Chapter 4 Risk and safety
This chapter aids in the understanding of why risk is such an important concept. It begins by presenting the techno-rational or scientific approach and goes on to provide interpretations from social and cultural perspectives. What becomes clear is that the understanding and management of risk and the promotion of safety are not simple matters. However, the concerns related to risk and safety need not always engender fear and anxiety. The second part of this chapter provides a framework that the midwife can use to support safe, effective and life-affirming care within this risk environment. The framework acknowledges the complex and often paradoxical nature of midwifery practice and provides a way for the midwife to put the management of risk and safety into practice and into perspective.
The assessment of risk and the promotion and protection of safe childbirth are key elements of the provision of maternity care. Risk and safety are strongly related concepts that the midwife must come to terms with as she works alongside women as they become mothers. Safe practice minimises and ‘manages’ risk; risks are assessed, avoided or managed in order to provide a safe environment in which to give birth. Risk affects the lives of midwives, both in the assessment of risk in the childbearing woman, and in the management of their own risk within the medico-legal context. Yet there is something about how risk is currently constructed, not only in maternity care but also throughout the Western world, that reflects rising levels of anxiety.
This increased anxiety about risk and safety is reflected in maternity care and is occurring despite a growing understanding of the causes, incidence and prevention of negative outcomes. This has been accompanied by increasing levels of intervention, accountability and surveillance, with significant implications for the way midwifery is practised (Skinner 2003). It challenges the model of birth as a normal part of human life and thus presents challenges for midwives attempting to enact in practice this model of normality. Midwives are faced with a significant paradox in attempting to work a ‘birth is normal’ perspective within a ‘birth is risky’ context. Working in this context requires the midwife to have a sophisticated understanding of the meanings of risk aversion and of safe practice.
In a sense, risk and safety have become opposing positions. There is little acceptance that taking risks is not only a normal part of life but is also essential. Without it humans do not develop. We can miss valuable and life-changing opportunities. In order to achieve safety we might sometimes put ourselves at risk of unforeseen and unknown risks. Sometimes you have to take risks to be safe, yet safe action may have unforeseen negative outcomes. Complete safety cannot be assured and there is no such thing as a risk-free birth. Risk in the current environment has become associated with the possibility of negative outcome rather than with the possibility of positive experience (Tulloch & Lupton 2003). It is the fear of negative outcome that is most often expressed. One rarely (if ever) reads reports of the risks of a positive outcome of a planned action. For example, how often is it expressed that if you plan a home birth you risk having a birth with no intervention?
It is important, then, for the midwife practising in this environment to have an understanding of how and why risk has become so prominent and to have some tools to deal with the reality of how this affects safe practice.
The first place to investigate, and the one that holds the dominant position in current risk discourse, is the techno-rational or scientific approach. It is here that we see research dominated by epidemiology and by the randomised controlled trial, and the use of this research in informing practice. These approaches to risk are focused on the mathematical calculations of risk associated with the probability of events occurring. Their main concerns are in the measurement of risks and effects. These approaches provide valuable information for the midwife in the provision of safe care and are an essential part of her knowledge base. For example, the meta-analysis of the randomised controlled trials on continuous fetal monitoring (CFM) indicates that for low-risk women, CFM increases the risk of unnecessary intervention (Thacker et al 2004). However, the application of the scientific evidence in the management of risk and the promotion of safety are seldom simple. There are several challenges that midwives face in assessing and managing risk from a science- or evidence-based framework.
For the individual healthcare practitioner there is a fundamental difficulty in extrapolating knowledge from large studies and applying it to individual situations. For example, the early identification of risk is notoriously imprecise in predicting adverse outcomes for the individual (Enkin et al 2000). Once the complexity of the individual situation is identified, the ability to know what the quantified risks of an adverse event occurring are may be further eroded. The quantification of risk must take into account not only the rate of adverse outcome but also the possible benefits, and must ensure that there is some consistency in how the risks are framed (Guise 2004).
The identification of risk is also tied up with control. Heyman (1998) contends that where healthcare practitioners claim to predict the probability of an outcome for individuals, there is a tendency to attempt to make decisions on their behalf. He states: ‘The health professionals’ crystal ball, although providing only cloudy, probabilistic glimpses of possible futures, through the methodology of epidemiology, leads them into attempting to manage risks on behalf of their clients’ (p 22). Skilled, clinical assessment and effective communication therefore remain core competencies for the midwife in assisting the client in decision-making around safe care. The scientific evidence is one important tool to inform this practice.
