practises and teaches at Mount Sinai Hospital where she is coordinator of the PrimaryCare. Obstetrics Interest Group. Acknowledgment. I thank Deana Midmer, ...
VIEWPOINT
PLATFORM Language in
obstetric care What do we really want to say?
ANNE BIRINGER, MD, CCFP
et me teil you about a delivery I did last week. This elderly primip had been a fertility failure until we artificially inseminated her. At 16 weeks, I put a Shirodkar in for her incompetent cervix, and she went to term. I induced her because of intrauterine growth retardation, but she failed to progress. So I ruptured her membranes and continued to pit her. She couldn't push the kid out so I did an easy lift-out with the Simpson's. I don't know what she is complaining about. If anyone else had been managing her labour, she would almost certainly have been sectioned. Does this paragraph describe a construction project, a difficult veterinary case, or a human birth? Although these terms look outrageous when compiled, they are common parlance in many labour and delivery areas and raise the issue of the language used in providing obstetric care. Obstetric jargon exemplifies the traditional premise that physicians control birth while women are passive agents who can fail the challenges of reproduction in countless ways. We "manage" labours and "deliver" babies for women with "inadequate pelvises" and who "fail to progress." However, although it is becoming increasingly clear that much of our obstetric jargon 880
Canadian Family Physician VOL 40: May 1994
disempowers women, it is difficult to abandon the old expressions. In 1973, Scully and Bart' published a shocking report describing the contents of 27 gynecology textbooks published between 1943 and 1972. They found that the books still fostered traditional sex-role stereotypes of women as primarily child producers, homemakers, and husband pleasers. The current medical knowledge of women's sexuality was presented inaccurately despite the findings of Kinsey and Masters and Johnson. Scully and Bart's study received wide publicity within the medical and lay press. Its publication coincided with the growth of feminist literature and, in particular, the feminist health movement. Two studies2'3 in the United States and Australia have partially replicated Scully and Bart's work. The authors hypothesized that more than a decade of criticism would have led to the elimination of sex stereotypes and paternalism from gynecology textbooks. In 1988, Elder and Humphreys2 published an analysis of the content of 28 gynecology textbooks published from 1978 to 1983. In 1990, Koutroulis3 analyzed the
recommended obstetrics and gynecology textbooks listed in the 1988 handbooks for medical students at four Australian universities. Both studies found that, although some authors made an effort to move to an egalitarian and nonsexist stance, sexist ideology still pervaded the textbooks. More difficult to assess is the extent to which sexist attitudes and language exist in classrooms, physicians' offices, and day-to-day practices. Morris4 states that "the use of a familiar term or practice not only reinforces our tolerance of it, but increases our belief that it is appropriate to accept it." Unless those members of the medical community who serve as models change their terminology, offensive jargon will continue to flourish.
