Mandie Scamell

Fateful moments and the categorisation of risk: Midwifery practice and the ever-narrowing window of normality during childbirth

In this article, we examine the ways in which risk is categorised in childbirth, and how such categorisation shapes decision-making in the risk management of childbirth. We consider the ways in which midwives focus on and highlight particular adverse events that threaten the normality of childbirth and the life of the mother and/or her baby. We argue that such a focus tends to override other elements of risk, especially the low probability of such adverse events, resulting in ‘an ever-narrowing window of normality’ and a precautionary approach to the management of uncertainty. We start our analysis with a discussion of the nature of childbirth as a fateful moment in the lives of those involved, and consider the ways in which this fateful moment is structured in contemporary society. In this discussion, we highlight a major paradox; although normal childbirth is both highly valued and associated with good outcomes in countries like the UK, there has been an apparent relentless expansion of ‘the birth machine’ whereby birth is increasingly defined through the medicalised practices of intensive surveillance and technocratic intervention. We explore the dynamics that create this paradox using ethnographic fieldwork. In the course of this work, the lead author observed and recorded midwives’ work and talk in four clinical settings in England during 2009 and 2010. In this article, we focus on how midwives orientate themselves to normality and risk through their everyday talk and practice; and on how normality and risk interact to shape the ways in which birth can be legitimately imagined. We show that language plays a key role in the categorisation of risk. Normality was signified only through an absence of risk, andhad few linguistic signifiers of its own through which it could be identified and defended. Where normality only existed as the non-occurrence of unwanted futures, imagined futures where things went wrong took on a very real existence in the present, thereby impacting upon how birth could be conceptualised and managed. As such midwifery activity can be said to function, not to preserve normality but to introduce a pathologisation process where birth can never be categorised as normal until it is over.

Time, risk and midwife practice: the vaginal examination

In this article, we examine the impact on midwifery practice of clinical governance in the UK with its shift from individual autonomous practice based on personal experience and intuition (embodied knowledge) to the collective control of work based on guidelines and protocols (encoded knowledge) associated with the scientific–bureaucratic approach to care. We focus on the ways in which midwives use partograms and associated vaginal examinations to monitor and manage the progress of labour. The partogram represents (among other things) a timetable for dilation of the cervix during labour. Women who fail to keep up with this timetable are shifted from a low-to-high risk category and subjected to additional surveillance and intervention. In this article, we draw on empirical evidence taken from two independent ethnographic studies of midwifery talk and practice in England undertaken in 2005–2007 and 2008–2010, to describe the ways in which midwives practice of vaginal examinations during labour both complies with, while at the same time creatively subverts, the scientific–bureaucratic approach to maternity care. We argue that although divergent in nature, each way of practicing is mutually dependent upon the other: the space afforded by midwifery creativity not only co-exists with the scientific–bureaucratic approach to care, but also sustains it.

Risk, pregnancy and childbirth: What do we currently know and what do we need to know? An editorial

In the first part of this editorial we reflect on some of the recent articles published in Health Risk & Society that contribute to our understanding of the ways in which the risks associated with pregnancy and childbirth are constructed. In the second part, we identify specific issues that would benefit from further study and which we would like to address in a forthcoming Health Risk & Society special issue.

The fear factor of risk – clinical governance and midwifery talk and practice in the UK

OBJECTIVE Through the critical application of social theory, this paper will scrutinise how the operations of risk management help to constitute midwives׳ understandings of childbirth in a particular way. DESIGN AND SETTING Drawing from rich ethnographic data, collected in the southeast of England, the paper presents empirical evidence to critically explore how institutional concerns around risk and risk management impact upon the way midwives can legitimately imagine and manage labour and childbirth. Observational field notes, transcribed interviews with various midwives, along with material culture in the form of documentary evidence will be used to explore the unintended consequences of clinical governance and its risk management technologies. KEY CONCLUSIONS Through this analysis the fear factor of risk in midwifery talk and practice will be introduced to provide an insight into how risk management impacts midwifery practice in the UK.

Effectiveness of vaginal breech birth training strategies: An integrative review of the literature.

BACKGROUND The safety of vaginal breech birth depends on the skill of the attendant. The objective of this review was to identify, synthesize, and report the findings of evaluated breech birth training strategies. METHODS A systematic search of the following on-line databases: Medline, CINAHL Plus, PsychINFO, EBM Reviews/Cochrane Library, EMBASE, Maternity and Infant Care, and Pubmed, using a structured search strategy. Studies were included in the review if they evaluated the efficacy of a breech birth training program or particular strategies, including obstetric emergency training evaluations that reported differentiated outcomes for breech. Out of 1040 original citings, 303 full-text articles were assessed for eligibility, and 17 methodologically diverse studies met the inclusion criteria. A data collection form was used to extract relevant information. Data were synthesized, using an evaluation levels framework, including reaction, learning (subjective and objective assessment), and behavioral change. RESULTS No evaluations included clinical outcome data. Improvements in self-assessed skill and confidence were not associated with improvements in objective assessments or behavioral change. Inclusion of breech birth as part of an obstetric emergencies training package without support in practice was negatively associated with subsequent attendance at vaginal breech births. CONCLUSIONS As a result of the heterogeneity of the studies available, and the lack of evidence concerning neonatal or maternal outcomes, no conclusive practice recommendations can be made. However, the studies reviewed suggest that vaginal breech birth training may be enhanced by reflection, repetition, and experienced clinical support in practice. Further evaluation studies should prioritize clinical outcome data.