The techno-rational model of maternity care also has particular implications for the understanding of what is normal and so has a special importance for midwifery, which claims expertise in ‘normal’ birth. Understandings of what is risky and what is normal both dominate and delineate midwifery practice and yet are often seen as juxtaposed positions. Normality has changed from being a social to a scientific concept, as we have come to accept the idea that one can’t know something unless it can be measured (Hacking 1990). Being normal therefore has come to mean both having no measurable risk factors and also being ‘average’. This search for measurable regularity and thus quantifiable normality has given rise to rules about childbirth that have not undergone in-depth analysis (Murphy-Lawless 1998). An example of this is the decision about what constitutes a normal labour. This needed to be measurable, so statistical data on the length of labour have been applied to individual women’s progress. Deviations from the measurable, statistically assessed norm are then seen as needing to be managed and controlled. In essence, then, science in the guise of medicine has re-created and redefined ‘normal’ and has seen pregnancy as normal only in retrospect (Cartwright & Thomas 2001; Symon 1998; Wagner 1994).
It is within this dominant techno-rational discourse that midwifery stays firm in its claim to expertise in normal childbearing. It is a precarious position to take, given who is defining normality and who is defining risk. The challenge for midwifery is to look beyond the techno-rational definitions of normal and to claim its own. Midwifery sees birth as a normal process, not only physiologically but also socially, culturally and spiritually (NZCOM 2005). This is reflected in the commitment that midwifery has to partnership and to women-centred care. One of the risks of this perspective, however, is the possibility of decreased emphasis on the physical aspects of what we currently call normal birth—that is, birth with no intervention.
The techno-rational approach has also tended to turn safety into a commodity, one that professionals are meant to be able to provide. Symon (1998), in his study of midwives’ and obstetricians’ attitudes to litigation, found that both midwives and obstetricians agreed that women had been given the impression that science (in the form of obstetric intervention) can achieve more than it actually can. The techno-rational model focuses on making danger visible (technology) and measurable (epidemiology) (Cartwright & Thomas 2001). But as Smythe (1998) points out, this is not always possible. There is, she says, unsafeness that is unknown. Some things can appear unannounced, suddenly and without warning. The normal and the abnormal can ‘mimic’ each other. She also comments that being safe or being unsafe (being at risk) is, in a sense, already there. Some women could give birth safely with no professional input and others will not give birth safely even with all the help that professionals can provide. So the midwife is there not to ‘sell’ a safe birth as some sort of objective, measurable commodity but to support safety and to uncover, as much as she can, the risks that might threaten this safety. This unknowable nature of risk and safety means that the midwife must be skilled and vigilant.
The techno-rational approach also implies that decision-making should be made by rational experts rather than by the ‘insignificant others’ (Stapleton 1997). Davis-Floyd (2002) describes this approach as technocratic. Based on the pre-eminence of technology and of mind–body separation, the technocratic approach, she says, treats the ‘patient’ as object and sees responsibility and authority as being held by the practitioner. This approach also presupposes that both the assessment of risk and the experts themselves are objective and rational and that people will make rational decisions about what is risky and what is safe (Lupton 1999). It is based on assumptions that the evidence provides clear answers so that choices will also be clear and self-evident. However, this is not often the case. Take, for example, clinical practice guidelines that recommend induction of labour for pregnancies that go past 41 weeks gestation. Menticoglou and Hall (2002), on close examination of the research on which these guidelines are based, estimated that it would take 1000 inductions of uncomplicated pregnancies at 41 weeks gestation to possibly save the life of one baby. The decision about whether this is a justifiable intervention will inevitably be based on what is valued or what is feared and is therefore not a rational process. Menticoglou and Hall also highlight the possible harm caused to women and their babies by the 999 unnecessary inductions, and also to other labouring women being cared for in a maternity unit busy doing these unnecessary inductions. The use of such clinical practice guidelines, they state, also has considerable implications for litigation when they are not strictly adhered to. How midwives assist mothers to make such decisions can therefore be fraught. Who has the power to decide whether these risks are worth taking? Decisions about risk and safety are therefore not as simple as one might think.
Heyman (1998) summarises the difficulties related to the application of science and technology by saying that although the techno-rational approach has made a huge contribution to human development, it:
cannot accurately predict most biographical outcomes, answer questions about values, or provide convincing solutions to the mind–body problem. Many of these issues come to a head in the management of health risks. [The] notion of probability, which underpins the idea of risk, does not provide a rigorous scientific tool, but only a heuristic, rule-of-thumb device which had both utility and limitations; and that the assessment of ‘adversity’ entails weighing up values in ways which sometimes are contested. (p 2)
The risks associated with childbirth, then, are not only understood in physical terms but must be understood within their societal and cultural contexts. As stated earlier, the current social context has highlighted risk as a central concern. This is not peculiar to maternity care. Beck (1999), a prominent sociologist in risk theory, has proposed that we now live in a ‘risk society’. Modern life, he asserts, has been based on the idea that technology and science can provide the answers to our problems. Progress and controllability have been fundamental beliefs in the search for safety and security. The success of modernity, as represented by science and technology, has led to globalisation and thus to a growing understanding of the multiple ways of living and viewing the world. Modernity has also led to individualisation and a sense of self-determination. This in turn has challenged traditional social understandings, including the role of women and the place of the family, leading to increasing uncertainty. This uncertainty is also reflected in the undermining of faith in science and technology; by the growing understanding that not only does technology not solve all our problems, it actually creates some of them.
