As with life, risk is an inevitable part of pregnancy, labour and birth. A good practitioner will always seek to minimize risk, but some risks will remain. There are different kinds of risk and steps taken to reduce clinical risk may increase psychological risk. Risks for a woman and baby are not always the most highly prioritised, either. Risks of litigation or disciplinary procedure against an organisation or practitioner may be more influential in determining a course of action, and may even create risks for a woman or her child.
'Risk assessment' is a blunt instrument
When we assess risk, all we are doing is estimating the probability of something happening. This works when one is considering large numbers of people, but it doesn't mean much on an individual basis: what matters to us is whether something happens or not. Nobody can offer us the certainty that a risk won't happen. Nor is there much advantage in being compared to people whose circumstances, lifestyle, state of health and all sorts of other factors may be quite different from our own.
Every time we get into a car, there is a statistical risk of our being involved in a road traffic accident. How we drive that car - the amount of care, attention, experience, ability and familiarity we have - alters the likelihood of this happening dramatically. However, the effect of these factors is impossible to calculate. An organization can make policies on the basis of statistics. Whether these policies or guidelines are right for an individual is a completely different matter and depends on the interpretation in a specific situation
So when we categorise a woman as being at 'high' or 'low' risk, we are disregarding all of her individual factors in favour of her assumed statistical similarities with others categorised in the same way. Unfortunately these labels can have a significant effect on the outcome of their labour. Women who are falsely labelled at high risk at the outset will be subjected to further testing. At worst they may suffer unnecessary and potentially harmful treatment. This kind of labelling encourages defensive thinking Inhibits good practice.
Consequences of risk management in birth
Routine intervention is now commonplace as a consequence of obstetric risk management. This accepted 'medicalisation' of birth effectively takes away the woman's control of the process and thus diminishes her ability to mother her infant. The risks of this approach to future generations are substantial. Unfortunately it is difficult to take legal action for 'diminished mothering' - its costs will be born by the whole of our society, rather than individual trusts.
From a global perspective it is acknowledged that the risk management approach to maternity care has not been entirely effective. This is because women considered to be low risk may still have unexpected complications and women considered to be high risk may turn out to have an uneventful pregnancy and birth. This approach has also resulted in a disproportionately high number of women finding themselves in a high-risk category.
What is really important?
At its heart, midwifery is about the care and support of women and their babies as well as supporting women's choices. Helping a woman understand her well-being indicators and minimize her risk, based on her perception and our assessment of her individual circumstances, is an important part of this. And it should always come before minimizing the risks of disciplinary procedure or litigation to ourselves and our organizations, however important these are.
Tips and tricks
- Make a list of the risks you think this woman faces – what are the greatest risks? How does the woman view these risk? Do any of these risks conflict (e.g. does her state of mind make the risk of admission into hospital greater than the risk of having the baby at home?)
- Make a list of all her well-being indicators - what did you find? Do they balance or offset the risks? What is her self-assessement?
- Record your decision making processes – in your notes, list the risks and well-being indicators you have identified and explain how you have made your decision about which ones to prioritize. What evidence have you used to support the decision? If you are concerned, discuss it with a colleague.
Further reading
Axton S (2000) The thinking midwife: arriving at a judgement
British Journal of Midwifery 8 (5): 287-291.
Cioffi J, Markham R (1997) Clinical decision-making by midwives: managing case complexity
Journal of Advanced Nursing 25: 265-275
Bates C
Assessing and managing risk in midwifery practice in Boyle M (Ed) (2002) Emergencies Around Childbirth Radcliffe Medical Press
Royal College of Midwives (2000)
Reassessing risk: a midwifery perspective Royal College of Midwives Trust, London
