Assessing Risk

I’ve been mulling over a few things in my head, most namely how a midwife can and should handle “risks” with her clients.

This topic always brings out the advocate in me.  I was well-trained to believe doctors handle care based on risk, and risk is based in fear.  Fear based practice is bad for mothers and babies because it leads to unnecessary intervention.  Yeah, I totally get that.  And yet somehow that alone is not enough to make me believe the best midwifery does nothing. Because doing nothing can be equally bad for mothers and babies.

Before you decide I’ve joined the dark side, remember that you have as well.  What do I mean?  Well for starters, do you talk about nutrition and exercise with the families you serve?  You probably do because you know that good nutrition and exercise does amazing things for preventing problems during pregnancy, birth and those first weeks postpartum. So what you have done is identified a risk and actually intervened. Your intervention was probably education and may have involved some diet history taking.  So you see, even as doulas or childbirth educators we already identify risks and intervene.

Why do we do this?  Because science shows us that families who do X are more likely to get Y.  You can identify X and Y for yourself.  What we need to understand is that IV antibiotics for Group B Strep positive women is theoretically no different from changing a woman’s diet.  Sure, the diet change doesn’t involve needles, but it does involve issues of culture, finance, nutrition and a woman’s feeling of self-determination.  It can be just as demoralizing to be told the food you choose to eat sucks and you need to change as it can to be told your body is not safe for your baby and you need to do something about it.

What makes me (and you and all midwives and want-to-bes) different from the doctors we complain about is that we have decided our interventions are better than theirs. We believe our ability to identify a problem is more keen than their’s.  We believe our interest in helping mothers is more noble than their’s. My dear friends, this is just egocentric.

There is a balance I have seen my favorite midwives do, a balance I hope to be able to practice myself one day.  It is the balance between identifying and responding to risks while not over-identifying and responding to risks. It is the balance between intervening and allowing the family the autonomy to make their own choices.  It is the balance between staying watchful, without having to be recognized for the watching you do.

I used to think all this took was a deep care for families and an acceptance of autonomy.  But as I study more I am realizing the part I have missed for so long is the ability to identify a real risk when I see it.  It is so easy to assume all problems are imaginary from where I sit.  I have tons of stories of women who have been told they had a problem when nothing bad happened to them.  I have no end to the “proof” that terrible things are made up by doctors who just want to control women.  But basing my decisions on what I have seen or been told is very short-sighted and is no different than the doctors who did episiotomy routinely because what they saw and were told was that it helped.

How do I recognize the difference between a woman whose blood pressure will rise during pregnancy without any adverse effects, and one whose very life will be threatened by it?  How do I know the difference between a woman who is just having a long labor and one who is in need of help?  The answer is that I have to educate myself to the best of my abilities.  I must understand the signs and symptoms of true problems.  I must be aware of the evidence for and against intervening in any number of ways. I must always have this information ready to pull out when I need it without being so overwhelmed that I am unable to serve healthy women.

My dear readers, this is the reason I feel midwifery education is so vital to the health of babies and mothers around the world. This is the reason I am working so hard now, and the reason I will continue to work hard.

Jennifer Vanderlaan (Author)