Language & Communication, Vol. I, No. 2, pp. 179-185, 1987 Printed in Great Britain.

0271-5309/87 $3.00 + 00 Pergamon Journals Ltd.

LABOURING UNDER LINGUISTIC DELUSIONS: THE IMPACT OF LINGUISTIC FACTORS IN INTERNATIONAL STUDIES OF

PRETERM LABOUR

SOPHIE ALEXANDER and CATHERINE SLATER

There is something of interest to report when a member of the medical profession finds it necessary to consult a linguist’ because she suspects that linguistic factors are intervening to invalidate straightforward comparisons of the treatment given in different countries to what appears to be ‘the same medical condition’. The findings presented in this paper undermine the widely-held view that medical conditions can always be defined in objective scientific terms, and that the words used to refer to them in different languages are mere labels which can be put into one-to-one correspondence. Far from it. Here, just as in other, more obvious areas of human experience, observations of the world about us are intimately bound up with the words we use to describe them.

The subject of this paper is the treatment of preterm labour (defined as occurring prior to 37 weeks gestation) in hospitals in English- and French-speaking countries.* Attitudes towards preterm labour vary a great deal internation~ly. In some countries, much effort and money are invested in its prevention. 3 This has been the case for some time in continental Europe, and more recently in parts of the U.S.A., Canada and Australia. Obstetricians in the United Kingdom and the Irish Republic, on the other hand, appear to have been more reluctant to adopt a policy of preventing or treating preterm labour, and have even questioned the rationale of doing SO.~

In countries of the first group, when a pregnant woman reports to hospital because she is worried about the ‘contractions’ she thinks she is feeling, she will be monitored (often electronic~ly) for symptoms of heightened uterine activity, and if this is confirmed, there is a strong likelihood that she will be declared ‘en &tat de menace d’acco~c~eme~t prt!maturP, or ‘in a state of presumed for impending) preterm labor”6 (as the condition is described in the U.S.A., Canada and Australia), and that she will then be treated with drugs to arrest the presumed/impending labour. In the United Kingdom and the Irish Republic, however, the response will be very different: the woman will be examined to ascertain whether or not she actually is in labour, and if the result is negative, she will often not be prescribed drugs, and she may well be sent home.

International studies designed to investigate the efficacy of tocolysis’ and the advisability of prescribing it run up against linguistic problems* which often go unrecognised for what they are. It is not possible to take ‘incidence of threatened preterm labour/delivery’ as a neutral starting point from which to compare results obtained in different hospitals. The difficulty arises from ‘our inability to recognize true premature labor at an early stage and to differentiate it from an episode of uterine contractility that does not lead to expulsion of the fetus’ (Haesslein, 1980, p. 323). This end result provides the only sure diagnosis, but it is of course a retrospective one. Hence there is a certain

Correspondence relating to this paper should be addressed to Dr. C. 3. Slater, Lady Margaret Hall, Oxford OX2 6QA, U.K.

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180 SOPHIE ALEXANDER and CATHERINE SLATER

fuzziness in the use of the term Zabour, which will often do duty for what might with greater accuracy be specified as suspected labour or established labour. Given this uncertainty surrounding the recognition of early labour, it is hardly surprising if the notion of ‘impending labour’ should prove highly problematical. If the ‘condition’ cannot be reliably diagnosed, and if furthermore some practitioners suspect that the mere existence of expressions like mencrce d’accouchement p&mature’ or impending preterm labor are themselves partly responsibte for belief in the existence of a corresponding clinical state, then this casts doubt on the validity of attempts to evaiulate the treatment programmes carried out in different countries. The important point to grasp is that the policy of different hospitals regarding the use of tocolytic drugs wiI1 be a major factor determining the use of the expression preterm labour: a case recorded as ‘preterm labour’ in one hospital, and treated accordingly, will not be given this label elsewhere, because the woman was left untreated and did not deliver preterm.

Heightened preterm uterine activity does not then necessarily result in a premature birth (see Fig. 1).

The widespread practice in hospitals outside the U.K. of administering drugs to women with symptoms suggestive of preterm labour must rely on the belief that within category B (impendingpreterm labour) there is a third category C of potentially arrestable (impending preterm) labour.’ In order to reach this category of women for whom it is claimed that drugs have an in~biting effect, it is in practice necessary to treat all women showing potential symptoms (i.e. categories A, B as well as C), even though many of them, if Ieft untreated, will not deliver early. The underlying rationale of this policy is that preterm births are so undesirable that it is preferable to treat some apparent cases of preterm labour unnecessarily, rather than fail to prevent arrestable instances.

