Why does language matter?

The issue of how language is used in the context of pregnancy loss is not new. Healthcare professionals such as doctors and midwives have been pointing to problems with the language used in clinical settings for decades. Meanwhile, public conversations about this sensitive topic on social media and in magazines and blogs have given a voice to the people who experience this language. Common between these different perspectives is the need for change.

Clinicians’ calls for change

It has been 40 years since medical literature in the UK first acknowledged that language can be an important aspect of patient care during and after pregnancy loss. In 1985, a letter was published in The Lancet asking for the word miscarriage to replace spontaneous abortion in clinical settings. In this strongly worded letter, three prominent obstetricians called for use of miscarriage in such contexts “on humanitarian grounds”, citing the distress the term abortion caused to patients (Beard et al., 1985). It appears to have been this letter which catalyzed the shift in clinical usage from abortion to miscarriage in British English when referring to the spontaneous loss of a baby before 28 weeks – the gestational threshold for categorization of stillbirth at the time.

This case shows us that clinical language, when felt to be problematic, can be changed for the benefit of patients. However, this is by no means the only call for language reform that has been made in relation to pregnancy loss, and few others have so far seen the same success.

As recently as 2011, clinicians in the US were still calling for a parallel shift from abortion to miscarriage in American clinical English (Silver et al., 2011). These clinicians also called for substitution of many other labels used in diagnosing pregnancy loss. The term blighted ovum was criticized as one that “makes no biological sense” and that suggests some abnormality in the mother as the reason for the loss. Similarly, the phrases cervical incompetence and cervical insufficiency were highlighted as diagnostic labels which “place ‘blame’ on the mother” with spontaneous cervical ripening suggested as a substitute. Meanwhile, the phrase chemical pregnancy was said to imply that the pregnancy was “not real”, leading at times to frustration and anger. More recently, other terms such as viable and non-viable, used to describe pregnancies, have been highlighted as ones which lead to confusion and “suboptimal care” (Pettker et al., 2023: 1).

In the last decade, UK clinicians have also highlighted problematic diagnostic labels and suggested alternatives in medical journals. In a 2018 blog published in the British Medical Journal called Humanising birth: Does the language we use matter? (Mobbs et al., 2018), the authors identify examples of poor communication around pregnancy loss, while in a comment piece in The Lancet in 2021, the authors provide a table of “insensitive language” and “appeal to colleagues worldwide to banish such terms from their vocabulary” (Vimalesvaren et al., 2021: 860).

Public calls for change

These concerns about language are mirrored in the public domain: in newspapers, magazines, and non-medical blogs. In an article in the US edition of Glamour magazine published online in January 2020, the word miscarriage was criticized following a surge of attention to this term on social media (Oré, 2020). Many social media users linked the word miscarriage to self-blame, citing pregnancy loss as a preferable alternative. Such public conversations may reflect a cultural movement away from miscarriage and towards pregnancy loss, which seems to be appearing in policy and public health messaging. But unlike the swift change documented to have followed the intervention of Beard and his colleagues in 1985, this change is happening very slowly.

A more systematic approach to criticising pregnancy loss terminology in the public domain is seen in the Peanut Renaming Revolution: The Motherhood and Fertility Glossary. Peanut, an app for facilitating friendships between parents, hosts this glossary on its website, with the intention of prompting a “renaming revolution”, which addresses the “reality that existing terminology does not value and empower women” through pregnancy and birth (Peanut, 2023: 1). This document was compiled through crowdsourcing on social media, and thousands of women are reported to have contributed harmful terms they had experienced.

Official language guidance

Given the growing sense that pregnancy loss terminology is unsatisfactory to many, it is perhaps not surprising that the last decade has seen the publication of several official “consensus” statements (e.g. Johnson et al., 2020; Kolte et al., 2015). These are documents intended to provide clarity and consistency in terminology use, and are produced following consultation between experts. The Language Guide circulated by the UK’s Royal College of Obstetricians and Gynaecologists in 2022 offers one such set of guidelines, intended to “create consistency, fairness and inclusivity”. Among others, this Guide recommends the substitution of incompetent cervix with cervical dysfunction, spontaneous abortion/early fetal demise with miscarriage, evacuation of retained products of conception with surgical management of miscarriage and parents who’ve suffered baby loss with parents of a baby who died.

