In modern midwifery and medical practice, risk-related words abound. There’s high risk, low-risk, increased risk and relative risk; risk analysis, risk management, risk factors and risk assessment. Happily, there are also a small number of terms which are suggestive of a decrease rather than an increase in risk, such as risk reduction, but the sheer number of risk-related words would give any alien visitor to Earth-based maternity services a good idea of where the emphasis lies in current practice.
Many more of the terms that we use – especially around labour and birth – are about what lies outside the margins of what we perceive as normality. We talk about babies being small-for-dates or large-for-dates, but not about babies being just-right-for-dates. Where is the normal variant of dystocia? We have terms to describe the incompetence of a woman’s cervix, or the failure of her labour to progress (within our systemic temporal limits, that is), but how many women read in their notes that they have an eminently capable cervix, or that they are experiencing a successfully progressive and beautifully timed labour and birth? As has long been noted, Western medicine has been so focused on defining what is pathological that there are few terms and expressions that tell a woman how marvellously capable her body is, or has been, or can be.
I suspect this is partly because of our use of central tendency (or the mathematical concept of the average) to define what is normal, which leads us to draw limits around the band of normality. Perhaps it is then more enticing to name what lies outside the band than what lies within it; by definition, what lies outside is the anomalous rather than the regular. We can simply denote that something is within the band of normality by using phrases such as “within normal limits” (WNL) or “nothing abnormal detected” (NAD), thus reducing our assessment of normality to acronyms and saving our linguistic creativity for the world of the outliers.
We don’t always use these acronyms, however; sometimes we use terms such as “uneventful” to describe something that follows a normal pattern, such as pregnancy or labour. But this doesn’t seem quite right either, from the perspective of the birthing woman. The term “uneventful”, to women, may sound like another way of saying, “because nothing abnormal happened, and you didn’t deviate from the average, your pregnancy/labour was actually quite boring…”
The use – and implications – of central tendency might not be quite so problematic if the limits developed were the result of careful analysis. For instance, if a group of Renaissance mathematicians had sat around and carefully worked out the average length of pregnancy or labour, the average growth of a baby, and so on, it might offer little consolation to the woman whose experience is outside of those boundaries, but it might be slightly easier to stomach as a general concept. However, in many cases, this has never happened, or else the data set on which initial limits developed was too small to be of any real use. People like Naegele and Friedman, for instance, actually only researched the experiences of very small numbers of women before announcing the average length of pregnancy and labour. I’m sure they were all very nice women, but, with such a small number in the original sample, how can we be sure that their experiences bear any relationship to the norms that we should expect to see in the millions of modern women who are so affected by them?
No matter whether we focus on the problems with the use of the mathematical average itself, or the unacceptably small samples from which many of the normal limits we use have been defined, or on the language used around the normal / abnormal continuum, if we are committed to woman-centred midwifery practice, we need to think about how we can work towards using concepts that are useful and empowering for women. If we are truly committed to facilitating, enhancing and increasing normal birth, perhaps we should start writing in women’s notes about cephalopelvically-well-proportioned babies who are perfect-for-dates being born to women following a well-timed and progressive labour, a period of marvellous pushing and preceding the birth of a happily-lying placenta. Or, if that all sounds like a bit of a mouthful, perhaps we should simply think about the language we use around risk and complication, consider the impact this may be having on women, and have a go at coming up with a few creative and eloquent alternatives of our own.