There are many obstetricians in the U.K. and the Irish Republic who deny the existence of a condition identifiable as impending preterm labour. There is no dispute that some women may be predisposed by their medical history (particularly their reproductive history) to deliver early: they are universally described as cases at high risk of pre~erm delivery (2 haut risque d~u~~ouchement premature) but this is something very different. The expression (impending)preterm labor, corresponding to the French menace d’accouchement pr&matur&, is found in medical literature from the U.S.A., Australia and Canada (e.g. Holbrook and Creasy, 1984),]’ but not in p ublications from the U.K. or the Irish Republic. In these countries, no intermediate state is recognised between non-labour and labour, and accordingly, a wait-and-see policy is adopted instead of the systematic tocolysis

LABOURING UNDER LINGUISTIC DELUSIONS 181

practised elsewhere: if early contractions stop spontaneously, the woman was not, after all, in labour; if they do not, and a baby is delivered, the initial symptoms can be read in retrospect as the beginnings of preterm labour. Over-zealous use of drugs is considered a greater risk than preterm deliveries per se. As handbooks on pregnancy put it: ‘Nothing will reliably stop a contracting uterus’ (Bourne, 1985, p. 398), or ‘Modern technology has produced very efficient incubators’ (Glover, 1977, p. 97).

How can these differing attitudes towards (impending) preterm labour be accounted for? Further evidence of a linguistic dimension to the question can be adduced from a study of the French and English terms used to refer to uterine activity. In the technical literature, the French term contraction and the English term contraction function as equivalents and are the only terms regularly used; however, in lay publications in English, a variety of terms are introduced: tightenings, cramps, pregnancy contractions, Braxton-Hicks contractions. ” Authors go to great lengths to convince their readers of the normality of early uterine activity. For instance Bourne, (1985, p. 321) explains: ‘. . . all muscles must contract and relax frequently, otherwise they will waste . . . uterine contractions occur throughout pregnancy at slightly irregular intervals, every 15, 20 or 30 minutes . . .

( I... . . . they may be obvious and uncomfortable . . .‘.

Like their English counterparts, French books for general readership use terms in addition to contractions to describe uterine activity, notably durcissement (‘hardening’, ‘tightening’), andpincement (‘pinching’ or ‘nipping’), but the message they try to convey is the opposite of the English one. Brassier (1965, p. 187) warns the reader: ‘Faites bien attention: apprenez a reconnaitre ce durcissement; il s’agit d’une contraction ‘. I2 And Papiernik (1983, p. 28) declares: ‘Les femmes enceintes ne savent pas interpreter les perceptions provoquees par les contractions uterines: c’est une raison frequente de l’exces de prematurite pour la premiere grossesse. “’ The author puts the view that premature delivery should be avoided at all costs in highly loaded terms as ‘notre refus de considerer la prematurite comme la sanction obligee d’une conduite coupable’.’ It must be noted that a similar approach was found in one work written in English: significantly, an American book on preterm births written by the mother of a handicapped baby who was born preterm (Harrison, 1983).

It is in the case-notes and oral exchanges from the Oxford hospital that the greatest variety of terms emerges: the expressions nigglings,” tightenings, and cramping, as well as the more scientific-sounding Braxton-Hicks, were all used by women themselves and found in their case-notes, which also sometimes resorted to periphrases like low intermittent abdominal discomfort, or intermittent abdominalpain. French seems to lack a similar range of terms appropriate to less formal styles of discourse. Only the term contractions is found in comparable situations, sometimes further qualified orally as bonnes (‘good’) or petites (‘small’).

There is a correspondingly different diagnosis of the clinical situation in which women have any of these symptoms before 37 weeks gestation. In the English notes, not in labour contrasts with query preterm labour or sometimes preterm labour, or else no attempt at all is made to label the ‘condition’. On the other hand, the notes from the continental hospitals studied use menace d’accouchement premature every time preterm regular uterine activity is present; again, this ‘threat’ is sometimes qualified as severe (‘serious’) or petite (‘mild’).

