Discussion
This project obtained a snapshot of the gender of those in obstetrics and gynaecology leadership positions within Australia and New Zealand. This was done in the settings of RANZCOG, RANZCOG accredited hospitals, and university O&G departments.
It was clear from this research that RANZCOG’s national committees, and RANZCOG’s affiliated hospitals, do have a gender leadership gap (Table 1 & 2). As seen in recent publications by Hofler et al and Ricciotti et al investigating the United States, this finding is consistent with the international O&G gender leadership landscape (8, 11, 12, 14). Following on from Ricciotti et al, our study also demonstrated geographical variation in leadership, with the North Island of New Zealand a clear outlier. Here Auckland City Hospital, with its all-female leadership, strongly influenced this distribution. Despite leadership position geographic variation, our survey data revealed equal rates of ‘desire for leadership’, and ‘barriers to leadership’ between Australian and New Zealand. It is not known whether this reflects views from the North or South Island, as this level of geographic granularity was not collected. Exploring the ‘leadership culture’ of the Auckland department might shed light on possible solutions to the gender leadership inequality in other institutions.
Within RANZCOG’s state T&A and hospital ITP positions, female leadership was found to more closely reflect the membership (Table 1). This finding of equal or over-representation in ‘educationally related’ and ‘mid-level’ leadership roles has been noted previously for females in both medicine (12, 67, 91, 197) and other professions (89, 154, 198, 199). This again mirrored the findings from Ricciotti et al’s recent study of O&G in the United States (14), and may reflect the previously reported cultural bias of women becoming teachers (174). The reasons for the larger proportion of women in these educational leadership roles was unclear from our study, but again highlights the uncertainty of a pathway to top-level leadership when mid-level leadership does not predict progression to this.
The secondary aims of this study were to explore RANZCOG members’ experience and perspectives, desires, and barriers to leadership. Survey demographics did not perfectly represent the membership (Table 4), receiving a higher response rate from female RANZCOG members than male. This potential source of bias needs to be acknowledged, especially as sample representativeness appears to be more relevant than sample numbers (200). Nonetheless as the most important sample analyses were comparisons between genders, it is unlikely that this effects the conclusions. The reason for the responder-membership gender discord is uncertain, but may represent higher levels of desire for leadership among women (Table 7), driving their participation in the survey.
Consistent with RANZCOG, university departments, and hospital data, this survey demonstrated the highest prevalence of leadership to be among male responders (Table 5). Acknowledging the historically masculinised workforce, yet recent feminisation, it is these findings that provoke questions on why females are under represented in O&G leadership.
One consideration for the gender leadership gap stems from desirability. Do females desire leadership differently than males? This survey found females were actually more likely to desire additional or future leadership positions than male colleagues (Table 7), consistent with the broader medical literature on female leadership desirability (57). Notably this held true for the specialist responders, while both male and female trainees had equal levels of leadership desire (Table 5). For both genders, age above 50 years was associated with lesser desire for future leadership. As this cohort represents the age majority of current leaders, it may reflect attainment of leadership and the possible anticipation of retirement.
With an anticipated finding of leadership under-representation, but a new finding of high desirability, this study explored barriers that contribute to the ‘glass ceiling’ for females. Male and female responders revealed the same top four identifiable barriers to future leadership (available time, family commitments, personal energy, and position availability; Graph 1, Appendix 1 q7), but with a higher prevalence among female responders. This is consistent with literature revealing females are more negatively affected by parenting commitments and impediments to medical careers (5, 201-203). Again reinforcing their desire for leadership, ‘lack of interest’ was a less prevalent reported barrier for women than male colleagues for this question.
Parenting issues influencing leadership or career opportunities were present for both genders, but much more prevalent among female specialists. This issue is not unique to O&G and exists in many areas of medicine (204, 205). This suggests a strong societal bias to gender expectations with regards to parenting, with strong historical cultural roots. Currently members are required to individually advocate themselves for issues such as part-time positions, extended parental leave, and access to childcare and feeding rooms within institutions. As a professional body that supports childbirth, RANZCOG is well positioned to challenge these norms by shifting the culture and advocating for these flexible and inclusive opportunities.
Two unexpected themes emerged within responders’ comments on barriers to leadership. The first was of ‘disillusionment’, and was strongly weighted toward ‘RANZCOG’ among female specialists, and the ‘current leadership’ among male specialists. Leadership, both for individuals and institutions, is challenged if there is poor membership engagement (206-208), and within our study ‘disillusionment’ responses increased in frequency with increasing responder age. This suggests further authentic engagement is required, from both RANZCOG and RANZCOG leaders, if we are to improve and sustain leadership desirability and diversity. The second unexpected theme was ‘learning leadership’. It is important to note that there is no formalised RANZCOG leadership curriculum (182). Instead it falls to the individual to meet leadership- training needs through opportunities with other non-RANZCOG institutions. Even respondents in areas with high levels of female leadership (eg. New Zealand) identified the need for further leadership training. If as a profession we seek gender equity within the leadership landscape, then opportunities for specialists and trainees alike to develop leadership skills should be provided (38, 40, 209).
