How the concept of risk influences maternity care
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.
Albers, L & Katz, V 1991, ‘Birth setting for low-risk pregnancies: An analysis of the current literature’, Journal of Nurse-Midwifery, vol. 36, no. 4, pp. 215-220, doi:10.1016/0091-2182(91)90081-Y
Australian Institute of Health and Welfare 2016, ‘Perinatal Deaths in Australia 1993-2012’, Perinatal Deaths Series, no. 1, viewed 29 May 2017, http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129557267
Australian Institute of Health and Welfare 2016, ‘Australia’s Mothers and Babies 2014’, Perinatal Statistics Series, no. 32, viewed 26 June 2017, http://www.aihw.gov.au/publication-detail/?id=60129557656
Bastos, M, Furuta, M, Small, R, McKenzie-McHarg, K & Bick, D 2015, ‘Debriefing interventions for the prevention of psychological trauma in women following childbirth’, Cochrane Database of Systematic Reviews, vol. 4, doi:10.1002/14651858.CD007194.pub2
Cluett, E & Burns, E 2009, ‘Immersion in Water in Labour and Birth’, Cochrane Database of Systematic Reviews, no. 2, doi:10.1002/14651858.CD000111.pub3
Comino, E, Knight, J, Webster, V, Pulver, L, Jalaludin, B, Harris, E, Craig, P, McDermott, D, Henry, R & Harris, M 2012, ‘Risk and Protective Factors for Pregnancy Outcomes for Urban Aboriginal and Non-Aboriginal Mothers and Infants: The Gudaga Cohort’, Maternal and Child Health Journal, vol. 16, no. 3, pp. 569-578, doi: 10.1007/s10995-011-0789-6
Dahlen, H.G, Jackson, M & Stevens J 2011, ‘Homebirth, freebirth and doulas: Casualty and consequences of a broken maternity system’, Women and Birth, vol. 24, no. 1, pp. 47-50, doi: 10.1016/j.wombi.2010.11.002
Davis, D, Baddock, S, Pairman, S, Hunter, M, Benn, C, Wilson, D, Dixon, L & Herbison, P 2011, ‘Planned place of birth in New Zealand: does it affect mode of birth and intervention rates among low-risk women?’, Birth, vol. 38, no. 2, pp. 111-119, doi:10.1111/j.1523-536X.2010.00458.x
Dhalen, H, Tracy, S, Tracy, M, Bisits, A, Brown, C & Thornton, C 2012, ‘Rates of obstetric intervention among low-risk women giving birth in private and public hospitals in NSW: a population-based descriptive study’, BMJ Open, doi:10.1136/bmjopen-2012-001723
Dhalen, H, Tracy, S, Bisits, A, Brown, C & Thornton, C 2013, ‘Rates of obstetric intervention and associated perinatal mortality and morbidity among low-risk women giving birth in private and public hospitals in NSW (2000–2008): a linked data population-based cohort study’, BMJ Open, doi:10.1136/bmjopen-2013-004551
Figueiredo, B, Canario, C & Field, T 2014, ‘Breastfeeding is negatively affected by prenatal depression and reduces postpartum depression’, Psychological Medicine, vol. 44, no. 5, pp. 927-936, doi:10.1017/S0033291713001530
Healy, S, Humphreys, E & Kennedy, C 2016, ‘Midwives’ and obstetricians’ perceptions of risk and its impact on clinical practice and decision-making in labour: An integrative review’, Women and Birth, vol. 29, no. 2, pp. 107-116, doi:http://dx.doi.org/10.1016/j.wombi.2015.08.010
Healy, S, Humphreys, E & Kennedy C 2017, ‘A qualitative exploration of how midwives’ and obstetricians’ perception of risk affects care practices for low-risk women and normal birth’, Women and Birth, doi:http://dx.doi.org/10.1016/j.wombi.2017.02.005
International Confederation of Midwives 2002, Appropriate Maternity Services for Normal Pregnancy, Childbirth and the Postnatal Period, viewed 26 May 2017, http://internationalmidwives.org/assets/uploads/documents/Position%20Statements%20-%20English/PS2011_001%20ENG%20Appropriate%20maternity%20services%20for%20normal%20pregnancy.pdf
International Confederation of Midwives 2005, Appropriate Use of Intervention in Childbirth, viewed 24 May 2017, http://internationalmidwives.org/assets/uploads/documents/Position%20Statements%20-%20English/PS2011_003%20ENG%20Appropriate%20use%20of%20intervention%20in%20childbirth.pdf
International Confederation of Midwives 2011, Home Birth, viewed 24 May 2017, http://internationalmidwives.org/assets/uploads/documents/Position%20Statements%20-%20English/PS2011_010%20ENG%20Home%20Birth.pdf
International Confederation of Midwives 2014, Keeping Birth Normal, viewed 24 May 2017, http://internationalmidwives.org/assets/uploads/documents/Position%20Statements%20-%20English/Reviewed%20PS%20in%202014/PS2008_007%20V2014%20Keeping%20Birth%20Normal%20ENG.pdf
Kildea, S, Kruse, S & Sherwood, J 2016, ‘Midwives Working with Aboriginal and Torres Strait Islander Women’, in Pairman, S, Pincombe, J, Thorogood, C & Tracy, S (eds), Midwifery: Preparation for Practice, 3rd edn, Elsevier Australia, pp. 207-226.
