Words have power

Words have power. I know this – the approach I used for my doctoral research requires you to look closely at how language shapes the social world. If you have hung around the birth world for a bit, you have probably made some conscious choices about whether you use the words “patient” and “delivery”. I spend most of my working week choosing which words work best to get the job done, so I have the luxury of having plenty of time to consider word choices and practice seeing the impact they have.

Until recently however, this particular word escaped my scrutiny.

That word is escalate

I wrote a fair bit about midwives being required by policy documents to “escalate” care when the fetal heart rate pattern was interpreted as abnormal in my thesis and in our 2022 paper titled “Midwives must, obstetricians may” (linked below). Our paper described how these documents made it logical for obstetric staff and for the team leader (the midwife overseeing the midwifery staff in the birth suite) to disruptively enter birth rooms without having been asked to do so, in response to what was seen at the central fetal monitoring station. The specific wording in two of these documents was:

In clinical situations where the fetal heart rate pattern is considered abnormal, immediate management should include: … Escalation of care if necessary to a more experienced practitioner.
Royal Australian and New Zealand Colleges of Obstetricians and Gynaecologists (RANZCOG) Intrapartum Fetal Surveillance Guideline (2014) p. 17

Follow local escalation procedures to senior midwifery and obstetric staff when CTG abnormal.
Queensland Health Intrapartum Fetal Surveillance Maternity and Neonatal Clinical Guideline (2015) p. 26

At the time I wrote the thesis, and then this paper, I took for granted the term “escalation”, rather than thinking more deeply about how it both reflects, and reinforces, hierarchies of power in maternity systems. Today’s post is about where I am up to with my thinking about this.

Why is the term “escalate” a problem?

At the heart of this word is “scale”. The word has multiple meanings, but when used in the word “escalate” the relevant meaning (I used the Oxford English dictionary) is a graduated range of values forming a standard system for grading something. When applied in the social world, it is the full range of different levels of people from lowest to highest. The origin of the term is from the Latin words scandere – to climb, and scala – a ladder.

Using the word “escalate” in maternity services implies that there is a scale of people, a hierarchy, with some at the bottom, others in the middle, and some at the top. In other words, there is a power structure with increasing social status at the top. So who goes where?

Looking back at the documents I quoted, and reapplying the approach I used in the original analysis of putting people back in when they were not explicitly referred to (based on my insider knowledge of how maternity care systems work), makes this hierarchy clear. Midwives providing direct clinical care were the ones lower down the ladder. “Senior midwives” were above them, and obstetric staff were even further up the ladder. Everyone in this system knows they have a place in this hierarchy, and knows there are potential consequences if you refuse to occupy your designated spot on the ladder – particularly if you attempt to climb up a rung or two!

You can also see in the quotes the assumption that being higher up the ladder relates to having more experience than those lower down the ladder. This was at odds with what I observed when collecting data (and in my clinical experience in general). Midwives who had been midwives for decades and were in their 50s and 60s were “escalating” care to 20-something year old registrars with two or three years of experience in maternity care provision. “Senior” is a tricky term too – it can relate to being older, more experienced, or having a nominated role that carries more responsibility and authority. Team leaders had a designated role with more responsibility and authority (as they had oversight over all the work on the birth suite) but they were not always older or had more years in midwifery practice than the midwives providing clinical care. The one midwife could be team leader some of the time, and provide direct clinical care on other shifts. Their seniority was not about who they were, but about their role that day.

Is there better terminology?

Does this hierarchy reflect the maternity system we want? Do we want a system with birthing women on the ground at the base of the ladder, and others arranged according to their historically assigned social value, with obstetrics dominant? I can now see how my use of the term “escalate” assumes that this taken-for-granted structure is the way things are, and is how things should remain. And that makes me uncomfortable.

For starters, the behaviours we call “escalation” don’t really fit this model. I think there are three components (maybe there are more – let me know if you come up with others) to what is happening when midwives are doing “escalation”. “Escalation” doesn’t always involve all three, but it can.

Communication – making sure the right people have access to the right information at the right time. For example, ensuring the team leader understands why the midwife is turning off the oxytocin infusion.
Accessing specific knowledge and skill sets – making sure the woman has access to the right mix of people who can assess, advise, and carry out appropriate interventions. For example, getting a second opinion from someone with CTG expertise when the midwife isn’t sure what to make of this particular CTG pattern, or having someone who knows how to safely perform an instrumental birth attend to do so.
Accessing people with specific authority, based on their role on the day – making sure care is coordinated within the service. For example, only some people have the authority to call the theatre team in from home for an unscheduled caesarean section out of hours.

These behaviours are important elements in safe maternity care provision, but they don’t require the existence of a linear hierarchy with obstetricians at the top. When we define collaboration as two autonomous people of equal social status working together to achieve something that neither can alone – you can see that collaboration, not escalation, is another way to think about what is happening.

Is there another term you think works better – and reflects the maternity care structure you would like to see exist? Let me know in the comments.

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References

Small, K. A., Sidebotham, M., Fenwick, J., & Gamble, J. (2022, Mar). Midwives must, obstetricians may: An ethnographic exploration of how policy documents organise intrapartum fetal monitoring practice. Women & Birth, 35(2), e188-e197. https://doi.org/10.1016/j.wombi.2021.05.001