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Reconceptualising risk in childbirth
Midwifery 38 (2016) 1–5
Contents lists available at ScienceDirect
Midwifery journal homepage: www.elsevier.com/midw
Editorial
Reconceptualising risk in childbirth$
Introduction This special issue of Midwifery brings together a collection of papers which are at the forefront of understanding how concepts of risk affect or impact upon the organisation and provision of clinical maternity care. The call for papers arose from an identified gap in the evidence; a special issue in Health, Risk and Society (Volume 16, no 1) explored risk during pregnancy and childbirth from social science perspectives, and many of the papers looked at the lived experiences of women in relation to risk. The starting point for that collection was the observation that although birth in high income countries is safer than ever before, we face what Taylor-Gooby has termed the ‘paradox of timid prosperity’, where anxiety seems to be on the increase, in the face of overall safety (Taylor-Gooby, 2000, p.3). In pregnancy and birth, risk has expanded to become a complex and ever-present notion, associated with dangers, hazard and probabilistic reasoning. As Andrew Bisits notes in his commentary (Bisits, 2016), we benefit from a proliferation of research, giving ever more information about absolute and relative risks in pregnancy and birth, but whilst this knowledge is valuable, it can add to the sense that pregnancy is a problematic or dangerous time. Women and their partners or families then need to tease apart ‘real’, ‘actual’ and ‘perceived’ risks, take into consideration the context of their own lives, beliefs and values and work their way towards negotiating aspects of care that they felt comfortable with, in a context which seems to privilege the biomedical construct of clinical risk (Rothman, 2014). The Health, Risk and Society special issue made a valuable contribution, but surprisingly few papers explored risk perspectives from maternity care professionals’ perspectives. Given the widespread and generalised concern with rising costs of maternity care and increasing rates of intervention without clear evidence of benefit (Birthplace in England Collaborative Group, 2011; World Health Organisation, 2015; Benoit et al., 2015), it seemed important to address this gap and to understand better the impact of risk on clinicians’ practice. Our call for papers (Coxon et al., 2015) particularly focused on the relationship between ‘risk’ and ‘normality’ and we invited papers that would add to our understanding of how midwives and others seek to ‘square the circle’ of promoting normality whilst managing risk. That was over a year ago, and much has happened in that time. Our call predated the UK publication of the Kirkup Report (Kirkup, 2015) into failings of maternity care at Morecambe Bay NHS
Foundation Trust in Cumbria, England, and this report has caused midwives and women using services to look again at the term ‘normality’ and consider its place in maternity care. One of the report's key findings was that attempts to ‘uphold normality’ and ‘over-zealous pursuit of the natural childbirth approach’ led to ‘inappropriate and unsafe care’ (p.13). Although the basis for this conclusion has been debated in the professional press and the media, it seems important to acknowledge that the term ‘normality’ has now developed into one with as many political charges and connotations as ‘risk’ already carries.
Risk-based practice in maternity care The position of women, families and midwives in relation to birth is undoubtedly affected by the prevalence of ‘risk’ thinking in maternity care. Lee et al. (2010) have argued consistently over the past decade that parenting occurs in the context of ‘risk society’, particularly in high income nations, and one of the consequences of this is that parents need to demonstrate an ability to be effective ‘risk managers’ for themselves, and for their children. The papers collated here support this view, and also demonstrate how the same pressures are brought to bear on clinicians. This creates a circular scenario whereby organisations ensure clinicians’ practice is oriented towards risk concerns; clinicians feel obliged to communicate information about risk to women and partners, and women and partners, already primed by cultural narratives of birth risk, experience pregnancy and birth through what Heyman et al. termed ‘the lens of risk’ (Heyman et al., 2010). The issue here is not that risks are discussed with women, (although as many of our contributors point out, the way risks are framed can limit the choices perceived to be available), but rather that such discussions are often unbalanced, focusing on unlikely but dramatic adverse outcomes without explaining the potential health gains for women and babies of careful and ongoing assessment, and considering options that are likely to incur fewer interventions overall. In this editorial, we identify thematic links between the special issue papers, and consider these in relation to risk theory and practice reflections. We note how individual papers address evidence gaps, and identify where these persist, and we finish by considering the contribution of the special issue as a whole to risk theory and the implications for ongoing service and practice development.
☆ We would like to acknowledge that we have referenced the title of Barclay et al’s paper within our Special Issue title; the phrase ‘reconceptualising risk’ neatly draws together the key themes within this issue.
http://dx.doi.org/10.1016/j.midw.2016.05.012 0266-6138/& 2016 Elsevier Ltd. All rights reserved.
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Editorial / Midwifery 38 (2016) 1–5
Maternity care and the culture of fear A clear theme amongst papers in this issue is that maternity care clinicians describe work practices which take place within an organisational culture of fear. In her commentary for this Special Issue, Hannah Dahlen (2016) reminds us of the political value of fear, and suggests that fear serves the purpose of increasing anxiety about safety during birth, which justifies a range of actions and interventions, and inflames debate about the benefits and timing of interventions. For clinicians and service managers, concern to prevent a poor outcome for the woman or infant is always paramount, but there is also fear of litigation, and of consequences of ‘risk’ investigations for the individual's professional standing and continued employment. This may mean that clinicians take preventative actions to offset risks that feel real, but may be hypothetical in terms of calculable risk. In their discussion of US obstetric nurses’ experiences, Striley and Field-Springer identify this category of risk as an ‘identity’ risk, or a ‘threat to the sense of self’ (Striley and Field-Springer, 2016), and their insight is borne out by the experiences of clinicians within the papers in our issue. In our call for papers, we suggested that midwives and nursemidwives practicing today have more rather than less autonomy than in the past, particularly in relation to supporting healthy women during normal or straightforward births. The papers in the special issue actively challenge this assertion, and argue instead that clinical autonomy is increasingly constrained, and that concerns about risk may eclipse or even ‘overwhelm’ notions of normality (Scamell, 2016, p. 14). In her paper, Mandie Scamell (2016, p. 14) explores how ‘institutional concerns around risk and risk management impact upon the way midwives can legitimately imagine and manage labour and childbirth’. She argues that the ‘risk’ model and the ‘normality’ model constitute two separate, and in fact, divergent approaches, and explains with reference to historical policy guidance how this situation has developed over time. Scamell also provides a theoretical position which has its origins in Science and Technology Studies (STS). This consists of an argument that clinical governance practices seek to ‘colonise the future’ by altering clinical