Milli Hill discusses the birthing 'grey areas'
If you believe everything you read, then you probably think that childbirth is one of the riskiest activities any human can undertake.
Actually, it isn't, and statistically you're massively more likely to meet your maker behind the wheel of your motor. However, whilst most episodes of Top Gear tend to skip the bit about your odds of death, it seems like we can't have a conversation about childbirth without focusing almost entirely on the seemingly limitless list of things that might go wrong.
This focus on risk is becoming disproportionate, says Cathy Warwick, CEO of the Royal College of Midwives
"There is concern at the RCM and among midwives, that our focus on risk, and the way that we are describing risk, is making women feel scared. Ironically, creating fear, in itself, causes risk – if women are fearful then they are less likely to release the hormones needed for a straightforward birth."
In spite of these concerns, all UK pregnant women are categorised in terms of 'risk'. Women for whom everything is optimal and normal get called 'low risk', and the others – who might have existing health conditions, or other 'risk factors', for example being over 35, previous caesarean, high BMI, or pregnant with twins - are 'high risk'.
Landing up in the high risk category will probably mean that you are told there are some things that aren't recommended for you, or even 'not allowed'; most commonly giving birth in water, in a birth centre or at home.
Sometimes this feels right and fair enough. If you've got a heart condition, for example, or scans show a potential health problem with your baby, you'll probably welcome the reassurance of a hospital birth and a team of medics to support you and make sure you are both as safe as possible.
For other women, it's not so black and white.
"I wanted to be in the birth centre but because of my age – 42 – the consultant said this was too risky."
"I really wanted a water birth but my blood pressure had raised
slightly so they said I couldn't."
"I had always wanted a home birth but I was told that because I had had a previous caesarean it wasn't allowed."
In these 'grey areas', it's very hard to judge where to put the line, says Cathy Warwick:
"The professional and the woman need to have sensible and constructive discussions, so that the woman is armed with all the facts. What worries me is that doctors and midwives can take 'guidelines' as 'rules' – we need more flexibility around greyer areas."
This lack of flexibility can often ignore the fact that women are the key decision makers in childbirth, not professionals, says Rebecca Schiller, co-founder of human rights charity Birthrights
"The legal principle of consent means that you cannot be compelled to give birth in any particular location or medical setting against your will, so long as you have mental capacity to make your own decisions."
Women are gradually becoming more aware of this right to choose, like Melanie, 36, who had her second baby at home against medical advice:
"I was told I was 'high risk' because of one previous caesarean which meant I couldn't use a midwife-led unit. So after doing my own research I chose to have a home birth. I compared statistics and decided I did not think it was helpful or positive to class women who want VBAC's (Vaginal Birth after Caesarean) as 'high risk'."
Women are also looking at ways to reduce their own personal risk, like Katherine, 29, who is planning a home birth in spite of her BMI of 42:
"What I'm doing to minimise my risk is avoiding over-medicalising my birth. Hypnobirthing, tens machine, birth pool etc are all ready to go. My blood pressure is fine at home yet always high at appointments - so I know I feel safer at home. I had a normal birth with this BMI two years ago and don't agree I have a 60% chance of caesarean. The scaremongering is the biggest risk if you ask me!"
"Risk is relative, it is never absolute" says Cathy Warwick of the RCM. "For example, if you choose to have your baby in a birth centre, you have a 40% chance of transfer. This sounds risky – but what we know is that even those women who do transfer still have better outcomes – and often feel more positive about their births - than those who choose an obstetric unit right from the start."
By asking questions and by understanding that risk can be presented in different ways by different people or policies, pregnant women can empower themselves with information and exercise their rights to make informed choices. However, if you are 'high risk' but don't want to have a home birth, your choices can be limited, as Rebecca Schiller explains:
"In spite of a human right to birth where and how you wish, in real terms it can be extremely difficult to negotiate the choice of water birth or birth centre once you are labelled 'high risk'. Women are then faced with a difficult choice between a consultant led birth (often lacking in facilities to promote their comfort and give them the best chance of avoiding unnecessary intervention) and a home birth that they may feel isn't safe or appropriate. This is unfair: no woman should be denied access to facilities that meet her needs."
It seems our current focus on risk is raising levels of fear and compromising freedom of choice – but is it actually making birth any safer? In the USA, a country that has a highly medicalised approach to childbirth, the maternal mortality rates are double those of the UK, and this is due in part to their emphasis on risk, says Cristen Pascucci of Improving Birth
"Our women and babies are continually put "at risk" in the name of avoiding risk. We have no problem pushing surgery on women "just in case," or giving two out of three women high-risk drugs to force labour even though those same drugs are known to cause fetal distress. We strap nine in ten women to monitoring belts that have false positive rates of over 99%, increasing their odds of major surgery but not improving health outcomes for babies – in America we have an amazing track record of actually introducing complications to labour, and making women uncomfortable, distressed, and violated, in the name of avoiding 'risk'"
The problem with our obsession with risk, both here and in the USA, is that the woman's experience in childbirth, and her individual needs and wishes are rarely considered. For example, the American Congress of Obstetricians and Gynecologists (ACOG) recently denounced water birth
, stating that it is potentially dangerous and has no benefits. Tell this to the thousands of women who have relished giving birth in water and found it not only soothed their labour pain but made them feel safe and in control.
This is irrelevant, the risk assessors would say. But for women, it's not irrelevant. Women care about safety when they birth, but a constant focus on what might go wrong steals any chance of enjoying childbirth, just as talking constantly about car crashes would take the edge off a ride in a convertible on a sunny day. Risk offers a one-size-fits-all approach to birth and blocks its ears to the voices of individuals; it can limit our freedom and make us prisoners of fear. And, most ironically of all, our constant focus on risk is in danger of making birth less safe.