Birth workers inherently assess and manage risk as part of their role. The concept of risk and the definition of safety in birth are a complex and sometimes paradoxical discussion which is strongly influenced by bias and perception.
Risk influences the birth settings we are offered.
Risk influences the choice to intervene.
Risk doesn’t always consider the emotional and mental wellbeing of mothers.
Risk can detach us from our cultural ways of birthing, especially in rural and remote areas.
Risk is an accepted part of healthcare. While the number of mothers and babies who die in the process of birth in Australia remain low and largely unchanged for at least the last 20 years (despite increasing intervention, which is no longer reducing poor outcomes), birth related deaths do still occur. It is unrealistic to eliminate all birth risk, despite the current risk adverse birthing culture we are currently facing and many women having the impression that obstetric intervention is not only the safest way to give birth, but can also achieve the impossible.
Midwives are advocates of normal childbirth, but are often unable to practice in the way we are actually obliged to by our Code of Ethics and International Standards (i.e. supporting women in all birth settings, including the home).
What should be more important than removing choice - is getting better at informed decision making.
The mother should always be the primary decision maker - but this requires full disclosure of all risks, benefits and altnenratives if it is to be valid.
Most Australian women birth in a hospital. 80% of births are either induced, augmented (altered), instrumental (forceps or vaccum) or via caesarean. That means that only 20% of women are birthing without any intervention at all.
Does that seem strange to you?
Obstetric perspective of risk influences how these maternity services are governed. The belief that birth is abnormal and safest if treated as a medical event, along with the fear of involvement in adverse outcomes is resulting in rising intervention rates for low-risk women.
Let’s focus on low-risk women for now - as high-risk women are often safer if medically managed.
As intervention increases, so too are negative outcomes related to intervention itself (birth trauma, haemorrhage, fetal distress, postnatal depression. low breastfeeding rates, higher-risk subsequent pregnancies).
The International Confederation of Midwives states that it is imperative to avoid unnecessary interference in the progress of physiological birth, which is a normal process for most women.
Birth requires a health-orientated approach in which intervention is only appropriate when there is a clear and present danger to the health of the woman or her baby that can reduced or eliminated through evidence-based technological interventions.
Conversely, The Royal Australian and New Zealand College of Obstetrics and Gynaecologists state that in a case of a physiological birth with no complications, minimal intervention is required and that even low-risk women can rapidly develop complications and therefore must have timely access to medical interventions.
While subtle in writing, these are two vastly different philosophies - the first is that birth is normal for most women, the second is that birth is a risk to be managed.
We see this interplay and polarity regularly in birth settings where both obstetricians and midwives work, and in the public hospital setting. Although obstetrics and midwifery are two totally different professions, (obstetrics dealing with abnormal birth, and midwifery dealing with normal birth) - in the hospital setting they are confused and intermingled. Midwifery is seen as a subset of obstetrics, and midwives often report to obstetricians.
This blurs and muddies the waters between who is ‘low-risk’ and who is ‘high-risk’, with obstetricians often involved in births which should be physiological.
An example? Instrumental birth.
19% of Australian vaginal births are assisted by either vacuum or forceps. RANZCOG says that instrumental birth is employed to accelerate birth when indicated, and is a safe option in select cases. They also acknowledge that instrumental birth is associated with fear of birth, post-traumatic stress, shoulder dystocia, haemorrhage, neonatal facial nerve palsy, corneal (eye) abrasion, retinal (eye) haemorrhage, skull fracture and/or intracranial haemorrhage, cervical spine injury and other maternal complications including vaginal trauma, third or fourth degree tears of the anal sphincter, urinary tract injury, and damage to pelvic floor and anal sphincter.
In an emergency is an instrumental birth helpful and life-saving? Absolutely yes. But the question should be, with risks like these, how can we be preventing the need for this in the first place?
This didn’t start when the woman started pushing - it started in pregnancy, it started with induction, it started with rupturing the membranes, it started with an epidural, it started with syntocinon.
How can we unwind the process and help keep birth normal wherever possible?
33% of Australian mothers (yep - 1 in 3) birth via Caesarean delivery. This statistic doubles for you if you are first time mother who is induced (66% or 3 out of 4).
The International Confederation of Midwives (2002) believes this increasing rate of Caesarean section is related to the threat of litigation, being service-oriented or meeting social needs rather than the need to change practice due to new evidence around prevention of negative outcomes.
RANZCOG says that Caesaren section is a safe procedure but also states (2010) that this method of delivery is associated with significantly increased risk of maternal morbidity, including haemorrhage, bladder trauma and requirement for intensive care, as well as complications in subsequent pregnancies such as ectopic pregnancy, preterm birth, unexplained stillbirth after 34 weeks and uterine scar rupture. There is also a negative association between caesarean delivery and early breastfeeding. Interestingly, Figueiredo, Canario & Field (2014) demonstrated that postnatal depression was significantly decreased in women who maintained exclusive breastfeeding for 3 months or more after birth.
Traumatic birth experiences have a negative impact on a woman’s emotional wellbeing postnatally and her ability to adjust confidently to motherhood.
Women are increasingly seeking alternative birth settings and models of care for a variety of reasons, including wanting a non-medicalised approach to birth and the associated positive birth outcomes with reduced rates of birth related trauma.
Where a woman plans to give birth has a significant influence on her birth outcome and the rate of intervention she is likely to receive.
There is no insurance cover for labour care for a planned home birth in Australia.
Olsen and Clausen (2012) found (and many others) that hospital-based birth settings are not any safer than planned home birth settings with an experienced midwife.
Women who receive continuity of care (the same care provider) in a midwife-led model, such as caseload midwifery or private practice midwifery, have better birth outcomes overall. They are more likely to experience physiological birth and have comparable or lower rates of adverse outcomes for themselves and their babies to other models of care.
The rise of women free birthing or hiring a doula is indicative of this growing trend that women feel less at risk birthing alone than they do in our current medical system.
The concept of risk has complex and sometimes paradoxical influences on how maternity care is offered in Australia.
Perception of risk is largely determined by the education, experience and bias of the viewpoint being considered and the desired outcome.
Midwives believe that birth should be allowed to progress physiologically unless there is a clear and immediate threat to the mother or baby. A medical approach to birth assumes that birth is a medical event safest managed by technology, and therefore interventions are appropriate at the physicians discretion with loose and unspecific guidelines for their use.
Many interventions are traumatic and may result in increased morbidity and mortality for both the mother and baby, including lower breastfeeding rates and adverse outcomes for maternal mental and emotional health postnatally.
Women are limited in where they can choose to give birth by financial, legislative and social factors.
Approaching birth as a medical service, rather than a significant life event for the woman, her family and the community does not lower risk of morbidity or mortality, and may actually increase it.
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