Fear, risk and supporting normal birth in midwifery practice.

I am writing this in response to a posting by Sarah Stewart. She has written an honest and insightful posting on how midwives cope with fear and risk. She considers the impact on practice when other midwives are involved in litigation. It seems to be especially difficult at these times to support women, or to maintain a midwifery identity considering birth as a normal and empowering life event. I am sure many midwives will identify with the situations she describes.

I too have struggled and debated the concept of risk and how we as midwives can promote normal childbirth and support women to birth without intervention, as we know the majority of women are able to do. Spiraling caesarean section rates force all midwives to look at their practice and consider what their contribution is to this phenomenon. For me, when I am considering risk, I try to turn it around. I consider the fact that almost always, no matter what the risk, it is much more likely that everything will be fine than the possibility that the risk, whatever it is, will eventuate and result in an adverse outcome. Sometimes the risks are so high that there is no question about the need for intervention, for example, placenta praevia or transverse or oblique lie at term. At other times the risks are very low, for example the risk of uterine rupture following previous caesarean when labour is spontaneous. Conflicting evidence about the chance of adverse outcomes makes decisions difficult for women and midwives need to support them to understand and make rationale decisions. If we approach risk in this way I believe women are more likely to have confidence in themselves and in us. Confident that they can birth their babies without intervention, but also confident that we will be watchful and will advise them if things are deviating from the expected path.
Our job, as midwives, is to acknowledge risk but not get it out of proportion. We need to assure women that we are aware of and vigilant to the possibilities of problems occurring which may require intervention. This is after all why women need the care midwives. We not only need to support women and assure them that all is well and that they can succeed in birthing a baby, we also need to be aware of what can go wrong and have the ability to deal with the situation in an emergency situation, or refer on to specialists when there is a necessity to do so. If this were not so women would birth without any support at all.