The language of labour
Midwives listens to the language of pregnancy and birth, and asks how it affects a woman’s experience during labour – and beyond.
Good communication is fundamental to midwifery. It is ‘the vehicle by which all else is learnt and relationships are built’ (Kirkham, 1993), and it incorporates everything from active listening and touch, to body language and tone of voice. But fundamentally it is about words.
Words reflect and influence our attitudes and behaviours in ways we are not always conscious of; they convey layers of meaning, and subtly – or not so subtly – define the power balance in conversations and relationships (Carboon, 1999).
Good words, bad words?
A recent article in the British Medical Journal lists examples of poor language choices in birth communication – language that provokes anxiety, is over-dramatic, violent, discouraging or patronising and offers alternatives (Mobbs et al, 2018).
Terms such as ‘fetal distress’, ‘rupture the membranes’ or ‘big baby’ should, the authors suggest, make way for ‘changes in the baby’s heart rate pattern’, ‘release the waters’ and ‘healthy baby’. ‘Poor obstetric history’ or ‘high risk’ is better described as ‘medically complex’, and ‘failure to progress’ as ‘slow labour’.
As well as avoiding ‘exclusive or codified language’ such as abbreviations and acronyms, the article also recommends dropping words and phrases that don’t respect a woman’s autonomy as an adult, an individual and as a decision-maker, such as ‘my lady’ or ‘good girl’, or ‘you must have/need/require’.
The language of power
The authors acknowledge that eyes may roll at the thought of ‘political correctness gone mad’ but argue that these suggestions are firmly rooted in woman-centred care, reflecting that ‘the role of birth attendant is no longer “owner” of the situation but “facilitator” of the health services’. It is ‘the duty of caregivers to use language that will help empower all women,’ they add (Mobbs et al, 2018).
But while it is relatively straightforward to change the literature and even alter practice, achieving a shift in deeply ingrained language and the thinking it reflects is difficult.
Words and phrases linger on, with the language of ‘managing’, ‘allowing’, ‘conducting’, ‘delivering’ and ‘risk’ still reflecting ‘who has the power in any given situation’ (Leap and Hunter, 2016).
Choosing your words carefully
Debating the most appropriate words has long been a part of midwifery discourse – much of it centred around calling out words and phrases that undermine a woman’s autonomy, heighten fear and anxiety, or foster self-doubt.
For example, using the word ‘patient’ to describe a woman during her pregnancy, with its connotations of passivity and compliance (Silverton, 2017), has now made way for ‘woman’ or ‘mother’ – although some still prefer ‘lady’ (Munson, 2016).
Similarly, the word ‘deliver’, which shifts power to the carers around a woman (Hunter, 2006), is now replaced more frequently with the more woman-centred ‘birth’.
The language of maternity care continues to be questioned. For example, is asking a woman in labour about pain relief at regular intervals ‘sabotage language’ and an ‘obvious undermining of her confidence’ for example? (Leap and Hunter, 2016).
Should the word ‘contraction’ be reframed as ‘surge’, ‘wave’, ‘rush’ or ‘expansion’, as some hypnobirthing practitioners already suggest?
And has the language of high risk/low risk in maternity care had its day? Research suggests that labelling a woman ‘high risk’ may negatively affect her psychosocial state (Stahl and Hundley, 2003) and result in higher levels of anxiety (Lee et al, 2012). ‘Complex care’ or ‘complex needs’ are terms filtering into maternity speak instead, but even here some have argued it is a case of replacing one unhelpful and vague catch-all with another (Davies, 2012).
Clearly, language choices in maternity care are far from clear-cut. Even the internationally recognised term ‘normal birth’ is fraught, as is the alternative ‘natural birth’, leaving women ‘questioning the binaries of normal/abnormal, natural/unnatural’ (Leap and Hunter, 2016) and risking marginalising those who need medical interventions (Lyerly, 2012). Currently, a raft of alternatives including ‘physiological birth’, ‘straightforward labour and birth’ and ‘optimal birth’ all remain on the table (Leap and Hunter, 2016).
The power of words
Louise Silverton, former RCM director for midwifery, believes poor communication, whether inappropriate language or the use of opaque medical terms, can have a real, negative impact.
‘Women can get very frightened, and we know that fear impedes physiology – when that happens, labour doesn’t progress, and that leads to more interventions.’
‘Delivery’ describing any type of birth is one of several phrases she’d like to see consigned to history.
‘The postman delivers, Amazon delivers – women give birth. Even if they are assisted to give birth, it’s a CS birth, a forceps birth – delivery takes away the woman’s agency,’ she says.
‘So, when you’re carrying out an examination of a woman, don’t say “you’re only two centimetres” – say “Your cervix is two centimetres open. You’ve got started – that’s really good.”’
The use of positive, supportive language is a key feature of midwifery care. Leap (2010) used the phrase ‘midwifery muttering’ to describe the quiet repeated use of words of encouragement throughout the labour which have a ‘steadying effect’ and create a ‘sense of calm’ (Leap and Hunter, 2016).
