Results

Data: RANZCOG Leadership #

In 2017 RANZCOG has a total female membership of 63% (1325 of 2530), a female specialist membership of 46% (945 of 2055), and a female trainee membership of 80% (380 of 475). This study’s results reveal that females remain in the gender minority in all national RANZCOG leadership roles (Table 1).

Educational leadership roles at RANZCOG (T&A state chair and ITP coordinators) most closely align with membership gender representation, where female specialists are overrepresented. The gender leadership gap is most pronounced at the highest level of leadership, the RANZCOG board.

Table 1. RANZCOG committees #

^{*National positions #ITP = Integrated Training Program}

Data: RANZCOG Affiliated Hospitals & Universities With an O&G Department #

The data from document review demonstrates that RANZCOG affiliated hospitals and university O&G departments demonstrate a gender leadership gap (Table 2 & 3). This gap closely aligns with the RANZCOG national committee statistics, with average female leadership being 26% for RANZCOG, 32% for RANZCOG affiliated hospitals, and 26% for university O&G departments in Australia and New Zealand.

Table 2. RANZCOG accredited hospitals Australia and New Zealand #

Table 3. Universities in Australia and New Zealand with O&G departments #

There were two notable outliers in the data. First, the North Island of New Zealand is an outlier with an overrepresentation in leadership, both at the hospital and university level. Significantly contributing to this is Auckland City Hospital, the largest O&G department in New Zealand, staffed exclusively by females in leadership. Despite this variation in intercountry hospital and university female O&G leadership representation, both countries had matched membership levels of desire for future/additional leadership, and matched levels of leadership barriers. Second, within Australia, Westmead hospital was a notable as an outlier with 80% female leadership. In contrast, amongst tertiary hospitals, Royal Prince Alfred Camperdown, Women’s and Children Adelaide, and the Gold Coast University hospital, had no females in leadership.

Data: RANZCOG Survey #

An online membership wide survey (Appendix 1) was disseminated via email on August 15th 2017, running for 21 days total, with a reminder email on day 14. A total of 770 responses were received (30.4% of members: 27.3% of male members, 33.1% of female members), with a 93% full completion rate.

Survey – Demographic Data #

Survey responder demographics (Table 4) are statistically representative of RANZCOG membership trainee and specialist mix (p=0.32). The responder sample is however not perfectly representative of RANZCOG membership gender, with a statistically significant greater proportion of female responders than RANZCOG female members (p=0.0079). This is also true for the specialist cohort, with a statistically significant greater number of specialist female responders than RANZCOG specialist female members (p=0.047). The responder sample of trainee gender is representative of the current RANZCOG trainee gender (p=0.319).

Table 4. Demographic findings from Survey respondents #

^{*N/A = Data not available from RANZCOG as not collected prior to July 2017.}

Survey – O&G Leadership Data #

95% of survey responders answered questions pertaining to leadership (Appendix 1, q5 & q6), with 31% of respondents holding a current RANZCOG, University or hospital leadership position.

Male responders were statistical significantly more likely to hold current leadership roles than female responders (Table 5). This held true for male specialist, but not male trainee members. Both male and female specialist members were more likely to hold leadership positions than both male and female trainee members. With regards to leadership aspirations, female responders were more likely to desire additional or future leadership positions than male responders (Table 6). Irrespective of site (RANZCOG, University or hospital), female specialists were statistically more likely to desire additional or future leadership positions (Table 7). This is significant, as responders in ‘outlier’ contexts that contained high levels of female leadership, expressed similar levels of desire than their colleagues in contexts with little or no female leadership. There was no difference observed between male and female trainees with regards to leadership position desire (p = 0.279).

Table 5. ‘Do you currently hold a leadership positions within RANZCOG, University or your hospital?’ #

Table 6. ‘Would you like to hold an additional leadership position now or in the future?’ #

Table 7. ‘Would you like to hold an additional leadership position now or in the future?’ #

The top four identifiable barriers (available time, family commitments, personal energy and position availability) to future leadership were consistent between genders (Graph 1). Women rated all identifiable barriers higher on average than their male counterparts, except for ‘lack of interest’.

