Risk and fear in the lived experience of birth without a midwife

Highlights

• Risk discourse is experienced as manipulative and coercive.

• A fearful ‘mood’ in the maternity services leads to the ‘dehumanisation’ of the woman.

• Talk about mortality raises important existential concerns which are unmet by health services.

• Risk discourse can lead to loss of trust and avoidance of maternity services.

Abstract

Purpose

the broad aim of this study was to examine the lived-experience of women who birth without a midwife or other health-care professional in the United Kingdom; the specific purpose of this paper is to examine risk discourse as experienced by these women.

Research design

reflective lifeworld research, a phenomenological approach was used in this study based on the philosophical writings of Husserl, Merleau-Ponty and Gadamer (Dahlberg et al., 2008). 10 in-depth interviews were conducted with women who had birthed without a midwife or other health-care professional present, interviews were transcribed and hermeneutically analysed.

Findings

women׳s lived-experiences of the maternity services in this study suggest a pervading mood of fear which finds voice in manipulative risk discourse and midwifery behaviours that can result in women avoiding maternity care. Fear based ׳risk-talk׳ is used as a scare tactic to coerce women into particular choices; if women do not comply they are labelled ׳risk-takers׳ and can become ostracised by the maternity care system.

Key conclusions

risk discourse and its emphasis on mortality and morbidity raises awareness of death and creates important existential concerns for women which are unaddressed by health-care professionals. This can lead to a loss of trust in health-care professionals and women sourcing positive support and a salutogenic approach to childbirth from outside the system.

Implications for practice

health-care professionals need to become aware of and address manipulative and coercive attitudes in risk discourse.

Introduction

There is a lack of data on the number of women choosing to birth without a midwife or other health-care professional (also referred to as unassisted birth or freebirth) in the United Kingdom, and there is no evidence of the resulting outcomes. Media reports, online discussions and midwifery literature suggest that in the UK increasing numbers of women are considering not using the maternity services during pregnancy and/or at birth (Edwards and Kirkham, 2012). The literature identifies that women choosing unassisted birth include both women with normal pregnancies and also women with complex pregnancies (Edwards and Kirkham, 2013). The phenomenon of unassisted birth outside the UK is documented mainly in Australia and North America (Dahlen et al., 2011, Freeze, 2008, Jackson et al., 2012) where home birth is either illegal or widely unavailable. Although still a small minority, the increasing number of unassisted births in the United Kingdom where choice regarding place of birth (including home birth) has been national policy in the maternity services for decades challenges many accepted norms regarding safety, risk and responsibility around birth (Cooper and Clarke, 2008, Edwards and Murphy-Lawless, 2006).

Just as authoritative knowledge is the knowledge accepted because of the authority of those who hold it (Davis-Floyd and Sargent, 1997), so ‘acceptable risks are those which are accepted’ and the ‘objectivity of a risk is a product of its perception and its staging… by experts’ (Beck, 2009; 13). This study looks at women who do not accept professional definitions of risk around birth and who experience the exercise of those definitions as coercive. This coercion is seen to have a negative effect upon all concerned, who seek to escape further threat (Sidman, 1989).

This article suggests that for some women, the encounter with maternity services is experienced as stepping into a risk obsessed system driven by fear, where avoidance (whether entirely or at the moment of birth) is the only means to preserve their fundamental beliefs about the normality of birth, and to safeguard what they understand to be the optimal conditions for having a normal birth, and a positive salutogenic attitude towards birth (Edwards et al., 2006).

The heavy emphasis on risk can ultimately lead to women feeling alienated by the maternity care system with little power to negotiate their preferred choices (Leap, 2010). Declining ‘standard’ antenatal procedures such as ultrasonography or other procedures whose primary function is to identify risk status exposes problems around the agency of choice and the conceptualisation of birth as ‘normal’ (Birthrights, 2013, Scamell and Alaszewski, 2012, Symon, 2006).

The dominance of risk discourse, referred to in recent literature as the ‘nocebo’ effect creates a climate where the suggestion of negative outcomes contributes to such outcomes (Symon et al., 2015). Thus, the maternity services with their emphasis on risk at micro (clinical encounter) and macro (risk management) levels can be understood as detrimental to normal birth prior to any iatrogenic considerations.