Midwives’ and obstetricians’ perceptions of risk and its impact on clinical practice and decision-making in labour: An integrative review

doi:10.1016/j.wombi.2015.08.010

Women and Birth

Volume 29, Issue 2, April 2016, Pages 107-116

https://doi.org/10.1016/j.wombi.2015.08.010 Get rights and content

Abstract

Background

Risk and risk assessment are increasingly affecting how maternity services are governed with rates of intervention continuing to rise in obstetric-led services for low-risk women.

Aim

This review synthesises original research that examines how perceptions of risk impact on midwives’ and obstetricians’ facilitation of care for low-risk women in labour.

Methods

A five stage process for conducting integrative reviews was employed. A robust search strategy incorporated electronic searches in The Cochrane Database of Systematic Reviews, EBSCO, EMBASE and Scopus from 2009 to 2014. The initial search resulted in the retrieval of 2429 articles which were reduced to 14 through a systematic process.

Findings

The results of this review revealed an over-arching theme of an assumption of abnormality in the birthing process leading to unnecessary intervention and surveillance. Three sub-themes are presented under this central theme – (1) external influences on risk perception that include practice guidelines and professional responsibility; (2) influence of personal fears and values on risk perception focusing on differing attitudes to physiological birth; (3) impact of professionals’ perceptions of risk on women's decision-making in labour.

Conclusion

Practice is influenced by an assumption of birth as abnormal and is compounded by issues such as institutional risk management, lack of midwifery responsibility, fear of involvement in adverse outcomes and personal values regarding physiological birth. These findings suggest that a shift in focus away from risk and towards health and wellbeing in the planning of maternity care may go some way towards providing a solution to the increasing intervention rates for low-risk women.

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.

References (53)

R.G. Jordan et al.
Risk assessment and risk distortion: finding the balance
J Midwifery Women's Health
(2009)
D. Cherniak et al.
Explaining obstetric interventionism: technical skills, common conceptualisations, or collective countertransference? Women's Studies International Forum
(2008)
H. Dahlen
Undone by fear? Deluded by trust?
Midwifery
(2010)
P. Kennedy
Healthcare reform: maternity service provision in Ireland
Health Policy
(2010)
M. Crowe et al.
Reliability analysis for a proposed critical appraisal tool demonstrated value for diverse research designs
J Clin Epidemiol
(2012)
F. Copeland et al.
Conflicting contexts: midwives’ interpretation of childbirth through photo elicitation
Women Birth
(2014)
S. Dove et al.
Being safe practitioners and safe mothers: a critical ethnography of continuity of care midwifery in Australia
Midwifery
(2014)
C. Seibold et al.
‘Lending the space’: midwives perceptions of birth space and clinical risk management
Midwifery
(2010)
L. Hood et al.
A story of scrutiny and fear: Australian midwives’ experiences of an external review of obstetric services, being involved with litigation and the impact on clinical practice
Midwifery
(2010)
L. Van kelst et al.
A hermeneutic phenomenological study of Belgian midwives’ views on ideal and actual maternity care
Midwifery
(2013)

M. Styles et al.

The Scottish Trial of Refer or Keep (the STORK study): midwives’ intrapartum decision making

Midwifery

(2011)

M. Page et al.

Intrapartum uncertainty: a feature of normal birth, as experienced by midwives in Scotland

Midwifery

(2014)

J. Rattray et al.

Foetal monitoring: a woman-centred decision-making pathway

Women Birth

(2011)

H.P. Kennedy

The problem of normal birth

J Midwifery Women's Health

(2010)

A. Keating et al.

Midwives’ experiences of facilitating normal birth in an obstetric-led unit: a feminist perspective

Midwifery

(2009)

M. Larsson et al.

Professional role and identity in a changing society: three paradoxes in Swedish midwives’ experiences

Midwifery

(2009)

K. Pollard

Searching for autonomy

Midwifery

(2003)

S. Downe et al.

Creating a collaborative culture in maternity care

J Midwifery Women's Health

(2010)

J. Sandall et al.

Improving quality and safety in maternity care: the contribution of midwife-led care

J Midwifery Women's Health

(2010)

V. Smith et al.

Salutogenically focused outcomes in systematic reviews of intrapartum interventions: a systematic review of systematic reviews

Midwifery

(2014)

H.M. Bryers et al.

