Unravelling US maternal mortality through critical discourse analysis

Abstract

Objectives:

Given that pregnancy health information seeking is common and considered impactful on health outcomes, the potential lack of fair and clear information within media may be an impediment towards women developing their own agency and working towards the transformation and betterment of their own outcomes.

Setting:

The USA has the worst maternal mortality rate of any developed country. Women’s opinions are shaped and informed by public media and discourse; therefore, a critical look at how public media texts support women’s agency is of significance.

Method:

Reducing maternal mortality requires more than just effective health interventions. This paper uses critical discourse analysis to examine two samples of widely viewed public discourse around the issue of US maternal mortality and reveals the murky and polarised dialogue contained in each.

Results:

The two samples may be representative of a larger lack of clarity in US discourse about maternal mortality, a body of discourse which – to the detriment of women’s maternal morbidity and mortality outcomes – subtly but powerfully either declines to admit mistakes or uses polarising, overly simplified language.

Conclusion:

Recognising the polarised dialogue surrounding maternal mortality and working towards a more reasoned discussion of the issue at hand may promote women’s advocacy and provide potentially better outcomes.

Keywords

Critical discourse analysis education maternal mortality USA

Introduction

Despite the country’s wealth, the USA is a dangerous place in which to give birth: any other developed, wealthy country is safer. The USA ranks last among developed nations in maternal mortality (Maternal Mortality Rate, 2015). Each year, about 700 women die in childbirth in the USA (Centers for Disease Control and Prevention, 2017), and more than half of these US maternal deaths are deemed preventable (Lu et al., 2015). This high rate of preventable maternal deaths is not new. The US maternal mortality rate has been rising for the past 30 years, and the USA is the only developed country where the maternal mortality rate is rising (Kassebaum et al., 2014). Taken together, these statistics may be said to represent US ‘crisis’ (Amnesty International, 2010).

It is important to understand that maternal mortality is a complex problem that does not have just one singular cause. While it is true that mothers today are older than before and more likely to have chronic diseases (Creanga et al., 2014), numerous economic, societal and health care policy and systems issues factor into maternal deaths (Campbell and Graham, 2006). Thus, there is considerable controversy about whom to blame and how to allocate resources to address the issue. Specifically, US maternal health providers tend to be divided into two camps (Fineberg, 2013). On one side of the spectrum, prominent advocates of natural childbirth, mainly midwives, call for minimal intervention, decry the high US caesarean section rate and sometimes endorse out-of-hospital births (Gaskin, 2008, 2011; Goer, 1999). Other voices, more often physicians than midwives, call this type of advocacy for a more natural approach ‘paternalism in a skirt’ (Dietz and Exton, 2016: 447), claiming that today’s increasingly older, more likely to be sick or obese mothers merit more technology-intensive intervention, not less (Tuteur, 2017).

What these sweeping ‘intervene more’ or ‘intervene less’ advocates may overlook is that decision-making needs to be contextualised: each woman needs to consider her own risks, health of her unborn child(ren), possible impacts on her family and potential future pregnancies (Campbell and Graham, 2006; Roth, 2000). Thus, the idea that women need education, understanding and agency in making informed decisions about maternity care are not solely humanised practices; in the USA as well as around the world, maternal agency is sound medicine (De Brouwere et al., 1998; Galadanci et al., 2016; Goldberg, 2009; Kongnyuy et al., 2009; Lu et al., 2015; Nosraty et al., 2016). All across the globe, when women gain knowledgeable and empowered voices in their health care, their own health outcomes, as well as their families’ health outcomes, improve (Al-Bannay et al., 2017; Diamond-Smith et al., 2017; Gee and Corry, 2012; Lan and Tavrow, 2017; Lu et al., 2015; Prata et al., 2017; Shimamoto and Gipson, 2017). Women in the USA do seek online and media information about their pregnancy, and such information seeking is considered impactful on maternal health outcomes (Criss et al., 2015; Guendelman et al., 2017). How the problem of maternal mortality is framed, and whether women are endued agency in their care and are framed as part of their own solution, merits consideration.

