Risk, opportunity, and the oppressive language of birth

(Warning and “Let’s get this straight” intro- slightly ranty and very hormonal post. I’m not setting out to suggest that increased risk doesn’t exist in certain scenarios, or that we shouldn’t take precautions. I’m not suggesting we should ignore evidence in pursuit of the birth we want. Quite the opposite- I’m suggesting that any evidence we consider should be individually appropriate to us, that our care should be managed as such, and that our autonomy should be maintained).

I can’t think of another scenario where risk levels are considered low, or high, but nothing in between. What should sit in the middle? Tolerable? Acceptable? I would like to see “normal”.

Because it’s getting rarer and rarer that the women I work with make it to the end of the pregnancy without being slapped with this “high risk” label. And for many of them, it does feel quite the beating.

Women with plans to birth physiologically as uninterrupted as possible, (not just for a jolly, but because they understand the physiology, the impact of the environment, the consequences of intervention, and the benefits of being able to move around freely, how all of this affects their babies, etc) suddenly imprisoned by a set of policies that tell them they won’t be allowed abc and will be having xyz intervention.

IVF, gestational diabetes (seemingly diagnosed in a very uncontrolled fashion), at risk of pre-eclampsia (even without symptoms), high bmi at start of pregnancy (even if managed to improve throughout), vbac, advanced maternal age (even with none of the associated conditions manifesting), previous elevated blood loss, over 41+3 gestation, hypermobility (new one for me), it is starting to feel pretty tricky to avoid ticking at least one of these boxes at some point in the pregnancy.

I am all for identifying issues, even potential issues, and informing women about the risks and benefits of any plans for their babies’ arrivals. But I am getting a bit peeved with the impact of this risk defined culture.

You’re now high risk, so…
– in central delivery suite, non- negotiable (even though midwife led unit is on same corridor. Unless you want a home birth, which is probably fine. Go figure).
– continuous monitoring (even though years of evidence suggests it increases interventions and fails to save babies lives in comparison to intermittent monitoring)
– no pool available (ok maybe there will be a pool available for high risk women, no one has used it yet, but you’re high risk so you’ll start on the high risk unit, and we will decide on the day if we’ve got high risk staff to accompany you in there, if the pool is free)
– you’ve managed to overcome any of the issues that put you in “high risk” to start with, we agree you’re as good a candidate as any for low risk management, but no, we won’t take the high risk label off the front of your notes, so they might not let you into the midwife led unit when you get there

“I’m high risk”.

Defining women with this way affects them in more ways than the restrictions then placed on them. It’s a label, a definition of their pregnancies and their births. A strong suggestion that they are unlikely to achieve a positive, healthy, low intervention outcome.

Lumping women with a variety of conditions and entire spectrums of severity under this title cannot be helpful. It plants negative expectations, and undermines individual care and choice. It’s oppressive. You’re high risk so…(insert automatic consequence).

How many more risk factors will join the list before “high risk” women outnumber the “low risk”. And so high risk in what context? Is birth really that risky?

Certainly it can be, but so can interventions, and we know that ‘high risk’ environments like Central Delivery Suites heighten the risk of these.

There are some wonderful midwives working tirelessly to support women by facilitating their choices where some way through the system allows it. But why such a battle? The uphill struggle is enough to put some women off, leaving them deflated in surrender, later telling me “if only I’d…” and piling blame onto themselves for not being more assertive at such a vulnerable time.

Let’s face it, even a third, middle ground, “normal risk” wouldn’t cut it. 3 categories isn’t much better than 2. But it would go some way in supporting women’s mental wellbeing if a huge proportion of them could escape the high risk label, and be offered a better opportunity to achieve a healthy, positive birth.


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