Risk, theory, social and medical models: a critical analysis of the concept of risk in maternity care

Midwifery

(2010)

D. Walsh et al.

Rethinking risk and safety in maternity care

M. Dodwell

Normal birth rates in England

(2012)

ESRI

Perinatal Statistics Report 2012, Dublin

(2013)

Z. Li et al.

Australia's mothers and babies 2011

(2013)

Health do maternity matters: choice, access and continuity of care in a safe service

(2007)

Cited by (75)

What is ‘physiological birth’? A scoping review of the perspectives of women and care providers
2024, Midwifery
Physiological birth was defined by the World Health Organization in 1997, however, clinical practices in childbirth have changed considerably since this time.
Ambiguous terms in healthcare such as ‘physiological birth’ may cause confusion amongst care providers and consumers.
To identify what is known about physiological birth, and how perceptions of physiological birth manifest in current literature.
This review followed the Joanna Briggs Institute methodology for scoping reviews and the PRISMA-ScR checklist. Four databases were searched using keywords relating to physiological birth. Relevant studies were identified using agreed criteria, and data were extracted and synthesised.
A total of 24 studies met the inclusion criteria for this review. Three connected factors were identified: (1) Physiological birth in a risk-averse system, (2) Dominant voices in birth, and (3) Lack of exposure to physiological birth. No unified universal definition of physiological birth was identified in the literature.
‘Physiological birth’ as a term lacks consistency. A risk-averse healthcare system could be a barrier to physiological birth. Dominant voices in the birthing space can dictate the way birth occurs. Lack of exposure to physiological birth may diminish the acquisition and maintenance of important skills and knowledge among care providers. Recognising the factors important to women could lead to a positive birth experience.
Excluding a woman's subjective experience from health professionals’ understanding of physiological birth increases the likelihood of risk management being the paramount objective in clinical decision-making. We propose it is timely to align clinical understanding of physiological birth with midwifery's woman-centred professional philosophy.
Women's experiences of consent to induction of labour: A qualitative study
2024, Sexual and Reproductive Healthcare
Induction of labour (IOL) does not require formal written consent, and little is known about how consent operates in this context. This prospective study explores pregnant women’s experiences of the IOL consent process.
Qualitative study using semi-structured, interviews with thirteen women admitted to hospital for IOL. Data were analysed using thematic analysis.
Three themes emerged: 1) Voluntary nature of consent: Some women experienced genuine choice; others perceived pressure to prioritise their baby. 2) Understanding the why and how, risks and benefits: Information provision and explanation was often minimal, particularly regarding risks and alternatives to induction. The possibility of IOL failing was not discussed 3) Non-personalised information process: Few women received information specific and relevant to their circumstance.
There is an urgent need for healthcare professionals to be supported in actively facilitating consent consultations which enable women undergoing IOL to make a fully autonomous, informed choice.
Women did not always experience choice about whether to be induced. This sense of disempowerment was sometimes exacerbated by inadequate information provision. The study reveals a practice imperative to address consent in IOL and we suggest there is an urgent need for HCPs to be offered high quality training specific to IOL.
Failure to progress or just normal? A constructivist grounded theory of physiological plateaus during childbirth
2024, Women and Birth
During childbirth, one of the most common diagnoses of pathology is ‘failure to progress’, frequently resulting in labour augmentation and intervention cascades. However, failure to progress is poorly defined and evidence suggests that some instances of slowing, stalling and pausing labour patterns may represent physiological plateaus.
To explore how midwives conceptualise physiological plateaus and the significance such plateaus may have for women’s labour trajectory and birth outcome.
Twenty midwives across Australia participated in semi-structured interviews between September 2020 and February 2022. Constructivist grounded theory methodology was applied to analyse data, including multi-phasic coding and application of constant comparative methods, resulting in a novel theory of physiological plateaus that is firmly supported by participant data.
This study found that the conceptualisation of plateauing labour depends largely on health professionals’ philosophical assumptions around childbirth. While the Medical Dominant Paradigm frames plateaus as invariably pathological, the Holistic Midwifery Paradigm acknowledges plateaus as a common and valuable element of labour that serves a self-regulatory purpose and results in good birth outcomes for mother and baby.
Contemporary medicalised approaches in maternity care, which are based on an expectation of continuous labour progress, appear to carry a risk for a misinterpretation of physiological plateaus as pathological.
This study challenges the widespread bio-medical conceptualisation of plateauing labour as failure to progress, encourages a renegotiation of what can be considered healthy and normal during childbirth, and provides a stimulus to acknowledge the significance of childbirth philosophy for maternity care practice.
A pre-post implementation study of a care bundle to reduce perineal trauma in unassisted births conducted by midwives
2024, Women and Birth
The perineal-bundle is a complex intervention widely implemented in Australian maternity care facilities.
