Tuesday, May 1, 2012

The Importance of Defining "Risk"

1. The possibility of suffering harm or loss; danger.
2. A factor, thing, element, or course involving uncertain danger; a hazard

As beautiful as birth can be, there is no arguing that it presents an element of danger and with that comes risk.  No matter where a baby is born, there are risks involved.  The greater questions are: How is risk defined?  What is considered "low-risk" and "high risk"?  How is risk assessed?  When do potential or actual risks provoke action?  What resources are immediately available to evaluate risk and take action if needed?  What will those actions be and who will make the decision that action is required?

Both the philosophy of the caregiver attending your birth and the environment in which you are giving birth greatly impact the answers to these questions. For example, a hospital is built on the practice of constantly assessing risk and using the resources immediately at hand to eliminate them.  They take on the patients with the greatest amount of risk and have endless protocols, technology, guidelines, and review processes to continually minimize them. In out-of-hospital birth, the answers to these questions get messy because they depend almost solely on the individual attending your birth and the philosophies that person carries with her.  This is especially true in states like Michigan, where there are no defined practices for what midwives can and cannot attempt in terms of risk.  

We often read or hear that home birth is "safe" for low-risk women or that midwives intend to attend only low-risk births.  Yet somehow, there are hundreds of women across the country sharing stories of babies who didn't survive out-of-hospital delivery for reasons that have more in common than you might think: breech delivery, VBAC (vaginal birth after cesearean)/Uterine Rupture, multiples, post date, macrosomia, etc. Do these situations come about as a result of error in assessing risk or are they an attempt to prove "birth works" by purposefully taking on what most would define as high risk births?  Truth be told, I believe the answer is a little of both.
For some midwives, nothing is considered high risk if you "trust birth".  In fact some proclaim that "birth is as safe as life gets".  Every situation to these midwives is "just a variation of normal".   Does anyone stop to think about what that really means?  Isn't anything that deviates from normal, no matter how far the deviation, considered a "variation"?  Maybe it's the use of the word just in this case that makes it sound so causal when the reality is that many of these conditions put mother and baby at much greater risk for birth injury or worse.  

The truth is that evaluating risk out-of-hospital is inherently more difficult and less precise because midwives do not have all the resources and technology available to assess basic statistics, like a baby's position and size. Midwives are only able to offer their best guess based on what they feel with their hands and sometimes this "stab in the dark" assessment is terribly inaccurate and inadequate.  I've heard stories of midwives who thought they were delivering a placenta and ended up delivering twins, as well as surprise breech deliveries . . oops! So, while some people argue that hospitals intervene too much because they over-evaluate risk, we must appreciate that they are often able to provide valuable information and services that are well outside the scope of midwifery.

Because out-of-hospital care is more difficult to manage, it is absolutely critical to engage the services of a competent midwife. This mean many things but, most importantly, she must operate within a clearly defined scope of practice (shared with you in writing in advance) and attend ONLY low-risk births. Within these parameters she must be skilled at evaluating risk, have clear definitions of "low" & "high" risk and be decisive in taking appropriate action (transfer of care) when things go pear shaped.  Incidentally, she must have a working relationship with an OB and hospital to ensure smooth & confident transfer of care.  

Even when a competent midwife attends a low-risk birth, emergencies can still creep up in an instant. Having adequate training and resources immediately available can make the difference between life and death.  The way your care provider defines, assess and acts upon risk factors and the tools she has at her disposal, will greatly impact the outcome of your birth. 

What else can help ensure that adhering to scope of practice and attending only low risk birth actually happen?  State regulation.  Michigan needs to define safety protocols for out-of-hospital birth, define midwives as only taking on low risk birth, and spelling out exactly what circumstances require transfer of care.  The countries that have had great success with midwifery have done just that.  Both the Netherlands and Canada have established absolute and non-absolute criteria for transfer of care and physician consultation.  They consider theses practices a screening mechanism to help consistently identify good candidates for out of hospital birth, a) to minimize risk and b) to ensure the best possible outcomes.  This kind of regulation helps a profession such as midwifery define its scope of practice and institutes a measure by which to hold its practitioners accountable.  Midwives regulating midwives is not responsible, ethical, or effective.  Just ask the families who have lost babies in the hands of midwives operating far outside these parameters.  Time for change. 

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