In advocating for maternal empowerment and education as part of the solution to maternal mortality, it is important to understand that, inevitably, language, be it spoken or written, is the means of transmission. Thus, this paper attempts to examine just how, in the public sector, maternal mortality is being conceptualised and explained. The polarisation of such discourse surrounding maternal mortality is well-defined (Fineberg, 2013). From the perspective of public impact and health information, the polarisation of discourse within the media is particularly relevant. This article considers a sample of two media commentaries, a PBS NewsHour/ProPublica report and a Technology, Entertainment, and Design (TED) Talk, which were selected based on their number of views. These media videos will be examined to illuminate what unclear language surrounding maternal mortality may look like and what effects such misleading discourse may have. Patient-informed decision-making in the USA concerning maternity is ‘inconsistently implemented’ (Goldberg, 2009: 32), even though such patient involvement in decision-making has been shown to lower maternal morbidity and mortality (Stevens et al., 2016). This paper argues that any form of shared decision-making starts with language. If maternal mortality is not calmly and fairly articulated using the means of transmission available – language – it may be difficult for women to gain the transformative knowledge they need to advocate for their own care.

Research questions

The question of how of language is used to enhance or confound community understanding of the maternal mortality crisis in the USA is not a question of mere theoretical importance but rather of life-saving and tangible significance. Using critical discourse analysis (CDA), this paper asks: in the media texts analysed, how does the language around maternal mortality, which is often unclear or polarised, educate or fail to educate US women about the issue so as to equip them to be their own advocates for safety and change?

Methodology

This paper uses CDA to explore a sample of public dialogue around the issue of US maternal mortality. CDA sees language as a tool, positioned within a historical, cultural and social context. Language can be used to serve the interests of some women or mute the rights of others (Janks, 1997). This paper aims to identify the power structures behind a sampling of the language around maternal mortality, with a focus on inspiring positive change (Fairclough, 1996). Although well-known CDA scholars have previously engaged with healthcare issues in their writing (see, for example, Fairclough, 1996; Gee, 2005), CDA has not been widely used in health education research. This lack of use, however, speaks to a preference for quantitative research in healthcare, not the lack of utility of CDA. In fact, given the complex nature of healthcare systems, particularly in the USA, CDA provides an ideal tool through which to gain insight into the intersection of healthcare policy, culture, language and patient outcomes (Evans-Agnew et al., 2016).

CDA can be conducted in a variety of ways. This article employs one of them, as outlined by James Paul Gee. Gee (2005) offers a framework of ‘big “D” Discourse’ and ‘little “d” discourse’. Big ‘D’ Discourse constitutes the social, cultural and political context surrounding language. In this case, big ‘D’ Discourse constitutes the dominant paradigm of healthcare in the USA in general: in the form of patients, doctors and nurses, hospitals and insurers, the Affordable Care Act and the uninsured. On the contrary, Gee defines little ‘d’ discourse as being language in use. More specifically, the little ‘d’ discourse is the language, visuals and tools that allow someone to be something: for a physician, this may include medical terminology, a white coat or scrubs, a name badge and/or a confident tone. Linguistically, little ‘d’ discourse is what exactly is said (or not said) in that healthcare context, for example, the euphemisms employed, the passive/active voice used, the sources referenced and the clarity conveyed or dampened. Taken together, both big ‘D’ Discourse and little ‘d’ discourse help the listener or reader make contextualised meaning out of the words said and signals displayed. Given that US healthcare is so bound up in a complex maze of politics, insurance companies, entitlements and professional organisations, this social context is key to understanding healthcare-related discourse.

Author bias and the ideal reader

As researchers, we have a bias and an agenda. We believe that the actions of all researchers, even those who claim objectivity, are informed in such a way. We do not consider ourselves to be advocates of either natural childbirth or technological, more interventionist birth; we do consider ourselves to be advocates for equipping women to make informed, contextualised choices about how they will give birth to their babies. Our interest stems from our involvement with immigrant women and is reactionary to the lack of personal agency we have often witnessed in their health and maternity care.

