Yesterday we talked about the value of birth plans. For most low-risk women, writing a birth plan is an easy task. But women at high obstetric risk may find the task more difficult due to unwanted recommendations intended to improve their safety. One way women at high obstetric risk handle such situations is by planning a home birth. What drives women at high obstetric risk to plan out of hospital births? These researchers found the choice was often driven by fear, and most of the women saw the choice to birth at home as a negative rather than a positive choice.1
Managing Fear with a Home Birth Plan
For me, the most interesting part of this study is the finding that women were managing both their fear and what they perceived to be their providers’ fears. Women balanced their fear of intervention and bad prior experiences with their fear that choosing to birth at home would be more risky. Women accepted the increased risk at home because they perceived their choices were limited due to their providers’ fears about potential bad outcomes without intervention. This is a messy space for women to navigate. It is disheartening to know that the women in this study saw home birth not as the best option, but the best of two bad options.
This is also a messy space for clinicians to navigate. As a health care provider it is important to be honest about risks and to follow standard protocols to ensure safety of the woman and the baby. The reality is, women who are at high obstetric risk are not receiving “routine” interventions when offered increased surveillance. Evidence shows that failure to identify and act on obstetric risk is a problem; in the US half our cases of maternal morbidity and mortality could have been prevented with timely, appropriate intervention.2 Nobody wants to be responsible for failing to provide life-saving care.
Is the problem our assessment of risk?
But on the flip side, I know from my research that our definitions of high obstetric risk do not always do a good job of identifying who will progress to morbidity and mortality. Instead of detailed risk prediction algorithms for obstetric care we’ve accustomed ourselves to lists of conditions as common as prior cesarean pushing a woman from the category of “low risk” to “high risk” without any middle ground for “normal risk”.
We also don’t know the size of the “prevention” we create with our care practices. Risk is a complicated metric because it doesn’t mean you “have” something, just that you have a higher probability of having something. And measuring the true probability of maternal morbidity and mortality with high obstetric risk is impossible because women receive care that reduces the probability of those bad things happening.