REVIEW ARTICLEMidwives’ and obstetricians’ perceptions of risk and its impact on clinical practice and decision-making in labour: An integrative review
Introduction
The concept of risk has largely altered from an accepted part of life to something that must be avoided or controlled.1 Risk and risk assessment are continually affecting how maternity services are governed.2 The perception that birth can only be considered safe in retrospect is creating a system where interventions are practiced in order to avoid the occurrence of prospective negative incidents.3 This technocratic model of birth extols technology and anticipation of pathology. This is in contrast to the social model that anticipates normality with technology seen as a servant and not a master.4
In the United Kingdom (UK) the normal birth rate stands at 42% which is a significant decrease since the 1990s.5 This figure accounts for women who birth without induction, pharmaceutical anaesthesia, forceps, ventouse, caesarean or episiotomy. Similar patterns are reflected in figures from Ireland and Australia.6, 7 This is despite encouragement for all women to have as normal a pregnancy and birth as possible which has been highlighted as crucial in the on-going focus of improving maternity care.8 Regardless of guidelines9 that urge professionals to foster the view that birth is safe for low-risk women and their babies, women's confidence in their ability to have a normal birth is increasingly diminished. This is often as a result of an increased focus on risk assessment and risk management with high-tech maternity units often viewed as the safest place to birth.2 Research exists to support the safety of out-of-hospital birth and a large prospective cohort study in the UK10 revealed that 30% of low-risk multiparous women are likely to have intervention if they birth in an obstetric-led unit compared to between 5% and 9% in a midwifery-led unit with equivalent perinatal outcomes.
Interventions are largely considered to be the domain of obstetricians. However, midwives are increasingly accepting these as normal within the hospital environment.10 Midwives working in obstetric-led settings are exposed to increasing amounts of intervention resulting in higher perceptions of risk regarding women who are in fact low-risk.12 This is equated to ‘learning the lessons of fear’11 and it is suggested that healthcare professionals are increasingly being obliged to work in this model of care, both willingly and reluctantly, in the interest of safety.12
Risk management policy and its associated operations within hospital institutions very often do not account for the underlying philosophy and assumptions of risk discourse that are present and have a bearing upon practice.4 Salutogenesis has been suggested as a theory to deliver changes to the planning and delivery of hospital-based maternity services.13, 15 This would incorporate a focus on what factors contribute to positive as opposed to negative outcomes and could make a contribution to tackling the high levels of intervention that appear to be elusive at present.13
The aim of this integrative literature review is to synthesise evidence of midwives’ and obstetricians’ perceptions of risk about birth when facilitating care for low-risk women in labour ward, hospital settings. It examines how these perceptions affect the use of interventions and technology in labour. Obstetricians are included in this review as they are involved in the planning of care for low-risk women in obstetric-led settings and in the delivery of care for their low-risk private patients.14 Although reviews exist that investigate midwives experiences of working in hospital labour wards10 and professionals’ views of fetal monitoring15 to our knowledge there are no existing literature reviews particularly pertaining to this topic. Due to the significant rates of intervention for low-risk women in obstetrical settings it is important that risk perceptions of both midwives and obstetricians working in this setting are examined to understand how they may be contributing to the rising intervention rates. This review asks the following two questions:
(1) What factors affect midwives’ and obstetricians’ perceptions of risk when facilitating care for low-risk women in labour?
(2) How do perceptions of risk impact on midwives’ and obstetricians’ clinical practice and decision-making when facilitating care for low-risk women in labour?
Section snippets
Methods
This review followed the systematic approach to integrative reviews devised by Cooper16 incorporating an up-dated methodology of this framework by Whittemore and Knafl.17 Particular attention was paid to the design and conduct of the search strategies, appraisal of study quality and methods for synthesis as these have been highlighted as areas of challenge by the Cochrane Qualitative Research Methods Group.18 This is a particularly appropriate review method for the nursing/midwifery disciplines
Discussion
The key findings from this integrative review of 13 studies report a culture of risk in maternity hospital settings which is heavily influenced by the assumption that childbirth is an unreliable process. It identifies how healthcare professionals are increasingly risk-adverse27, 35, 37 and engage in unwarranted surveillance and technology in an attempt to protect themselves from perceived litigation.34, 39 Also highlighted is the diminished responsibility and decision-making of both midwives
Conclusion
The concept of risk and how it affects maternity care is complex but it is clear that the assumption of abnormality surrounding birth is contributing to the risk culture. This is compounded by midwives’ and obstetricians’ fears of adverse outcomes and litigation and the effect of this on them both personally and professionally. It is recommended that there is a stronger emphasis on the provision of maternity services from policy level through to practice which decreases the focus on risk and
Acknowledgements
The main author of this paper is a PhD student with the Department of Nursing of Midwifery in the University of Limerick. She is in receipt of a grant, in the form of a monthly stipend, from this University to pursue a PhD but there is no conflict of interest in the reporting of data. The co-authors are supervisors of this PhD.
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