9 January 2023
A group of 1400 health practitioners, researchers and members of the public today sent a letter to NHS England urging that the imminent Maternity Gender Inclusion Programme (MGIP) be put on hold.
The letter warned that a scandal similar to the events that led to the closure of the Tavistock Gender Identity Development Service (GIDS) could be repeated in the MGIP – which would train midwives at 40 NHS Trusts – due to reliance on poor research and the influence of activist organisations.
NHS England opened the £100K contract for the programme on 16 December 2022 with a closing date of 11 January 2023, giving prospective training providers less than a month over the Christmas holiday period to apply.
The only study referred to in the contract is the Improving Trans Experiences of Maternity Services (ITEMS) report launched by the LGBT Foundation in April 2022, which is not peer reviewed and contains significant flaws in its methodology and analysis. The ITEMS report is referred to throughout the MGIP invitation to quote.
Signatories of the letter included consultant psychiatrist David Bell, formerly a staff governor at the Tavistock & Portman NHS Trust which included GIDS, who said: “As someone who was instrumental in exposing the damage done to patients by an unthinking acceptance of ideologically based claims, which had no evidence base, I am shocked at this repetition of ideology again trumping careful examination of the evidence and little thought as to the likely damage.”
The ITEMS report recommended the introduction of ‘inclusive language’ for all maternity service users, which typically includes the addition of de-sexed terms such as ‘pregnant people’ and ‘chestfeeding’. This recommendation is at odds with evidence and current MBRRACE-UK, NICE and Public Health England guidance to use plain English and be inclusive of women with low literacy or English skills.
The ITEMS report directly compares its own survey of 121 trans maternity service users who gave birth in the past 30 years with an official UK maternity services survey that surveyed 17,151 women who gave birth in 2019.
Despite being commissioned to fill a knowledge gap on transgender maternity service users, the ITEMS research does not mention any specific medical needs that trans individuals and their babies may have as a result of treatments such as testosterone use or chest masculinisation mastectomy.
Across several sectors including healthcare and education, training courses run by advocacy groups such as Stonewall and Mermaids have had to be withdrawn in recent years at great cost to public bodies.
The letter to NHS England’s National LGBT Programme Manager Lizzie Streeter, who is coordinating the programme, was written by With Woman, a grassroots group that represents maternity and infant health practitioners including midwives and obstetricians who are concerned about the influence of gender ideology in the sector.
Members of the With Woman network typically remain anonymous in order to protect their jobs within the NHS, but within just 24 hours of being circulated last Wednesday the letter had been signed by over 650 healthcare practitioners, researchers and members of the public.
A spokesperson for With Woman said: “Given how poorly the ITEMS research was undertaken it simply cannot be relied upon to inform training or healthcare guidance.”
“Despite its bogus methodology and analysis, the ITEMS report underpins NHS England’s new training for midwives on transgender service users. We want trans and non binary people giving birth to have good experiences and evidence-based care, and are therefore making an urgent call to pause the programme.”
The current estimate of prevalence of trans and non binary maternity service users is at most 1 in 2000. With Woman says this makes it hard to justify the level of funding and hours dedicated to this training across 40 NHS England Trusts at a time when the health service is under immense and urgent pressure.
Ali Ceesay from Woman’s Place UK said: “We support NHS efforts to improve maternity services in their provision of safe, person-centred care. Any policy development, including training, must be based on carefully considered evidence, sound methodology and clinical need. This training proposal fails to do this.”
“Sex inequalities in health care provision are well documented as are race inequalities in maternity care. We urge the NHS to focus their funding and expertise to make well documented improvements so that services are safe for women.”
Dr Louise Irvine said on behalf of the Clinical Advisory Network on Sex and Gender: “As the Cass interim report implied, areas of the NHS such as GIDS have been subject to ideological capture at the cost of person-centered, evidence-based care. We hope NHS maternity services do not make the same mistake.”
Concerns have also been raised about the short timeframe for the training provider procurement process. With Woman’s spokesperson said: “One wonders if they already know who will win this contract and what their training will look like.”