behaviours in the present, even though the ‘imagined future event’ is rare, the ability to avert problems through this approach is unknown, and the rate of new and unexpected complications which may have arisen as a result of taking a risk-based approach is rarely considered. Mandie Scamell's paper also shows that midwives are aware they need to be seen to behave in a particular (risk-averse) way, but feel conflicted when they are committed personally to supporting women to achieve a normal birth. In the end, argues Scamell, risk speaks much more loudly than normality. Several of the papers explore the ways in which clinicians, despite being attuned to evidence-based practice, find themselves to be unwilling but effective participants in risk amplification exercises when they do ‘risk talk’ (e.g. see Van Wagner (2016), Plested and Kirkham (2016)). Vicki Wagner (REF) looks specifically at the practice of risk talk, whilst Joan Skinner and Robyn Maude (Skinner and Maude 2016) observe ‘tensions of uncertainty’ through exploring the implications of counselling women when the actual outcomes for the individual and her family are unknown and unknowable. Skinner and Maude (2016) make the case for expanding the field of interest beyond risk, and encompassing uncertainty as an important part of the experience of birth. Focusing on the perspectives of women whose pregnancies are affected by risk issues, Suzanne Lee and colleagues provide two linked papers (Lee et al., 2016a, 2016b), one of which explores women's responses to information about clinical risk, (Lee et al., 2016a) whilst the other presents data about how women whose pregnancies are at increased risk perceive interactions with health care professionals, when they discuss planned place of birth (Lee et al., 2016b). Like Van Wagner (2016), Lee et al. note that strategies used
by clinicians to communicate risk are under-developed, and argue that this topic needs far better understanding given that women's beliefs about risk are part of their individual personal philosophies, which form long before pregnancy. In exploring the implications of ‘risk talk’, Van Wagner also shows that discussing risk signals the need for leaning towards technology, and argues that during risk discussions, clinicians are expected to present numerical data, explain or discuss complex statistical concepts to communicate ‘evidence based medicine’, even though the actual evidence available may be limited. As Andrew Bisits also makes clear in his commentary, explaining and contextualising low prevalence absolute risk data is a complex task, and a fuller appreciation of effective means of doing so is needed. It is also clear that clinicians feel they are asked to share information in a manner that selectively presents risks, because the emphasis is on being certain that all possible and potential risks are communicated. There is a clear need for further research on this issue, to understand better whether numerical information about ‘probable’ and ‘possible’ risk is valued by women, and if so, how this should be conveyed or presented effectively. This is particularly important because, as Lee et al.'s work argues, (Lee et al., 2016a) current approaches are likely to be ineffective. In this paper, which draws upon a psychological perspective, Lee et al. demonstrate how women selected or ‘heard’ information which aligned well with their prior beliefs. This suggests that ‘confirmation bias’ (or being more ‘open’ to congruent messages) contributes to the process of ‘doing risk talk’, and that discussions which may already be uneven or framed in a particular way are only partially heard. Both Lee et al.'s papers arise from research of women who have known risk factors during pregnancy, some of whom planned home birth, whilst others planned to give birth in hospital obstetric units. Understanding decisions, preferences or choices which are at odds with clinical recommendations is an issue which has been historically under-researched, and it is valuable that several included papers have engaged with this issue. Lianne Holten and Esteriek de Miranda (Holten and de Miranda, 2016) summarise recent literature on ‘unassisted birthing’, and this is one of the first reviews to do so, whilst Miriamni Plested and Mavis Kirkham's paper (Plested and Kirkham, 2016) contains a phenomenological study of how women experience birth without a midwife. As Dahlen has previously argued (Dahlen et al., 2011), ‘freebirth’ is to some extent a logical, if unintended, consequence of women's alienation from mainstream maternity services, especially if they find their needs and concerns are not listened to by clinicians, or they are unable to secure access to services such as homebirth with a midwife. In their paper on service configuration and closures in remote and rural areas of Australia, Lesley Barclay et al. (Barclay and Kornelsen, 2016 [p. 10 of v1]) report consequences such as unplanned births without skilled staff present, birth ‘on tarmac’ awaiting airlift or avoidance of antenatal and intrapartum care as consequences of withdrawing services that are accessible to women. Through their detailed study, these authors make the case that over-reliance on biomedical risk perspectives as a basis for service decision-making has numerous implications for women and families, including separation, cost and lost opportunities to birth locally, even when the cultural and spiritual motivations for doing so are well known. They conclude that whilst clinical health considerations are clearly important, making decisions on the basis of these alone, or attempting to do so without the consent of the population served, may actually diminish the safety of women and babies, and argue that our understanding of risk in maternity care needs to be much broader, incorporating the social, emotional and cultural implications of maternity service provision.
Editorial / Midwifery 38 (2016) 1–5
Potential solutions to problems created by risk-averse practices Barclay et al.'s paper (Barclay and Kornelsen, 2016) suggests that one solution to the impasse created by risk-averse practice is to reconceptualise risk, by moving beyond immediate clinical concerns to embrace a broader range of issues, but also recognising the unintended consequences of imposing a single perspective on service-level decision-making. This proposal also implicitly calls for a shift towards a more collaborative approach for service-provider decisions, one which considers the dynamics operating within the local population too. Whilst the paper originates in remote and rural Australia, similar debates are taking place in many countries where geography affects clinical infrastructure and decision-making, so this issue seems to have international relevance, and the overall message about engaging with local concerns is arguably relevant to any maternity care provider organisation, regardless of geographical constraints. Two other papers in the issue present solutions to risk-management issues. Again working from a service-level perspective, Gayle McLelland et al. (2016) outline the contribution of paramedics in Canada to improving safety of planned home births. Recognising that women who plan home births in Canada are a minority group, so that adverse clinical situations are rarely encountered by paramedics, McLelland et al. outline how simulation training can help paramedics prepare for potential scenarios, increasing the skills and confidence of clinicians and strengthening integration between services to better support women and families. In their prospective epidemiological study, Anke Posthumus et al. (2016) consider ways of predicting adverse birth outcomes in an urban population in Rotterdam, Netherland; although their work could not be more different from Barclay et al.'s research, they reach an intriguingly similar conclusion. To anticipate and understand likelihood of adverse birth outcomes, the authors argue, both medical and nonmedical risks, which are predominantly understood as socio-economic factors in this paper, need to be considered.
