Risk assessment is an integral part of midwifery and medical practice and yet also something we need to think about more.
A few years ago, I spent some time reflecting on the issues raised by revised guidelines on venous thromboembolism (VTE), which is the medical term for a type of blood clot. Because VTE is, as Julie Frohlich wrote, ‘a killer’ (2010: 27), we want and need to do everything we can to prevent it. But the universal risk assessment recommended by these (and similar) guidelines also has implications which affect women and families.
Is it justifiable, I wondered, to carry out risk assessment either generally or for a specific condition without first seeking informed consent?
Does it matter whether risk assessment is formal or informal?
And how do we balance our desire to take all possible steps to prevent maternal death with the importance of ensuring that women consent to those actions which may impact on their choices and experiences?
I am re-sharing this article, in a revised and updated form, as many of the issues are still relevant today.
The ramifications of risk assessment
My questions about whether people should need to explicitly consent to formal risk assessment are based on my understanding that this practice can and does have ramifications. For many years, giving women information and advice about their risk status has been an integral aspect of midwifery care. This may seem innocuous to some, but the degree to which is happens and the way it has affected experiences has changed drastically in the three decades in which I have been involved in midwifery.
Being labelled as ‘at risk’ can lead to anxiety. It can affect our perception of pregnancy as a normal, healthy state. I suspect that, when it comes to risk assessment for things like VTE, many of us focus more on the concept of choice as it relates to discussion around invasive interventions (such as the administration of anticoagulant therapy) than on the implications of risk assessment itself.
Yet it is increasingly common that women are denied the right to birth in particular settings as a result of being deemed ‘at risk’. This doesn’t just apply to VTE but in many other areas as well; group B strep, BMI and gestational diabetes, as just a start.
The problem of labelling
Labelling someone as “at risk” can also lead to the recommendation of further screening and/or prophylactic measures, each of which may again have emotional and social as well as physical implications.
All of these issues may be considered minor by some compared to the potentially fatal nature of VTE. But they’re not minor to everyone. And labelling someone as “at risk” has wider implications which aren’t always considered.
The setting of birth, for example, has a direct effect on the amount of intervention experienced by women. And the interventions offered to those deemed to be “at risk” themselves carry risks which can also occasionally be fatal.
In addition, it is good practice to measure the relative value of such recommendations. That might be done, for instance, by working out how sensitive and specific assessments are in identifying the women who may experience problems such as VTE. Currently, however, guidelines recommending that risk be assessed in relation to specific areas do not tend to discuss such measures. That’s partly because our focus is drawn to the seriousness of one outcome rather than on assessment of the wider picture. I’ve written about that in depth in In Your Own Time.
Age and size
Particular care may be needed where some of the risk factors that we are assessing are common. Here I am thinking about issues like someone’s BMI and so-called advanced maternal age, both of which are increasingly prevalent. More women are deemed to have a high BMI than ever before. More couples are choosing to have their families later. These things mean that increasing numbers of women are deemed to be at risk for VTE.
But the actual risk that any given woman will experience this remains very low. Furthermore, both high BMI and advanced age are considered risk factors on the basis of expert opinion rather than research findings.
Given the ramifications, should women be asked to consent to risk assessment?
Risk assessment as a continual process
If only it were as simple as that last question makes it sound!
Risk assessment is not limited to serious conditions such as VTE, and neither does it occur only on a formal basis. It happens continually, sometimes on a semi-formal or formal basis (such as where women who have had a previous caesarean section are denied access to birth centre care).
More often, it occurs informally. It’s a part of midwives’ and doctors’ daily practice. It happens without conscious thought. Midwives are constantly alert for signs that all is not well; while we focus on guarding and promoting normality, we understand that problems will occur and need to be aware of this possibility. If someone who knew nothing about birth saw me sat beside a family a few minutes after a healthy baby has been born at home, they may well think that I am merely admiring the baby and congratulating his parents. Yet I would also (among other things) be monitoring the new baby’s well-being, listening to his breathing, keeping an eye on the woman’s general condition and blood loss, watching for signs of placental separation, paying attention to how the new family was interacting and recording all of this in the woman’s notes.
Ducks, risk assessment and knitting
Tricia Anderson used to describe midwives as being a bit like ducks: on the surface, we appear to be gliding along, smiling and admiring the woman’s belly or her baby, while underneath we are often thinking as hard and as fast as the duck’s little legs are peddling furiously underwater. I absolutely want women to perceive that I am gliding along in this manner (unless, of course, there really is a problem, in which case I would like to reserve the right to flap my metaphorical wings if I think this will help). That’s why I knit at births.
My looking relaxed helps them to relax, which in turn will promote the hormones that facilitate pregnancy, birth and breastfeeding. No matter whether we describe what we are doing as ‘ensuring that all is normal’ or ‘assessing for potential risks’, we cannot argue that ongoing risk assessment is not a constant focus for all qualified maternity professionals.
It may not be something which is constantly obvious or under discussion, but this may be because there is a level of implied consent attached where a woman seeks maternity care, wherein she can expect that her caregivers will assess her status and inform her of any issues that may be relevant to her experience and/or decision making.
Given that this is the case, how can we not justify formally undertaking assessment of a woman’s risk status in relation to a condition that can be fatal? Surely this is even more justifiable than the less formal assessments that occur in everyday practice?
Evaluating risk assessment
When the first volumes of Effective Care in Pregnancy and Childbirth were published, one of the chapters was entitled ’Formal risk scoring during pregnancy’ (Alexander & Kierse 1989). The authors described this area of care as a mixed blessing which carried significant implications and warranted further research.
These words are, I think, even more true today.
I would argue that the focus has moved away from exploring and evaluating the concept of risk assessment in itself and towards adding more and more means of undertaking this. My reflection made me think more about the nature of this concept, the kinds of risk assessment that I undertake as a midwife and how important it might be to look more closely at the way in which we think and act and talk to women about this in practice.
I do remain concerned that we should be doing everything we can to prevent serious conditions like VTE from affecting as many women as possible. But we surely also need to continue unpacking and researching concepts such as risk assessment in order to ensure that we are not forgetting the importance of questioning the fundamentals.
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A version of this article was originally published as Wickham S (2010). Reflecting on risk assessment. EM 1(2): 50-51.