— ENDS —
For further information and to arrange interviews, contact firstname.lastname@example.org
About With Woman
We are birth workers and activists, focused on the pregnancy, birth, and breastfeeding concerns of women. Sex-based language is important due to sex-based oppression.
Our name comes from the Middle English origins of the word midwife, mid (“with”) + wife (“woman”), expressing the sense of ‘a woman who is with the mother’.
- With Woman letter to NHS England (full text appended below):https://with-woman.org/2023/01/04/open-letter-pause-midwifery-training-based-on-flawed-research/
- LGBT Foundation ITEMS report:https://dxfy8lrzbpywr.cloudfront.net/Files/97ecdaea-833d-4ea5-a891-c59f0ea429fb/ITEMS%2520report%2520final.pdf
- NHS England Maternity Gender Inclusion Programme:https://www.contractsfinder.service.gov.uk/Notice/15f52c9c-4f7b-403b-a9f5-a0fb50780e66
- With Woman blog post: “Ideological capture at the heart of the NHS”: https://with-woman.org/2023/01/05/ideological-capture-at-the-heart-of-the-nhs/
- Woman’s Place UK: https://womansplaceuk.org/
- Clinical Advisory Group on Sex and Gender: https://can-sg.org/
About the Maternity Gender Inclusion Programme
Following the recommendations in the ITEMS report, on 16 December NHS England issued an Invitation to Quote (tender) for training providers to bid for a £100k contract to design and deliver a “gender inclusive training package linked to objectives to improve trans and non-binary awareness and inclusion within maternity services, amongst professionals (midwives, maternity support workers, nurses etc)” with “multiple sessions offered virtually and in-person to fit alongside clinical commitments”. The training should include “best practice examples”.
Alongside this the provider is expected to develop downloadable support materials (e.g. information posters that are inclusive of trans and non-binary birthing people, and inclusion plan templates), as well as offering ongoing follow-up and advice. The contract requires the provider to deliver the training to 40 NHS Trusts between January and March 2023. The provider is asked to evaluate the project at the end, and to “work with NHS England to build a case for future sustainability of the training”.
The ITQ refers to the ITEMS recommendation that “training, as a priority, should be designed and delivered by trans and non-binary led organisations, or individuals”. It also expects the provider to have “strong communications management and sensitive media handling” and for a communications professional to be hired for the purposes of “media management”.
(A copy of the ITQ is available on request)
With Woman’s letter to NHS England (full text)
Open letter, January 2023: Pause £100k midwifery training based on flawed research into trans maternity experiences
NHS England National LGBT Programme Manager
Dear Lizzie Streeter,
Re: Request for deferral of the Invitation to quote for the £100k Maternity Gender Inclusion Programme until there is both a published and comprehensive review of pilot schemes that are representative, and a solid evidence base for best practice for this client group.
Thank you for your work on the provision of care for trans and non-binary maternity service users. We emphatically support your aim to provide high quality care to all users for maternity services. However, we have concerns about the Maternity Gender Inclusion Programme (MGIP).
The Improving Trans and Non-binary Experiences of Maternity Services (ITEMS) research by LGBT Foundation  on which the programme is based is not peer reviewed and contains significant flaws in its methodology and analysis as outlined below. It is therefore an inappropriate basis for a training project funded by the NHS.
The proposed training has no evidence base and there has been no assessment of impacts on other groups of service users or evaluation of costs to scarce NHS resources and midwives’ time. In these cost-limited times it is crucial to have an evidence base for any proposed spend and we therefore feel it unethical to proceed without access to results of these pilot schemes.
Our concerns are as follows:
1. The ITEMS research is not peer reviewed and has significant methodological and analytical flaws
The ITEMS research was commissioned to fill a knowledge gap, but given how poorly the research was undertaken it cannot be relied upon to inform training of maternity health workers or for any changes to maternity services.