Choice, Risk, and Moral Judgment: Using Discourse Analysis to Identify the Moral Component of Midwives’ Discourses

In this chapter we examine midwives’ discourses in relationship to risk and place of birth. We analyse the ways in which these discourses take place at the intersection of two discrete imperatives: to provide pregnant women with choice over where and how they give birth; and to protect mothers and babies from harm. When midwives’ assessment of risk of harm during birth is aligned with their assessment of the riskiness of a woman’s preferred place of birth then there is little need or purpose in scrutinising this choice. However where there is a misalignment then midwives feel obliged to interrogate the choice, especially when midwives categorise a mother as high risk and they want to restrict the range of choices. In this chapter we focus on the discursive methods that midwives use to shape mothers’ decisions when pregnant women are unwilling to accept midwives’ risk categorisation and/or the recommended place and method of birth.

‘She can't come here!’ Ethics and the case of birth centre admission policy in the UK

Using ethnographic data lifted from an investigation into midwifery talk and practice in the South of England, this paper sets out to interrogate the ethics underpinning current admission policy for Free Standing (midwifery led) Birth Centres in the UK. The aim of this interrogation is to contest the grounds upon which birth centres admissions are managed, particularly the over-reliance on abstract calculations of risk—far removed from the material lived experience of the mother wishing to access these birth centre services.

Deliberate acquisition of competence in physiological breech birth: A grounded theory study

PROBLEM Research suggests that the skill and experience of the attendant significantly affect the outcomes of vaginal breech births, yet practitioner experience levels are minimal within many contemporary maternity care systems. BACKGROUND Due to minimal experience and cultural resistance, few practitioners offer vaginal breech birth, and many practice guidelines and training programmes recommend delivery techniques requiring supine maternal position. Fewer practitioners have skills to support physiological breech birth, involving active maternal movement and choice of birthing position, including upright postures such as kneeling, standing, squatting, or on a birth stool. How professionals learn complex skills contrary to those taught in their local practice settings is unclear. QUESTION How do professionals develop competence and expertise in physiological breech birth? METHODS Nine midwives and five obstetricians with experience facilitating upright physiological breech births participated in semi-structured interviews. Data were analysed iteratively using constructivist grounded theory methods to develop an empirical theory of physiological breech skill acquisition. RESULTS Among the participants in this research, the deliberate acquisition of competence in physiological breech birth included stages of affinity with physiological birth, critical awareness, intention, identity and responsibility. Expert practitioners operating across local and national boundaries guided less experienced practitioners. DISCUSSION The results depict a specialist learning model which could be formalised in sympathetic training programmes, and evaluated. It may also be relevant to developing competence in other specialist/expert roles and innovative practices. CONCLUSION Deliberate development of local communities of practice may support professionals to acquire elusive breech skills in a sustainable way.

Sarah's birth. How the medicalisation of childbirth may be shaped in different settings: Vignette from a study of routine intervention in Jeddah, Saudi Arabia.

BACKGROUND The expansion of the medicalisation of childbirth has been described in the literature as being a global phenomenon. The vignette described in this paper, selected from an ethnographic study of routine intervention in Saudi Arabian hospitals illustrates how the worldwide spread of the bio-medical model does not take place within a cultural vacuum. AIM To illuminate the ways in which the medicalisation of birth may be understood and practised in different cultural settings, through a vignette of a specific birth, drawn as a typical case from an ethnographic study that investigated clinical decision-making in the second stage of labour in Saudi Arabia. METHODS Ethnographic data collection methods, including participant observation and interviews. The data presented in this paper are drawn from ethnographic field notes collected during field work in Saudi Arabia, and informed by analysis of a wider set of field notes and interviews with professionals working in this context. FINDINGS While the medicalisation of care is a universal phenomenon, the ways in which the care of women is managed using routine medical intervention are framed by the local cultural context in which these practices take place. DISCUSSION The ethnographic data presented in this paper shows the medicalisation of birth thesis to be incomplete. The evidence presented in this paper illustrates how local belief systems are not so much subsumed by the expansion of the bio-medical model of childbirth, rather they may actively facilitate a process of localised reinterpretation of such universalised and standardised practices. In this case, aspects of the social and cultural context of Jeddah operates to intensify the biomedical model at the expense of respectful maternity care. CONCLUSION In this article, field note data on the birth of one Saudi Arabian woman is used as an illustration of how the medicalisation of childbirth has been appropriated and reinterpreted in Jeddah, Saudi Arabia.

Effectiveness of Vaginal Breech Birth Training Strategies: An Integrative Review of the Literature

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