ScienceDirect.com - Journal of Midwifery & Womens Health - Women Give Birth and Pizzas Are Delivered: Language and Western Childbirth Paradigms.
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For all of you interested in conscious use of language, this article makes a clear and succinct commentary on just how powerful words are.
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Personal reflection
Women Give Birth and Pizzas Are Delivered: Language and Western Childbirth Paradigms
Lauren P. Hunter, CNM, PhD [Author Vitae]
- Available online 28 February 2006.
This article examines two differing health paradigms, their language, and their effect on the culture of Western childbirth practices. Specifically, the differences in perspectives and language between the dominant paradigm/culture (the biomedical model of curing) and the alternative paradigm/culture (a holistic model of caring) are explored. Examples of language from the medical, midwifery, and nursing literature that affect childbirth culture and the care of childbearing women and their families are examined. The use of language as a tool of power and its known and postulated effects on the childbirth experience, nursing care, midwifery practice, and holistic care are explored. The author argues for the use of a woman-centered paradigm for childbirth experiences.
Introduction
Language is a powerful tool of communication. The spoken or written word is the way human beings communicate their societal and cultural norms and values. [1], [2], [3], [4] and [5] The dominant culture has the advantage of using language to shape social policy and culture. Words can be used in social interactions to influence others.3
Kitzinger,6 an advocate of women’s right to control their own birth process, states that language socially controls women’s lives because it is man-made and expresses men’s views and perspectives. She believes women’s experiences are unspoken because there is no language in which the experience can be expressed. One reason gynocentric science (women’s knowledge) has been invisible is because the androcentric (male-centered) model has placed a premium on the written word and written results as documentation of scientific procedure.7 Kahn2 reviewed hundreds of years of Western writing that portrays the patriarchal influence on childbirth and childbirth language from a sociologic perspective. She concludes that this patriarchal influence is responsible for the lack of woman-centered language and the neglect of the use of women’s experiences in childbirth as legitimate knowledge.
Midwives, nurses, and women, however, often transmitted their wisdom and knowledge through personalized contact and encounters. The professions of midwifery and nursing have a historical and cultural tradition of imparting knowledge in an oral manner, which has further contributed to lack of recognition in the current medical paradigm. This article describes the language of two different health paradigms and the effect language has on the culture of Western childbirth practices.
The paradigm of the science of caring: a holistic model of care
The science of caring is the paradigm from which the philosophical and theoretical bases of midwifery and nursing originate. To define caring and its many meanings would be impossible because of the volume of literature and differences in opinion about the concept “care.” [8], [9], [10] and [11] The fact that care has more than one definition should not be disconcerting. Instead, it is congruent with a midwifery/nursing science that emphasizes the uniqueness of each nurse-client encounter. Meleis10 states that caring is a human behavior that encompasses the holistic being: physical, emotional, social, spiritual, and moral. The crux of caring is centered on the relationship between the caregiver and the client. Each experience is a unique encounter and contextual in nature. Dahlberg,8 Hagell,9 and Sterk et al.11 describe the caring relationship as an “intersubjective experience.”
Caring encounters concentrate on the relationship with and the supporting of the client instead of focusing on illness and pathology. This is supported by the Cochrane review by Hodnett12 of the positive outcomes of continuous social support during labor and the integrated review by Hunter13 of the importance of a provider being with women during childbirth to provide advice and information, comfort, and presence within a reciprocal relationship. Midwifery models of care emphasize the empowerment of women as partners in care and the provider-client relationship as central components. [14], [15], [16] and [17]
The paradigm of the biomedical model
The dominant paradigm in Western childbirth care, the biomedical model of science, has several traditional tenets. The model emphasizes pathology that is diagnosed and treated on the basis of three Cartesian principles. [9] and [18] First, the mind is considered separate from the body. From the Cartesian viewpoint, neither can influence the other. Second, physical nature is viewed mechanistically. The body is a machine that, if broken, can be fixed by medical intervention. Finally, Cartesian science is based on a written language of logic and rationalism. Emotive language and contextual information is not considered valid scientific data.
Increased use of technology has contributed to the continuation of these objective constructs as the dominant force in obstetric practice. Technologic interventions and medical terminology become symbols of power in the hospital setting and reinforce the control of the provider at the expense of the woman. [1] and [19] Sandelowski20 observes that technology most often consists of inanimate objects, and as such, increases the view of the “human body” as an artifact of or orifice for technology.
In feminist work on gender and science, Keller21 discusses the perceived differences in human nature and language between the dominant masculine paradigm, which are objective, reasoning, mechanistic, and rational, versus the alternative feminine paradigm of language, which is subjective, emotional, intuitive, artistic, and in tune with nature. Androcentric language affects current descriptions of disease states, research, general health matters, and to some extent, the paradigm of other health care professions.