New directions: the contribution of the special issue collection Perhaps fittingly for a special issue on ‘risk’, the research contained within these papers seems to raise an alarm. The authors are not risk-naïve, and none suggest that clinical risk is something that we should dismiss or underplay; clinicians understand that bad things do happen in maternity care, and there is an evident and international endeavour to improve access to safe, high quality maternity care for women and babies. The alarm arises from the way in which risk has become a predominant concern, one which, according to these papers, shapes practice, constrains clinicianwoman relationships, and closes down opportunities for honest and trustful relationships. One common consequence of risk-averse practice is an expectation of early ‘just in case’ intervention; another is that clinicians, particularly midwives, feel increasingly hemmed in and unable to ‘support normality’ without feeling fearful for their careers, livelihoods and professional identities as ‘good’, ‘safe’ or ‘effective’ practitioners. A rarer consequence is breakdown in relationships between women and maternity services, such that women choose to birth alone rather than open their doors to a midwife, because that means ‘letting in’ protocol-driven care, risk aversion and the expectation that something will go wrong. The papers which focused on ‘risk talk’ or how clinicians and providers ‘perform’ risk awareness begin to suggest that risk management as it is currently understood might be considered an intervention in its own right. Clinicians’ accounts suggested their work involves a Catch-22-like situation; outlining ‘the risks’ means raising awareness of rare and unlikely outcomes, things which even women at low clinical risk ‘should’ know about, but the act of doing
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so reduces women's confidence in themselves and in their ability to give birth. This in turn makes it more likely that they seek care in high-acuity settings, where, it is well established, the likelihood of interventions which might otherwise have been avoided increases.
Theoretical contribution of the special issue collection The papers collected here draw on a range of risk theories, but most have referenced socio-cultural accounts of risk which broadly position risk as both ‘real’ (calculable, measurable) and ‘constructed’, by individuals and institutions, with reference to wider social contexts, narratives and to shared cultural beliefs. Key authors in this field are cited (Douglas, 1966; Douglas and Wildavsky, 1982; Giddens 1991; Douglas, 1992; Beck 1992; Lupton, 1997, 1999, 2012), and their insights explored in relation to maternity care. These empirical accounts are valuable and clearly show how risk impacts upon practice, but it is still interesting to ask why the concept of ‘risk’ has become quite so powerful within maternity care, given the parallel argument that women in the high income countries featured here are healthier than ever before and have better access to good quality maternity care, and birth is consequently safer than in the past. In their recent book, Lee et al. (2014) explore the rise of ‘risk consciousness’ particularly in relation to parenting, and explore its societal consequences. Their arguments are outlined here in some detail because they seem to have clear applicability to the issues discussed in our collected papers. In their analysis, ‘risk consciousness’ has several features. Firstly, ‘risk’ is understood to have expanded from the original meaning of a calculable ‘probability’ to include any possible poor outcome, which Lee et al. link to increased anxiety about outcomes which are considered to be uncertain; accordingly, the focus of ‘risk’ discussions has also expanded to include possible as well as probable outcomes. Secondly, Lee et al. note that anxiety around ‘the child’ has increased, and that society, once viewed as nurturing and protective, is now considered to present dangers to children from which they need protection, and parents are expected to be vigilant against these dangers. Further, the decisions parents make (for example, about infant feeding, or spending ‘quality time’ with children) and the ways they behave towards children are seen as potentially wrong, ineffective, or even damaging, unless ‘expert’ advice is sought and taken. In ‘risk’ society, ‘poor’ parental decisions are considered to have long-term consequences as the child grows into adulthood, which Lee et al. describe as an argument of ‘parental determinism’. Building on Furedi's (2011) work in this field, Lee et al. (2014) also propose that risk consciousness becomes more prevalent where ‘cultural authority is weak’ (ibid p,13), and traditional value systems seem to have lost their hold. Risk regulation then moves into this space, and becomes the means by which moral regulation of social behaviour takes place. Through these mechanisms, ‘risk management’ and ‘risk regulation’ become prominent, and ‘risk’ messages carry strong moral overtones, focusing overt attention on parental behaviour and decisions. This in effect places blame on individuals, shifting thinking away from other explanations for poor outcomes, such as social inequalities, ineffective services or inadequate infrastructure. The papers in this collection suggest that as well as being relevant to pregnant women and parents-to-be, ‘risk consciousness’ affects clinicians in very similar ways; it also raises the possibility that clinicians, through performing ‘risk management’, are also participating in the moral regulation of women and new families, an idea which requires further consideration, discussion and debate. As these papers show, practicing maternity care in a risk-averse culture is fraught with anxiety for clinicians, and it is easy to see how such anxiety is conveyed to women and families. However, it would be an oversight to end without noting the resilience shown by women and clinicians as they engage with the requirements of
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Editorial / Midwifery 38 (2016) 1–5
‘risk management’ in pregnancy and birth. Within these papers, there is evidence that women and clinicians return time and again to the concept of women's ability to birth, and clinicians’ ability to support the birth process respectfully, and that despite the perceived sense of threat to livelihood and challenge to professional judgement that risk-based approaches present, birth as a normal, everyday activity remains a ‘touchstone’ for reasoning about risk in pregnancy and birth. Epidemiological research into birth outcomes amongst healthy women confirms that there is reason to have confidence in this ability; increasingly, national policies shift incrementally towards providing space for ‘normal’ birth to take place. We see evidence of this in England, where policy actively promotes birth in midwife-led settings for women who are at low risk of complications, and in the Netherlands, where the practice of home birth has been upheld and robustly defended. More recently, professional bodies in countries such as US, which have been traditionally more conservative, are beginning to revisit their statements on issues such as home birth (American College of Obstetricians and Gynecologists, 2011). Such changes are happening, but they are incremental and there is also ample evidence that maternity services still fail to listen to women, both when they ask for help to give birth with minimal intervention, and when they seek acute obstetric care. Freebirth has perhaps caught the professional imagination in high income countries so readily because this teaches us that in extremis, when preferred services are not available to women, or when relationships with clinicians break down, women will vote with their feet and birth where they feel safest – and that may not be in a health care facility. The papers collected here begin the work of understanding how clinicians and women make sense of risk in the context of maternity care, which itself exists within a wider culture of anxiety about birth, parenting and what these things mean for the future of society, but there is much more work to be done here. Understanding is in its infancy, and in some cases, the papers published here are initial explorations of emerging realities that arise as a consequence of risk management. There are some strategies that can help us now; Andrew Bisits’ proposal (Bisits, 2016, p. 12) that ‘any discussion of risk should start with the acknowledgement that childbirth has never been safer’ points the way towards a starting point based on evidence and consensus, and his argument that information about risks and benefits of different treatment options should where possible be shared when women and clinicians have time to discuss these fully, rather than ‘flooding’ information at a given appointment is also valuable (Bisits, 2016, p. 12). This point also speaks to the importance of establishing trusting relationships within a continuity model of care, as cornerstone of safe and high quality maternity care provision (Sandall et al., 2013). Whatever our individual perspectives on risk, normality or interventions, it is valuable to revisit the point with which Hannah Dahlen's commentary also ends. She asks us to remember that it is not always ‘the intervention’ or not giving birth ‘naturally’ which is problematic; instead, ‘What traumatises women most is how they are treated during birth and lack of control, communication and consent’ (Dahlen, 2016, p. 6). With this thought in mind, and with due thanks to our many contributors, we invite you to read and engage with the articles in this special issue of Midwifery on risk in pregnancy and birth.