The central claim that 30% of trans people gave birth wholly unattended (free-birthed) is not borne out by the data. To the question “Did you get support from NHS or private midwives during your pregnancy/ pregnancies?” 30% answered no. This is taken to mean that 30% gave birth without any professional attendance whatsoever (freebirthing) – a wholly unsubstantiated assumption (page 19 of the report). The question could reasonably be interpreted to be querying whether people felt supported by the midwives who cared for them.
Thus, it is possible that no people gave birth without midwifery care, or that some were high risk pregnancies and were cared for by an obstetrician.
The study compares a small sample of trans service users (n=121) over a 30-year period, 45% before 2015, at unspecified locations, with a very large group who gave birth over a three month period (n=17,151) in England, making the comparisons unreliable. Any differences in the results may well be attributable to the development of maternity services in the last 30 years such as record keeping, personalised decision making, support for infant feeding or continuity of carer. It is not clear when the pregnancies occurred in relation to the transition, nor whether the transition was social, medical or surgical. This is significant data for maternity care.
Additionally, the study did not include any research on medical needs of TNB maternity service users or on infants, and did not consider how the impact of any changes they recommended would impact others.
2. The ITEMS recommendation to introduce de-sexed language for all maternity service users is incompatible with evidence and current guidance.
One of the ITEMS recommendations is to introduce gender inclusive (de-sexed) language for all maternity service users. However, no research or assessment has been carried out to determine the impact of these changes on women who do not identify as trans or non-binary, particularly on vulnerable groups, despite evidence that it can detract from important public health messages .
The most recent MBRRACE-UK report  noted that the most disadvantaged women were at highest risk of adverse pregnancy outcomes and stated that clear language must be used in antenatal care. NICE guidance on antenatal care states that antenatal services need to recognise women’s circumstances, such as low literacy or English skills .
A well researched paper in Frontiers in Global Women’s Health on the impact of language change details many detriments to the widespread desexing of the language of female reproduction , including unintended consequences – such as using parent to mean mother – leading to poor postnatal care.
We point to Public Health England’s own guidance  on improving health literacy, which states that plain English should be used in health communications and medical jargon avoided.
3. A scandal similar to Tavistock could be repeated in NHS maternity services due to poor research and the influence of advocacy organisations.
Recent events at the Tavistock Gender Identity Development Service have shown how practice underpinned by poor research and the influence of advocacy organisations with a particular ideology has led to a scandal that we do not want to see repeated in maternity services.
As the Cass Interim report has shown, good intentions are not enough . Healthcare and training must be informed by proper evidence and have clinical credibility as well as credibility within the community and advocacy circles.
In healthcare and education numerous training courses run by advocacy groups such as Stonewall or Mermaids, or the GP training on Gender Diversity , have had to be withdrawn due to concerns, to great cost.
There is a danger in commissioning training from advocacy groups without sufficient clinical expertise in this area. Considerable public funding has already gone into previous research on trans pregnancies that has yielded very limited credible peer-reviewed results .
4. The scope and scale of the training programme is disproportionate and could have real implications for neonatal or maternal outcomes.
There has been no analysis of opportunity costs. In these times of limited resources to pull every midwife in 40 NHS trusts away from clinical practice for a set amount of time could have real implications for neonatal or maternal outcomes.
The current estimate of prevalence of TNB maternity service users is at most 1 in 2000, therefore most midwives will not care for a trans or non-binary person during their career. This begs the question of time and cost effectiveness for a training with no clinical credibility which we do not see taken into account in the tender as it stands.
5. The pilot studies are an inadequate basis for rolling out the project to 40 NHS Trusts.
The pilot studies are an inadequate basis for rolling out the project to 40 Trusts due to a lack of (published) independent evaluation or data of the projects’ impact, and any unintended downsides on trans or non-trans populations, especially disadvantaged groups.
The trial in Brighton and Hove is not representative of the country as a whole due to there already being two gender inclusion midwives for an unspecified number of clients, existing publicity, and a higher than average trans population.