But remaining positive doesn’t mean being closed to concerns, adds Louise. ‘If you are leaving the room for any reason, be quite clear about where you are going and how long you’ll be.
‘Be careful to involve the woman in any conversation, or explain that you are just going to brief your colleague and go into the corner of the room. You should not be saying anything that you haven’t shared in layman’s terms with the woman and her partner.’
A lasting impact
It is not only during labour, but throughout a woman’s pregnancy journey that midwives must choose their words carefully, rooting out the negative connotations in so many everyday turns of phrase, says Louise.
‘Rather than saying “I think I’d like to give birth at home”, say “I’m planning a home birth” – be positive.
‘And my absolute bête noire – “going to try to breastfeed” – just sows the seeds that you are not going to succeed before you’ve even started,’ she adds.
Clearly, the impact of communication at this time extends well beyond a woman’s pregnancy and birth experience: poor support and communication during labour and birth is associated with a higher rate of postnatal mental health problems, including postnatal depression and post-traumatic stress disorder
Lynn Jackson-Taylor, hypnobirthing practitioner and co-founder of a perinatal mental health website, believes that communication and language during this time has a profound effect on a woman’s fundamental self-belief.
She says: ‘If a midwife can help a woman have that “I am capable” attitude, that’s positive in the early days with her baby, it’s positive for her self-belief in motherhood and in womanhood.
‘But if you’re telling a woman for example that “if your baby doesn’t come in the next 20 minutes we are going to have to intervene”, that comes across as a major ultimatum – a threat. ‘It’s perfectly possible you can turn it around and help a woman rediscover “I am capable” – a lot of that is done simply through the way you say things.’
So what can midwives do?
While there is a dearth of evidence on interventions to inform eﬀective communication between maternity care staﬀ and healthy women (Chang et al, 2018), some maternity units are taking steps to improve communication. University Hospitals of Morecambe Bay NHS Foundation Trust has developed a staff training programme that draws on families’ real experiences to illustrate the impact of words. (see below)
Mel Elliston, chair of the local Bay-Wide Maternity Voices Partnership and a practising doula, co-designed and developed the project, conducting 16 filmed conversations with women that now form the basis of a staff training day. She says: ‘Everything that’s said, and more importantly the way it’s said, can have a deep and lasting impact on women, and care providers have
it in their power to make a positive difference by the way they speak to women and the vocabulary they use.’
For Mel, the key is an individualised approach. She suggests that care providers can ask a woman how they would like something described, or how much information they need, or tune in to the language she favours.
But even more important than the vocabulary is the intent and the feeling behind it.
‘If a midwife can somehow impart her confidence to the woman that she can do it – show a sense of belief in her – she can help a woman feel her own strength, trust in her body and empower herself.
‘It’s not just the vocabulary,’ adds Mel. ‘It’s the belief in the person; you can’t just say the right words – you need to believe them.’
The ‘our Communication Matters in Maternity at Morecambe Bay’ Project
Sally Sagar, senior engagement and development matron at University Hospitals of Morecambe Bay NHS Foundation Trust, says: ‘As doctors and midwives we can use terminology that might be everyday to us, but can actually be quite shocking to women.
‘One woman I went out to see had had a number of miscarriages. To her, they were all her children – she had named them, they were part of her family – but with a subsequent pregnancy a doctor had insisted they weren’t babies, they were miscarriages. That really upset her.
‘Another woman I saw said she came out of her room holding her baby and walked down the corridor. A midwife popped her head out and said: “Babies don’t bounce, you know.”
‘When I spoke to the midwife, what she’d meant was “just be careful you don’t trip and fall,” but the woman was feeling vulnerable at the time and felt like she was doing something
wrong in how she cared for the baby.
‘We are just asking people to be mindful of the terminology they use, to consider how women can be impacted by the language, and make sure they absolutely understand what you mean.’
The communication workshops began in November, and every member of staff who comes into contact with a woman on her maternity journey will attend.
Sally says: ‘We have seen our complaints reduce since November and women are showing greater satisfaction in our surveys. Women who have given birth with us before are reporting that care has improved.’
A mother’s story
Lou Holroyd, a mum-of-three from Morecambe, is one of the women to share her story as part of the ‘Our communication matters in maternity at Morecambe Bay’ project.
She was left traumatised by an experience with a locum registrar who stitched her vaginal tear following the birth of her first child, without proper anaesthesia. She told him she was in terrible pain, but he replied: ‘Well you’re the one with a baby boy over there, not me,’ and continued.
A supportive midwife and hypnobirthing techniques helped her rebuild her confidence prior to the birth of her second child. But after labouring at home, her experience in hospital was devastating, despite the fact she gave birth just 15 minutes after arriving.
‘The midwife was really very cold and abrupt – she was very commanding and demanding. She told me to get on the bed, she kept saying: ‘I need to examine you. I need to examine you.’ I had a lot of anxiety after such a bad experience being stitched up the first time. I don’t think she realised how far along I was. I was in too much pain to be examined, I didn’t want to be examined.