References American College of Obstetricians and Gynecologists, 2011. Planned Home Birth: Committee Opinion. (Number 476, pages 1–4, February 2011, reaffirmed 2015), http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Planned-Home-Birth, Accessed 03.06.16.
Barclay, L., Kornelsen, J., 2016. The closure of rural and remote maternity services: Where are the midwives? Midwifery 38, 9–11. Beck, U., 1992. Risk Society: Towards a New Modernity, first ed. Sage Books, London. Benoit, C,. et al., 2015. Maternity care as a global health policy issue, first ed. In: Benoit, C., Declercq, E., Murray, S.F., Sandall, J., van Teijlingen, E., Wrede, S. (Eds.), The Palgrave International Handbook of Healthcare Policy and Governance. Palgrave Macmillan, UK, pp. 85–100. Birthplace in England Collaborative Group, 2011. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the birthplace in England national prospective cohort study. British Medical Journal 116 (9), 1177–1184 〈http://dx.doi.org/10.1136/bmj.d7400〉. Bisits, A., 2016. Risk in obstetrics – perspectives and reflections. Midwifery 38, 12–13. Coxon, K., Bisits, A., Sandall, J., 2015. Call for special issue of midwifery on risk in childbirth. Midwifery 31, 257–258, Available at 〈http://linkinghub.elsevier.com/ retrieve/pii/S0266613814002964〉. Dahlen, H.G., 2016. The politicisation of risk. Midwifery 38, 6–8. Dahlen, H.G., Jackson, M., Stevens, J., 2011. Homebirth, freebirth and doulas: casualty and consequences of a broken maternity system. Women and Birth: Journal of the Australian College of Midwives 24, 47–50 〈http://www.ncbi.nlm. nih.gov/pubmed/21163719〉 (accessed 31.07.14.). Douglas, M., 1966. Purity and Danger, first ed. Routledge, London, New York. Douglas, M., 1992. Risk and Blame, first ed. Routledge, London. Douglas, M., Wildavsky, A., 1982. Risk and Culture: An Essay on the Selection of Technical and Environmental Dangers, first ed. University of California Press, Berkeley, CA. Furedi, F., 2011. The objectification of fear and the grammar of morality, first ed. In: Hier, S. (Ed.), Moral Panic and the Politics of Anxiety (Chapter 6). Routledge, London and New York. Giddens, A., 1991. Modernity and Self Identity: Self and Society in the Late Modern Age, first ed. Stanford University Press, California. Heyman, B. et al., 2010. Risk, Safety and Clinical Practice: Health Care Through the Lens of Risk, Available at 〈http://www.scopus.com/inward/record.url?eid¼ 2-s2. 0-84921891005&partnerID¼ 40&md5¼ 207ea32c709638ae1b59428e6449a90a〉. Holten, L., de Miranda, E., 2016. Women's motivations for having unassisted childbirth or high-risk homebirth: An exploration of the literature on ‘birthing outside the system’. Midwifery 38, 55–62. Kirkup, B., 2015. The Report of the Morecambe Bay Investigation, Available at 〈https://www.gov.uk/government/uploads/system/uploads/attachment_data/ file/408480/47487_MBI_Accessible_v0.1.pdf〉. Lee, E., et al., 2014. Parenting Cultural Studies, 1st edn Palgrave Macmillan, Basingstoke, Hampshire. Lee, S., Ayers, S., Holden, D., 2016a. How women with high risk pregnancies perceive interactions with healthcare professionals when discussing place of birth: A qualitative study. Midwifery 38, 42–48. Lee, S., Ayers, S., Holden, D., 2016b. Risk perception and choice of place of birth in women with high risk pregnancies: A qualitative study. Midwifery 38, 49–54. Lee, E., Macvarish, J., Bristow, J., 2010. Risk, health and parenting culture. Health, Risk & Society 12, 293–300 〈http://www.tandfonline.com/doi/abs/10.1080/ 13698571003789732〉 (accessed 31.07.14.). Lupton, D., 1997. Foucault and the medicalisation critique, first ed. In: Petersen, A., Bunton, R. (Eds.), Foucault Health and Medicine. Routledge, London, pp. 94–112. Lupton, D., 2012. “Precious cargo”: foetal subjects, risk and reproductive citizenship. Critical Public Health 22, 329–340. Lupton, D., 1999. Risk and Sociocultural Theory: New Directions and Perspectives, 1st edn, Lupton, D. (Ed.). Cambridge: Cambridge University Press. McLelland, G., McKenna, L., Morgans, A., Smith, K., 2016. Paramedics' involvement in planned home birth: A one-year case study. Midwifery 38, 71–77. Plested, M., Kirkham, M., 2016. Risk and fear in the lived experience of birth without a midwife. Midwifery 38, 29–34. Posthumus, A.G., van Veen, M.J., Bonsel, G.J., 2016. An antenatal prediction model for adverse birth outcomes in an urban population: The contribution of medical and non-medical risks. Midwifery 38, 78–86. Rothman, B.K., 2014. Pregnancy, birth and risk: an introduction. Health, Risk & Society 16, 1–6. http://dx.doi.org/10.1080/13698575.2013.876191, January 2015. Sandall, J., et al., 2013. Midwife-led continuity models versus other models of care for childbearing women. The Cochrane Database of Systematic Reviews, 8, p.CD004667. Available at: 〈http://www.ncbi.nlm.nih.gov/pubmed/23963739〉 (accessed 20.01.14.). Scamell, M., 2016. The fear factor of risk – clinical governance and midwifery talk and practice in the UK. Midwifery 38, 14–20. Skinner, J., Maude, R., 2016. The tensions of uncertainty: Midwives managing risk in and of their practice. Midwifery 38, 35–41. Striley, K., Field-Springer, K., 2016. When it's good to be a bad nurse: expanding risk orders theory to explore nurses’ experiences of moral, social and identity risks in obstetrics units. Health, Risk & Society, 1–20, Available at: http://www. tandfonline.com/doi/full/10.1080/13698575.2016.1169254. Taylor-Gooby, P., 2000. Risk and welfare, first ed. In: Taylor-Gooby, P. (Ed.), Risk, Trust and Welfare. Palgrave Macmillan, London. Van Wagner, V., 2016. Risk talk: Using evidence without increasing fear. Midwifery 38, 21–28. World Health Organisation, 2015. WHO statement on caesarean section rates. Human Reproduction Programme, 1–8, Available at http://apps.who.int/iris/ bitstream/10665/161442/1/WHO_RHR_15.02_eng.pdf, Accessed 3.6.16.
