juno midwives

Language is a key component of how we humans communicate with each other, and good communication is a cornerstone of safe and effective care. In our combined 20 years or so of experience as midwives, we have heard fellow midwives, doctors and anaesthetists communicate beautifully with women and birthing people. We have seen how kind, respectful, and supportive words can make all the difference to how someone feels and possibly even make a difference to their birth outcome. Unfortunately, we also frequently witness healthcare professionals using language that belittles, disrespects, coerces, puts down and demeans women and birthing people.

To paraphrase Elizabeth Prochaska (former chair and co-founder of Birthrights), women are allowed to make decisions that we as healthcare professionals may find morally incomprehensible. It is a great reminder, for those that need it, that all decisions during pregnancy and childbirth ultimately lie with the woman/birthing person. It is not the role of a midwife or doctor to persuade or coerce women into making decisions that they believe to be the right ones. We forget in maternity care that women and birthing people are autonomous human beings and they can make decisions that do or do not align with hospital guidelines and policies or the expectations and beliefs of a healthcare professional.

In our previous blog post, we explored the idea of ‘Am I allowed…?’ in relation to commonly offered screening tests and interventions. We hear the word ‘allowed’ being used frequently in maternity care – both by women and birthing people and by midwives and doctors. ‘Allow’ suggests someone else (i.e. a midwife or a doctor) has to give a woman or birthing person permission to do something. In truth, human rights law states that women and birthing people have the right to make decisions about their care. It does not state that midwives or doctors must make decisions on behalf of women and birthing people in their care. 

The NICE pregnancy and birth guidelines frequently use the word ‘offer’, when discussing interventions and common screening tests. Which sounds innocuous, right? Offering something would suggest that women and birthing people can accept or decline that offer equally. Based on experience, we know this is frequently not the case and there are a couple of key issues here.

1. The ‘offer’ is often not really an offer. Let’s look at that in terms of ‘offering’ a vaginal examination.

This is what we would expect an offer from a healthcare professional to look like:

“NICE guidance suggests offering women a vaginal examination every 4 hours when in established labour. It is your choice if you would like to have one or not. The benefits to having one are: they may help aid clinical decision-making by knowing how dilated your cervix is and what position your baby is in. The risks are: the chance of infection increases the more vaginal examinations you have, they are painful for some women and they provide limited information in that they only tell us how dilated the cervix is at that point in time – they cannot predict when a baby will be born. There are alternative ways of knowing if someone is progressing in labour. There is also no research to say that doing routine vaginal examinations during labour improves outcomes. Would you like some time to discuss with your birth supporters if you do or do not want a vaginal examination?”

Versus what we actually see in hospital practice:

“You’re due an examination now.”

“Can I examine you?” (with no conversation about benefits/risks/alternatives)

“We’ll examine you at X time.”

And even…the healthcare professional entering the room and putting their gloves on without actually asking for consent before getting ready to do a vaginal examination.

1. When an ‘offer’ is declined, we have heard the following:

“She’s refusing to do X.”

“She’s uncooperative.”

“She’s being difficult.”

“She’s crazy.”

“Go and speak to her and persuade her to have X.”

Where an intervention is considered the norm and routine by healthcare professionals, such as routine 4 hourly vaginal examinations, it often isn’t presented as something that women and birthing people have a choice in.

The language used around vaginal examinations and the interventions that require a vaginal examination (artificially rupturing the membranes, doing a membrane sweep, applying a fetal scalp electrode) can be extremely problematic:

“Good girl”

“Just relax”

“This won’t hurt.”

“I’m just going to examine you.”

“You’re not making this easy for me.”

“I need to put this clip on the baby’s head.”

“I gave you a good sweep whilst I was there.”

“I’m going to leave my hand inside.”

Some of this language is creepy at the very least, but most of it screams of coercion and a lack of consent. Lack of consent for sweeps is a recurring issue – have you seen our PSA on Instagram? 

When women and birthing people do not meet the expected time frames of labour (which, by the way, are reductionist, not evidence-based and only serve the hospital as means of getting women in and out as quickly as possible), the language used centres the woman or birthing person as the problem.

“Your progress is a bit slow.”

“You have failed to progress.”

“Your contractions aren’t very strong.”

“Your cervix is only X cm dilated.”

This language fails to acknowledge the system’s unrealistic time frames or any prior intervention that may have occurred. It also fails to look at, for example, why a woman or birthing person’s contractions may not be ‘strong’ – do they feel safe? Have we created an environment that would promote the release of oxytocin? Or is it perhaps the bright lights, constant interruptions and unfamiliar faces that are resulting in contractions that don’t seem so strong? Read about physiological labour plateaus here.

Take into account also, women whose first language is not English. NICE recommends that an interpreting service is used – but again, this is not something we see routinely in practice. Or something used when there are ‘big’ decisions to be made ie. a caesarean section, rather than seemingly smaller decisions such as a vaginal examination.

This language is deeply embedded in our maternity system. We’ve worked across several different hospitals, and we hear the same things. We are committed to evolving as practitioners, to learning, to making birth better for women and birthing people, to demonstrating to our colleagues and student midwives an appropriate and respectful way of speaking to both them and the women and birthing people who trust us to care for them.

Read

Sophie wrote about offering vaginal examinations for the British Journal of Midwifery.

Birthrights have really useful factsheets about your rights during pregnancy & birth.