However, the recommendations made by the different statements and guidelines don’t always match, and this makes change difficult. While one 2015 statement recommends anembryonic pregnancy, for example, another in 2020 recommends we avoid this phrase. Another problem is that this guidance doesn’t give us an up-to-date picture of how language is actually being used and received. Abortion is repeatedly mentioned – but is this term still actually used in the UK in the context of spontaneous loss? Miscarriage is often listed as a preferred term – but what about the growing public sense that it is thought problematic by many? Importantly, since these documents are not based on empirical research with patients themselves, they don’t tell us about the varied preferences of those with lived experience of such loss.

We are still far from establishing a standardised terminology, or a consistent set of words and phrases chosen to cause the least harm and confusion. While specialist expertise is undoubtedly crucial in identifying this language, we also need an accurate picture of contemporary usage and the preferences of those affected by that language now. In the following section, we introduce a project which has begun to gather this data.

Towards evidence-based guidance for pregnancy loss language

In 2023, the ‘Linguistic Challenges in Communicating about Pregnancy Loss’ (EstELC) project set out to explore the role of language in pregnancy loss experiences empirically, and to try to identify how language can be best used to support those experiencing loss. Over the course of a year, we heard from people from across the UK, who have experience of accessing or delivering healthcare for pregnancy loss. The project was guided and supported by an expert advisory group with members from professions across healthcare, academia, policy, and the charity sector.

A total of 339 participants provided written testimonies on the impact of language in receiving or delivering healthcare during and after pregnancy loss experiences. 42 of these were then invited to take part in one of ten Listening and Discussion Groups with other lived experiencer participants, or other healthcare professionals, if they felt able to.

Hundreds more people expressed interest in participating in Listening and Discussion Groups than the project was able to accommodate.

In the following step, you will hear just some of the testimonies collected first hand.

Share your examples

Have you read, watched, listened to, or explored anything that has already influenced your understanding of this topic? Add a link in the comments below and tell us why you found them helpful.

Links and references:

• Beard, R.W., Mowbray, J.F., & Pinker, G.D. (1985). Miscarriage or abortion. The Lancet, 2(8464), 1122–1123. https://doi.org/10.1016/s0140-6736(85)90709-3.
• Johnson, J., Arezina, J., Tomlin, L., Alt, S., Arnold, J., Bailey, S., Beety, H., Bender-Atik, R., Bryant, L., Coates, J., Collinge, S., Fishburn, J., Fisher, J., Fowler, J., Glanville, T., Hallett, J., Harley-Roberts, A., Harrison, G., Horwood, K., Hardicre, N. K. (2020). UK consensus guidelines for the delivery of unexpected news in obstetric ultrasound: The ASCKS framework. Ultrasound, 28(4), 235–245. https://doi.org/10.1177/1742271X20935911.
• Kolte, A.M., Bernardi, L.A., Christiansen, O.B., Quenby, S., Farquharson, R.G., Goddijn, M., Stephenson, M.D. (2015). Terminology for pregnancy loss prior to viability: A consensus statement from the ESHRE early pregnancy special interest group. Human Reproduction, 30(3), 495–498. https://doi.org/10.1093/humrep/deu299.
• Pettker, C.M., Turrentine, M.A., & Simhan, H.N. (2023). The Limits of Viability. Obstetrics & Gynecology 142(3),725-726. https://doi.org/10.1097/AOG.0000000000005280.
• Royal College of Obstetricians and Gynaecologists. (2022, November). RCOG Language Guide. Royal College of Obstetricians and Gynaecologists.
• Silver, R.M., Branch, D.W., Goldenberg, R., Iams, J.D., & Klebanoff, M.A. (2011). Nomenclature for Pregnancy Outcomes: Time for a Change. Obstetrics & Gynecology, 118(6), 1402–1408. https://doi.org/10.1097/AOG.0b013e3182392977.
• Vimalesvaran, S., Ireland, J., & Khashu, M. (2021). Mind your language: Respectful language within maternity services. The Lancet, 397(10277), 859–861. https://doi.org/10.1016/S0140-6736(21)00031-3.