Medical Board of Australia 2014, Good Medical Practice: A Code of Conduct for Doctors in Australia, viewed 29 May 2017, http://www.medicalboard.gov.au/Codes-Guidelines-Policies/Code-of-conduct.aspx
Medical Insurance Group Australia (MIGA) 2016, Application Form, viewed 26 June 2017, http://www.miga.com.au/library/MidwivesApplicationForm_February2016.pdf
Northern Territory Government 2016, Homebirthing in the NT, viewed 2 June 2017, https://nt.gov.au/wellbeing/child-health-pregnancy-and-birthing/homebirthing
Nursing and Midwifery Board of Australia 2008, Code of Professional Conduct for Midwives in Australia, viewed 1 June 2017, http://www.nursingmidwiferyboard.gov.au/documents/default.aspx?record=WD10%2f1355&dbid=AP&chksum=Mm624fvql2ZEKdEmT3l2ng%3d%3d
Olsen, O & Clausen, J 2012, ‘Planned hospital birth versus planned home birth’, Cochrane Database of Systematic Reviews, no. 9, doi: 10.1002/14651858.CD000352.pub2.
Remote Primary Health Care Manuals 2015, Labour and Birth, viewed 2 June 2017, http://remotephcmanuals.com.au/publication/cpm/Labour_and_birth.html
Sandall et al. (2016) - Sandall, J, Soltani, H, Gates, S, Shennan, A, Devane, D 2016, ‘Midwife-led continuity models versus other models of care for childbearing women’, Cochrane Database of Systematic Reviews, no. 4, doi: 10.1002/14651858.CD004667.pub5
Skinner, J & Dahlen, H 2016, ‘Risk Fear and Safety’, in Pairman, S, Pincombe, J, Thorogood, C & Tracy, S (eds), Midwifery: Preparation for Practice, 3rd edn, Elsevier Australia, pp. 87-102.
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 2013, Caesarean Delivery on Maternal Request, viewed 2 June 2017, https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Caesarean-Delivery-on-Maternal-Request-(C-Obs-39)-Review-Nov13.pdf?ext=.pdf
The Royal Australian and New Zealand College of Obstetrics and Gynaecologists 2016, Delivery of the Fetus at Caesarean Section, viewed 2 June 2017, https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Delivery-of-fetus-at-caesarean-section-(C-Obs-37)-Review-November-2016_1.pdf?ext=.pdf
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 2016, Evidence-based Medicine, Obstetrics and Gynaecology, viewed 26 June 2017, https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical%20-%20General/Evidence-based-medicine,-Obstetrics-and-Gynaecology-(C-Gen-15)-Review-March-2016.pdf?ext=.pdf
The Royal Australian and New Zealand College of Obstetrics and Gynaecologists 2014, Home Births, viewed 28 May 2017, https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Home-Births-(C-Obs-2)-July-2014_1.pdf?ext=.pdf
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 2002, Instrumental Birth, viewed 28 May 2017, https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Instrumental-Vaginal-Birth-(C-Obs-16)-Review-March-2016.pdf?ext=.pdf
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 2015, Perinatal Anxiety and Depression, viewed 1 June 2017, https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Perinatal-Anxiety-and-Depression-(C-Obs-48)-Review-March-2015.pdf?ext=.pdf
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 2010, Provision of Routine Intrapartum Care in the Absence of Pregnancy Complications, viewed 28 May 2017, https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Provision-of-routine-intrapartum-care-in-the-absence-of-pregnancy-complications-(C-Obs-31)-Updated-Mar-2015.pdf?ext=.pdf
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 2014, Warm Water Immersion During Labour and Birth, viewed 1 June 2017, https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Warm-water-immersion-(C-Obs-24)-Jul-2014.pdf?ext=.pdf
Young, K & Kruske, S 2013, ‘How valid are the common concerns raised against water birth? A focused review of the literature’, Women and Birth, vol. 26, no. 2, pp. 105-109, doi:http://dx.doi.org/10.1016/j.wombi.2012.10.006