From a research perspective, the dominant biomedical paradigm emphasizes “hard” data, which produces operational and tangible outcomes. The gold standard for research is the randomized controlled trial that seeks the one truth for each hypothesis. As the professions of midwifery and nursing have struggled to gain legitimacy, they too have emphasized this scientific standard, requiring quantifiable, objective research as the benchmark of true science. This view has contributed to the lack of women’s voices and perspectives in women’s health research that may be more amenable to (contextual) qualitative data collection.
From the perspective of the medical model, childbirth is considered a pathologic condition that is inherently risky and should take place in a hospital to ensure safety. By emphasizing risk, Sterk et al.11 and Wagner22 argue that even more power is created for the provider who is the only person who can reduce or control the chance of risk.
An example of the power of the biomedical model is provided in an ethnographic study conducted in England. The research performed by Machin and Scamell19 used two study groups: 20 women who took prenatal classes and made informed choice about childbirth options (medical care versus alternative care) and 20 women who did not take classes, and who relied on their providers to “take care of things as they saw fit.” The women in the informed choice group described themselves as wanting control and empowerment over the birth process. The women in the second group did not want to challenge the medical model and did not see the need for control over decision-making activities. The researchers found that the women in the group who resisted the medical model of care during pregnancy ultimately succumbed to the model during childbirth. From the interviews and observation data, the authors concluded that because the women were vulnerable during labor, they gave in to the prevailing symbolic messages, language, power, and control of the dominant medical culture. Both the providers and the environment in the study conveyed the message that science (i.e., technology and medicalized childbirth) was the safest route for their birth.
Role of language
Hewison’s23 grounded theory study of nursing power via language in client interactions was based on the premises that 1) language is an integral part of social interactions, 2) the way language is used reveals the power structure of the social encounter, and 3) nurses function with minimal power in encounters with other health professionals. Although power through verbal social interaction can be shared, she discovered that the most common form of nurse-patient interaction was “controlling the agenda.” Verbal communication was used to ensure that the patient was aware of her submissive role in the hospital and in compliance with hospital routines and procedures instead of for caring encounters.
Nichols and Humenick24 discuss the need for positive expression surrounding birth based on neurolinguistic science, which suggests that language affects the brain and nervous system. In a feminist discourse on women and resilience, Stewart25 agrees that feelings of inadequacy and deficiency can occur if humiliating language is used to describe childbirth, because the language used gives form to the experience. Indeed, this could be one reason for the newly evolved psychiatric terminology, “tokophobia,” used to describe the fear and anxiety some women experience surrounding childbirth.26
Fenwick et al.27 surveyed 59 women in Australia and North America about their perceptions of their birth experience after having a cesarean birth. All participants were members of an organization that supports consumer information about cesarean birth. Survey participants who had negative experiences identified health professional’s language, attitudes, and care practices as dismissive. Although the study findings are limited by selection bias, the content analysis highlighted the fact that communication difficulties were found between obstetric providers who used mechanistic language and women who spoke experientially about birth. Participants stated that their wishes and feelings were not acknowledged, and that the language used by providers was abusive, aggressive, and/or misleading, especially when routine practices were questioned.
Miles28 provides an excellent example depicting the different perspectives present between parents and the obstetricians with respect to childbirth. At an open forum to discuss the possibility of an alternative birth center, each group’s comments used to describe the childbirth process were recorded. Obstetricians chose objective words that indicated the need for control, such as death, risk, control, protection, costs, proof, management, standards, and efficacy, whereas parents chose words that were subjective, care oriented, and relational, such as, family, love, bonding, feelings, anxiety, unhurried, quiet, meaningful, and life ritual, as descriptors of childbirth.
Disempowering and pejorative words that emphasize the poor quality of the uterine “machine,” women’s inability to give birth, and the ability of obstetric providers to resolve these issues are rampant in obstetric language. For example, the process of the fetus traveling through the birth canal is referred to as “the mechanism of labor.” A woman’s labor that does not progress on a specific timetable is referred to as “arrested.” If “active management” is unable to speed the progression of labor, the process is referred to as a failure, as in, “failure to progress.” Contractions of the uterus can be labeled “inadequate” or “false,” and the cervix can be considered “unfavorable” or “incompetent.” A woman’s gestational term is called a “confinement,” and babies are “delivered” by the provider, not “borne” by the mother. A vaginal birth after previous caesarean birth is called a “trial of labor” and, if unsuccessful, is yet one more failure for the woman as her body betrays her and is referred to as a “failed attempt” at vaginal birth. First-time mothers have “untried pelvises.” Ultimately, mother and baby become the mechanistic “maternal-fetal unit.”