The data under consideration suggest that the Anglo-French difference in approach to preterm labour is reinforced, and possibly even generated, by the terminology used to describe

182 SOPHIE ALEXANDER and CATHERINE SLATER

its symptoms. Where English regularly uses more than half a dozen terms to describe uterine activity, the only serious contender in French is contractions, and French-speaking obstetricians stress the necessity of early recognition. It is as if French speakers could not escape the ultimate implications of contractions, and once their presence is diagnosed, caregivers are insidiously drawn into treating all cases. The recognition of a symptom which entails systematic treatment brings into existence the condition needing to be treated: the ‘menace d’accouchement pr&mature”. There is a triangular relationship between the observation of symptoms, the availability of treatment (whether effective or not), and the postulation of a corresponding nosological entity to account for them. It may not be possible to determine which came first, treatment or ‘clinical condition’; what can be said in this instance is that the expression menace d’accouchement premature’ does not appear in the medical literature prior to the treatment era (although this fact is still compatible with the possibility that belief in the existence of the condition provided the motivation for developing the drugs). It is also the case that the English term impendingpreterm labor is only used in centres in the U.S.A. etc. where active management is taking place.

The British, on the other hand, not being faced with an ineluctably awesome symptom, have no word for a situation in which they observe clinical signs which may herald the onset of labour, but in all likelihood do not (see Anderson, 1981). Consequently, they feel less incentive to intervene pharmaceutically.

It is tempting to draw a parallel, again from the field of preterm births, with another ill-defined nosological entity which has gained international acceptance: ‘cervical incompetence’. It was suggested 30 years ago (Shirodkar, 1955) that in some cases the cervix dilates virtually without uterine activity. The treatment offered is known as cerclage in both French and English. In this case, there is less scope for the development of a rich, semi-lay vocabulary to refer to the condition because diagnosis is not based on subjective observations reported by the women concerned. There is, however, a striking similarity between cerclage and tocolysis: for both, there is a twentyfold variation in use among different consultants and hospital units. This cannot plausibly be related to a twentyfold variation in the incidence of an objective correlate of either ‘cervical incompetence’ or ‘threatened preterm labour’.16

There is nothing unusual about this situation from a linguistic point of view. Everyday language is full of terms whose mere existence is sufficient to persuade speakers that there must by ‘something objective out there in the real world’ for these terms to be describing. How many people stop to wonder in what sense they have ‘a mind’, or ‘a memory’? The mistake is to think that this phenomenon is not found in scientific discourse. The moral to be drawn as far as international, multilingual studies in the medical (or any other) field are concerned is that if the necessary agreement is to be reached on which cases to include for comparison (see Herron et al., 1982), it is absolutely indispensable to check the comparability of the concepts at issue by looking closely at the words people use. All the more so where the consequences may involve expensive and potentially harmful forms of intervention.

NOTES

‘Our grateful thanks are due to Dr Iain Chalmers of the National Perinatal Epidemiology Unit, Radcliffe Infirmary, Oxford, for putting us in touch initially, and fostering this cooperation with his helpful advice and encouragement.

LABOLJRING UNDER LINGUISTIC DELUSIONS 183

*The study was carried out at the John Radcliffe Hospital, Oxford, the Hopital Erasme, Brussels, the Matemite de Haguenau (Bas-Rhin), and the Hopital La Grave, Toulouse. Comparison of English and French words relating to preterm labour used by caregivers and pregnant women is based on data obtained from three types of source: (1) Medical literature: articles listed in the Register of Controlled Trials in Perinatal Medicine established by the National Perinatal Epidemiology Unit (Radcliffe Infirmary, Oxford) with funds provided by the World Health Organization. Index Medic-us 1983 and 1984, entries under birthweight; gestation (length of); infant (premature); labour (premature); perinatology; pregnancy (maintenance of); prenatal care. (2) Lay literature: books on pregnancy and delivery, and, specifically, premature birth. (3) Hospital practice: (a) case-notes of all women admitted in 1983 to the J.R.H. (346 records) and the H.E. (175) in ‘preterm labour’, whether they delivered immediately, later (but still preterm), or after 37 completed weeks; (b) conversations involving midwives and women in antenatal clinics and delivery suites; (c) discussions with anglophone and francophone obstetricians about their definitions of labour and the clinical antecedents of preterm delivery.

3There is a striking difference in the numbers of women admitted to different hospitals ‘in preterm labour’ and given tocolytic treatment: Oxford: 0.9%; Toulouse: 17%; Brussels and Haguenau: 20%; Paris: 50% [at an unnamed hospital reported on in Brtart (1981)].

4Boylan and O’Driscoll(l983) report an unaccountable decrease in spontaneous preterm delivery in Dublin, while Chng (1981) has shown that spontaneous preterm delivery has a negligible effect on perinatal mortality in Aberdeen.

5Cases of ‘menace d’accouchement premature’ are commonly referred to as ‘des MAP’, in French textbooks as well as oral usage.