Leadership has many styles, with context an important consideration for achieving leadership success (35, 36, 39-41, 43, 48, 82, 194). Feminist leadership is more commonly associated with a democratic or participatory style (41, 42). Within Eagly et al’s meta-analysis, female leaders were found to be more transformational than male leaders (38), with previous findings that transformational leadership produces higher levels of effectiveness and engagement (40). Should RANZCOG take up the challenge of leadership training, the recognition of ‘gendered’ leadership traits and the value of feminist leadership may lead to improved diversity and subsequent engagement with members.
In the recently published 2017 McKinsey and Company report (210), women in healthcare leadership remain under-represented across the United States. The finding for women within medical leadership across Australia is similar (97). Gender bias has been long recognised as a contributor to the ‘sticky floor’ and ‘glass ceiling’ that challenges women desiring medical leadership (15, 29, 30, 34, 60, 93, 130). Gender bias was also a highly recognised barrier to leadership among female responders in this study (Table 8). This persisted across all ages, across trainee and specialist cohorts, and across countries, with females ranking gender-biased perceptions of ‘lesser credibility’ and ‘lesser capability’ higher than their male colleagues. This perception aligns with previously reported ‘credibility and capability’ data (211), revealing lower levels of perceived performance for females in leadership, even when matched as ‘effective leaders’ (88).
Subthemes of ‘lesser capable surgically’ and ‘pregnancy and parenting’ were noted among female responders. This issue of perceived reduced skill capability due to pregnancy or parenting is a known gender bias previously reported within the surgical arena (212). Promoting female surgeon role models, providing mentoring, appreciating the presence of implicit gender biases, reducing structural barriers to accommodate for parenting and careers, have all played roles in reducing this bias in surgical specialties (29, 213, 214). RANZCOG could benefit from focusing on these issues to ensure all members have equality in surgical training.
Both male and female responders raised a new theme of ‘male gender bias’, although this predominated from male specialists. Here gender discrimination sources were reported from institutions, consumers, and colleagues. This presents a unique challenge to obstetrics and gynaecology. Should institutions respond to consumer choice for female providers, often at odds with the training needs of male doctors within the profession? And do we risk further male discrimination as obstetrics and gynaecology is increasingly feminised? Levensen et al acknowledged this concern in medicine over a decade ago (215), going on to suggest feminisation could lead to a reduced status of the profession and potentially lower incomes. Although these specific concerns were not raised within this study, concerns over reduced opportunities for same-sex mentoring and role modeling (213), fewer full-time workers (108, 216), patient reluctance for male providers, and reduced male participation within the specialty, were all noted. This is a very real issue for RANZCOG’s future.
Gender quotas, utilising positive discrimination, provide one avenue to improve gender diversity in organisations (217). From the study’s data it was clear that responders want gender leadership equality, but not equity. This was suggested by the overwhelming prevalence of the ‘best person for the job’ theme when expressing opposition to gender quotas. Concerns were expressed that highly qualified male councilors may be overlooked by a quota system, reducing the expertise of RANZCOG leadership, and that gender quotas create negative stigma, threatening the legitimacy of women perceived to be ‘token’ rather than valued for professional skills and attributes (218, 219). Although debunked in research of other professional groups (124), these concerns have yet to be evaluated within the medical profession and are worthy of consideration.
Multiple solutions are required to address the gender leadership gap in medicine, and many have been trialled successfully (16, 116, 135, 141, 146, 171, 220, 221). These include addressing organisational culture, providing mentoring and sponsorship, offering flexibility to workplace structures that support parenting and lifestyle considerations, leadership training, and adopting gender equality and anti-discrimination policies. It also calls for women to build self-efficacy (222), and challenge the gender culture that women have often been born into (72). Responders within our study mentioned all these possible solutions.
Limitations of our study include the discordance between membership and survey responder gender demographics, and the necessarily narrow definition of leadership, excluding leadership roles outside RANZCOG, Universities, and public hospitals. Future study in this field may benefit from expanding the leadership definition, the application of incentive to improve survey response, the use of paper or face-to-face surveys, and in-depth interviews with successful female leaders to establish their leadership pathways.
In conclusion, this study shows that a gender leadership gap is present within RANZCOG affiliated obstetrics and gynaecology. Members of RANZCOG reveal differing opinions of leadership desires, gender bias and the role of gender quotas. Suggested solutions include leadership training, reducing structural barriers to leadership, improving awareness of gender biases, acknowledging the risk of male discrimination in our increasingly feminised speciality, and improved engagement from RANZCOG with the wider membership. Notably this study’s findings are not unique to obstetrics and gynaecology, or to the broader field of medicine.
An awareness of the leadership barriers revealed through this research provides RANZCOG with an opportunity to engage with membership-driven solutions towards achieving leadership gender equality. In turn, this might drive cultural gender leadership change, not just for RANZCOG, but for the broader community invested in women’s healthcare. Now is the time for RANZCOG to lead the way to gender leadership equality.