Risk: the game of life

It was in 2004 that I first wrote about a “small but growing group of women who are refusing to obey the label of “high-risk” and who are instead becoming experts on their own specific health issues and making their own decisions based on their personal circumstances.” In response to a request from midwives who are looking at the growing number of women who are rejecting ‘offers’ of high-tech care from the maternity services and instead seeking a different way of birth, I am re-posting the excerpts from this article which are still relevant to this debate.

When we really think about the implications of the “high-risk” label, it is little wonder that women are challenging this concept. Women and their pregnancies may be labelled “high-risk” when the probability of an adverse outcome is greater than the average probability of an adverse outcome. Yet if we were really concerned about reducing risk around childbirth, we would be doing less to prevent perfectly healthy women having home births, and more to eradicate poverty and sub-optimal nutrition.

Labelling a woman as “high risk” is really only helpful if we can actually do something to reduce the risk. All too often, we can’t. What we can do, though, is to massively increase the level of anxiety a woman experiences during pregnancy and birth by applying our technologies and tests to assess the level of risk further. Indeed, we now have tens of screening tests, each of which can very effectively increase a woman’s anxiety and inhibit her ability to grow and birth her baby. If there were a prize for the society which created the greatest level of anxiety in pregnant and birthing women, ours would be a hot favourite.

In fact, prizes and outcomes are among the key issues in this area. People have completely different views on the outcomes that are important to them, on what they are willing to “risk” in order to achieve that outcome, and a personal comfort zone around risk-taking behaviour. You only have to watch a family play a board game which involves taking risks with money to see that some people are happy to bet all they have in the hope of gaining a big lead, while accepting the prospect that they might spend the rest of the evening watching from the sidelines, while others are very careful, hoping that prudence is the best tactic. These trends extend from the frivolous to the focal aspects of our lives, yet there is little application of the theory in this area to real-world health care practice.

The decisions that we make about our pregnancy and childbirth journeys can shape our experiences, health and lives, as well as those of our families. But those decisions can be complex. This book is a guide to the different perspectives and approaches that exist, and it offers tips, tools and ways of thinking which will help you make the decisions that are right for you.

None of the women I mentioned above took the risks of what they were doing lightly. Several of them made the choice to give birth at home in response to a lack of support from an institution for the kind of low-intervention experience they wanted. They all knew that the probability of a problem might be increased in their situation and thought long and hard before they made their decision. In becoming experts on the condition that they experience, some of these women realised that the suggestion that women with “risk” factors are better off giving birth in a hospital is often based on professional fear about what could go wrong rather than genuine evidence that this leads to better outcomes when everything is taken into account.

I feel it is quite unlikely that there are any plans for a research study to determine whether women with “risk” factors are better off giving birth at home or in a hospital. But, in the absence of quantitative data, we do at least have an age-old kind of evidence: women who have gone against the grain to provide us with living proof that we do not always know what is right for them.