Descriptive terms for women attending antenatal clinics: mother knows best?
Correspondence: Mr D. L. Byrne, Department of Obstetrics and Gynaecology, Royal Cornwall Hospitals Trust, Truro, Cornwall TR1 3LJ, UK.
Objective To determine the noun for ‘women who attend antenatal clinics’ that is most accepted by the women themselves.
Design Cross sectional study.
Setting Consultant-led antenatal clinics in Cornwall.
Population All women attending consultant-led antenatal clinics over a two-month period.
Methods The women were surveyed by written questionnaire.
Main outcome measures The first, second and third choices of descriptions offered to women attending antenatal clinics. Secondary outcome measures include the relation of maternal age, gestation, civil status, occupation and obstetric history to the individual's choice of description.
Results Questionnaires were received from 446 women, constituting 13% of the antenatal population of Cornwall. Their median age was 28 years and median gestation 22 weeks; 255 (57%) had one or more children and 289 (65%) were married. The most popular choice of description was ‘patient’ (39% of first choices made), whereas the most accepted description was ‘pregnant woman’ (26% of totalled second and third choices). While women who selected ‘patient’ as first choice were slightly younger (mean 27.5 years) than the remaining women (mean 28.4 years), the choice of ‘pregnant woman’ was not related to any of the other recorded characteristics of the respondents. Commercial terms that consistently were selected least included ‘client’, ‘consumer’ and ‘customer’.
Conclusion Some professional bodies and government organisations have criticised the use of the term ‘patient’ to describe antenatal women. In this, the largest study to investigate what the women themselves would choose, ‘patient’ is the most favoured term.
The term ‘patient’ has been in use since Hippocrates first established the fundamental principles of the doctor-patient relationship1. Over the last 20 years, however, this description has been challenged from various quarters as being paternalistic, authoritarian and out of line with modern thinking2. In accordance with this trend, the government white paper The Health of the Nation stated that term ‘client’ is preferable to ‘patient’, as the former implies ‘a willingness to seek out the views of the professional, which will then be taken into account when decisions are made’3. In fact, careful review of the derivation of these terms demonstrated that ‘patient’ suits the government's stated intentions better than ‘client’4.
The controversy is more heated when the discussion moves to obstetrics, where the noun for antenatal attenders is open to wide ranging suggestions but emphatic personal views. One midwifery journal has a deliberate editorial policy to prohibit the term ‘patient’ when applied to pregnant women5. The editor's prime justification for this is that pregnant women are not ill, but her deeper concern is that the term ‘patient’ encourages unnecessary medical intervention5. A more balanced view from the same profession encouraged midwives to examine the meaning of the words they use and understand that ‘patient’ is the most suitable descriptive term for a pregnant woman6. This view was greeted with mixed, but strong, opinions in the letters section of the journal7.
The common strand to these articles is that individuals are trying to dictate what pregnant women should be called, so as to avoid patronising them or mistreating them in some way. It has not occurred to these authors that by voicing their personal prejudice they risk doing exactly that. Only one study has investigated women's opinions. It concluded that it was not possible to find one term that will satisfy all pregnant women and that the term favoured differed with the context in which it was used. Commercial terms such as ‘client’ and ‘consumer’ were the least popular, ‘softer’ terms such as ‘mother-to-be’ were more favoured. The authors, however, only allowed subjects a restricted number of choices. We carried out our study in an effort to establish the most suitable collective noun for pregnant women in our area.
All women who attended antenatal clinics in Cornwall were surveyed with a written questionnaire for two consecutive months. The survey covered 10 consultantled antenatal clinics: four at the district general hospital and six in community hospitals. On arrival in the clinic waiting area, the women were given a self-explanatory questionnaire and pen, irrespective of their gestation or purpose for their visit. No verbal instructions were given and the anonymous questionnaire was collected, even if incomplete or blank, before the woman saw any healthcare professional.
The questionnaire asked the woman's age, occupation, gestation and whether she had had a previous pregnancy. In addition, it asked how many children she had and her civil status. Finally, the women were asked to mark their first, second and third choice of which description they preferred for themselves, from the following list given in alphabetical order: client, consumer, customer, mother, patient, pregnant woman, woman, Other (specify). The system of preferential choice was used to distinguish the term they wished to be called (first choice) from those they would accept (second and third choices).
Statistical analysis was carried out using SAS for Windows. All tests of significance have been calculated using nonparametric methods because of skewness of some of the distributions.
During the study period 613 women attended clinics, and responses were received from 446 women (73%). Maternal age ranged from 15 to 44 years, with a median age of 28 years and a mean of 28.0 (SD 5.4 years). The stated occupation for 163 women (37%) was housewife/mother, 100 (23%) were skilled workers, 91 (21%) were unskilled workers, 60 (14%) were professional/managerial and 29 (7%) were students or unemployed. Three women gave no occupation.
Gestational age ranged from 9 to 42 weeks with a median of 22 weeks and a mean of 25.8 (SD 10.3). For 152 women (34%) this was their first pregnancy. One hundred and eighty-nine women (43%) had no previous children, 150 (34%) had one child, 64 (14%) had two children, 29 (7%) had three, 9 (2%) had four and 3 (1%) had five children. Two did not answer these questions.
Of the respondents, 289 (65%) were married, 119 (27%) were in a stable relationship, 25 (6%) were single, 7 (2%) were divorced and 5 (1%) were separated.