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Senior Lecturer, Guest Editor Kirstie Coxon, RN, RM, BSc, MA, PhD King's College London, Florence Nightingale Faculty of Nursing and Midwifery, UK
Professor, Associate Editor 'Midwifery' Jane Sandall , RN, RM, HV, BSc, MSc, PhD King's College London, Division of Women's Health, School of Medicine, UK
Professor, Associate Editor 'Midwifery' Caroline Homer , MScMed (ClinEpi), PhD University of Technology Sydney, Australia
Professor, Editor in Chief ‘Midwifery’ Debra Bick, RM, BA, MMedSci, PhD King's College London, Florence Nightingale Faculty of Nursing and Midwifery, UK
Medical Co-Director-of-Maternity, Guest Editor 'Midwifery' Andrew Bisits , MD Royal Hospital for Women, Barker St. Randwick, NSW2031, Australia
Contents lists available at ScienceDirect
Midwifery journal homepage: www.elsevier.com/midw
Editorial
Reconceptualising risk in childbirth$
Introduction This special issue of Midwifery brings together a collection of papers which are at the forefront of understanding how concepts of risk affect or impact upon the organisation and provision of clinical maternity care. The call for papers arose from an identified gap in the evidence; a special issue in Health, Risk and Society (Volume 16, no 1) explored risk during pregnancy and childbirth from social science perspectives, and many of the papers looked at the lived experiences of women in relation to risk. The starting point for that collection was the observation that although birth in high income countries is safer than ever before, we face what Taylor-Gooby has termed the ‘paradox of timid prosperity’, where anxiety seems to be on the increase, in the face of overall safety (Taylor-Gooby, 2000, p.3). In pregnancy and birth, risk has expanded to become a complex and ever-present notion, associated with dangers, hazard and probabilistic reasoning. As Andrew Bisits notes in his commentary (Bisits, 2016), we benefit from a proliferation of research, giving ever more information about absolute and relative risks in pregnancy and birth, but whilst this knowledge is valuable, it can add to the sense that pregnancy is a problematic or dangerous time. Women and their partners or families then need to tease apart ‘real’, ‘actual’ and ‘perceived’ risks, take into consideration the context of their own lives, beliefs and values and work their way towards negotiating aspects of care that they felt comfortable with, in a context which seems to privilege the biomedical construct of clinical risk (Rothman, 2014). The Health, Risk and Society special issue made a valuable contribution, but surprisingly few papers explored risk perspectives from maternity care professionals’ perspectives. Given the widespread and generalised concern with rising costs of maternity care and increasing rates of intervention without clear evidence of benefit (Birthplace in England Collaborative Group, 2011; World Health Organisation, 2015; Benoit et al., 2015), it seemed important to address this gap and to understand better the impact of risk on clinicians’ practice. Our call for papers (Coxon et al., 2015) particularly focused on the relationship between ‘risk’ and ‘normality’ and we invited papers that would add to our understanding of how midwives and others seek to ‘square the circle’ of promoting normality whilst managing risk. That was over a year ago, and much has happened in that time. Our call predated the UK publication of the Kirkup Report (Kirkup, 2015) into failings of maternity care at Morecambe Bay NHS
Foundation Trust in Cumbria, England, and this report has caused midwives and women using services to look again at the term ‘normality’ and consider its place in maternity care. One of the report's key findings was that attempts to ‘uphold normality’ and ‘over-zealous pursuit of the natural childbirth approach’ led to ‘inappropriate and unsafe care’ (p.13). Although the basis for this conclusion has been debated in the professional press and the media, it seems important to acknowledge that the term ‘normality’ has now developed into one with as many political charges and connotations as ‘risk’ already carries.
Risk-based practice in maternity care The position of women, families and midwives in relation to birth is undoubtedly affected by the prevalence of ‘risk’ thinking in maternity care. Lee et al. (2010) have argued consistently over the past decade that parenting occurs in the context of ‘risk society’, particularly in high income nations, and one of the consequences of this is that parents need to demonstrate an ability to be effective ‘risk managers’ for themselves, and for their children. The papers collated here support this view, and also demonstrate how the same pressures are brought to bear on clinicians. This creates a circular scenario whereby organisations ensure clinicians’ practice is oriented towards risk concerns; clinicians feel obliged to communicate information about risk to women and partners, and women and partners, already primed by cultural narratives of birth risk, experience pregnancy and birth through what Heyman et al. termed ‘the lens of risk’ (Heyman et al., 2010). The issue here is not that risks are discussed with women, (although as many of our contributors point out, the way risks are framed can limit the choices perceived to be available), but rather that such discussions are often unbalanced, focusing on unlikely but dramatic adverse outcomes without explaining the potential health gains for women and babies of careful and ongoing assessment, and considering options that are likely to incur fewer interventions overall. In this editorial, we identify thematic links between the special issue papers, and consider these in relation to risk theory and practice reflections. We note how individual papers address evidence gaps, and identify where these persist, and we finish by considering the contribution of the special issue as a whole to risk theory and the implications for ongoing service and practice development.
☆ We would like to acknowledge that we have referenced the title of Barclay et al’s paper within our Special Issue title; the phrase ‘reconceptualising risk’ neatly draws together the key themes within this issue.
http://dx.doi.org/10.1016/j.midw.2016.05.012 0266-6138/& 2016 Elsevier Ltd. All rights reserved.