6. Funding allocated to the programme would be better spent developing high-quality research to support the target group effectively.
Transgender and non-binary maternity service users deserve high-quality maternity care. Appropriate research is needed to inform such health care provision. This research should include the needs, maternity care experiences and outcomes of those who identify as transgender and non binary. It should also include investigation of the medical needs that individuals and their fetuses and infants might have as a result of medical treatments such as testosterone use or chest masculinisation mastectomy.
The ITEMS research does none of the above and is fundamentally inadequate for the purposes of informing high-quality maternity care for trans and non-binary people. The funding allocated to the MGIP would be better spent getting high-quality data on the prevalence and clinical needs of this client group to generate clinically credible data to target support most effectively.
We the undersigned, therefore request you put an immediate hold on the Maternity Gender Inclusion Programme (MGIP).
We would be glad to have the opportunity to meet with you to discuss our concerns. Please contact email@example.com to arrange a meeting with representatives of the undersigned.
(See Open Letter for the full list of signatories)
Anna Scott, Midwife, NHS
Katherine Hales, Senior Midwife CoC Teams
Deborah Hughes, Registered Midwife
Dr Louise Irvine, General Practitioner, Clinical Advisory Network on Sex and Gender
Linda Bryceland, Director of Midwifery
Lucy Griffin, Hospital Consultant
Catriona Cusick, Midwife NHS
Anna Melamed, Midwifery Lecturer
Ann Stevens, Health Visitor
David Bell, Retired Consultant Psychiatrist
Sinead Helyar, Nurse, NHS
Dr Az Hakeem, Consultant Psychiatrist
Dr Tessa Katz, GP
Louise Barraclough, Lead Nurse/ Specialist Safeguarding Lead
David Morgan, Consultant Psychotherapist
Sarah Ardizzone, Midwife, NHS
Rosemary Curtis, Retired Health Visitor and commissioner of maternity services
Sally Millar, Senior Research Fellow, Retired (ex University of Edinburgh)
Judith Green, Director, Woman’s Place UK
Ali Ceesay, Director, Woman’s Place UK
Irene Williams, Retired nurse
Delia Hazrati, Radiographer Personal capacity
Philip Hopley, Psychiatrist
Sharon Gamon, Practice Development Midwife Private Midwives
Nick Mann, GP, NHS
Anne Dean, District Nurse/Rehabilitation Service Manager(retired), NHS Greater Glasgow & Clyde
Milli Hill, Author of the Positive Birth Book
Ann Sinnott, Director, AEA
Sibyl Grundberg, Osteopath
Pamela Morrison, Lactation Consultant, Private practice
Jane Robinson, Retired nurse and full time woman
Nicky Neighbour, Antenatal practitioner (retired)
Kate Souper, Retired Doctor
Valerie Haldon, Retired midwife
Loreto, Breastfeeding supporter
Caroline Meagher Training Manager 3rd sector health and social care
Claire Fewster, Counsellor
John Rubinstein, Helper of Midwives Haven
Stephanie Blennerhassett, Retired Nurse
Catherine Williams, Childbirth educator and Masters student in medical anthropology
Charlotte Edun, Research Assistant (Maternity)
Labour Women’s Declaration Working Group, Labour Women’s Declaration
Charlotte Enderby-Ryall, Midwife, NHS
Jancis Shepherd, Retired Lead Midwife for Education/ Head of Midwifery, Previously, University of West London
Ms Denise Sumpter, Maternity and Breastfeeding informal advocate
Alison Arrowsmith, Midwife
Diane Dear, Retired nurse. Mother.