The most popular choice of description was ‘patient’ (206/534; 39% of first choices made), whereas the most accepted description (total of second and third choices) was ‘pregnant woman’(159/621; 26% of totalled second and third choices). If all choices were combined (first, second and third) ‘patient’ remains the most popular selection (345/1155; 30%). The distribution of the seven descriptions and choices is shown in Table 1.
Table 1. The number of women who chose each of the offered descriptions as first, second or third choice. Values are given as n.
Some women made two or three choices without indicating order of preference. These have all been treated as first choices, so totals differ from number of respondents. Fifty-seven women chose ‘Other’: 29 of these were for name/first name/Mrs…; eight were for mum-to-be; seven were for lady/ ladies; five were for expectant mum; and one choice for each of pregnant, my love, anything except client, lady mum, expectant mum-to-be, pregnant client, any and lady parent, mum-to-be.
Factors affecting choice
The data were examined for any relation between each respondent's characteristics (e.g. age or gestation) and the chosen descriptions. The respondents who chose client as their first choice were at an earlier stage of pregnancy (mean 21.8 weeks) than the remainder of the population (mean 26.0 weeks; P= 0.058). Those who included it in any of their three choices had fewer children (mean 0.69) than those who did not select it at all (mean 1.00; P= 0.024). The three women who included consumer in their choices were at an earlier gestation (mean 19.0 weeks) than those who did not (mean 25.8 weeks).
The four women who made customer their first choice were at an earlier stage of pregnancy (mean 20.8 weeks) than the rest (mean 25.8 weeks). Those that included customer in their three choices had fewer children (mean 0.33) than those who did not include it (mean 0.96; P= 0.005).
The women who selected mother as their first choice had more children (mean 1.18) than the remaining women (mean 0.80; P= 0.002). Those who included this in any of their choices had more children (mean 1.05) than those who did not choose it at all (mean 0.74; P= 0.005). Interestingly, 33% of women who selected mother as their first choice had no children. This also applied to 37% of women who chose mother as second choice and 53% of women who chose mother as the third choice, compared with 52% of the women who did not choose mother at all.
The 206 women who selected patient as first choice were slightly younger (mean 27.5 years) than the remaining women (mean 28.4 years; P= 0.19). The choice of pregnant woman was related to age, in that those women who chose it all tended to be younger than those who did not choose it (P= 0.086).
Choice of the title woman was related to occupation: 15% of professional/ managerial women made this their first choice, compared with 5% housewife/ mothers, 5% skilled workers, 3% unskilled workers and 0% student/ unemployed. In contrast, 45% students/ unemployed included this description among their three choices, compared with 40% professional/ managerial, 31% housewives/ mothers, 30% skilled workers and 24% unskilled workers. Choice of the title woman was also related to age. Respondents who put woman as their first choice were older than those who did not (P= 0.058).
This is the largest study of how women who attend antenatal clinics would choose to be described by professional healthcare workers and concludes that the most accepted description is patient
The findings also confirm that the more commercial descriptions of client, consumer, and customer are consistently least favoured. These descriptions were constantly the last three selections whether first, second or third choice was considered individually or in combination.
The minority of women who chose the commercial terms were earlier in their pregnancy and had fewer children. The latter would make this group less likely to choose mother, as the term was chosen by women who had more children. These findings suggest that women who chose the commercial terms may have changed their views as pregnancy advanced or as they had more children. However, to explore this fully a longitudinal study would be needed.
It is surprising that younger women were more likely to choose the term patient as this is widely considered a more traditional and old fashioned term. This finding appears to conflict with the widely held belief that young women would choose more ‘modern’ terms. The term pregnant woman was consistently popular but not related to any of the respondent's characteristics, except possibly age. It is a non-emotive descriptive term and appears to be accepted as such. In the German language there is only one name for a pregnant woman: Schwangere Frau, often shortened to Schwangere (simply meaning pregnant). It is entirely descriptive and happily accepted without the controversy we experience. Perhaps the term pregnant woman fits in to this category.
One of the objections voiced about the term mother is that it does not apply to women who are pregnant for the first time. Our findings show that the women themselves do not share this concern, as 33% of women with no children made this their first choice. Clearly they consider themselves mother to their fetus. This choice was not related to gestation, so this is not just women in late pregnancy voicing their preference.
It might be argued that this is a small study of a rural community and is not applicable to the population as a whole. This population comprises 13% of our annual deliveries. To conduct this study on a similar proportion of all women attending antenatal clinics would require more than 65,000 women to be enrolled nationwide. Such a large investigation might well promote widespread discussion which might influence the true findings. The only other study of women's preferences8 was carried out in a population of city dwellers and came to the same conclusions, suggesting that the finding is not unique to our rural antenatal population and may be appropriate for the country as a whole.
This investigation shows an overwhelming rejection of commercial descriptions for women attending antenatal clinics in favour of more traditional terms such as patient, mother and pregnant woman. While pregnant woman is the more cumbersome term, it is not related to any of the individual's demographic characteristics and may be the least controversial. There is no one term which satisfies all women who attend antenatal clinics but these terms are closer than those currently favoured by some authors and government reports. The study finding may not surprise many healthcare professionals who still work in clinical practice, but may come as a shock to editors and authors who have made contrary assumptions based only on their own prejudice. Perhaps mother does know best… and Big Brother should listen.