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Maternity care and the culture of fear A clear theme amongst papers in this issue is that maternity care clinicians describe work practices which take place within an organisational culture of fear. In her commentary for this Special Issue, Hannah Dahlen (2016) reminds us of the political value of fear, and suggests that fear serves the purpose of increasing anxiety about safety during birth, which justifies a range of actions and interventions, and inflames debate about the benefits and timing of interventions. For clinicians and service managers, concern to prevent a poor outcome for the woman or infant is always paramount, but there is also fear of litigation, and of consequences of ‘risk’ investigations for the individual's professional standing and continued employment. This may mean that clinicians take preventative actions to offset risks that feel real, but may be hypothetical in terms of calculable risk. In their discussion of US obstetric nurses’ experiences, Striley and Field-Springer identify this category of risk as an ‘identity’ risk, or a ‘threat to the sense of self’ (Striley and Field-Springer, 2016), and their insight is borne out by the experiences of clinicians within the papers in our issue. In our call for papers, we suggested that midwives and nursemidwives practicing today have more rather than less autonomy than in the past, particularly in relation to supporting healthy women during normal or straightforward births. The papers in the special issue actively challenge this assertion, and argue instead that clinical autonomy is increasingly constrained, and that concerns about risk may eclipse or even ‘overwhelm’ notions of normality (Scamell, 2016, p. 14). In her paper, Mandie Scamell (2016, p. 14) explores how ‘institutional concerns around risk and risk management impact upon the way midwives can legitimately imagine and manage labour and childbirth’. She argues that the ‘risk’ model and the ‘normality’ model constitute two separate, and in fact, divergent approaches, and explains with reference to historical policy guidance how this situation has developed over time. Scamell also provides a theoretical position which has its origins in Science and Technology Studies (STS). This consists of an argument that clinical governance practices seek to ‘colonise the future’ by altering clinical behaviours in the present, even though the ‘imagined future event’ is rare, the ability to avert problems through this approach is unknown, and the rate of new and unexpected complications which may have arisen as a result of taking a risk-based approach is rarely considered. Mandie Scamell's paper also shows that midwives are aware they need to be seen to behave in a particular (risk-averse) way, but feel conflicted when they are committed personally to supporting women to achieve a normal birth. In the end, argues Scamell, risk speaks much more loudly than normality. Several of the papers explore the ways in which clinicians, despite being attuned to evidence-based practice, find themselves to be unwilling but effective participants in risk amplification exercises when they do ‘risk talk’ (e.g. see Van Wagner (2016), Plested and Kirkham (2016)). Vicki Wagner (REF) looks specifically at the practice of risk talk, whilst Joan Skinner and Robyn Maude (Skinner and Maude 2016) observe ‘tensions of uncertainty’ through exploring the implications of counselling women when the actual outcomes for the individual and her family are unknown and unknowable. Skinner and Maude (2016) make the case for expanding the field of interest beyond risk, and encompassing uncertainty as an important part of the experience of birth. Focusing on the perspectives of women whose pregnancies are affected by risk issues, Suzanne Lee and colleagues provide two linked papers (Lee et al., 2016a, 2016b), one of which explores women's responses to information about clinical risk, (Lee et al., 2016a) whilst the other presents data about how women whose pregnancies are at increased risk perceive interactions with health care professionals, when they discuss planned place of birth (Lee et al., 2016b). Like Van Wagner (2016), Lee et al. note that strategies used
by clinicians to communicate risk are under-developed, and argue that this topic needs far better understanding given that women's beliefs about risk are part of their individual personal philosophies, which form long before pregnancy. In exploring the implications of ‘risk talk’, Van Wagner also shows that discussing risk signals the need for leaning towards technology, and argues that during risk discussions, clinicians are expected to present numerical data, explain or discuss complex statistical concepts to communicate ‘evidence based medicine’, even though the actual evidence available may be limited. As Andrew Bisits also makes clear in his commentary, explaining and contextualising low prevalence absolute risk data is a complex task, and a fuller appreciation of effective means of doing so is needed. It is also clear that clinicians feel they are asked to share information in a manner that selectively presents risks, because the emphasis is on being certain that all possible and potential risks are communicated. There is a clear need for further research on this issue, to understand better whether numerical information about ‘probable’ and ‘possible’ risk is valued by women, and if so, how this should be conveyed or presented effectively. This is particularly important because, as Lee et al.'s work argues, (Lee et al., 2016a) current approaches are likely to be ineffective. In this paper, which draws upon a psychological perspective, Lee et al. demonstrate how women selected or ‘heard’ information which aligned well with their prior beliefs. This suggests that ‘confirmation bias’ (or being more ‘open’ to congruent messages) contributes to the process of ‘doing risk talk’, and that discussions which may already be uneven or framed in a particular way are only partially heard. Both Lee et al.'s papers arise from research of women who have known risk factors during pregnancy, some of whom planned home birth, whilst others planned to give birth in hospital obstetric units. Understanding decisions, preferences or choices which are at odds with clinical recommendations is an issue which has been historically under-researched, and it is valuable that several included papers have engaged with this issue. Lianne Holten and Esteriek de Miranda (Holten and de Miranda, 2016) summarise recent literature on ‘unassisted birthing’, and this is one of the first reviews to do so, whilst Miriamni Plested and Mavis Kirkham's paper (Plested and Kirkham, 2016) contains a phenomenological study of how women experience birth without a midwife. As Dahlen has previously argued (Dahlen et al., 2011), ‘freebirth’ is to some extent a logical, if unintended, consequence of women's alienation from mainstream maternity services, especially if they find their needs and concerns are not listened to by clinicians, or they are unable to secure access to services such as homebirth with a midwife. In their paper on service configuration and closures in remote and rural areas of Australia, Lesley Barclay et al. (Barclay and Kornelsen, 2016 [p. 10 of v1]) report consequences such as unplanned births without skilled staff present, birth ‘on tarmac’ awaiting airlift or avoidance of antenatal and intrapartum care as consequences of withdrawing services that are accessible to women. Through their detailed study, these authors make the case that over-reliance on biomedical risk perspectives as a basis for service decision-making has numerous implications for women and families, including separation, cost and lost opportunities to birth locally, even when the cultural and spiritual motivations for doing so are well known. They conclude that whilst clinical health considerations are clearly important, making decisions on the basis of these alone, or attempting to do so without the consent of the population served, may actually diminish the safety of women and babies, and argue that our understanding of risk in maternity care needs to be much broader, incorporating the social, emotional and cultural implications of maternity service provision.
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Potential solutions to problems created by risk-averse practices Barclay et al.'s paper (Barclay and Kornelsen, 2016) suggests that one solution to the impasse created by risk-averse practice is to reconceptualise risk, by moving beyond immediate clinical concerns to embrace a broader range of issues, but also recognising the unintended consequences of imposing a single perspective on service-level decision-making. This proposal also implicitly calls for a shift towards a more collaborative approach for service-provider decisions, one which considers the dynamics operating within the local population too. Whilst the paper originates in remote and rural Australia, similar debates are taking place in many countries where geography affects clinical infrastructure and decision-making, so this issue seems to have international relevance, and the overall message about engaging with local concerns is arguably relevant to any maternity care provider organisation, regardless of geographical constraints. Two other papers in the issue present solutions to risk-management issues. Again working from a service-level perspective, Gayle McLelland et al. (2016) outline the contribution of paramedics in Canada to improving safety of planned home births. Recognising that women who plan home births in Canada are a minority group, so that adverse clinical situations are rarely encountered by paramedics, McLelland et al. outline how simulation training can help paramedics prepare for potential scenarios, increasing the skills and confidence of clinicians and strengthening integration between services to better support women and families. In their prospective epidemiological study, Anke Posthumus et al. (2016) consider ways of predicting adverse birth outcomes in an urban population in Rotterdam, Netherland; although their work could not be more different from Barclay et al.'s research, they reach an intriguingly similar conclusion. To anticipate and understand likelihood of adverse birth outcomes, the authors argue, both medical and nonmedical risks, which are predominantly understood as socio-economic factors in this paper, need to be considered.