Professor Alan Johnson
Anne Stafford, Non-practising Midwife
Sian Howard, Mother, social worker
Maggie Mellon, Committee Member, EBSWA Evidence Based Social Work Alliance
Anna Zobnina Executive Director European Network of Migrant Women
Delyth Rennie Children and Family social worker (retd),
Alison Wren, Former biology teacher in young mothers PRU
Ceri Williams, Retired college principal
Rebecca Durand, English for Speakers of Other Languages (ESOL) Lecturer
Rose Rickford, Sociology PhD candidate University of York
Cathy Devine, Independent Researcher
Linda Law, Emergency Nurse Practitioner
Susan Swan, Yoga therapist supporting expectant clients and soon to be step-grandmother
Dr Ruth Livingstome, Retired GP and Clinical Director
Dr David Pilgrim, Chartered Clinical Psychologist
Maureen O’Hara, Lecturer in Law
Barbara Anne Marshall, Social worker
Bronwen Davies MSc, RMN, RGN, Retired nurse
Jo Campbell, Health and social care worker
Jane Symons, Health journalist
Doreen Wallace, Nurse
Lynsey McCarthy-Calvert, Counsellor
Christine Dellen, Former Breastfeeding Counsellor
Lindsey Robinson, Psychotherapist
Christine Biddlecombe, Clinical Nurse Advisor
Margaret Fairlie, Retired nurse
Dr Angela Dixon, GP
Andreia Nobre, Voluntary doula, journalist, author of the Grumpy Guide to Motherhood
Mrs Janette D Leck, Registered Nurse Adult (RT’d)
Samantha Foster, Charity worker with food banks
Siobhan Scanlan, Recently retired midwife
Gerry Holloway, Mother/grandmother
Lorna Fitzpatrick, Retired Social Worker
Fay, Childrens social care
Dr Shonagh Dillon
Georgina Toye PhD, Biomedical Research Scientist, Retired
Dr Lesley Semmens
Janet Lallysmith, Training and development
Suzanne Wood, Research and Development Project Manager
Hannah Mitchell, GP
Kerryann Lund, Retired teacher
Sarah Panzetta, Fertility awareness practitioner
Linda Whitehead, Retired occupational therapist
Dr Anne McConville FFPH, Public health doctor, retired
Susan Yavetz, Maternity services user
T Green, Obstetrician
Dr K Sharma, GP
Bev Marshall, Clinical Researcher & Mother
Robert Withers, Jungian analyst, Society of Analytical Psychology
Joanne Priest, Educator
Elizabeth Darran, Retired Psychologist
Margaret Kane-Dickson, Public Health Practitioner
Gina Burton, Retired Ambulance technician
Helen Cook, Nurse Leader, NHS
Claire Robinson, Senior Project Manager (national), Health Education England
Katharine Arnold, Specialist registrar, general and geriatric medicine
Harriett Robins Kennish, Mental Health Liaison Occupational Therapist (signing on behalf of myself, not my NHS trust).
Karen Moore, Senior Nursing Assistant, NHS Foundation Trust
Angela Thompson, Obstetrician and Gynecologist
Lindsay Duncan, Retired, Local authority
Jo Webb, Health Psychologist and Lactation Consultant
Kirsten Dawson, Health visitor
Chris Henderson, Retired early years strategist., Local authority
J metcalfe, Early years senior practitioner / SEMH practitioner
Judy Thomas, Retired Senior Practioner Child Protection
Kate Skillicorn, Policy Officer, Eden District Council
Victoria newcombe, Coordinator, CIC
Natasha Dykins, Retired doctor
Sally Frances, Social Worker
Bryony Skey, Retired psychoanalytic psychothetapist, NHS
Dr Alice Hodkinson, GP
Susan Turner, Midwife (retired)
Chan Moruzi, Researcher
Caroline Kane, Midwife, NHS
Julie Woods, RN(MH) Retired.
