Secondary Qualitative Analysis of Stigmatizing and Nonstigmatizing Language Used in Hospital Birth Settings

Objective: To more clearly understand the use of stigmatizing and nonstigmatizing language in electronic health records in hospital birth settings and to broaden the understanding of discrimination and implicit bias in clinical care.

Design: A secondary qualitative analysis of free-text clinical notes from electronic health records.

Setting: Two urban hospitals in the northeastern United States that serve patients with diverse sociodemographic characteristics during the perinatal period.

Participants: A total of 1,771 clinical notes from inpatient birth admissions in 2017.

Methods: We used Krippendorff's content analysis of categorial distinction to identify stigmatizing and nonstigmatizing language. We based our categories for the content analysis on our pilot study and preexisting categories described by other researchers. We also explored new language categories that emerged during analysis.

Results: We reviewed 1,771 notes and identified 10 categories that demonstrated stigmatizing language toward patients, nonstigmatizing language toward patients, and stigmatizing language among clinicians. We identified a new stigmatizing language category, Unjustified Descriptions of Social and Behavioral Risks. Positive or Preferred Language and Patient Exercising Autonomy for Birth are two new categories that represent language that empowers patients. Clinician Blame and Structural Care Barriers are new language categories that imply complex interprofessional dynamics and structural challenges in health care settings that can adversely affect the provision of care.

Conclusions: The results of this study provide a foundation for future efforts to reduce the use of stigmatizing language in clinical documentation and can be used to inform multilevel interventions to reduce bias in the clinical care in birth settings.