Our goal in writing this paper is, as Gee (2005) suggests, ‘to think more deeply about the meanings we give people’s words so as to make ourselves better, more humane people and the world a better, more humane place’ (p. xi). Indeed, a decade ago, scholars documented that Black women die at a rate of several times that of White women (Tucker et al., 2007). Unfortunately, this disproportionate rate of African American maternal mortality has held steady; most recently, it has been reported that African American women continue to experience mortality at 3.4 times the rate of their White counterparts (Creanga et al., 2017). The need to understand the social determinants that may impact this disparity has been called ‘critical’ (Creanga et al., 2014: 9).

The ideal reader of this paper merits a mention. Not only do we want to make the article physically available, we want to make it comprehensible. Too often, academic writing is not written in a way that is readable to the general public, and drawing on Gee’s (2005) ideas, we strongly believe that rigorous research can, and in fact should, be clear and easy to read. Empowering change via inaccessible prose is a dubious exercise at best. To that end, we have avoided the use of jargon for its own sake and assumed a more conversational tone when possible. We aim to make the information available to as many women, families and caregivers as possible. Our intent in writing this piece is not to provide an obstetric overview of all that is wrong or could be wrong with maternal healthcare: such a work would be far beyond the scope of one paper. We aim to spark a dialogue that leads to more informed choices.

Text selection

In selecting texts for analysis, CDA researchers often aim to open a conversation about language and the power it wields. CDA should be understood as the start of a conversation, as a prompt for others to enter important conversations. Choosing pieces that represent public, not necessarily academic, discourse around maternal mortality in the USA was important. In this study, YouTube™ was searched for ‘maternal mortality in America’, and the top search results were chosen. Interestingly, and relevant to the analysis, the two most-watched videos (at the time of search) on the topic subtly epitomise the two common distinct views on the state of US maternal health, with one featuring a doctor-centred model and the other advocating for midwifery-based care. The first search result was a PBS NewHour television report which featured a National Public Radio (NPR)/ProPublica report on maternal mortality in the USA and a case study of the maternal death of Lauren Bloomstein (https://www.youtube.com/watch?v=nWUMQGD713M&t=84s). The underlying written report cited in the video has been referenced widely in the popular media (Martin and Montagne, 2017; May, 2017; Solé, 2017). The second search result, and thus the second text for analysis, was a TED talk by a midwife on the US crisis of maternal mortality (https://www.youtube.com/watch?v=2v5A3BxU4Uc&t=289s). This second video features a TED talk by midwife Linda Robinson (TEDxDirigo, 2016), who links her experiences as a midwife in the war-torn Democratic People’s Republic of Congo (DRC) to her more recent experience in the USA.

PBS NewsHour

Big ‘D’ Discourse

We begin our analysis by looking at the PBS NewsHour segment and how it positions maternal mortality within the larger society of what Gee (2005) would call the big ‘D’ Discourse or, simply, the ‘whats’ and the ‘whos’ (p. 22) in the text. First, we will examine the imagery employed, that is, the large visual ‘whats’. The PBS report begins by displaying a picture of an NPR/ProPublica Report;¹ the viewer can clearly see that the title of the report is ‘The last person that you’d expect to die in childbirth’. This visual, written message seems to present a proposition: namely, that if death could happen to Bloomstein, a nurse, then no one can do anything to reduce her own risk; these things just inevitably occur. In presenting the ‘whos’, that is, Bloomstein herself and her caregivers, the report continues to subtly frame Bloomstein’s death as inevitable. According to the report, many US persons may erroneously assume that women who die in childbirth have ‘bad healthcare’, but Bloomstein had ‘good prenatal care’ and ‘all of those things’ (implying good healthcare). The ProPublica reporter then goes on to assert that

It’s not that her [Bloomstein’s] doctors were not good doctors, but they did not recognise what was going on because they were not on the same page about what the standards are and what we should do.