Graph 1. ‘What factors stop you from seeking a leadership position or additional leadership positions?’ #

Survey – O&G leadership thematic analysis #

Twenty percent of responders who completed the quantitative survey responses on O&G leadership also provided free text comments to the question ‘any comments regarding O&G leadership?’ Of the 146 members with free text responses, 51% were female and 49% male. Among the trainee sample only female trainees responded (<1% of overall responders).

As described in the methodology, Braun and Clark’s thematic analysis framework (187) was used to facilitate identification of themes. Aiming for a snapshot of information, and some perspectives on aspirations and views about leadership, ‘leadership barriers’ emerged as the strongest theme in this section of responses.

Trainee responders #

Among the female trainee responder cohort (n=14) the majority reported desiring leadership (62.4%), with more than 85% reporting an awareness of gender barriers to future leadership opportunities. Very few leadership positions are available for trainees. In keeping with this, only one trainee identified as currently holding a leadership positions. This was within RANZCOG as a trainee representative for the college council, an important place for trainees to voice their concerns or support for curriculum changes.

Female specialist responders #

In response to the question ‘any comments regarding O&G leadership?’, the overwhelming singular theme from textual analysis amongst female specialists was that of ‘leadership barriers’. This was found in 83% of female responder comments. Within this theme of ‘leadership barriers’, subthemes of ‘disillusionment’ (40% of responses), ‘financial and time’ barriers (27% of responses), and ‘gender barriers’ (22% of responses), and ‘learning leadership’ (13% of responses), were present.

Disillusionment #

Comments demonstrating a ‘disillusionment’ theme most commonly pertained to members’ disillusionment with the ‘institution’ of RANZCOG (46% of comments). These are found in Box 2. Acknowledging the enormous diversity that will exist within the RANZCOG membership, these comments reveal that these RANZCOG members do not feel authentically represented by their leadership. Other comments relating to disillusionment referred to hospitals or health systems cultures (Box 3).

Time and Financial Barriers #

Responders indicated available ‘time and financial’ considerations were strong barriers to leadership (graph 1). This was further reflected in responder free text comments (Box 4). Among this responder cohort, comments on time as a barrier were more prevalent than financial barriers. This was particularly so amongst the under 50-year-old responders, and possibly reflects increased parenting demands within this age cohort. Within this subtheme responders explicitly referenced the impact of leadership on family time.

Gender Barriers #

Many of the comments related to gender barriers revealed the common thread of ‘denial of opportunity due to gender’ (Box 5). Whether real or perceived, these comments suggests multiple issues including a system failure with the feedback process if unsuccessful applicants feel they are only left with ‘gender’ as a discriminator for promotion. It also strongly suggests the process of selection needs improved transparency to ensure gender is not a real or perceived discriminator.

Learning Leadership #

A further theme that arose within this responder cohort was that of training for, or ‘learning leadership’ (Box 6). These comments were strongly directed toward registrar training years, especially the early years of the formal training program, and were most prevalent amongst a younger age cohort (> 30 years). Interestingly, despite the dominant female leadership of New Zealand (Table 2 and 3), female responders from New Zealand equally commented on their desire to ‘learn leadership’.

Male specialist responders #

Male responders contributed to 48.6% of the free text comments. The ‘barriers to leadership’ theme again predominated (60% of responders), and was followed by responders noting their past or current leadership role (31% of responders) as their only response. This is consistent with RANZCOG’s historically masculinised leadership.

Within this theme ‘barriers to leadership’, the subthemes of ‘disillusionment’ (60%) ,‘financial and time barriers’ (22% of responses), ‘learning leadership’ (19%), and ‘a changing of the guard’ (16%) predominated. Among male responders there were no comments relating to ‘gender bias’ as a barrier to leadership. This was consistent with the lower self-reported prevalence of gender bias in the male specialist cohort (Table 8).

