The women of Australia deserve real choice. Real autonomy. Real respect. How does risk status fit into this theme? Women who are classed as high risk are often denied choice and autonomy. However they do not get any say in how their risk status is determined. Women are finding that they are being classed as high risk, for reasons they are not happy with, and then being denied options that are otherwise available to women who fit into the low risk category. Often what they are denied is continuity of care with a known midwife – in other words, high risk women are being denied the gold standard level of care. Ironic much?
Women want continuity of care with a known midwife. Image courtesy of Wikimedia Commons.
I’ve been reading stories from a lot of women who have been assigned as high risk. And here’s what I’m hearing: They are generally assigned this label without ANY consultation whatsoever and it is not negotiable. They are never asked how they feel about or perceive their risk status. When I asked a group of “high risk” women what they most wanted but were being denied the responses were: waterbirth, homebirth with an IM, midwifery care, being able to birth at their local hospital and clarity around risk status and actual risks.
Thankfully we are also seeing an increase of women fighting this. But fighting it isn’t easy. It requires huge emotional output, exceptional negotiation skills and very strong support. Seeking alternatives to “standard” or “routine” care is a tough road to travel. And because so much standard care for high risk women is not evidence based or woman centred it is more often these women who are seeking alternatives. Due to the difficulty of this journey we are seeing increasing numbers of high risk women simply leaving the system and seeking the services of independent midwives to attend them at home.
This, however, presents a whole new set of challenges. Midwives are actively discouraged from attending high risk women at home and we are therefore seeing a rise in the number of high risk women choosing to birth unassisted when they would prefer to birth with a skilled attendant. When I asked what women would like one response (that was made by a few different women) was that they would like to be able to be open about their homebirth plans without fear of their midwife being reported simply for supporting them.
Just so we are clear – a number of midwives are being reported for nothing more than supporting a woman’s informed decision to birth at home or make some other "non recommended" decision. And it’s not the women doing the reporting. Anyone can make a report to the Australian Health Practitioner Regulation Agency (AHPRA), regardless of whether they are involved in the birth. Therefore women are finding that other health care practitioners are reporting their midwives for providing services to them. This is known as vexatious reporting and is a very serious thing to have happen. For a start the midwife’s business will be on hold pending the outcome of the investigation. And the period of time it takes to investigate will likely be measured in years. Being the subject of a vexatious report will usually mean the end of a midwife’s career of being with woman – regardless of the actual outcome of the investigation.
Women are leaving the system behind in favour of "alternative" care. Image courtesy of Wikimedia Commons.
There’s been a fair bit of discussion lately about how homebirth is “safe” for low risk women, but high risk women are really missing from this conversation. Are high risk women really suitable for homebirth? Any woman is suitable for a homebirth where she has made an informed decision that homebirth is best for her, her baby and her family. Even if that woman is high risk. If we are truly talking about risk to the woman and the baby then how can anyone else be making this decision? How can anyone claim to have a higher stake or care more about the outcome than the woman herself?
Women want access to water for labour and birth - regardless of whether they fit the box for low risk. Image courtesy of Wikimedia Commons.
This leads me to believe that when we talk about high risk we are not actually talking about risk to the woman, but rather the risks to the hospital. We know that obstetrics is practiced very defensively with an emphasis on butt-covering. What better way to cover butts than to ensure that everyone is assigned a classification and then putting protocols in place based on those classifications? By taking away the individuality and practising routinely we actually increase risks to individual women – because we are looking at the “classification” rather than the “person” - but we decrease risks to the institution.
The take home message on risk classification is this: We need to stop ticking boxes and start talking to women. After all – women hold the responsibility of their decisions…don’t they deserve the right to make them?
Further reading about the maternity care revolution: