Deconstructing prophylaxis – part 2

I [once] wrote about some of the issues surrounding prophylaxis, which is the category into which many of the interventions currently offered to pregnant women fall.  I offered a breakdown of some of the main questions that need to be considered when a woman decides whether to have a prophylactic intervention: the baseline risk and severity of the condition which might otherwise occur, the efficacy of the prophylaxis and the side effects and / or risks of the prophylaxis.  I finished up by asking whether it was better to offer Tufty-type maternity care, which warns of and seeks to prevent every possible danger, or to look at other possibilities?

One of the reasons I asked this question is that I have noticed two things occurring in our society, perhaps as a backlash to the cultural emphasis that has been placed on safety.  Both have potentially significant implications for midwives.

First of all, as far as the wider safety rules are concerned, it seems that more people are challenging these in choosing to decide for themselves.  There is a backlash against the recent banning of see-saws in some areas (which have been removed from parks in case children hurt themselves) and a number of teachers’ groups are challenging the ruling that they must not hug children on the grounds that this denies children essential human contact.  Even senior politicians are coming out against the idea of a “nanny state” (At the time of writing this article, current issues included John Reid’s comments on the banning of smoking and some of the responses to the part of the Government gambling bill which means that children may no longer be allowed to try and win teddy bears in arcades in case this creates an addiction to gambling).

Instead, more people are supporting the idea that, as long as others are not harmed, people should be able to decide to take risks with their own lives and health if they choose.  Many are choosing to make a distinction between the really useful prevention rules (i.e. wear your seat belt and don’t run around with a pen in your mouth) and those which they consider guidelines: it is good to eat lots of vegetables, but sometimes chocolate is good and often guilt is not.   Moreover, we are realising that these rules are not guarantees and are seeing some of the paradoxes inherent in some of the rules.

Secondly, the past few years has seen a massive leap in the level of interest in ‘dangerous’ sports and activities such as bungee jumping (albeit with all kinds of safety harnesses attached).  Is this also a reflection of a desire to eschew the safe life, perhaps in response to our over-protective society?

I suspect that aspects of both of these trends are also occurring in maternity care.  Over the past few months, I have heard midwives note that women today are more questioning than ever. It is now not only the case that women make complaints when they are not given treatment that they felt should have been offered (which is one of the things we have always feared in the maternity services, leading to our tendency towards over-treatment and routine intervention), but an increasing number of women are complaining that they or their babies were given treatment which they later felt to be unnecessary.

I’m not sure what the equivalent of bungee jumping is in maternity care, but I wonder if it is the trend towards ‘unassisted’ birth?  It is true that this is happening more in the US than the UK at present, but it is happening in the UK.  I recently heard Elizabeth Davis speak about how this is something midwives need to pay close attention to: if we are not offering the kind of service that women want, they are bound to go elsewhere ~ not because they are being deviant, or seeking to harm their babies or themselves, but rather as a last resort because they cannot get the kind of care they really want.

It would seem that the decline of universal prophylaxis ~ at least where this is defined as routine prevention rules which are applied to everybody in the same way ~ has now begun.  Within the last few years, we have seen one move, at least in theory, from the idea of policies to the idea of guidelines, which sought to address issues around the need to individualise care.  As more people in the wider world challenge the idea that safety and the prevention of danger are the bottom line, and realise that absolute safety is rarely attainable, this is going to influence attitudes towards the maternity services.  With any luck, the realisation that other aspects of life, such as love, spirituality and compassion, are also important, might mean that we can re-consider some of the philosophical tenets on which maternity care is based.


This article was originally published as Wickham S (2005). Deconstructing prophylaxis – part 2. TPM 8(2):31.
 photo credit: tubblesnap Twas Dark via photopin (license)