Disillusionment #

Comments pertaining to the ‘disillusionment’ theme were most commonly focused towards the culture within the current leadership (68% of responses – Box 7), towards with RANZCOG itself (23% of responses – Box 8), and to administrative challenges (9%). Comments here suggested a strong sense of disenchantment and pessimism with past and/or current leadership position. Although present in the female specialist cohort, these were much more commonly seen amongst male respondents.

Time and financial barriers #

Within this cohorts’ free text comments ‘time and financial barriers’ was another common subtheme (Box 9). This correlated with responses seen from male responders in graph 1. Within this subtheme male responders made more comments on ‘financial barriers’ than with female responders. This may indicate a higher level of financial responsibility among the male responders, and/or the type of practice these responders work within (as public practice more commonly makes financial allowances for leadership activities).

Learning Leadership #

As seen with female responders, the theme of ‘learning leadership’ arose from male responders. These comments were strongly associated with the need to be taught leadership, and promote mentorship (Box 10). Interesting this cohort of responders was an older cohort compared to female responders raising these issues.

Changing of the guard #

A new subtheme arose from male responder free text comments that was not seen previously. This theme implied a ‘changing of the guard’, with responders looking to pass on their leadership knowledge and/or positions to the next generation, or to encourage a higher turnover through RANZCOG leadership positions (Box 11). Responders among this theme report a higher rate of past and current leadership roles. A minority of responders countered the ‘changing of the guard’ theme, commenting, “they should listen more to their tribal elders” (M, 70+, Australia), and “we have entered a new era of ageism” (M, 70+, Australia). These were from respondents all over the age of 70 years, and possibly reflect perceived judgement of their leadership capacity reducing with age.

Survey – Gender Bias Data #

Question 9 of the survey (Appendix 1) asked responders ‘have you experienced gender bias during your training or specialist years?’, with just under half of all responders reporting gender bias (Table 8). Female responders were more likely to report gender bias than male responders. Among specialists, females were more likely to report gender bias than males. Within the trainee cohort, a trend toward higher levels of gender bias amongst female was present, but did not reach statistical significance. When analysed as separate cohorts, trainees were also more likely to report gender bias than their specialist colleagues (p=0.0057).

Table 8. ‘Have you experienced gender bias during your training or specialist years?’ #

^{* Combined ‘No’ and ‘Unsure’, so comparing men to women answering ‘Yes’ versus ‘Not Yes’.}

Question 10 of the survey (appendix) was a closed question pertaining to gender biases that limit leadership, with eight listed answer options. In response to this question, ‘what gender biases, if any, do you believe exist for trainees and specialists that limit leadership opportunities?’, responders identified ‘lack of consideration for family responsibilities’, ‘others perceiving a lesser credibility due to gender’, ‘lack of mentoring’ and ‘others perceiving a lesser capability due to gender’, as the leading four biases (graph 2). There were however significant differences across female and male responders. Female responders listed ‘lack of consideration of family responsibility’ (46%) as their most prevalent gender bias. This remained true for both female trainees and female specialists. In contrast, male responders listed ‘none’ as the most common (43%) gender bias that limit leadership opportunities. Within the male trainees cohort family responsibilities (33%) was the most common gender biases. Of interest mentoring ranked as a third most prevalent gender biases for female trainees, but did not reach the top five for male trainees, suggesting improved mentoring opportunities for males trainees.

Graph 2. ‘What gender biases, if any, do you believe exist for trainees and specialists that limit leadership opportunities?’ #

Survey – Gender Bias Thematic Analysis #

Twenty percent (20%) of survey responders provided free text responses to the question ‘any comments regarding O&G gender bias?’. Using the same inductive thematic analysis (187) approach described above, coded themes from the data set were identified.

Trainee responders #

Trainee responses represented less than 1% of the free text comments. All three male responder comments reflected awareness that both males and females could experience gender bias. One example of this was “have observed in different departments biases towards both genders“ (M, 30+, Australia).