New directions: the contribution of the special issue collection Perhaps fittingly for a special issue on ‘risk’, the research contained within these papers seems to raise an alarm. The authors are not risk-naïve, and none suggest that clinical risk is something that we should dismiss or underplay; clinicians understand that bad things do happen in maternity care, and there is an evident and international endeavour to improve access to safe, high quality maternity care for women and babies. The alarm arises from the way in which risk has become a predominant concern, one which, according to these papers, shapes practice, constrains clinicianwoman relationships, and closes down opportunities for honest and trustful relationships. One common consequence of risk-averse practice is an expectation of early ‘just in case’ intervention; another is that clinicians, particularly midwives, feel increasingly hemmed in and unable to ‘support normality’ without feeling fearful for their careers, livelihoods and professional identities as ‘good’, ‘safe’ or ‘effective’ practitioners. A rarer consequence is breakdown in relationships between women and maternity services, such that women choose to birth alone rather than open their doors to a midwife, because that means ‘letting in’ protocol-driven care, risk aversion and the expectation that something will go wrong. The papers which focused on ‘risk talk’ or how clinicians and providers ‘perform’ risk awareness begin to suggest that risk management as it is currently understood might be considered an intervention in its own right. Clinicians’ accounts suggested their work involves a Catch-22-like situation; outlining ‘the risks’ means raising awareness of rare and unlikely outcomes, things which even women at low clinical risk ‘should’ know about, but the act of doing
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so reduces women's confidence in themselves and in their ability to give birth. This in turn makes it more likely that they seek care in high-acuity settings, where, it is well established, the likelihood of interventions which might otherwise have been avoided increases.
Theoretical contribution of the special issue collection The papers collected here draw on a range of risk theories, but most have referenced socio-cultural accounts of risk which broadly position risk as both ‘real’ (calculable, measurable) and ‘constructed’, by individuals and institutions, with reference to wider social contexts, narratives and to shared cultural beliefs. Key authors in this field are cited (Douglas, 1966; Douglas and Wildavsky, 1982; Giddens 1991; Douglas, 1992; Beck 1992; Lupton, 1997, 1999, 2012), and their insights explored in relation to maternity care. These empirical accounts are valuable and clearly show how risk impacts upon practice, but it is still interesting to ask why the concept of ‘risk’ has become quite so powerful within maternity care, given the parallel argument that women in the high income countries featured here are healthier than ever before and have better access to good quality maternity care, and birth is consequently safer than in the past. In their recent book, Lee et al. (2014) explore the rise of ‘risk consciousness’ particularly in relation to parenting, and explore its societal consequences. Their arguments are outlined here in some detail because they seem to have clear applicability to the issues discussed in our collected papers. In their analysis, ‘risk consciousness’ has several features. Firstly, ‘risk’ is understood to have expanded from the original meaning of a calculable ‘probability’ to include any possible poor outcome, which Lee et al. link to increased anxiety about outcomes which are considered to be uncertain; accordingly, the focus of ‘risk’ discussions has also expanded to include possible as well as probable outcomes. Secondly, Lee et al. note that anxiety around ‘the child’ has increased, and that society, once viewed as nurturing and protective, is now considered to present dangers to children from which they need protection, and parents are expected to be vigilant against these dangers. Further, the decisions parents make (for example, about infant feeding, or spending ‘quality time’ with children) and the ways they behave towards children are seen as potentially wrong, ineffective, or even damaging, unless ‘expert’ advice is sought and taken. In ‘risk’ society, ‘poor’ parental decisions are considered to have long-term consequences as the child grows into adulthood, which Lee et al. describe as an argument of ‘parental determinism’. Building on Furedi's (2011) work in this field, Lee et al. (2014) also propose that risk consciousness becomes more prevalent where ‘cultural authority is weak’ (ibid p,13), and traditional value systems seem to have lost their hold. Risk regulation then moves into this space, and becomes the means by which moral regulation of social behaviour takes place. Through these mechanisms, ‘risk management’ and ‘risk regulation’ become prominent, and ‘risk’ messages carry strong moral overtones, focusing overt attention on parental behaviour and decisions. This in effect places blame on individuals, shifting thinking away from other explanations for poor outcomes, such as social inequalities, ineffective services or inadequate infrastructure. The papers in this collection suggest that as well as being relevant to pregnant women and parents-to-be, ‘risk consciousness’ affects clinicians in very similar ways; it also raises the possibility that clinicians, through performing ‘risk management’, are also participating in the moral regulation of women and new families, an idea which requires further consideration, discussion and debate. As these papers show, practicing maternity care in a risk-averse culture is fraught with anxiety for clinicians, and it is easy to see how such anxiety is conveyed to women and families. However, it would be an oversight to end without noting the resilience shown by women and clinicians as they engage with the requirements of
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‘risk management’ in pregnancy and birth. Within these papers, there is evidence that women and clinicians return time and again to the concept of women's ability to birth, and clinicians’ ability to support the birth process respectfully, and that despite the perceived sense of threat to livelihood and challenge to professional judgement that risk-based approaches present, birth as a normal, everyday activity remains a ‘touchstone’ for reasoning about risk in pregnancy and birth. Epidemiological research into birth outcomes amongst healthy women confirms that there is reason to have confidence in this ability; increasingly, national policies shift incrementally towards providing space for ‘normal’ birth to take place. We see evidence of this in England, where policy actively promotes birth in midwife-led settings for women who are at low risk of complications, and in the Netherlands, where the practice of home birth has been upheld and robustly defended. More recently, professional bodies in countries such as US, which have been traditionally more conservative, are beginning to revisit their statements on issues such as home birth (American College of Obstetricians and Gynecologists, 2011). Such changes are happening, but they are incremental and there is also ample evidence that maternity services still fail to listen to women, both when they ask for help to give birth with minimal intervention, and when they seek acute obstetric care. Freebirth has perhaps caught the professional imagination in high income countries so readily because this teaches us that in extremis, when preferred services are not available to women, or when relationships with clinicians break down, women will vote with their feet and birth where they feel safest – and that may not be in a health care facility. The papers collected here begin the work of understanding how clinicians and women make sense of risk in the context of maternity care, which itself exists within a wider culture of anxiety about birth, parenting and what these things mean for the future of society, but there is much more work to be done here. Understanding is in its infancy, and in some cases, the papers published here are initial explorations of emerging realities that arise as a consequence of risk management. There are some strategies that can help us now; Andrew Bisits’ proposal (Bisits, 2016, p. 12) that ‘any discussion of risk should start with the acknowledgement that childbirth has never been safer’ points the way towards a starting point based on evidence and consensus, and his argument that information about risks and benefits of different treatment options should where possible be shared when women and clinicians have time to discuss these fully, rather than ‘flooding’ information at a given appointment is also valuable (Bisits, 2016, p. 12). This point also speaks to the importance of establishing trusting relationships within a continuity model of care, as cornerstone of safe and high quality maternity care provision (Sandall et al., 2013). Whatever our individual perspectives on risk, normality or interventions, it is valuable to revisit the point with which Hannah Dahlen's commentary also ends. She asks us to remember that it is not always ‘the intervention’ or not giving birth ‘naturally’ which is problematic; instead, ‘What traumatises women most is how they are treated during birth and lack of control, communication and consent’ (Dahlen, 2016, p. 6). With this thought in mind, and with due thanks to our many contributors, we invite you to read and engage with the articles in this special issue of Midwifery on risk in pregnancy and birth.
