Can maternity care move beyond risk? Implications for midwifery as a profession
Maternal and infant mortality rates are reassuringly low in developed countries. Despite this, birth is increasingly seen as risky by women, health professionals and society in general. In wider society, women are subjected to a litany of risks regarding birth, including sensationalising negative incidents by the media. Within maternity care, both structural and operational factors contribute to heightened risk perceptions. Women are processed through a system where risk-management strategies can take precedence over individualised care as health professionals attempt to protect themselves from implication in adverse outcomes and litigation. This results in increasingly interventionist care, depriving women of psychosocial safety in the birth process. Midwifery, as a profession promoting trust in normal birth, is threatened by this dominant medical model of maternity care and interventionist birth practices. Midwives need to act to reclaim their role in promoting normal birth, while balancing considerations of risk with the principle of woman-centred care.
Changes in society, including higher levels of education in the population and higher expectations of health services, have resulted in a belief that risk can be controlled or even prevented, and nowhere is this more apparent than in maternity care. The focus of birth has shifted from accepted uncertainty towards risk prevention, resulting in increased employment of clinical governance and risk-management strategies (Scamell and Alaszewski, 2015). As a consequence, the language of birth has evolved to incorporate words such as ‘hazard’, ‘harm’, ‘blame’, ‘vulnerability’ and ‘safety’ (MacKenzie Bryers and van Teijlingen, 2010). As birth becomes reconceptualised in these terms, there is little tolerance for accidents where individuals—including midwives, obstetricians and women—are held accountable for adverse events (Scamell and Alaszewski, 2015).
Risk management was originally meant to protect, but in health care today, risk management may be exposing people to more intervention than is necessary (Edwards and Murphy-Lawless, 2006). This develops from heightened, and sometimes irrational, perceptions of risk. Such perceptions mean health professionals are reluctant to accept even a minimal possibility of risk (Scamell and Alaszewski, 2012), demonstrated by existing maternity practice where intervention and surveillance are employed even in the absence of risk factors (Rattray et al, 2011; Scamell, 2011).
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