The 17 female trainees responding with free text comments held subthemes reflecting the statements: ‘female gender bias is present’ (12/17), ‘we risk male gender bias’ (3/17) and ‘gender bias does not exist’ (2/17). Although the majority of respondents acknowledged gender bias could exist for both males and females, comments strongly weighted toward female gender bias (Box 12). Two responders noted experiencing gender bias from other females, with an example from one responder: “women need to be aware that they themselves hold gender bias against other women. Women hinder other women from leadership” (F, trainee, 30+, Australia).

Female specialist responders #

Female specialist responses contributed to 50% of free text comments. The prevailing theme for this cohort was that of ‘female gender bias is present’ (57%). Fourteen percent (14%) of responders indicated they did not believe gender bias existed either in their own institutional setting or in the broader speciality. Other comments included those noting ‘gender bias is improving’ (11%), ‘we risk male gender bias’ (8%), and ‘males are now under-represented’ (5%). No comments refuted the presence of gender bias.

Female gender bias is present #

Several data extracts involving the theme ‘female gender bias is present’ were made. Some described personal stories, one alluded to the pipeline’, while others acknowledged the gender biased culture around them (Box 13).

Within this theme of ‘female gender bias is present’, subthemes of ‘lesser capable surgically’ (Box 14) and ‘pregnancy and parenting’ dominated (Box 15).

As noted amongst the female trainee responders, the following statement provided an insightful recognition that females too can all hold female gender biases: “bias even from female training supervisor – got away with comments about female registrar than a male supervisor would have dared passed judgement on” (F, specialist, 40+, New Zealand). Recognising our own implicit biases is an invaluable step towards challenging all biases (42). Interesting these comments came from both Australian and New Zealand responders, with the later location the outlier for higher levels of female representation in leadership.

Male specialist responders #

Male specialists provided 38% of the free text comments to the question ‘any comments regarding O&G gender bias?’. The majority (48%) of comments pertained to the theme ‘male gender bias is present’ (see below). Eighteen percent (18%) of responders indicated gender bias no longer existed, or was never present, in O&G. Examples of this are included in Box 16. Counter to this cohort were the 17% of male specialist comments that pertained to the presence of female gender bias (Box 17).

Male gender bias is present #

The overwhelming singular theme in response to ‘any comments regarding gender bias’ was that of ‘male gender bias is present’ (Box 18). This was present in 48% of free text comments from male specialist responders. Within this theme existed a subtheme of ‘patient preference for female providers’ (Box 19). Within the public system, consumer choice is balanced, often at odds, with the training needs of males within the profession.

Survey – Gender quota Data #

Questions 12 and 13 asked responders about quota use within RANZCOG with the following questions, ‘should RANZCOG consider a gender quota system for federal council and state councils?’. The majority of responders opposed quota use for federal and state council (63% and 65% respectively, Table 9). This remained true among specialist (66%) and trainee responders (50%). Between genders, female responders were statistically significantly more likely to support gender quotas, compared to their male colleagues, at both federal and state level.

Table 9. Gender quotas #

^{*’No’ and ‘Unsure’ were combined to indicate ‘Not Yes’ in the statistical analysis. Statistical significance remained when comparing ‘Yes’ and ‘No’ and ‘Yes’ and ‘Not Yes’}

Survey – Gender quota thematic analysis #

Among the 93% of responders who answered questions on gender quotas (q 14, Appendix 1), 33% provided written comments to the question ‘any comments regarding gender quotas?‘. This question attracted the highest number of free text responses from the survey. Within these responses 63% of respondents articulated their opposition to gender quota use, similar to the 63% and 65% that opposed federal and state council quotas seen in table 9.

Male trainee responders #

Six of the 21 male trainees (29%) provided written comments on gender quota. Here an equal proportion of responders supported (3/6) and rejected (3/6) the proposal of quota use. Trainees opposed to quotas expressed statements including merit including ‘use the most capable, qualified and motivated person for the job no matter what gender’ (M, 40+, New Zealand) . Those trainees in favour of quotas expressed statements including ‘I believe gender quotas, in general, are a good idea. Both, so that the representation is more representative, and because I believe better gender balance makes for better leadership’ (M, 30+, Australia).