Implementing change It is time to examine the commonly accepted jargon of obstetric care. What are we really saying to women? How is it interpreted? Attitudes toward birth are slowly changing, but the language must change along with the philosophy. Can language actually change before attitudes change? What are the obstacles to change? How can we implement change? What are acceptable, useful alternatives? Elder and Humphreys2 found that one third of the obstetrics and gynecology textbooks they examined implied that a woman's chief function should be childbearing. Certainly our language places women on "reproductive trial." Women can fail at many levels from
VIEWPOINT * PLATFORM
"ovarian failure" to "fertility failure" to "failure to progress" to "breastfeeding failure." Their pelvises are "inadequate," their cervices are "incompetent" or "unfavourable," and their labours "dysfunctional." Women are given a "trial of labour," a "trial of forceps," and then get "sectioned" when they "fail." Contrary to the philosophy of empowering women around issues of pregnancy and childbirth, our language roots us in the traditional premise that physicians are in control and patients are passive agents. Nouns are used as verbs as we "pit" them (against whom?) and "section" them. Construction terms creep in, for example, an easy forceps delivery is described as a "lift-out," or a generous pelvis is described as "big enough to drive a truck through." Indeed, the almost mystical nature of birth is denied when a previous birth experience or pregnancy is described as "unremarkable" or "uneventful." For whom? Does the lack of medical complications diminish the power of the birth experience? Certainly the medical environment desexualizes birth, largely for the comfort of those attending. But by denying the uniqueness of each woman's experience, we deny the momentousness of childbirth for the woman giving birth and the child being born. Women are infantilized by inappropriate terms of endearment, such as "love, honey, good girl," and often the second stage of labour is turned into a sports event, cheerleaders and all. Whether these women are "clients, "patients," "mothers-to-be,," "maternants," or "pregnant women" is a matter of debate. The appropriate term is determined by the nature of the relationship with the physician, the cultural context, and individual preferences. In an excellent commentary in the British Journal of Obstetrics and
Gynaecology, Bastian' describes how "the use of depersonalizing language and the terminology of failure and inadequacy may adversely affect a woman's confidence and self-esteem." As a lay person, she gives many examples of how our jargon can be devastating to childbearing women. As well as many of the expressions that have been mentioned above, she comments on military metaphors, such as "hostile" mucus or the description of a baby's head as a "battering ram" against a "rigid and unyielding" perineum. She points out how "consumer unfriendly" much of ourjargon can be. Alternative phrases for negative jargon The medical profession is starting to respond to consumer demands to watch our use of jargon, which is open to misinterpretation. The Cesarean Birth Planning Committee6 has advised that terms with a negative connotation or that imply judgment of the woman are to be avoided. The members, which included representatives from nursing, family medicine, obstetrics, and consumers, also suggested alternatives for several of the commonly used but objectionable phrases. They provided "nonprogressive labour" as an alternative for "failure to progress," "possible labour" for "false labour," and "labour" instead of "trial of labour." We can go to our midwife colleagues for other ways to describe what we do in obstetrics. While women themselves "deliver babies" we actually "attend births" (derived from birth attendant rather than simply show up) or "assist or facilitate birth." By using cesarean section and Pitocin as nouns, we stop "sectioning" and "pitting" women. Their labours can be "augmented with oxytocin" or they might require a
cesarean section for some indication. A pregnant woman might develop toxemia of pregnancy; however, she does not "become toxic." And referring to a woman as "the section in room 12" or "the cord prolapse" depersonalizes care. It is important to differentiate between the woman as a whole and as an anatomical or physiological event that is part of her, but over which she has no control. Women do not "fail to progress." Their labours might not be progressive, but this does not make them failures. To say that a woman has an "inadequate" pelvis implies that she had some control in the matter. The woman is not inadequate despite the fact that she has a narrow pelvis or prominent ischial spines. A recent guest editorial in the Journal of the Society of Obstetricians and Gynaecologists of Canada focused primarily on the risk of the "pervasive modern disease of taking ourselves too seriously and replacing the short and simple with the long and incomprehensible."7 Although the author conceded that "perhaps it is appropriate that we change some of our language," he provided some exaggerated examples of how ridiculous "politically correct" terminology could be. I agree with him that a "chronologically gifted primigravida" is not going to be happier than an "elderly primigravida." But why can she not be a 38-year-old woman in her first pregnancy? Granted, this is a slightly longer phrase, but given how the definition of "elderly" in obstetrics has changed over the years, do we have to retain a judgmental term that is of questionable accuracy? The author also asked to retain the term "trial of forceps" stating that "here, in a sense, it is the obstetrician who is on trial and, indeed, it may be quite appropriate Canadian Family Physician VOL 40: May 1994
881
VIEWPOINT * PLATFORM
to conjure up the atmosphere of the courtroom when performing mid-forceps." I cannot imagine that the image of "performing" in a courtroom is helpful to most practitioners, when in fact, all that is happening is an attempt at a forceps birth.