‘I was scared so I clamped my knees closed – I ended up giving birth flat on my back with my legs still closed.
‘She demanded I opened my legs because the baby’s head was out, but by that point I was non-responsive to her – she had no warmth in her tone - I shut down. It was only when my husband said: ‘Lou you really need to open your legs, the baby’s head is out and your squashing it,’ that I responded.
‘I had no relationship with her. I had no trust that she would be careful. I felt like I would have the same experience I had before when that locum registrar stitched me up. I would never have wished to give birth like that.’
With the birth of her third child in 2016, her experience was completely different.
‘The midwife was just so kind. She let me take things in my own stride – she was patient. She made suggestions – but they were just suggestions, not demands or commands. She listened to the things I wanted, like low lighting for example, and I was really keen for a waterbirth and I wanted to have my hypnobirthing CD on. She listened to me and made things happen as best she could.
‘And she praised me – she praised me for the smallest things – that meant a lot at that time. I felt more empowered – more in control, more confident – a lot less vulnerable than I had with my second birth.
‘I don’t really remember the words, but I remember the tone of voice, the warmth, the positivity. During my first and third births the midwives looking after me were so kind, so calm and relaxed – their warmth came through. I felt like I genuinely mattered, my baby genuinely mattered.
‘But when I look back on the bad experiences, I don’t just remember the tone, the negativity, I remember the words – they played in my head over and over again. It’s hard to escape, even years later. It’s not something I think about a lot now – but I’ll remember those words, those experiences, for a long time to come.’
Mind your language
Good practice in birth communication
- Avoiding phrases that are anxiety-provoking, over-dramatic or violent.
SWAP: Fetal distress
FOR: Changes in baby's heart rate pattern.
SWAP: Trial of forcepts
FOR: Let's see if we can help the baby out using forceps
- Avoid discouraging or insensitive language.
SWAP: Failed induction
FOR: Unsuccessful induction.
SWAP: Poor maternal effort
FOR: Not finding it easy
- Respecting women as autonomous adults.
SWAP: My woman
FOR: Use her name or say 'the woman I am caring for'.
SWAP: Good girl (during labour)
FOR: You're doing really well
- Respecting a woman's autonomy as a decision-maker.
SWAP: You must have/need/require a CS.
FOR: I would recommend/suggest/advise CS because...(give benefits, risks and alternative for any recommendation)
SWAP: Patient refused
FOR: She declined
- Respecting women as individuals.
SWAP: The primigravida in room 12
FOR: Use her name or say: The woman in room 12.
SWAP: I'll go and consent her
FOR: I'll go and ask if she's happy with that and ask her to sign a consent form/discuss informed consent.
- Replacing exclusive or codified language with plain language.
FOR: Your waters have broken.
FOR: Extra bleeding after childbirth.
Carboon F. (1999) Language power and change. Australian College of Midwives Incorporated Journal 12(4): 19-22.
Chang Y-S, Coxon K, Portela AG, Furuta M, Bick D. (2018) Interventions to support effective communication between maternity care staff and women in labour: a mixed-methods systematic review. Midwifery 59: 4–16.
Davies L. (2012) Clinical complexity: the Emperor’s new clothes? Essentially MIDIRS 3(6): 17-22.
Hunter L. (2006) Women give birth and pizzas are delivered: language and western childbirth paradigms. J5ournal of Midwifery & Women's Health 51(2): 119-24.
Kirkham M. (1993) Communication in midwifery. In: Alexander J, Levy V, Roch S (eds) Midwifery practice: a research-based approach. Palgrave: London.
Leap N. (2010) The less we do the more we give. In: Kirkham M (ed) The midwife-mother relationship (second edition). Palgrave Macmillan: London.
Leap N, Hunter B. (2016) Communication and thoughtful encouragement. In: Supporting women for labour and birth: a thoughtful guide. Routledge: London.
Lee S, Ayers S, Holden D. (2012) Risk perception of women during high risk pregnancy: a systematic review. Health, Risk & Society 14(6): 511-31.
Lyerly A. (2012) Ethics and ‘normal birth’. Birth 39(4): 315-7.
Mobbs N, Williams C, Weeks AD. (2018) Humanising birth: does the language we use matter? See: blogs.bmj.com/bmj/2018/02/08/humanising-birth-does-the-language-we-use-matter (accessed 7 August 2018).
Munson K. (2016) Student voice: Yes, my lady. See: rcm.org.uk/news-views-and-analysis/analysis/student-voice-yes-my-lady (accessed 7 August 2018).
RCM. (2012) Evidence based guidelines for midwifery-led care in labour: supporting women in labour. See: rcm.org.uk/sites/default/files/Supporting%20Women%20in%20Labour_1.pdf (accessed 7August 2018).
Silverton L. (2017) Mind your language. British Journal of Midwifery 25(10): 618. See: magonlinelibrary.com/doi/10.12968/bjom.2017.25.10.618 (accessed 7 August 2018).
Stahl K, Hundley V. (2003) Risk and risk assessment in pregnancy – do we scare because we care? Midwifery 19(4): 298-309.