Blankenship KM, Bray SJ, Merson MH Structural interventions in public health. AIDS. 2000; 14:S11-21

Brocklehurst P, Hardy P, Hollowell J, Linsell L, Macfarlane A, McCourt C, Marlow N, Miller A, Newburn M, Petrou S, Puddicombe D, Redshaw M, Rowe R, Sandall J, Silverton L, Stewart M Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ. 2011; 343

Byrne C, Kennedy C, O'Dwyer V, Farah N, Kennelly M, Turner MJ What models of maternity care do pregnant women in Ireland want?. Ir Med J. 2011; 104:(6)180-2

Byrom S, Downe S What's going on in maternity care?. In: Byrom S, Downe S London: Pinter & Martin; 2015

Carlton T, Callister LC, Christiaens G, Walker D Labor and delivery nurses' perceptions of caring for childbearing women in nurse-managed birthing units. MCN Am J Matern Child Nurs. 2009; 34:(1)50-6

Cheyne H, Abhyankar P, McCourt C Empowering change: realist evaluation of a Scottish Government programme to support normal birth. Midwifery. 2013; 29:(10)1110-21

Cheyney MJ Homebirth as systems-challenging praxis: knowledge, power, and intimacy in the birthplace. Qual Health Res. 2008; 18:(2)254-67

Chief Nursing Officers of England, Northern Ireland, Scotland and Wales. 2010. (accessed 10 Feburary 2016)

Cooper T Promoting normal birth: courage through compassion. In: Byrom S, Downe S (eds). London: Pinter & Martin; 2015

Coxon K, Scamell M, Alaszewski A Risk, pregnancy and childbirth: What do we currently know and what do we need to know? An editorial. Health, Risk & Society. 2012; 14:(6)503-10

Coxon K, Sandall J, Fulop NJ To what extent are women free to choose where to give birth? How discourses of risk, blame and responsibility influence birth place decisions. Health, Risk & Society. 2014; 16:(1)51-67

Cuidiú. Consumer Guide to Maternity Services in Ireland. 2011. (accessed 10 February 2016)

Dahlen H Undone by fear? Deluded by trust?. Midwifery. 2010; 26:(2)156-62

Dahlen HG Managing risk or facilitating safety?. Int J Childbirth. 2014; 4:66-8

Dahlen H, Gutteridge K Stop the fear and embrace birth. In: Byrom S, Downe S (eds). London: Pinter & Martin; 2015

London: The Stationery Office; 1993

London: DH; 2007

Downe S, Byrom S Turning the silence into a roar. In: Byrom S, Downe S (eds). London: Pinter & Martin; 2015

Dublin: ESRI; 2013

Edwards NP, Murphy-Lawless J The instability of risk: women's perspectives on risk and safety in birth. In: Symon A (ed). London: Churchill Livingstone; 2006

Everly MC Facilitators and barriers of independent decisions by midwives during labor and birth. J Midwifery Womens Health. 2012; 57:(1)49-54

Hall WA, Tomkinson J, Klein MC Canadian care providers' and pregnant women's approaches to managing birth: minimizing risk while maximizing integrity. Qual Health Res. 2012; 22:(5)575-86

Healy S, Humphreys E, Kennedy C Midwives' and obstetricians' perceptions of risk and its impact on clinical practice and decision-making in labour: An integrative review. Women Birth. 2015; pii:S1871-5192(15)00291-7

Hood L, Fenwick J, Butt J A story of scrutiny and fear: Australian midwives' experiences of an external review of obstetric services, being involved with litigation and the impact on clinical practice. Midwifery. 2010; 26:(3)268-85

Hunter B, Segrott J Renegotiating inter-professional boundaries in maternity care: implementing a clinical pathway for normal labour. Sociol Health Illn. 2014; 36:(5)719-37

Hyde A, Roche-Reid B Midwifery practice and the crisis of modernity: implications for the role of the midwife. Soc Sci Med. 2004; 58:(12)2613-23

Jordan RG, Murphy PA Risk assessment and risk distortion: finding the balance. J Midwifery Womens Health. 2009; 54:(3)191-200

Keating A, Fleming VE Midwives' experiences of facilitating normal birth in an obstetric-led unit: a feminist perspective. Midwifery. 2009; 25:(5)518-27

Kennedy P Healthcare reform: maternity service provision in Ireland. Health Policy. 2010; 97:(2-3)145-51

Knight M, Kenyon S, Brocklehurst P, Neilson J, Shakespeare J, Kurinczuk JJOxford: MBRRACE-UK/National Perinatal Epidemiology Unit; 2014