The uncertainty about societal roles and loss of faith in technology have led to a generalised insecurity and anxiety, along with a loss of faith in professionals and in technology. We are in a state of being ‘in between’, where we have not yet created social and cultural forms that replace the tenets of modernity. We are, according to Beck (1999), not yet postmodern but are living in what he calls ‘late modern’ society, where we live with, among other things, the paradox of losing faith in experts while at the same time still expecting that their work will be free of negative outcomes. The levels of anxiety that are produced become counterproductive. In terms of maternity care, this reflexive culture means that maternity practitioners can be constantly questioned, challenged and increasingly restricted in their practice. The accountability that results causes fear and stress not only in the practitioners but also in the consumers of maternity care, as they themselves are required to make choices with risks attached that are difficult or impossible to quantify.
Ironically, this desire to avoid or control all risk in itself creates its own problems. Annandale (1996) comments that the consumerism and managerialism that have emerged as part of the risk society have tended to further increase the levels of anxiety and, paradoxically, to undermine the quality of care that is provided. It is this combination of managerialism in the form of protocols and guidelines, and consumerism in the form of informed choice and consent, that provides the current background for midwifery practice. One needs only to reflect on the increase in caesarean section rates in light of the ‘risk society’ to see how this can be applied to maternity care and to midwifery. In the effort to control for all risk, both for the mother and baby and for the maternity practitioner, caesarean sections are an increasingly used intervention. Yet this intervention comes with its own risks. The dilemma for the midwife is to work in this increasingly constrained environment while providing care that is flexible and truly women-centred. And all this in an environment focused on risk aversion.
The risk society as manifest in maternity care reflects the tension between both the acceptance and the rejection of modern biomedicine. Davis-Floyd (2002) accepts the valuable knowledge that biomedicine has provided but also contests its dominance. The anxiety associated with risk and safety can be seen, then, as having its origins in the movement beyond an uncritical acceptance of biomedicine. The resurgence of midwifery and the increase in the valuing of humanistic or holistic care could be seen as part of the movement towards a new, more postmodern way of viewing the world. We certainly seem to be in a state of transition.
Another way to view risk and safety is to take a cultural view. Cultural perspectives attend not so much to the way in which current social forms are reflective of risk (as in Beck’s ‘risk society’), but to the way in which societal forms themselves affect the way decisions about risk are made. One of the most influential thinkers in this field is the anthropologist Mary Douglas (Douglas 1992; Douglas & Wildavsky 1982). Douglas points to the lack of uniformity in opinions about what makes something risky, how risky it might be and what should be done about it. She rejects both the scientific, objectivist approach and an individual rational choice approach to risk decision-making. Instead, she proposes that risks are decided upon according to the cultural meaning associated with them, and is critical of experts’ attempts to get to the objective truth of risk by protecting it from the ‘dirty’ side of politics and morals. People, she proposes, do not make decisions about risk according to individualised circumstances and beliefs, but are culturally conditioned to prefer some types of decisions over others. Their beliefs and actions therefore are culturally constructed. Within any culture there will be subgroups and communities who have varied value bases and ethical systems. These ethical systems too are culturally constructed and may vary. This variety is not related to any misguided perception, as objectivists would propose, but to different political, moral and aesthetic positions (Lupton 1999).
Values and uncertainties are an integral part of these choices, and Douglas proposes that the choices between risky alternatives are not value-free. Choice in the end, therefore, is essentially based on social rather than scientific knowledge. This decision-making process can also be seen as political. Who should make decisions, who and what should matter, are related to whose knowledge is regarded as authoritative. Douglas’s position does acknowledge that dangers and risks are real but proposes that it is impossible to rank them in any rational sense. There are simply too many of them (Douglas & Wildavsky 1982). A cultural approach therefore helps us to see risk decision-making as a result of community consensus, rather than rational individual choice. It is this community consensus that gives preference to some risks over others. We see this clearly in the decision-making processes around birth. Take, for example, a woman’s decision to deliver her breech baby without intervention, compared with an obstetrician’s wish to deliver that baby by caesarean section; or a woman’s choice to have an epidural anaesthetic despite her midwife’s commitment to normal birth. How do the women’s decisions reflect their cultural and community perspectives? Whose knowledge is authoritative? How is fear being expressed? And, of course, who is at risk?