Obstetric jargon has been described as judgment and value ridden, in addition to mechanistic.18 Examples include lazy uterus, boggy fundus, and floppy cervix. Value-laden language can also lead to the stereotyping of women and to generalizations about how childbirth services should be provided. In turn, stereotyping can become a substitute for communicating with the laboring woman.29 Bastian30 postulates that the language itself is instrumental in forcing the mother/woman to maintain a passive and invisible role during childbirth.
Walton4 provides further examples of inappropriate words used during childbirth and discusses the power of words as socially owned symbols that reflect our culture. She argues that words only remain in use if they are useful to a culture and symbolically valid. One interesting childbirth metaphor she discusses is the provider’s use of the term “check a woman,” in reference to a vaginal examination. She further states that this terminology represents a power imbalance between the mother and the provider, because “to check” means either to “restrain or stop” or to “tick off a list.” If the provider is “ticking off a list” when “checking,” the mother is reduced to a product that must be assessed and a passive participant in the relationship, rather than a “partner in care.” She argues that the use of the word “patient” as a label for laboring women conjures up the thought of illness, submissiveness, and compliancy. Alternatively, the label “client” encourages the woman to become a consumer of an institutional product or procedure instead of attending to her own needs.
Kitzinger6 adds that even technical terms involving childbirth are male dominated because many of the normal physical “sensations” of childbirth have been named after the man who “describes” the process rather than the woman who experiences the “sensation.” Braxton-Hicks contractions, the painless uterine tightening a woman begins to “sense” as early as 6 weeks into her pregnancy, are named after the male physician who first “discovered” them. Another example of the androcentric dominance of childbirth language can be found by scanning the titles of manuscripts in current obstetric journals. The titles lend credence to the belief that women are viewed as objects, as opposed to living beings, and that the experience of childbirth is objectified and mechanized. One such example of this type of discourse is displayed in the following title of an article published in Obstetrics and Gynecology: “Induction of Labor in the Nineties: Conquering the Unfavorable Cervix.”31
Freda,32 in a discourse on ethical debates surrounding childbirth, stated that one of the last frontiers to be changed in the 21st century would be the end of medicalized birth and pejorative terminology concerning childbirth. She thought that nursing students would look back at the language used in the 1990s as evidence of control of providers over women and the passivity of laboring women and view these as oddities. Unfortunately, at the time of this writing, her predictions have not come true.
The language of holistic care and midwifery
A burgeoning number of articles have been published in midwifery and feminist-oriented journals since the 1990s that focus on changing the language surrounding childbirth. Ferguson,33 a Welsh midwife, advocates that the simple word “birth” should replace “confinement.” She argues that women should no longer be confined to bed during childbirth and that “confinement” is simply another word for hospital routines and medical management. Unfortunately, in the United States, many women are routinely confined to a bed during their labor and birth.
Zeidenstein5 discuses how it has been easier for midwives who practice homebirths to use woman-centered language that is respectful and truthful. However, the very existence of homebirth, which is frightening to those providers who feel the need to control childbirth in the name of safety, has created its own medicalized metaphors. Women who plan homebirth but require hospitalization for complications during labor are often called “train wrecks,” and the title of this article is borrowed from the often-verbalized obstetric phrase, “the only thing that should be delivered at home is a pizza.”
For changes in language and childbirth to occur, midwives and nurses must consciously use terminology in a manner that is empowering and reflective of the holistic model of care from which the professions originate. This new language can reflect women’s voices, philosophy, and their need for interpersonal relationships and encounters within the childbirth experience. [15], [34], [35] and [36] Institutions can also contribute to the empowerment of women through the use of caring, supportive, family-centered language in maternity care. Phillips37 provides an excellent example of this when he examines the terminology surrounding hospital visitation. Visitation guidelines that empower clients to make their own decisions regarding visitors use words such as welcome, encourage, and choose, whereas those that favor institutional power and staff control use phrases such as “allowed to be present” and “limited to the following number of visitors.”
Kirkham38 states that we must create a language for midwifery and for childbearing women that expresses our intuitive and creative dimensions and experiential knowledge. Labia means lips and labial is a sound using the lips.39 Considering that two sets of lips, the labia majora and labia minora, surround the birth opening, women’s voices should be heard clearly with articulated power during birth.
A wonderful example of woman-centered language for childbirth can be found in the words that are encouraged by those belonging to the hypnobirthing movement. Wainer40 replaces the medical words “mucous plug” with “birth gel” or “baby gel.” “Gel” conjures an image of softness and ripeness, which is congruent with early labor and with the feelings that women express during this time. The words “surge” or “wave” would replace the medical terminology of “contraction” or “pains.” Wainer further argues that women in the past have responded to words that have been used to describe their labor. For instance, she believes we have a high rate of “cephalopelvic disproportion” (CPD) and “failure to progress” precisely because women have been doing what providers have requested: “contracting.” She refreshingly suggests that women’s cervixes no longer need to “dilate” but, instead, “circle” around the baby’s head. Kahn2 describes the historical and current significance of the circle as a symbol of unity, wholeness, fulfillment, and perfection within the culture of birth and adds that providers do not really deliver a newborn, but instead “usher” the child into the world.