6This spelling is adopted deliberately here to mark the usage as non-British.

7 Pharmacological intervention to inhibit uterine activity.

81n addition to the more obvious pitfalls besetting such comparisons, e.g. criticizable adjustments introduced to compensate for overtly different population characteristics; apparently similar socioeconomic patterns concealing significant differences in populations; discrepancies between coding and diagnostic practices exemplified in different data bases (see International Journal of Epidemiology, 1984; Keirse, 1984).

‘Results of randomized control trials conducted on women admitted to hospital ‘in preterm labour’ reveal that 50% in the placebo group delivered preterm, 50% did not; whereas in the group treated with drugs 20% delivered preterm, 80% did not (see Wesselius de Caspariis et al., 1971).

“Other related expressions commonly used include: established early preterm labour [Walters and Wood (Melbourne, Victoria) 1977, p. 261; threatenedpremature delivery [Kuhn et al. (Melbourne, Victoria) 1982, p. 4021; established orpresumedpreterm labor [Milner et al. (Hamilton, Ontario) 1984, p. 6061; threatenedpremature labor [McCarthy (U.S.A.) 1957, p. 134; Fuchs and Stakemann, 1959, p. 291. These last two papers date from an earlier period, before the widespread use of modern tocolytic drugs in late pregnancy, and this may suggest that the expression threatenedpremature labor was originally modelled on threatened abortion. The term threatened (or threatening) is also regularly used to qualify preterm labour (rather than preterm delivery) in papers written in English by non-Anglophone authors. In some cases, one may suspect a calque from the French [e.g. Richter (Bale, Switzerland) 1977, p. 482). Francophone authors only use the term menace d’accouchement premature; the English term preterm labor does not appear to have a French equivalent *travail premature. Significantly, the French translator of Niswander 1980 regularly translates preterm labor by MAP. He also feels it necessary to expand the original chapter on ‘Premature Labor’ with a special supplement on the ‘Menace d’accouchement premature’, arguing that the approach to this problem is rather different in Europe. In fact, the medical picture presented here does not differ substantially from the one given in the main body of the chapter. It is difficult not to suspect that the translator may have been motivated by a feeling based on linguistic factors: that a chapter with the title ‘Premature Labor’ simply could not have given due weight to the dangerous menace d’accouchement premature (even after he had used this French expression to translate the original title). In any event, if there is a scale of attitudes to this ‘condition’ ranging from the U.K. through the U.S.A. to France at the other extreme, it would seem plausible to see the French approach as being inextricably bound up with the use of the loaded term menace.

“So named after the obstetricians who first identified them. This expression is introduced to most women in the U.K. by their midwives or antenatal teachers.

‘*‘Pay careful attention. learn to recognize this tightening: it’s a contraction.’ Cf. ‘des petits pincements qui sont des contractions’ (Pernoud, 1986, p. 293).

13‘Pregnant women don’t know how to interpret the sensations produced by uterine contractions: this is a frequent cause of the high incidence of premature births in first pregnancies.’ 14

. . ‘our refusal to consider premature birth as an inevitable punishment for reprehensible behaviour.’

15Also found in Popular literature, e.g. Rosamond Lehmann [1936 (1981 edn, p. 297)]: [Olivia]: ‘I’m having a miscarriage.’ [Doctor]: ‘Any pain now?’ [Olivia]: ‘Just a niggle.’

184 SOPHIE ALEXANDER and CATHERINE SLATER

160ne is irrestibly reminded of one of the more illustrious of ‘francophone’ ailments which have not crossed the Channel. Twenty years ago, French people of all ages were ‘suffering’ from crises defoie, which were responsible for fatigue, headache, indigestion and neurasthenia. More recently the same complaints have been attributed to a new ailment: spusmophilie, which supersedes the crise de foie [see chapter entitled ‘Les maludies imuginaires’ in Cohers (1985, pp. 27-38)]. The English translation is generally considered to be ‘bilious attack’, but they do not really correspond, either in symptoms or in prevalence.

REFERENCES

ANDERSON, A. B. M. 1981 Second thoughts on stopping labour. In Studd, H. (Ed.), Progress in Obstetrics ond Gynrecology, Vol. 1. Churchill-Livingstone, Edinburgh.

BOURNE, G. 1985 Pregnancy. Cassel, London.

BOYLAN, P. and O’DRISCOLL, K. 1983 Improvement in perinatal mortality rate attributed to spontaneous preterm labor without use of tocolytic agents. American Journal of Obstetrics and Gynecology 145, 781-783.