In fact, what ‘was going on’ was pre-eclampsia, something that the very same broadcast refers to as ‘textbook, basic to OBGYN care’. When taken all together, these statements show a reluctance to criticise any aspect of Bloomstein’s care. If Bloomstein’s care was indeed ‘good’, then why did she die of something ‘basic to OBGYN’ care and why did her caregivers ‘not recognise what to do’?

Little ‘d’ discourse

The PBS report’s reluctance to offer any sustained criticism of the US healthcare system is also evident in its little ‘d’ discourse. At the micro level, this broadcast fails to clearly and directly say that Lauren Bloomstein did, in fact, die within the US healthcare system from pre-eclampsia, about which (according to the report itself) ‘everyone knows what to do’. Namely, throughout the report, never once is Bloomstein directly classified to as ‘dead’ or having suffered ‘death’; even clear synonyms of ‘death’ are avoided.

Instead, Bloomstein’s death is in fact implied, and she is referred to a ‘statistic’ and perhaps most inappropriately, ‘a character in this tragic story’. In fact, Bloomstein was not a ‘character’, but rather a real person who died. What more, she is repeatedly referred to by her first name, ‘Lauren’, when most often, in the USA, in public contexts, respect is shown to persons by referring to them by their last names or by both their first and last names. At the very least, it should be somehow stated that Ms Bloomstein, a mother, did die of pre-eclampsia, despite being in a well-resourced setting, and potentially, her death could have been avoided. Call for change that may be presented is so muted that the status quo appears to be an inevitable reality.

TED talk

Big ‘D’ Discourse

The second text, a speech by Midwife Linda Robinson, contrasts sharply with the PBS NewsHour report in that these text levels pointed clear criticism at the US maternity system, going so far as to draw stark parallels between Congolese and US maternal care. Contextualising her speech – that is, laying out the big ‘D’ Discourse context – Robinson begins by relating her own experience as a midwife in war-torn DRC, a place where ‘local doctors cut women open without anaesthesia and they die’. She connects her Congolese experiences to US ones:

When I left Congo, I promised the women I would tell their story. I felt it was the only lasting good I could do to raise awareness of what happens to women affected by war and I’ve done that. I wrote about it and they speak about it, and now I feel I have to tell a story of women right here in The USA.

Robinson explains that when she was returning to the USA, she had felt concerned that she would not be able to show compassion to US women, but her fears were unfounded. Robinson makes a connection between the DRC and the USA, stating that she sees ‘parallels’ or ‘universal unfairness’, and that ‘we traumatise women in my country too. We just put a cleaner face on it’. The primary support for her assertions is that US women lack access to vaginal births after caesarean sections (VBACs), a service which is often recommended by even the mainstream medical community (see American College of Obstetricians and Gynecologists, 2017). Robinson spends much of her speech telling the story of a woman who was unable to access VBAC services near her home and who was considering living in a camper near the ‘only hospital that would support her decision in New Hampshire’. However, without negating the trauma and difficulty faced by the US women, it is important to note that the Congolese crisis of lethal caesarean sections during war and the US difficulty of accessing care in an industrialised country are similar in some ways but are different in other important respects. In the Congolese case, the women died, but this particular US woman’s survival was, at least, rather likely.

In terms of maternal survival, in industrialised countries, VBACs are significantly less likely to result in death for the mother as compared to a repeat caesarean section. However, statistically, babies are more likely to die during a VBAC attempt than in a repeat caesarean section because of the increased risk of uterine rupture associated with VBAC attempts (Rezai, 2016). Robinson condemns providers that say, ‘if you attempt a vaginal birth, your baby could die’, but in fact the statement is not untrue. Unfortunately, babies do die. Therefore, depending on the tone employed and accompanying or omitted facts, this statement is not necessarily a way for women to be ‘emotionally manipulated’. The decision whether or not to have a VBAC is a uniquely personal one, best made by the mother when she has complete picture of her past labour, her own current risks, the risks to her baby and the risk to any potential future pregnancy. Information that her baby may die, unpleasant as this information is, is something that a woman should know.

