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

Abstract

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.

Keywords:

• risk
• risk categorisation
• risk management
• midwifery
• midwives
• childbirth

Notes

1. This section provides only a brief descriptive account of methods. Detailed discussion of the methodological implications of the research design, in terms of author impact and construction of identity, translation of culture, sequential consent, etc., has been presented elsewhere and is beyond the remit of this paper.

2. Ten midwifery managers, 10 midwives, two student midwives, two independent midwives and threepressure group representatives.

3. The first author is a registered midwife, but for the purposes of the study is licensed to practice as a maternity care assistant.

4. Stretch and sweep is a procedure where a midwife or doctor will ‘sweep’ a finger around the cervix during an internal examination. The aim is to separate the fetal membranes from the cervix, leading to a release of prostaglandins and subsequent onset of labour (National Institute for Health and Clinical Excellence 2008, p. xii).

5. Both interventions into the birth process are done by midwives without any recourse to the multidisciplinary team. These are what might be called midwifery interventions and, assuch, are seen not as interventions at all, but as part of a process for facilitating normal birth (Annandale 1988).

6. The partogram, or picture of labour, is a universal chart designed in the 1970s for recording observations of mother and baby, including contraction pattern rate and strength, cervical dilatation, etc.

7. Vaginal examination.

8. The text being analysed here is the printed 2004 version. It should be noted that the online version has an update to include a more up-to-date International Confederation of Midwives definition which does include reference to normality. The modality of this reference, however, is significantly reduced as the word is sandwiched between other risk-orientated concerns and appears in a list of five activities, four of which coalesces around risk and abnormality.