‘YOU ARE ONLY IN EARLY LABOUR, YOU ARE NOT IN ACTIVE LABOUR YET’: MIDWIVES’ LANGUAGE AND BEHAVIOUR AND THE MEANING WOMEN MAKE OF IT

(150 words) Effective communication, respectful language and compassionate behaviour are vital elements within maternity care for midwives to develop trusting relationships with childbearing women and their families. This paper reports examples of midwives’ negative language and behaviour during childbirth that were perceived as uncaring by first-time mothers. Findings are presented as four themes: a) ‘you are only in early labour, you are not in active labour yet’; b) lack of midwife’s presence; c) non-individualised behaviour; d) inflexibility: being procedures and rules oriented. The midwife’s negative language, lack of presence, inflexible and non-individualised behaviour may result in the women feeling humiliated, ignored and dissatisfied with their birth experience. Midwives should continue to communicate with labouring women and their families, utilising positive language as an important component of individualised and respectful care.


INTRODUCTION
Effective communication, respectful language and compassionate behaviour are vital elements for developing trusting relationships and achieve positive outcomes for childbearing women and their families (NMC, 2015, Cumberlege et al., 2016, Borrelli, 2014, NHS, 2012, Borrelli et al., 2016).Previous research has focussed on negative language and depersonalised care with authors arguing the case for more compassionate, humanised and individualised care (Bohren et al., 2015, Reed et al., 2017, Harris and Ayers, 2012, Mobbs et al., 2018).However, evidence shows a reality far from this ideal, with healthcare professionals often using risk-based, failure-related, patronising and undesirable language alongside inadequate information provision, poor communication and practices perceived as uncaring (Simkin et al., 2012, Goldborth, 2009, Baker et al., 2005, Eliasson et al., 2008).These may cause emotional trauma and long-term damage for labouring women (WRASM, 2011).This paper will share and discuss examples of midwives' negative language and behaviour during childbirth reported by first-time mothers who participated in a larger study exploring women's expectations and experiences of a good midwife (AUTHORS BLINDED, 2016; AUTHORS BLINDED, 2017).

METHODS
A qualitative Straussian grounded theory methodology was adopted.The research sites were three National Health Service (NHS) Trusts offering home, freestanding midwifery unit (FMU) and obstetric unit (OU) as birth settings.The purposive sample of the larger study included 14 first-time mothers in good general health with a straightforward singleton pregnancy.A total of 26 tape-recorded face-to-face semi-structured interviews were conducted, including interviews with 14 women in the third trimester of pregnancy and with 12 mothers postnatally.
Ethical approval was obtained before entering the research sites.Informed consent was gained prior to participation, women were free to withdraw at any time and pseudonyms are used.More detailed information on the study are reported elsewhere (AUTHORS BLINDED, 2016;AUTHORS BLINDED, 2016;AUTHORS BLINDED, 2017).

FINDINGS
The majority of women recounted positive experiences, but postnatally five interviewees shared their experiences of midwives' negative language and behaviours; this paper focuses on these.Findings are presented as four themes: a) ' Midwives were considered to use negative language during the early labour stage either during telephone conversations or at the time of hospital triage.Within these episodes, midwives were described as labelling the woman as being 'only in early labour' and 'not in active labour yet'.The participants derived their own meaning of the language used by the midwives, considering the latent phase as an ineffective and static stage of labour, where no evident progression was present.The use of words such as 'only' and 'yet' in early labour made women worry about the duration of labour.Moreover, the women felt that the midwife did not understand their individual needs and the pain they were experiencing:

Non-individualised behaviour
In contrast to interviewees who reported a trusting woman-midwife reciprocal relationship which transgressed traditional client-professional boundaries, Sophia felt that the midwife was neither professional nor friendly, being there just to do her job, doing only quick routine checks and acting like the woman was 'just the client': I felt like she wasn't very professional, she wasn't that friendly, she kind of made you feel like you were just the client, she was just doing a routine check that she normally does 15 times a day (Sophia) Some participants argued that the midwife was 'quick to go' when her shift finished.Moreover, some interviewees agreed that the care appeared sometimes to be more dictated to the routine tasks required by the ward's workload rather than shaped on individual needs.This non-individualised behaviour often resulted in the women feeling dissatisfied with the care received: It was all very much of the fact they were moving you off the labour ward to take you down to the postnatal ward (Michelle) She was quite quick to go when her time was up (Melissa) Louise indicated that she was disturbed by the midwife's general attitude, mainly due to the language used and the way of speaking to over-talk the woman's voice rather than concentrating on and listening to her: In regard to possibility of choice, Louise reported that the midwives completely ignored her birth plan and therefore she felt that her preferences were not respected.Even if she was planning to give birth in a FMU and then she was admitted to an OU, she argued there were still choices that the caregivers could have made according to her initial birth plan.She was disappointed by the fact that she was not offered the possibility to go through her birth plan with the midwife at any stage of labour: Did they really respect my decisions or how I wanted things?They completely ignored my birth plan.They knew that I wanted a natural birth and it wasn't natural but there were still things that […] I could have done according to the birth plan.(Louise)