BRASSIER, E. 1965 Mon Enfunt va naitre. Editions du Pantheon, Paris.

BREART, Cl., GOUJARD, J., BLONDEL, B., MAILLARD, F., CHAVIGNY, C., SUREAU, C. and RUMEAU- ROUQUETTE, C. 1981 A comparison of two policies of ante-natal supervision for the prevention of prematurity. International Journal of Epidemiology 10, 241-244.

CHAMBERLAIN, G. (Ed.) 1982 Pregnancy Questions Answered. Churchill-Livingstone, Edinburgh.

CHNG, P. K. 1981 An analysis of preterm singleton deliveries and associated perinatal deaths in a total population. British Journal of Obstetrics and Gyncecology 88, 814-818.

COHERS, C. 1985 Medecins ou mugiciens? Arthaud, Paris.

DANA, J. and MARION, S. 1971 Donner la vie. Le Seuil, Paris.

FUCHS, F. and STAKEMANN, G. 1959 An endeavour to reduce neo-natal mortality through treatment of threatened premature labor with large doses of progesterone. Actupediutricu scandinuvica suppl. 118 48.29-30.

GLOVER, P. (Ed.) 1977 Understunding your Pregnancy. Angus and Robertson, Sydney.

HAESSLEIN, H. C. 1980 Premature Labor. In Niswander, K. R. (Ed.), Manual of Obstetrics: Diagnosis and Therapy. Little, Brown, Boston, MA.

HARRISON, H. 1983 The Premature Baby Book. St. Martin’s Press, New York.

HERRON, M. K., KATZ, M. and CREASY, R. K. 1982 Evaluation of a preterm birth prevention program: preliminary report. American Journal of Obs?etrics and Gynecology 59, 452-456.

HOLBROOK, R. H., Jr. and CREASY, R. K. 1984 Prevention of preterm delivery. The important role of early recognition. Postgraduate Medicine 75, 177-185.

Internotional Journal of Epidemiology 1984 Editorial: Improving databases for international studies. 13, 267-268.

KEIRSE, M. J. N. C. 1984 Perinatal mortality rates do not contain what they purport to contain. Luncet i,

1166-1168.

KUHN, R., SPIERS, A. L., PEPPERELL, R. J., EGGERS, T. R., DOYLE, L. W. and HUTCHINSON, A. 1982 Betametazone, Albuterol and threatened premature delivery: benefits and risks. Obstetrics and Gynecology 60, 402-408.

LEHMANN, R. 1936 The Weather in the Streets, 1981 edn. Virago Press, London.

MCCARTHY, J. J. 1957 Preliminary report on the use of Relaxin in threatened premature labor. American Journal of Obstetrics and Gynecology 14, 134-138.

MILNER, R. A., ENKIN, M. W. and MOHIDE, P. T. 1984 The importance of clinical trial in preterm labor. Chnicul Obstetrics and Gynecology 27, 606-613.

NISWANDER, K. R. (Ed.) 1980 Manual of Obstetrics: Diagnosis and Therapy. Little, Brown, Boston, MA. (French translation by Maria, B. 1981, MEDSI, Paris.)

PAPIERNIK, E. 1983 Prevention de la prematurite. In Le Vaguer&e, L. (Ed.), CJn Enfant neprematurement. Stock, Paris.

PERNOUD, L. (Ed.) 1986 J’attends un enfant. Pierre Horay, Paris.

REDSHAW, M. E., RIVERS, P. A. and ROSENBLATT, D. B. 1985 Born Too Early. Oxford University Press, Oxford.

RICHTER, G. 1977 Evaluation of success in treatment of threatening premature labor by betamimetic drugs. American Journal of Obstetrics und Gynecology 127, 482-486.

LABOURING UNDER LINGUISTIC DELUSIONS 185

SHIRODKAR, V. N. 1955 A new method of operative treatment for habitual abortion in the second trimester of pregnancy. Antiseptic 52, 299-300.

WALTERS, W. A. and WOOD, C. 1977 A trial of oral Ritodrine for the prevention of premature labour. British Journal of Obstetrics and Gyncecology 84, 26-30.

WESSELIUS DE CASPARIIS, A., THIERY, M., YO LE SIAN, A., BAUMGARTEN, K., BROSENS, I., GAMISANS, O., STOLCK, J. G. and VIVIER, W. 1971 Results of double blind, multicentre study with Ritodrine in premature labour. British Medical Journal 3, 144-147.