Overcoming biases There is no question that we have to change our use of language. However, why am I personally having difficulties? I think that I am moderately aware of my use of medical jargon, informed about feminist issues, and woman-centred, particularly in my obstetrics practice. But I am frequently embarrassed by the expressions that so easily roll off my tongue! Does this reflect a simple training effect, habit, or more deeply seated attitudes? We all enter medical school with our own (and a reflection of society's) biases and preconceived ideas about women and childbirth. However, the undergraduate and postgraduate training years are a critical period when many of these initial biases become integrated into the practice of medicine. It is generally accepted that labour and delivery rooms are difficult territories to enter for new interns, residents, or staff physicians changing hospitals. Indeed, the newcomer often feels "on trial" until proven worthy of the easy collegiality among professionals who have spent many days and nights together and shared many intense experiences. This "clubishness" perpetuates attitudes and, more superficially, language use. What easier way to demonstrate that you are indeed a member of this "club" than to use the same jargon? For trainees, it is a matter of demonstrating competency and familiarity with new terms. 882
Canadian
Famniy Phyvsician VOtol.;: MIay 1994
Even for newly arrived family physicians or midwives, use of the accepted argot can ease the transition. However, in many situations, family physicians in the case room feel that they are constantly on trial. At what point does it feel safe to risk exclusion by appearing to be different, knowing that this will place your practice and patients under intense scrutiny and judgment? It is often easier to emulate those with the power. We are becoming more aware of the potential impact that language can have on the women in our obstetric practices. Articles about language in obstetric care have been published in at least two journals read by obstetricians, and official bodies are recommending that we rework some of our commonly used phrases. Once again consumers have played an important part in holding up a mirror to the profession to reflect how our jargon can be interpreted. It is important, however, that we change not just the words we use, but the underlying attitudes about birth and the women engaged in it. The "politically correct" terminology will ring hollow when applied in a non-woman-centred manner. As clinicians and educators, we need to recognize and clearly define the subtle and blatant forms of sexism that enter our offices, hospitals, and classrooms. Noticing and calling attention to familiar terms that reinforce derogatory definitions of womens' nature or potential is an important part in the process of change. Writers and editors must also be vigilant, as our writing reflects the profession's attitudes. In addition, trainees need appropriate role models at all stages of their training who demonstrate both the language and attitudes that empower women. As difficult
as this can be, we will be helped as the critical mass of people concerned about these issues grows. It is an ideal opportunity for family physicians involved in maternity care to take a position of leadership. We will be helped by our patients, midwives, and nurse colleagues and, I hope, more of our m medical colleagues. Dr Biringer is an Assistant Professor in the Department of Family and Community Medicine at the University of Toronto. She also practises and teaches at Mount Sinai Hospital where she is coordinator of the Primary Care Obstetrics Interest Group.
Acknowledgment I thank Deana Midmer, BScN MEd, and midwives Robin Kilpatrick and Linda Moskowitz for their valuable suggestions and unique perspectives on this topic.
Requests for reprints to: Dr Anne Biringer, Mount Sinai Hospital, 600 Universi_y Ave, Suite 413, Toronto, ON M5G IX5 References 1. Scully D, Bart P. A funny thing happened on the way to the orifice: women in gynaecology textbooks. Am ] Sociol 1973;78(4): 1045-50. 2. Elder RG, Humphreys NV Sexism in gyinaccology textbooks: gender stereotypes and paternalism, 1978 through 1983. Health Care 'omen Int 1988;9:1-17. 3. Koutroulis G. The orifice revisited: women in gynaecological texts. Gommunity Health Stud 1990;XIV(l):73-84. 4. Nlorris MIB. An excursion into creative sociology. New York: Columbia, 1977. 5. Bastian H. Confined, managed and delivered: the language of obstetrics. Br]J Obstet (Cynaecol 1992;99:92-3. 6. Cesarean Birth Planning Committee. Appropriate use of cesarean section. Recommendationsfor a quality assurance program. Toronto: Ontario Ministry of Health, 1991. 7. Baskett TE The language of reproduction: what's in a word? 7 SOGC 1993; 1 5(6):683-6.