Larsson M, Aldegarmann U, Aarts C Professional role and identity in a changing society: three paradoxes in Swedish midwives' experiences. Midwifery. 2009; 25:(4)373-81

Liva SJ, Hall WA, Klein MC, Wong ST Factors associated with differences in Canadian perinatal nurses' attitudes toward birth practices. J Obstet Gynecol Neonatal Nurs. 2012; 41:(6)761-73

MacKenzie Bryers H, van Teijlingen E Risk, theory, social and medical models: a critical analysis of the concept of risk in maternity care. Midwifery. 2010; 26:(5)488-96

MacLennan A, Nelson KB, Hankins G, Speer M Who will deliver our grandchildren? Implications of cerebral palsy litigation. JAMA. 2005; 294:(13)1688-90

Maternity Care Working Party. 2007. (accessed 19 February 2016)

Meaney S, Sweeney S, Delaney J, Clarke A, Greene RA, Sugrue SCork: Health Service Executive; 2015

Munro D Open disclosure: a perspective from Ireland. In: Byrom S, Downe S (eds). London: Pinter & Martin; 2015

National Institute for Health and Care Excellence. Intrapartum care for healthy women and babies. 2015. (accessed 10 Feburary 2016)

Dublin: NMBI; 2015

Page M, Mander R Intrapartum uncertainty: a feature of normal birth, as experienced by midwives in Scotland. Midwifery. 2014; 30:(1)28-35

Possamai-Inesedy A Confining risk : choice and responsibility in childbirth in a risk society. Health Sociology Review. 2006; 15:(4)406-14

Rattray J, Flowers K, Miles S, Clarke J Foetal monitoring: a woman-centred decision-making pathway. Women Birth. 2011; 24:(2)65-71

Rothman BK Pregnancy, birth and risk: an introduction. Health, Risk & Society. 2014; 16:(1)1-6

Sandall J, Soltani H, Gates S, Shennan A, Devane D Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst Rev. 2013; 8

Sandall J, Murrells T, Dodwell M, Gibson R, Bewley S, Coxon K, Bick D, Cookson G, Warwick C, Hamilton-Fairley D The efficient use of the maternity workforce and the implications for safety and quality in maternity care: a population-based, cross-sectional study. Health Services and Delivery Research. 2014; 2:(38)

Scamell M The swan effect in midwifery talk and practice: a tension between normality and the language of risk. Sociol Health Illn. 2011; 33:(7)987-1001

Scamell M Childbirth within the risk society. Sociology Compass. 2014; 8:(7)917-28

Scamell M, Alaszewski A Fateful moments and the categorisation of risk: Midwifery practice and the ever-narrowing window of normality during childbirth. Health, Risk & Society. 2012; 14:(2)207-21

Scamell M, Alaszewski A Social policy for midwives. In: Lindsay P, Peate I London: Taylor and Francis; 2015

Smith V, Begley CM, Clarke M, Devane D Professionals' views of fetal monitoring during labour: a systematic review and thematic analysis. BMC Pregnancy Childbirth. 2012; 12

Styles M, Cheyne H, O'Carroll R, Greig F, Dagge-Bell F, Niven C The Scottish Trial of Refer or Keep (the STORK study): midwives' intrapartum decision making. Midwifery. 2011; 27:(1)104-11

Surtees R ‘Everybody expects the perfect baby… and perfect labour…and so you have to protect yourself’: discourses of defence in midwifery practice in Aotearoa/New Zealand. Nurs Inq. 2010; 17:(1)82-92

Symon A The midwife and the legal environment. In: Wilson JH, Symon A (eds). Edinburgh: Butterworth-Heinemann; 2002

Symon A The risk–choice paradox. In: Symon A London: Churchill Livingstone; 2006

Walsh D Risk and normality in maternity care: revisioning risk for normal childbirth. In: Symon A London: Churchill Livingstone; 2006

Wiklund I, Wallin J, Vikström M, Ransjö-Arvidson AB Swedish midwives' rating of risks during labour progress and their attitudes toward performing intrapartum interventions: a web-based survey. Midwifery. 2012; 28:(4)E456-60

Wilson J, Symon A The way forward: clinical competence, co-operation and communication. In: Wilson JH, Symon A (eds). Edinburgh: Butterworth-Heinemann; 2002

Can maternity care move beyond risk? Implications for midwifery as a profession

02 March 2016
Volume 24 · Issue 3


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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