Little ‘d’ discourse

Robinson’s criticism of the US healthcare system is very evident from even the smaller linguistic details of her talk (the little ‘d’ discourse). During the second half of her speech, Robinson cites the lack of availability of VBACs as a prime example of what is wrong with US maternal healthcare. Expressing dismay, she classifies the situation in which mothers undergo repeat caesarean sections without adequate access to VBAC as an instance of women being ‘emotionally manipulated’. She also decries such lack of access as ‘mutilation … for profit and convenience’ or in the case of a death, ‘manslaughter’. Continuing to talk about lack of access to VBACs, she likens (potentially) unneeded repeated caesarean sections to street-level violence and urges action, saying that ‘if we saw some violent person coming at a woman on the street with a knife, we’d call 911’. She concludes her talk by advocating for better healthcare availability and community support for pregnant rural women, pointing out that ‘driving more than two hours in labor is torture’. Taken together, the words – ‘mutilation’, ‘knife’ and ‘torture’ – paint a strong and emotionally jarring picture.

Conclusion

In this study, two texts – or colloquially, videos – were chosen for analysis. Together, these videos provide a study of the lack of clarity and polarised language so common in maternal healthcare in the USA. In the first video, the PBS NewsHour piece, women are painted as nearly powerless in making improved decisions to improve their own outcomes. This video demonstrated a reluctance to use clear language to describe the death of a victim of the maternal healthcare system, and any criticism of the prevailing obstetrician-led US maternal healthcare system is quite muted indeed. At the other end of the spectrum, in the TED talk, (retired) Midwife Linda Robinson implies the US healthcare system is one of ‘mutilation’ in which events akin to knifings regularly take place. Our observation of the ‘polarised’ (McIntyre et al., 2012: 706) language in these two texts is not in itself unique, but using CDA to provide a specific form of analysis is an innovation in academic literature.

One clear limitation of this study relates to the nature of CDA itself. As is common in CDA, this analysis looked closely at a small set of text with the explicit goal of unravelling and revealing the power dynamics contained within the language and spurring further discussion and exploration of these findings (Sriwimon and Zilli, 2017).

Certainly, not all readers will agree with our analysis of the two texts in which we use little ‘d’ and big ‘D’ discourses to call out the overstatements and lack of clarity in some of the discourses surrounding maternal mortality, but perhaps the analysis offered here will trigger important conversation. Others have begun to call out a similar midwife versus obstetrician dynamic so prevalent in the USA, as this discourse leaves women to sort through the blaming and rhetoric. Instead of name-calling or refusing to admit fault, there is a need to acknowledge that while evidence-based medicine has come a long way in the last hundred years (Enkin et al., 2013), the optimal choices about where (home, hospital or birth centre) and with whom (an obstetrician or midwife) to give birth remain complex, contextualised ones. Fineberg (2013) points out that medical facilities vary in their ability to provide complex care, providers vary in their skill level and risk factors to a specific woman vary. Furthermore, each woman’s individual convictions in terms of family size and the desire to balance risk to herself versus her baby are valid considerations in terms of the mode of delivery (Block, 2007; Rezai, 2016; Roth, 2000). Informed choice – based on a rational, accurate description of the risks and benefits of various modes of pregnancy care – is an ethical mandate (Fineberg, 2013). In trying to understand the risks and benefits, there are perhaps some basic questions that women could begin to ask.

Gee (2005) points out that language is reflexive, that is, language not only describes a situation but also creates and feeds reality. Perhaps the longer women tolerate the existence of high levels of maternal mortality in the USA, and the longer we accept the unclear, exaggerated, biased or incomplete accountings of the circumstances, the worse the situation will become. Specific to this context, Gaskin (2011) encapsulates this idea of progressive worsening when she states ‘the status of motherhood is progressively lowered when women themselves have little understanding of the needs of women who give birth and of the abilities of their own bodies’ (p. 41).

