A duo of thought-provoking articles on risk

495014275_9af97e50fd_nA couple of research articles relating to the notion of risk got my attention a few weeks back, and I’d like to share them with you in case you’ve not yet spotted them.

Firstly, we have ‘Nocebo and the potential harm of ‘high risk’ labelling: a scoping review’, which looks at the concept of the nocebo effect. This term describes the phenomenon wherein somebody experiences negative effects as a result of being exposed to suggestions of negative outcomes.  Symon et al (2015) found evidence that this happens, with various studies reporting that this affected from 3% to 27% of women.  Symon et al (2015) also found claims that nocebo is more often found in women than men, and that it may be especially prevalent in those with type A personality, those who are of a pessimistic nature and those with morbid conditions such as panic or depressive disorders.  Prior expectations may also play a role.

This paper is important because, although we have begun to use the term nocebo, it hasn’t been well defined and, until we start to define something, it is hard to measure or even to talk about it.  Whether or not others will agree with the definition proposed by these researchers is something that only time will reveal, but I think many midwives and birth folk will share the concern that these researchers have for the impact of negative labelling on women:

The language of risk permeates communication between those providing and receiving care: ‘risk assessment’, ‘risk screening’, ‘risk factors’. Pregnancies are referred to as either ‘high’ or ‘low’ risk. It seems inevitable that this language will impact on service users. Stahl and Hundley (2003) found that high risk  labelling of pregnant women had a significantly detrimental effect on their psychological state. Others have concluded that pregnant women labelled high risk have more stress or negative emotions (Hatmaker & Kemp 1992) or perceive loss of control (Tracy 2006).  Maternity professionals’ increasing focus on risk was a top service user research priority (Cheyne et al. 2013a). It is intriguing that much of this literature focuses on pregnancy rather than any other aspect covered by health care, but that attributable poor clinical outcomes (e.g. low birth weight or preterm birth) are not cited. Nevertheless, increased fear and anxiety from being labelled ‘high risk’ is an untoward outcome in itself (Simmons & Goldberg 2011). Cannella et al. (2013, p. 302) note that ‘pregnant women under stress and those who are less optimistic have been shown to take poorer care of themselves and thereby may increase their actual risk’. (Symon et al 2015: 8)

The second risk-related paper is one of my favourites so far this year, and I imagine that other readers will also find this rather interesting.  The researcher unpacked, analysed and compared the contents of information pamphlets which are given to women to help them make decisions about the use of (a) epidural analgesia and (b) water during labour and birth.  What they found was that, although epidural analgesia is the more dangerous of the two options, this was not reflected in the leaflets.  Instead, the leaflets presented waterbirth as a ‘risky’ practice which, the authors argue, has the effect of limiting midwifery practice and women’s choices.

Why am I so happy to see the publication of these papers which, when you think about it, both show that our current system is far from woman-centred?

Because research like this is helping us to see where the real problems lie.  And, by providing a counterpoint and a challenge to the risk-focused culture, it is helping us to help more and more women see that they may want to scratch the surface and ask questions about what is on offer in order to be able to access the kind of maternity care that is right for them and their families.



Newnham EC, McKellar LV, Pincombe JI (2015). Documenting risk: A comparison of policy and information pamphlets for using epidural or water in labour  Women and Birth  doi:10.1016/j.wombi.2015.01.012

Symon A, Williams B, Adelasoye QA et al (2015). Nocebo and the potential harm of ‘high risk’ labelling: a scoping reviewJournal of Advanced Nursing.  Article first published online: DOI: 10.1111/jan.12637


photo credit: Like a Leopard (on tree top) via

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