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Melanie Jackson is mother of two, Midwife in private practice, PhD graduate, part-time blogger, obsessed veggie patch owner and even more obsessed crocheter

Sunday, 20 March 2011

Risk is in the Eye of the Beholder

For this past year I have been researching what motivates and influences mothers to choose a free-birth or ‘high-risk’ homebirth as part of my PhD thesis ‘birthing outside the system’. It has become dramatically obvious that women who make choices that are seemingly against the system have a very different perception of risk than our medically minded counterparts.

                The concept of risk is just that, a concept, one that can be perceived and understood differently by everyone based on their previous experiences, research and influences throughout life. Obstetrics argues that their definition or perception of risk is ‘right’ and authoritative (Murphy-Lawless 1998 p.22) and touts their management and intervention as the best and most sure way of reducing the risk of childbirth. Medicalised management of birth is a hallmark of mainstream birth services; these services perceive their management of birth to be the only ‘right’, ‘best’ and ‘safe’ way to birth, dismissing all other options as ‘dangerous’, ‘irresponsible’, ‘risky’ and ‘wrong’, but, what if medical management of birth is ‘wrong’? What if they unequivocally have it wrong? This is certainly the question asked by the highly intelligent, critical and knowledgeable women who have shared their stories for my research. 

                For mothers who choose to birth at home, medical interventions and interruptions in the birth process are seen as ‘dangerous’ and ‘risky’. They feel that the risk of something going wrong at their birth proliferates the more they part-take in or make themselves vulnerable to the medical management of birth. One woman explains, ‘I look at interference a bit like risk, every time someone new comes across you or does something, that’s a risk that something goes wrong, every time you get a medication there is a risk it’s the wrong one, every time they do something there’s a risk that flows onto something else, so if no-one is doing anything to you or performing any unnecessary tests, then there is no risk there’- (homebirth mother). This is in dramatic conflict with the medical message that interventions are designed and employed in order to reduce risk.

                The medical use of risk language alongside birthing generates fear around the process of labour and birth and if birth is marketed as risky, then it will be perceived as scary. By the use of risk language, obstetrics has perpetuated the myth that childbirth is to be feared and thus throughout history convinced mothers to conform to their birth management in order to avoid something going wrong (Murphy-Lawless 1998, p.18). The medicalisation of birth has allowed obstetrics to redefine what is considered ‘normal’ and ‘abnormal’. By developing a conceptual difference between abnormal and normal the medical profession have secured a large and growing market for their services in perpetuity by the creation of false needs and then catering to these newly perceived needs (Ballard & Elston, 2005, p.230). By the social process of medicalising birth, modern obstetrics can justify managing labour and birth by intervening to make each individual labour and birth conform to the obstetric definition of normal. By defining what is constituted as normal birth, obstetricians have monopolised control over events which occur outside the norm under the guise of ‘risk management’.

Women who remain unconvinced by the obstetric definition of ‘risk’ see no reason in accepting medical interventions and therefore see no reason to enter hospitals. The very place they are most at risk of being subjected to interruption and intervention while they are trying to give birth is at hospital. Home birthing women see intervention as risky and thus will not be convinced to accept them as a way of avoiding adverse outcomes; in fact, they believe that the risk of adverse outcomes at birth is increased by unnecessary intervention. One mother comments, ‘I don’t see induction now as the safe way out, actually having an induction now is the risk to me, that is tempting fate, not carrying a well baby to full term and comfortably to post-dates, that’s not the risk, it’s the unnecessary induction’ (homebirth mother). Another mother also comments, ‘they interfere so that’s why things happen, they end up with forceps or vacuum or caesarean because they put up drips (to speed labour) and they just stuff women up’ (homebirth mother).

The question must be asked, how can it be that modern medicine believes they can make birth safer by interfering, to avoid complications and minimise risk when a home birth mother believes interventions make her birth more dangerous, will cause complications and increase her risk? Is it possible that both are right? if not- who is wrong? The answer lies in what women have described to me as ‘medically indicated intervention’ and ‘necessary intervention’. The women who have contributed to my study saw the absolute necessary place of obstetrics in emergency care for birth complications; we can all agree that when a caesarean is legitimately needed we want a skilled obstetrician (not a midwife) to perform the surgery, but where the bone of contention exists is- who defines necessary?

Just like modern obstetrics and home birthing women have different perceptions of ‘risk’ they also have different definitions of necessary. Women who birth their babies at home see ‘necessary intervention’ as one that is ‘medically indicated’ and a response to a real threat to the mother and baby, one that is truly required because the mother and baby are at risk of death or damage. One mother was asked during her interview if she think thought there was a right place for intervention, she replied, ‘yeah, if there is a problem, if there is a risk, there’s something possible that’s going to affect the mother or the baby and that’s their only way of getting out a healthy baby then yeah, that’s the advantage of living in today’s society’ (home birth mother).

You might ask, why else would an intervention be performed if not for the safety of the mother and baby? The answer not only lies in the findings from my study but also my personal experience working in the hospital system. Deviating from the medically defined norm of time in pregnancy will find you shafted into an induction, not because you and your baby are at risk, but because the hospital policy says so. Not dilating at the medically defined speed will see you augmented with medication, which will see you strapped to the medically defined ‘best’ way of monitoring your baby, which will see you in much greater pain then if you had free movement, which would increase the ‘risk’ of you needing pain medication, which would increase the ‘risk’ that your baby will need to be pulled out with forceps and need intervention to breathe, which will increase the ‘risk’ of breastfeeding being unsuccessful.  Digressing from medical definitions of normal and hospital policy will see you managed with intervention, not to decrease your risk, but to increase your conformity to the medically defined boundaries of normal- which may or may not be right. 
Risk is in the eye of the beholder, every day we make decisions about the risks we are willing to take. You take a risk getting in your car, buying sushi, having sex, taking a panadol, going for a jog, drinking hot coffee and gardening on a hot day, I took the risk today of aggravating my repetitive strain injury while typing, but it was a risk I was willing to take. The medical system and home birthing women perceive risk differently and are willing to take different risks based on different motives, but while each ones perception is different, it is not less or wrong, just different. What is ‘right’ and ‘best’ can only be determined by each individual and where the conflict lies is in who defines what is ‘best’ and which risks are ‘right’ to take.   
If you would like to, or know someonw who you think would like to participate in this research please e-mail mkjackson@live.com.au. For more information on accessing a homebirth midwife visit http://www.ellamaycentre.com/

with love
Mel xo

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