One way to further this understanding is through patient–caregiver dialogue about misunderstandings and mistakes. In the PBS NewsHour report, we encounter a view of doctors as demigods. This view is not unusual but is dangerous. A cultural shift that admits, and does not necessarily penalise, genuine mistakes and human limitations is needed to improve patient safety (National Public Radio, 2014) and doctor well-being alike. After all, when mistakes go unanalysed, improvement and prevention of harm cannot take place. It is significant, however, that not only are patients themselves damaged by a doctor-is-always-right culture, physicians and caregivers too may be adversely impacted by the inability to admit mistakes. Doctors-in-training report a fear of being shamed for admitting their mistakes (Martinez and Lehmann, 2013). Physician burnout, which is correlated with high rates of physician depression and suicide, is a severe problem across all medical specialities. One of the most effective ways to treat obstetrician–gynaecologist burnout is through engagement, that is, ownership of work and the ability to grow and solve problems (Lee et al., 2017). However, this kind of growth is impeded if the physician has been socialised to pretend to be all knowing and invincible. Women do, in fact, often seek health information from physicians (Smedley et al., 2014), so what physicians say or do not say truly matters. We need to rethink our approach to medical mistakes, and this rethinking begins with the language that we implement and support.

Once we can admit that caregivers might not always be right, we can talk about how we can use our resources and technology to their greatest potential. Too often, resources, both human and technological, are misallocated because of the aforementioned midwife–doctor dichotomy (Fineberg, 2013) present in the USA. Robinson illustrates this dichotomy when she suggests that obstetricians perform ‘mutilation’ with a ‘knife’. While some obstetricians do misuse their power (Block, 2007; Roth, 2000), others do not, but do the best that they can in a dysfunctional system. Caesarean sections are sometimes needed service and save lives when used appropriately (Rezai, 2016). Midwives, who do not perform caesarean sections, can provide low-risk women with care as good as or safer than that of physicians (Conesa Ferrer et al., 2016; Sandall et al., 2016). We need to start asking not who is doing the ‘mutilating’, but who can provide the most appropriate safe level of care needed by an individual woman.

A move away from polarised rhetoric may represent more choice for women, but structural barriers are also material. Although the 2010 Affordable Care Act brought about positive change by lowering the number of uninsured pregnant women, currently about 12% of US women lack health insurance (Daw and Sommers, 2019). Insurance and financial concerns affect a women’s choice where to birth (MacDorman and Declercq, 2016). Obstetric care provider shortages, projected to worsen in the future, are also problematic (Stonehocker et al., 2017). We may need change in how we view, frame and understand maternal mortality in the USA, but we also need access to care.

It bears repeating that a plethora of evidence from diverse global contexts shows that women have better pregnancy outcomes, and ultimately health outcomes for their whole families, when they are educated about their health conditions and options (Diamond-Smith et al., 2017; Gee and Corry, 2012; Lan and Tavrow, 2017; Lu et al., 2015; Prata et al., 2017; Shimamoto and Gipson, 2017). Put another way, when provided with the resources to do so, women can make decisions that enhance their own safety. However, if an educational text (a webpage, book, speech, video, class, etc.) engages in dialogue designed to either obscure risk or demonise another party that provides a sometimes necessary service, what are we to make of the intent of the text? In the case of covering-up or name-calling, is the educational and transformative value of a text truly optimal? Educators, clinicians and advocates need to work to transform current US dialogue around maternal health to point out lapses in care and provide information that empowers women to make their own best, informed choices. Obtuse or polarising dialogue is not a good way forward. While the overall healthcare system in the USA is woefully broken, when informed women start to demand good-quality care appropriate to their situation and circumstances – care that optimises their survival – we can hope that models of care will shift to focus on helping women in the USA to achieve safe and satisfying childbirth.

Footnotes

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

ORCID iD

Rebecca Allen

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