DISCUSSION
The significance of being assisted by a midwife with caring behaviours and the importance of information provision during childbirth have been reported in a paper previously published by the authors (AUTHOR BLINDED, 2016).This paper focusses on the meaning that mothers inferred from midwives' negative language and behaviour during childbirth.The following attitudes were identified as undesirable: being procedures and rules' oriented; not establishing a trusting relationship; demonstrating non-individualised behaviour; just doing their job and routine checks; being quick to go; not staying with the woman for as long as she needs; not listening, nor understanding, nor believing her; using negative language.
Caregivers' attitudes were sometimes perceived as dismissive and some participants reported that their individual needs and the pain they were experiencing were not understood or believed, especially during early labour.Inflexibility with procedures was perceived as resulting in a 'superficial', 'routinized', 'related to tasks' professional-client interaction mostly controlled by the carer.Fraser (1999) found that some women defined midwives as being more rules oriented rather than individually-focussed and treating mothers as not being clever enough or not having their own opinions.Green (2012) stresses the importance of treating childbearing women as individuals and with respect, with their concerns and values being taken into account.Women should receive clear advice and evidence-based information appropriate to personal needs and preferences that will allow them to be active participant in their care.
The findings presented here highlight the impact that midwives' words may have on a woman's experience and also reflect existing evidence.Participants' interpretation of midwives' language resulted in feeling discouraged and disempowered.Fenwick et al. (2003: 10) reported that mothers termed the language used by some healthcare professionals as 'abusive', 'aggressive' and 'misleading', particularly when routine practices were questioned.Simkin et al. (2012: 157) cited examples of language that could be easily interpreted as something is deviating from normality, for example 'You're pushing the wrong way'.Midwives' negative language and depersonalising behaviour resulted in women feeling humiliated, ignored, discouraged from speaking or asking questions and dissatisfied with the birth experience (Bowers, 2002, Eliasson et al., 2008) .When this was the case in the present study, negative feelings seemed to be related to individual caregivers more than the overall care received.Unless women establish a trusting rapport with the caregiver, they may have a tendency to hold back, not listen to what is advised or feel unhappy with the care received (Fraser, 1999, Eliasson et al., 2008).This is concerning as trusting relationships, partnership, empowerment, compassion, respectful care and personalised care planning are key principles of maternity care provision (DH, 2012, Cumberlege et al., 2016, Green et al., 2000, Sandall et al., 2016).

CONCLUSION AND IMPLICATIONS FOR PRACTICE
Understanding the impacts that negative language and behaviours have on childbearing women is crucial to promote positive, compassionate and empowering practices within maternity care provision.The caregiver who satisfies a woman's need for caring during childbirth is more likely to be effective in meeting midwifery care goals than the professional who is perceived as uncaring (Halldorsdottir and Karlsdottir, 1996).The NICE (2014:17) encourages midwives to 'establish a rapport with the woman and be aware of the importance of tone and demeanour, and of the actual words used'.With this in mind, midwives should continue to communicate with labouring women and families, utilising positive language as an important component of individualised and respectful care.

'You are only in early labour, you are not in active labour yet'
Michelle felt that the midwife was concerned more about the cervical dilatation rather than looking at her holistically considering how she was coping with the pain: had a real impact on me her saying 'But you're only in early labour, you can't have gas and air yet'.I then went for another 2 hours thinking 'I am only in early labour, how much more painful is this going to get?' (Michelle) They were like 'There's nothing we can do, you're not in labour, you've just got to wait'.That makes you feel uncomfortable.(Sophia)Ifeltreallyuncomfortable.'You'renot in labour because you're smiling'.[…]'That'sjustme!'.(Sophia)Lack of midwife's presenceSome women were disappointed by the fact that the midwife was not present in the labour room for the expected amount of time and not assessing them step-by-step as persons with individual needs throughout the duration of labour.Melissa and Michelle would have preferred a midwife providing more physical presence, staying longer, sitting down in the labour room and dedicating one-to-one time to support them and assess the labour progress, rather than quickly going in and out from the room.The non-presence of the midwife towards the end of labour was reported by Melissa as causing a greater level of anxiety and worry: She kept going out and in, rather than staying [...]She was just standing so it felt like she was still ready to go back out.(Melissa)Iwonder whether if they were coming in to see me more frequently, […] made a case by case assessment, they would probably have gone 'she doesn't need gas and air, she needs more attention'.The midwife didn't believe I was having intense contractions.[…]Shedidn't look at the whole picture.(Michelle)

being procedures and rules oriented Some
interviewees felt annoyed by the perceived inflexibility of the midwife, especially in terms of inconsistency between the protocols and guidelines referred to and the provision of womancentred care based on individual needs.Jayne and Louise felt as if their possibility of choice was overwhelmed by procedural issues.Examples of routine care included vaginal examinations done inflexibly every four hours or strict criteria for being admitted to the Alongside Midwifery Unit.When this was the case, the participants felt as if the healthcare professionals were not willing to modify their procedures to meet women's expectations:They didn't let me onto the midwifery-led unit.They put me on the ward and I got so upset, I was crying[…]Just because it's not how they do it, because it's different, don't judge me for it, just respect it (Louise) She said 'Oh, babies are so stupid because they can just hold on to the cord and that's what causes the heart beat drop'.I was like 'You can't say that!' (Louise) Rather than the midwife concentrating on me, she tried to speak louder to over-talk my voice.[…] 'Just shut up and concentrate on me!'.(Louise) Inflexibility: every 4 hours'.I don't care that you only do it every 4 hours, I am not a statistic, I want you to do it.(Jayne)