References American College of Obstetricians and Gynecologists, 2011. Planned Home Birth: Committee Opinion. (Number 476, pages 1–4, February 2011, reaffirmed 2015), http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Planned-Home-Birth, Accessed 03.06.16.
Barclay, L., Kornelsen, J., 2016. The closure of rural and remote maternity services: Where are the midwives? Midwifery 38, 9–11. Beck, U., 1992. Risk Society: Towards a New Modernity, first ed. Sage Books, London. Benoit, C,. et al., 2015. Maternity care as a global health policy issue, first ed. In: Benoit, C., Declercq, E., Murray, S.F., Sandall, J., van Teijlingen, E., Wrede, S. (Eds.), The Palgrave International Handbook of Healthcare Policy and Governance. Palgrave Macmillan, UK, pp. 85–100. Birthplace in England Collaborative Group, 2011. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the birthplace in England national prospective cohort study. British Medical Journal 116 (9), 1177–1184 〈http://dx.doi.org/10.1136/bmj.d7400〉. Bisits, A., 2016. Risk in obstetrics – perspectives and reflections. Midwifery 38, 12–13. Coxon, K., Bisits, A., Sandall, J., 2015. Call for special issue of midwifery on risk in childbirth. Midwifery 31, 257–258, Available at 〈http://linkinghub.elsevier.com/ retrieve/pii/S0266613814002964〉. Dahlen, H.G., 2016. The politicisation of risk. Midwifery 38, 6–8. Dahlen, H.G., Jackson, M., Stevens, J., 2011. Homebirth, freebirth and doulas: casualty and consequences of a broken maternity system. Women and Birth: Journal of the Australian College of Midwives 24, 47–50 〈http://www.ncbi.nlm. nih.gov/pubmed/21163719〉 (accessed 31.07.14.). Douglas, M., 1966. Purity and Danger, first ed. Routledge, London, New York. Douglas, M., 1992. Risk and Blame, first ed. Routledge, London. Douglas, M., Wildavsky, A., 1982. Risk and Culture: An Essay on the Selection of Technical and Environmental Dangers, first ed. University of California Press, Berkeley, CA. Furedi, F., 2011. The objectification of fear and the grammar of morality, first ed. In: Hier, S. (Ed.), Moral Panic and the Politics of Anxiety (Chapter 6). Routledge, London and New York. Giddens, A., 1991. 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How women with high risk pregnancies perceive interactions with healthcare professionals when discussing place of birth: A qualitative study. Midwifery 38, 42–48. Lee, S., Ayers, S., Holden, D., 2016b. Risk perception and choice of place of birth in women with high risk pregnancies: A qualitative study. Midwifery 38, 49–54. Lee, E., Macvarish, J., Bristow, J., 2010. Risk, health and parenting culture. Health, Risk & Society 12, 293–300 〈http://www.tandfonline.com/doi/abs/10.1080/ 13698571003789732〉 (accessed 31.07.14.). Lupton, D., 1997. Foucault and the medicalisation critique, first ed. In: Petersen, A., Bunton, R. (Eds.), Foucault Health and Medicine. Routledge, London, pp. 94–112. Lupton, D., 2012. “Precious cargo”: foetal subjects, risk and reproductive citizenship. Critical Public Health 22, 329–340. Lupton, D., 1999. Risk and Sociocultural Theory: New Directions and Perspectives, 1st edn, Lupton, D. (Ed.). Cambridge: Cambridge University Press. McLelland, G., McKenna, L., Morgans, A., Smith, K., 2016. Paramedics' involvement in planned home birth: A one-year case study. Midwifery 38, 71–77. Plested, M., Kirkham, M., 2016. Risk and fear in the lived experience of birth without a midwife. Midwifery 38, 29–34. Posthumus, A.G., van Veen, M.J., Bonsel, G.J., 2016. An antenatal prediction model for adverse birth outcomes in an urban population: The contribution of medical and non-medical risks. Midwifery 38, 78–86. Rothman, B.K., 2014. Pregnancy, birth and risk: an introduction. Health, Risk & Society 16, 1–6. http://dx.doi.org/10.1080/13698575.2013.876191, January 2015. Sandall, J., et al., 2013. Midwife-led continuity models versus other models of care for childbearing women. The Cochrane Database of Systematic Reviews, 8, p.CD004667. Available at: 〈http://www.ncbi.nlm.nih.gov/pubmed/23963739〉 (accessed 20.01.14.). Scamell, M., 2016. The fear factor of risk – clinical governance and midwifery talk and practice in the UK. Midwifery 38, 14–20. Skinner, J., Maude, R., 2016. The tensions of uncertainty: Midwives managing risk in and of their practice. Midwifery 38, 35–41. Striley, K., Field-Springer, K., 2016. When it's good to be a bad nurse: expanding risk orders theory to explore nurses’ experiences of moral, social and identity risks in obstetrics units. Health, Risk & Society, 1–20, Available at: http://www. tandfonline.com/doi/full/10.1080/13698575.2016.1169254. Taylor-Gooby, P., 2000. Risk and welfare, first ed. In: Taylor-Gooby, P. (Ed.), Risk, Trust and Welfare. Palgrave Macmillan, London. Van Wagner, V., 2016. Risk talk: Using evidence without increasing fear. Midwifery 38, 21–28. World Health Organisation, 2015. WHO statement on caesarean section rates. Human Reproduction Programme, 1–8, Available at http://apps.who.int/iris/ bitstream/10665/161442/1/WHO_RHR_15.02_eng.pdf, Accessed 3.6.16.
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Senior Lecturer, Guest Editor Kirstie Coxon, RN, RM, BSc, MA, PhD King's College London, Florence Nightingale Faculty of Nursing and Midwifery, UK
Professor, Associate Editor 'Midwifery' Jane Sandall , RN, RM, HV, BSc, MSc, PhD King's College London, Division of Women's Health, School of Medicine, UK
Professor, Associate Editor 'Midwifery' Caroline Homer , MScMed (ClinEpi), PhD University of Technology Sydney, Australia
Professor, Editor in Chief ‘Midwifery’ Debra Bick, RM, BA, MMedSci, PhD King's College London, Florence Nightingale Faculty of Nursing and Midwifery, UK
Medical Co-Director-of-Maternity, Guest Editor 'Midwifery' Andrew Bisits , MD Royal Hospital for Women, Barker St. Randwick, NSW2031, Australia