Lisa Littman, MD, MPH, Physician-scientist trained in Obstetrics, Gynecology, Preventive Medicine & Public Health
Jean Ruane, Retired Lecturer Mental Health Nursing, Other
Dr j. Gasper
Ann Stuart, Retired SRN RCM
Nina Griffith, BSc, MSc, PGDip Adult Nursing
Lucy Hunter Blackburn, Policy analyst and mother
Helen Catt, Psychologist
Iris, Communications & SM Representative, Standing For Women
Tanya Croall, Women’s health Physiotherapist
Molly O’Brien, Midwife, Midwife educator
Gina Docherty, Policy manager (health)
Anonymous, Midwife Academic
Dr Heather Brunskell-Evans, Medical Humanities
Dianne Landy, Co-Founder, Mana Wāhine Korero
Emma Mansell, Midwife
Shirley Roper, Retired Midwife
Helen Le Fevre, Retired nurse
Hilary Burrage, Adjunct Professor
Shareefa Shsh, Registered Nurse Emergency care, NHS
Lyn Tiller, Aurora New Dawn
Michelle Bennett, Social Worker
Elinor Holmquist, Pregnancy advisor
Dr Faye Carey, Psychoanalytic psychotherapist
Heather Thornton, NHS worker
Lisa Koekemoer, Public health, Consultant
Sue Brailey, Midwife
Jackie Dyer, Retired NHS Senior Manager
Dr Shawn Walker, Senior Research Fellow, King’s College London
Anna Tracey, Registered Nurse
Sandra Lawler, Retired Nurse
Dr Lenny Cornwall, Consultant Psychiatrist
Sheila Stallard, Retired Consultant Breast Surgeon
Dr Rae Elizabeth WEBSTER, Hospital Consultant (retired), NHS
Luisa Jbira, Midwife, NHS
Lisa Saffron, Author of It’s a Family Affair – the complete lesbian parenting guide, Diva Books.
Joyce West, Retired health care consultant
Kathleen Cruddas BSc MBA, Retired NHS Manager
Danielle Sinnett, Academic and mother
Emma Gwilliam, Nurse
Shelley Charlesworth, Researcher, Transgender Trend
Karen Ross, Retired Midwife
Sally Poxon, NHS
Louise Currie, Retired Midwife, NHS Scotland
Julie Norton, Data Analyst
Niamh Mac Mahon, Teacher of biology
Manuela Herrera, Psychologist
Helena, Public Health Nurse
Dr FIona Dean, Ex GP
J Baker-Carr, Lecturer
Helen Kay, Researcher
Linda Hamilton, Concerned woman, mother and researcher,
Maura Dalton, Retired social worker.
Dr Firat Cengiz, Mother, academic
Debbie Epstein, Emerita Professor University of Roehampton
Jennifer Stephenson, Midwife & Practice Educator
Elizabeth Turner, Diabetes Research Midwife
(See Open Letter for the full list of signatories)
Trans and non-binary experiences of maternity services: survey findings, report and recommendations, LGBT Foundation 2022 https://dxfy8lrzbpywr.cloudfront.net/Files/97ecdaea-833d-4ea5-a891-c59f0ea429fb/ITEMS%2520report%2520final.pdf
‘Inclusive’ language on maternity care risks excluding many women, The Guardian, 6 May 2022 https://www.theguardian.com/lifeandstyle/2022/may/06/inclusive-language-on-maternity-care-risks-excluding-many-women
Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK, MBRRACE-UK | NPEU (2020) https://www.npeu.ox.ac.uk/mbrrace-uk
Information and support for pregnant women and their partners. NICE guideline: Antenatal care:
Effective Communication About Pregnancy, Birth, Lactation, Breastfeeding and Newborn Care: The Importance of Sexed Language, Gribble et al. Frontiers in Global Womens Health, 07 February 2022 https://doi.org/10.3389/fgwh.2022.818856
Improving health literacy to reduce health inequalities, Public Health England & UCL Institute of Health Equity https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/460709/4a_Health_Literacy-Full.pdf
The Cass Review, Dr Hilary Cass: https://cass.independent-review.uk/
Doctors outraged at NHS trust’s two-hour lesson on ‘gender unicorns’, The Telegraph, 2022 https://www.telegraph.co.uk/news/2022/10/22/doctors-outraged-nhs-trusts-two-hour-lesson-gender-unicorns/
Trans Pregnancy, University of Leeds https://transpregnancy.leeds.ac.uk/about