invisible. Although the WHO recommends medical abortion, most women in Japan must have a surgical abortion with curette dilatation

7. Power dynamics in the article

(e.g., East/West, privileged/unprivileged,)

Midwives are a female profession that differentiates from “the medical focus that is otherwise present at the hospital and among other professions.”

Power dynamics—YES! Midwives are less privileged compared to doctors = hierarchy, a female job

7. Power dynamics in the article

(e.g., East/West, privileged/unprivileged)

As midwives are supervised and employed by obstetricians, midwives cannot decline the routines (the sharp curette method)

  (a) Acceptable, unacceptable practices? (e.g., not acceptable to leave midwives with a fetus that is still alive)

“Midwives experience losing the ability to set the conditions for their own work [...]. Instead they choose to focus on their own professional identity and hold on to their ideals, even though it is difficult at the hospital” (918)

Not acceptable that midwives should be responsible for handling a dying fetus

“The increasing influence of physicians becomes apparent in the counselling of pregnant women/couples after diagnosis of fetal abnormalities. [...] Several midwifes are critical of the counselling sessions. They believed that physicians had already made a decision as to whether or not to perform late TOP before speaking to the woman/couple” (917–18)

   (a) Acceptable, unacceptable practices? (e.g., misogyny or pro-women centered)

Not acceptable that health care providers can decline abortion care

  (b) Who does the article talk about as the “good” professional and who is the “other” = othering, e.g., fat women as deviating from the norm?

The midwives are perhaps the “good” professionals

   (b) Who does the article talk about as the “good” professional and who is the “other” = othering, e.g., fat women as deviating from the norm?

Difficult to say: nurses? midwives?

East/West (midwives in US and EU are allowed to refuse to take part in an abortion)

8. What is not talked about in the article

What other professions or the women think

What is not talked about: The reason why midwives must handle the dying fetus: Is it their responsibility?

Men/fathers or partners are not discussed in the article

8. What is not talked about in the article

Authors relationship to the field of research

How do women experience abortion services?

Is abortion care contradictory to midwifery?

Women’s situations in abortion care are not talked about

The costs (financial, psychological, and physical)

Ethical issues are there but rarely discussed

Anti-feminist approaches

  1. Focus of data extracts and analysis from two articles on ethical dilemmas in abortion care