Female trainee responders #

Of the total 111 female trainees, 23 (21%) provided free text comments on gender quota use. Seventy eight percent (78%) of responses indicated an opposition to gender quota use, with ‘merit first’ as the sentiment expressed by over 95% in this cohort. Comments reflecting this included; “should be talent, interest and ability based alone” (F, 30+, Australia), and “it should be person who’s best for the job” (F, 20+, New Zealand). It is worth acknowledging one outlying comment; ‘gender quotas are unfair to people with potential, but do not belong to a specific gender’ (F, 30+, Australia). This comment challenges traditional binary gender identities, risking discrimination against those who identify as neither male nor female.

Free text comments from female trainee responders who supported gender quotas included; “minimum quotas should be introduced for both genders. Currently there are fewer female specialists holding leadership roles with RANZCOG. As the number of female specialists increase, there will be under-representation of male specialists” (F, 30+, Australia). This potential impact on male representation within RANZCOG leadership was also expressed by three of the responders who opposed gender quotas.

Male specialist responders #

Male specialists represented 44% of the responders commenting on gender quota use, with seventy eight percent (78%) of responders indicating they did not support gender quotas. The statement ‘best person for the job’ reflected the dominant theme, with ‘merit’ (51%) and ‘the pipeline’ (26%) the subtheme present within this responder cohort. Other comments remarked on the importance of ‘equality for all’ and consideration for a ‘gender quota’ minimum.

Best person for the job #

Within the theme ‘best person for the job’, merit dominated as the criteria for this. Free text comments reflecting this theme are included in Box 20. Further to these were comments pertaining to the ‘pipeline’, that female numbers alone would naturally correct the leadership gender gap (Box 21). Within the free text responses were a small number of statements (6) reflecting awareness that barriers might limit women seeking/achieving leadership. These are included in Box 22.

Female specialist responders #

Among the female specialist responders, 31% provided free text comments on gender quota use. Just over half of this cohort (56%) expressed an opposition to quota use at RANZCOG. The variation in opposition rates to gender quotas between male and female specialists were consistent with difference seen between genders seen in Table 9.

Within the responses opposing gender quotas use, the statement ‘best person for the job’ again resonated as the dominant theme. Within this ‘best person for the job’ theme, ‘merit’ (66%) and ‘the pipeline’ (12%) again represented the subthemes. Free text comments reflecting ‘merit’ are included in Box 23, and ‘pipeline’ in Box 24. The ‘merit’ subtheme reverberated strongly among both male and female specialists. Within this female specialist cohort, 50% of responders provided actionable changes that could reduce barriers to women seeking leadership including; “what needs to happen is that the practicalities i.e. meetings by tele conference, decentralisation, move exams out of central Melbourne - this will allow much wider participation” (F, 50+, Australia).

Within the group of female specialist responders agreeing with ‘gender quotas’ use, 25% indicated a desire to have matched membership and leadership gender representation. Comments reflecting this subtheme of ‘authentic gender representation’ are included in Box 25. Another 23% of responders’ responses suggested quotas provide a tool to ‘highlight gender bias’, ‘change the culture’ and ‘reduce the gender leadership gap’ and, at a faster rate than the ‘pipeline’ (Box 26).

Survey – Concluding thematic analysis #

Participants were invited to submit concluding comments at the end of the survey following the statement; ‘thank you taking the time to complete this survey…if you would like to add any additional comments please do so below‘. From the 770 survey respondents, 63 (8%) choose to write free test comments. The dominant theme within this concluding section was ‘solutions to reducing structural barriers for leadership’. Comments reflecting this only came from female responders (Box 27), and added practical steps to the suggested solutions to gender leadership equality in the gender quota sub-section of the results.

A smaller cohort of responders (mostly males), from both Australia and New Zealand referred back to their concerns that the feminisation of our specialty will reduce future opportunities for males. This was nicely summarised in the following statement; “there were 21 applicants for the interview to join the program last week. One was male. “Huston, we have a problem!” (F, 50+, Australia).