Most bundle components have limited or conflicting evidence and the implementation required many midwives to change their usual practice for preventing perineal trauma.
To measure the effect of perineal bundle implementation on perineal injury for women having unassisted births with midwives.
A retrospective pre-post implementation study design to determine rates of second degree, severe perineal trauma, and episiotomy. Women who had an unassisted, singleton, cephalic vaginal birth at term between two time periods: January 2011 – November 2017 and August 2018 – August 2020 with a midwife or midwifery student accoucheur. We conducted logistic regression on the primary outcomes to control for confounding variables.
data from 20,155 births (pre-implementation) and 6273 (post-implementation) were analysed. After implementation, no significant difference in likelihood of severe perineal trauma was demonstrated (aOR 0.86, 95% CI 0.71–1.04, p = 0.124). Nulliparous women were more likely to receive an episiotomy (aOR 1.49 95% CI 1.31–1.70 p < 0.001) and multiparous women to suffer a second degree tear (aOR 1.18 95% CI 1.09–1.27 p < 0.001).
This study adds to the growing body of literature which suggests a number of bundle components are ineffective, and some potentially harmful. Why, and how, the bundle was introduced at scale without a research framework to test efficacy and safety is a key concern.
Suitably designed trials should be undertaken on all proposed individual or grouped perineal protection strategies prior to broad adoption.
Pregnant persons and birth partners' experiences of shared decision-making during pregnancy and childbirth: An umbrella review
2023, Patient Education and Counseling
This umbrella review aimed to summarize evidence on pregnant persons and/or their birth partners' experiences and expectations of SDM during pregnancy and childbirth.
We searched eight databases from 2011 to 2023. Quantitative, qualitative and mixed methods systematic reviews were included in this review.
We have identified 26 reviews that report on 622 primary studies involving over 213,000 pregnant persons and 22,000 birth partners, examining a broad range of decision-making scenarios in maternity care. The three-talk model was used to categorise the themes which include communication, weighing options, and making a decision. Multiple reviews have reported that pregnant persons and birth partners have mixed experiences in several decision-making scenarios, with insufficient information and inadequate consideration or answers to their questions being common issues. Pregnant persons and birth partners prefer clear explanations, simple communication, and involvement in decision-making. Exclusion from the decision-making during pregnancy and childbirth may lead to negative experiences, whilst involvement improves satisfaction, reduces distress and fosters empowerment.
The review highlights the importance of promoting SDM in maternity care, as it is fundamental to promoting maternal, newborn, and family well-being.
Health systems should redesign antenatal classes and train healthcare providers to enhance communication skills and encourage informed decision-making by pregnant persons and birth partners.
Keywords
Skills and knowledge of midwives at free-standing birth centres and home birth: A meta-ethnography
2023, Women and Birth
When midwives offer birth assistance at home birth and free-standing birth centres, they must adapt their skill set. Currently, there are no comprehensive insights on the skills and knowledge that midwives need to work in those settings.
Midwifery care at home birth and in free-standing birth centres requires context specific skills, including the ability to offer low-intervention care for women who choose physiological birth in these settings.
To synthesise existing qualitative research that describes the skills and knowledge of certified midwives at home births and free-standing birth centres.
We conducted a systematic review that included searches on 5 databases, author runs, citation tracking, journal searches, and reference checking. Meta-ethnographic techniques of reciprocal translation were used to interpret the data set, and a line of argument synthesis was developed.
The search identified 13 papers, twelve papers from seven countries, and one paper that included five Nordic countries. Three overarching themes and seven sub-themes were developed: ‘Building trustworthy connections,’ ‘Midwife as instrument,’ and ‘Creating an environment conducive to birth.’
The findings highlight that midwives integrated their sensorial experiences with their clinical knowledge of anatomy and physiology to care for women at home birth and in free-standing birth centres. The interactive relationship between midwives and women is at the core of creating an environment that supports physiological birth while integrating the lived experience of labouring women. Further research is needed to elicit how midwives develop these proficiencies.

View all citing articles on Scopus

View full text

REVIEW ARTICLEMidwives’ and obstetricians’ perceptions of risk and its impact on clinical practice and decision-making in labour: An integrative review

Abstract

Background

Aim

Methods

Findings

Conclusion

Introduction

Section snippets

Methods

Discussion

Conclusion

Acknowledgements

J Midwifery Women's Health

Midwifery

Health Policy

J Clin Epidemiol

Women Birth

Midwifery

Midwifery

Midwifery

Midwifery

Midwifery

Midwifery

Women Birth

J Midwifery Women's Health

Midwifery

Midwifery

Midwifery

J Midwifery Women's Health

J Midwifery Women's Health

Midwifery

Risk, theory, social and medical models: a critical analysis of the concept of risk in maternity care

Midwifery

Rethinking risk and safety in maternity care

Normal birth rates in England

Perinatal Statistics Report 2012, Dublin

Australia's mothers and babies 2011

Health do maternity matters: choice, access and continuity of care in a safe service

REVIEW ARTICLE
Midwives’ and obstetricians’ perceptions of risk and its impact on clinical practice and decision-making in labour: An integrative review