Risk: Let's look at the bigger picture

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In my 30 years as a midwife I have seen the perception of risk shift from what was an accepted reality, which we carefully and cautiously managed, to become an unacceptable and avoidable commodity. Risk seems to have become the core force to be reckoned with in maternity care. Its techno-rational, reductionistic approach has distracted us from our core focus, woman-centred, holistic care and we have a real challenge ahead to reclaim the centrality of this position. In the current risk climate, if something unpredictable happens, then it is seen that we cannot have done our risk management well enough and someone must be blamed. As a result we are protocolled, and guidelined into a corner where we find ourselves chasing our own tails with ever increasing levels of fear and anxiety. In the process we are destroying the core of what we are trying to achieve and, ironically, creating new risk and causing more damage. We only have to look at the caesarean section rates and such sequelae as placenta acreta, or the damage caused by a routine admission CTG for low-risk women, to confirm this hypothesis. Its time to stop this nonsense and put risk back where it belongs; to put risk into perspective and to put this perspective into practice.

So why has this happened? What is the big picture of risk and how might this help us? Beck,¹ a German sociologist, provides a useful analysis of risk and coined the term ‘the risk society’. He proposed that our current anxieties about risk can be traced back to the beginnings of modernity. We believed in progress, that we should be able to have control over our lives and that nature was there to be exploited. Technology would find a way of solving all our problems and science was seen as the perfect rational project. These beliefs are beginning to be thoroughly undermined, and we see this most profoundly in the damage to the environment that now threatens our very existence. In this risk context we, in the West at least, have become highly anxious, still clinging to the idea that more technology is the only answer, yet increasingly understanding that it cannot be. As we face the consequences of the success of modernity and technology, we are now beginning to challenge its assumptions. This is very disconcerting, as we have not yet created societal and cultural structures to replace modern life as we know it. We are not yet, according to Beck, post-modern. We live a contradictory existence, and feel as a consequence, a great deal of anxiety. On the one hand we have lost faith in experts, yet on the other we still demand that the experts produce work free of any negative outcome. We strive more and more intensely to avoid or control risk even while knowing that we can never achieve it. This is happening in almost every area of life. In terms of maternity care, this reflexive culture of what Beck calls ‘late modernity’ means that we as health practitioners can be constantly questioned and challenged, both by consumers and managers of maternity care. The accountability that results causes fear and stress not only in practitioners but also in consumers. We need, Beck states, to undergo a paradigm shift, to move to a more holistic and cooperative way of being. We need then to reconfigure risk and to come to much broader understanding of its meaning and its implications.

So what has all this got to do with midwifery? As I contemplated the big picture of risk and pondered what this might mean to us as midwives, I was struck by two things. The first was that current perspectives on risk are not just problems that originate in maternity care, or even just in health care. This is a universal and complex problem that cannot be blamed on the media or on managers or doctors or women. It is fundamentally about the current socio-cultural form in which we still approach life's challenges in a reductionistic, techno-rational way. To some extent, knowing this can free us up from personal and professional paranoia. The problem is not just manifest in maternity care, but is fundamental to how we in the West approach life itself. Growing levels of anxiety about risk are related not only to the failure of technology to eliminate it, but to the fact that technology itself also creates risk. The very basis of Western assumptions of living is being undermined.

The second thing that struck me is how perfectly positioned midwifery is to make a real difference here. At our very core, we are focused on the protection and promotion of normal birth and it is great to see this aspect of our work being lifted to the fore. Above all other professions we hold a holistic, relational position. It is part of our raison d’etre. We are also fundamentally not technology bound. But probably one of our most powerful attributes is that we can claim a very different way of doing professionalism, not restricted by any particular knowledge framework. This can free us up from self-protected drives for autonomy and allow us to seek unique and creative collaborations. In a sense midwifery is THE profession to face and solve the risk dilemma. We have a very important role to play, as we as humans attempt to reconstruct what it means to be human. After all, we are at every birth, with every new mother and family. We are all about connection and protection. I think we need to be overtly brave about this, reclaiming and developing this position, using the knowledge generated by ourselves and others to work towards shifting the current risk paradigm. We can only do this by consciously examining and challenging our own and others constructs of risk and life.

What this means is that we need to FIRST attend to changing hearts and minds, not JUST the model of care. We need to open up to possibilities of collaboration with others, rather than focusing on professional autonomy. We should not be too small minded and need to look further a field in our collaborations. We need to work actively alongside others who also work ‘with women’, both to challenge them and to learn from them. We need to seek knowledge frameworks that will challenge and extend us, such as the biosciences, human geography, or architecture, to name but a few. We need to attend to all aspects of practice, acknowledging and working with the complex task we undertake. The time has past for the seeking of simple solutions for complex situations.

I think we in New Zealand, where the midwifery- led model of care is now the norm, are learning that autonomy and continuity of midwifery care are not, of themselves, the solution to the rising intervention rates in birth. Despite having developed a strong and autonomous midwifery profession, which now provides most primary maternity care, we have not succeeded in making a significant dent in our risk framework. Our intervention rates and our medico-legal environment attest to this. Do not get me wrong. Midwifery-led care as it has evolved in New Zealand is a truly magic way of working and we are immensely appreciative and proud of what we have achieved. It does allow for amazing possibilities of connected, holistic care. But for us, the continued rise in birth interventions, despite our model of care, has left us puzzling. What we now face is the real challenge of midwifery in the 21st century; the changing of hearts and minds. We have learned that changing the model of care alone does not do this, and that having professional autonomy does not, of itself, do this. It will take both the imagination of what might be, and a focus on our core values and perspectives. The tough work for us is really beginning. Our ‘with women’ focus can be our guide. If we keep this focus we can explore other perspectives and possibilities. We need to be much more sophisticated knowledge synthesisers, while at the same time not losing site of what we hold precious.

For those of you who struggle for the right for autonomy and for women's right for continuity of midwifery care, remember that the risk environment in which your care is embedded can and does undermine the benefits of this model. Alongside your efforts for midwifery-led care must come the focused and purposeful shifting in your own and others perspectives of risk and of life itself—no mean feat. Attending to risk is no simple matter. There is unfortunately no ‘quick fix’ for risk. It is not a matter of better documentation or following the guidelines. It will take stronger, more focused hearts, broader minds, patience and persistence. Current Western constructions of risk have taken us to a place both of paralysis and of global self-destruction. Midwifery is in the perfect position to challenge this and to gently yet firmly show that there is another way.

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Reference 

1. Beck U. World risk society. Malden: Polity Press; 1999.
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