Implications for practice and policy
To be perceived as legitimate providers in the health care arena, the professions of midwifery/nursing often conform to the dominant paradigm instead of the caring paradigm. Fahy41 found that Australian midwives and nurses who offered empowerment to laboring women by encouraging them to define childbirth from their own perspective were “disciplined by the dominant power.” Sterk et al.11 contend that because midwives/nurses are conditioned to function within the dominant paradigm, they contribute to the passivity of patients through their lack of individualized “caring.”
Condon42 argues, ironically, that the public sees “caring” as belonging in the domain of women and that this association is harmful to the caring professions. Hagell9 further discusses how the type of knowledge that an epistemologic community uses (i.e., caring) can affect the profession’s legitimacy. Many argue that “women’s work” (i.e., women’s knowledge) has always been considered invisible and unimportant by the dominant male culture. [7], [9] and [25] Ginzberg7 states that women’s knowledge, midwifery, home economics, and cooking are designated as art, and insignificant by the andocentric paradigm. She contends that if these practices were male dominated, they would have been awarded the distinction of “sciences” instead of “arts.”
Caring research has been considered less powerful. If one identified the type of research and language that would flow from a philosophy of caring, holism, and woman-centered knowledge, it would be encounter-oriented, contextual, phenomenal, and experience-based. The dominant medical paradigm refers to this as soft research or soft outcomes. Oakley43 argues that so-called “soft” outcomes for childbearing women, such as maternal satisfaction, family bonding, and postpartum depression, are essential factors to be studied along with “hard” outcomes.
Page44 describes power as the ability to put ideas into action, and Wagner22 states that those in power control information. To encourage the practice of childbirth within a woman-centered context, it is imperative for the professions of midwifery/nursing to make several powerful political changes. It is evident that the language surrounding childbirth must change if we are to honor the process of childbirth as a miraculous experience for women who can trust their bodies to be powerful and capable of a natural phenomenon. Kamphuis45 states that although words help to shape our attitudes, changes in attitudes can help to create new language. This new language needs to be fostered in educational institutions of midwifery, nursing, and medicine. [30] and [46] This task should be achievable because the half-life of knowledge, especially in high-technology fields such as health care, is less than 3 to 5 years.47
One way this change can be facilitated is by the use of appropriate, woman-centered language that emphasizes caring and respect. Page44 concludes that giving power to the mother and family during pregnancy and childbirth is an initial basic building block for future “positive personal power” to be used during a lifetime of parenting. It is our responsibility to share our power with our clients by providing a relationship, including appropriate language that is structured to meet the needs of the woman. [48] and [49] Part of this process includes empowering women and their families. Empowerment can occur through interpersonal understanding in a relationship that fosters reciprocity, mutuality, and dialogue, during which the needs of the woman and her family are discovered through the process of the communication.50
It is important that the professions of midwifery/nursing recognize that our history and cultural tradition is of imparting knowledge in an oral manner of communication. As we develop and use woman-centered language, we can create a body of written text that documents our profession’s legitimate knowledge and ways of knowing. If we are going to listen to women, we need to help them create a language that is meaningful to the speaker.
Our challenge is to honor and use our own knowledge of caring and holism. It is crucial to bring this knowledge into the main arena of childbirth as a worthy science that complements and works with other paradigms through creation of a common language and model of caring for health care providers.
Conclusion
Women want and need both a healthy baby and a satisfying childbirth experience. To achieve these goals, the “competing” paradigms must combine to create an environment that is not “hard” versus “soft,” nor men versus women, but rather, an integration of “differing” paradigms that will complement each other. Parker and Gibbs51 suggest that through midwifery’s struggle to support both traditional and scientific practice in childbearing, we have become excellent mediators for future melding between communities, professions, cultures, and paradigms. Although this will continue to be a difficult and stressful task, this author believes that midwives are the best choice because we speak and understand the multiple languages surrounding childbirth. We are the profession that will make sense of multiple truths from all paradigms in our continuing efforts to construct the most empowering setting in which women can “give birth.” Through woman-centered language and personal empowerment of birthing women, the professions of midwifery/nursing can reverse the culture of risk that prevails in the current childbirth milieu.
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Address correspondence to Lauren P. Hunter, CNM, PhD, Nurse-Midwife Program Director and Advisor, San Diego State University, College of Health and Human Services, School of Nursing, 5500 Campanile Drive, San Diego, CA 92182-4158.
Vitae
Lauren P. Hunter, CNM, PhD, is the Director of Graduate Nurse-Midwifery Education and an Assistant Professor at San Diego State University, San Diego, California.
