May I have a repeat rant today, please? Because in the few days before writing this blog post I had conversations with three different, unrelated and very caring midwives. All were caring for bright, informed women who were experiencing difficulties getting the care they want. And in each case the reason was the same. The women had been subject to a risk assessment or screening test, carried out without their knowledge or consent.
I just need to rant about this again, even though I have done so before, because I still don’t think this is OK. And when we encounter things that are not OK, we need to get them out in the open.
I suspect that most midwives and birth workers can easily imagine the scenarios. One woman has fallen foul of the criteria for entry to the local midwifery-led unit (MLU). The difference between her BMI and the BMI of someone who would be allowed (and, yes, what a horrid word that is in this context) to give birth in the MLU is so marginal that, if it wasn’t so tragic, it would be laughable. The difference was 0.5. You couldn’t make it up, could you?
Another woman has been advised that she now (apparently) needs to have interventions or monitoring during labour and birth. Oh, and she needs to be in an environment that would not necessarily be her choice (although she hadn’t yet made up her mind). This is because, also without her knowledge or consent, a risk assessment has found her to be at risk of venous thromboembolism.
The third woman’s choices have now been limited because she has been found to be positive for group B strep. This was the result of her urine being screened for this without her specific knowledge that this was one of the things that it was being tested for. She “thought the sample was being tested for protein and glucose like at other antenatal visits”. She is adamant, having read widely on this topic, that she would not have consented to testing for GBS had she been asked.
I distinctly remember one of the very first chapters of the very thick Effective Care in Pregnancy and Childbirth tomes that had just been published as I was beginning midwifery. It was about systems of risk assessment (Alexander and Kierse 1989). Reading this chapter was a real eye-opener for me. It helped me understand that there was little evidence underpinning much of what I was being taught to do on a daily basis. Even more importantly, I learned that the act of assessing risk itself was an intervention which (oh, the irony) carried risks.
There can, I know, be fine lines between different kinds of risk assessment. There’s the informal kind of risk assessment that is an integral and inseparable part of the role of a birth attendant. (Otherwise why are we there; we don’t have the monopoly on making a good cup of tea.) And then there is formal risk scoring (like, for example, in the VTE example). The fact that both of these exist within the wider context of a culture that seems incessantly and sometimes obsessively focused on the promotion and prevention of risk further compounds the issue.
The answer is simple. I just want people to ask women for their permission before the concept of risk is used to delineate and dictate what a woman may and may not do with her body. Especially when so few of the things that done in the name of preventing or reducing risk are based on sound evidence that they really make a difference.
If only risk assessment did come with a risk warning…
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Alexander S, Keirse MJNC (1989). Formal risk scoring during pregnancy. In: Chalmers I, Enkin M, Kierse MJNC (1989). Effective care in pregnancy and childbirth. Oxford: Oxford University Press: 345-365.