The Individual Assessment of Risk

     Earlier this year, the factions within the world of childbirth advocacy were up in arms once again spurred by the release of a study through the Midwives Alliance of North America Statistics Project which concluded that planned midwife-led homebirths for low-risk women lessened the use of intervention and increased the incidence of physiological birth while not increasing adverse outcomes.  Immediately, there were rebuttals from the anti-homebirth movement calling the data flawed and citing research conducted from within their own camp where they concluded that babies born at home with midwives were four times more likely to die than babies born in hospitals.  Both groups question the other’s methods.  Both groups say that their way is potentially “safer”.

                These arguments of risk are not limited to homebirth vs. hospital birth.  Take VBAC (vaginal birth after cesarean) for instance.  If you Google “is vbac safe”, all of the top choices will tell you that for most women it is.   Some of the sources even say it is safe for up to 90% of women who would seek VBAC birth.  Despite this body of evidence that shows VBAC is a reasonable option for many mothers with a prior cesarean surgery, only around 8% of women in the United States VBAC.  Women seeking VBAC are given numbers and claims about its safety that don’t add up in order to be dissuaded.  Yet, even with clear evidence in support of VBAC being a safe option, those who consider themselves advocates of VBAC are also giving women unrelated risk scenarios in order to make a comparison, potentially clouding a person’s perception of the risk.  As you can read in Jen Kamel’s (www.vbacfacts.com) blog post “Lightening Strikes, Shark Bites, & Uterine Rupture,” comparing two dissimilar events can be problematic when trying to convey risk to someone.

                Whose responsibility is it to convey the risks of pregnancy and birth to women?  Is it possible to explain your understanding of the risks of a choice in unbiased terms or by simply adding your understanding of the risks in question are you imposing your choice onto another?  Assessing or sharing the risks and benefits of choice is not an easy spot to be in as a mother, a birth professional, or a care provider.  It is inevitable that we will feel that we or someone we know could have made a better choice.  There may even be times when we feel so strongly about the choice of another that we feel we must save them from it without asking ourselves whose choice it is to make and whose responsibility are the consequences of choice in the childbearing year?

                Do numerous studies and the varying opinions of “professionals” help make clearer the inherent risks of our choices in maternity care?  Regardless of fact, the discernment of risk is largely individual and is impacted by the personal values, beliefs, and experiences of a person.  There is no one way in which a person understands and assesses risk, and some of the ways in which we process risk can compete with one another.  It is apparent that when discussing risk, it is near to impossible not to impress personal assessments onto your explanation.

                What is right for one mother may not be right for another.  Accepting or avoiding risks of options in childbirth is not the responsibility of anyone but the person faced with the choice.  Let us take VBAC as an example.  One mother may have experienced her prior cesarean surgery as traumatic.  Maybe she suffered PTSD as a result of the experience.  She felt belittled by her care provider and felt like the surgery she experienced was unnecessary.  Faced with the choice of VBAC or repeat cesarean, this mother could feel that choosing a setting where she is fully supported in a TOLAC (trial of labor after cesarean) will give her the best chances at VBAC therefore allowing her to remain in control of her birth and give herself and her baby the safest possible start.  This mother may also after researching her local options decide that the location best suited for her birth would be home.  In making these choices on her own terms and being supported in preparing herself for this birth, this mother is eliminating fear.  The risk 0.5-1% risk of uterine rupture seems so very small compared to the potential loss of control, feelings of disrespect, and feelings of harm she had experience while undergoing cesarean before.

                Another mother experienced a cord prolapse after her waters released during her first birth.  She had been laboring naturally and moving as she wanted throughout her labor until that point.  Fortunately, she was at the hospital with competent care providers who assessed the situation quickly and her baby was delivered via cesarean with no lasting complications.  When asked if she would like to VBAC for her next delivery, she asks for a repeat cesarean.  The thought of potential uterine rupture or another cord prolapsed overwhelms her and she feels safer if she can plan her birth.  She wants to be in control of the situation and allowing the doctor to perform another cesarean, while she is awake and everyone is healthy does so much to reduce the fears she has of complications.  The increase risk of problems in future pregnancies seems low to her compared with the potential for complications in birth that she has already experienced.

                The “right” choice for a person is subject to time, place, and experience.  The “right” choice is not unchangeable.  It is as fluid as the human condition.  It is an individual choice.  Our current climate of debate about the safety of our various options in childbirth and the active pursuit to limit or eliminate options from women is to put the whole of humanity in danger.  It is to decry the personal and to take away the right of an individual to accept the responsibility for the choices they make for themselves and the choices we make as a parent.  Neither of the women described above are making a “selfish” choice as critics on both sides have accused women.  They made the choice that gave them the space to transition into the mothering of this new person in safety and peace.

                It does us no good to spend countless hours debating these studies never one to satisfy the other.   It does nothing to improve the standards of maternity care in this country or the world.  All it does is breed confusion and misinformation, and results in skewed judgment and blame.  We can cry out for the right to choose.  We can cry out for protection.  We can cry out for mothers to take responsibility for their births.  The crying will be for naught if we cannot accept that assessment of risk is individual and in order for pregnancy, birth, and yes, even parenting to be healthy there must be room left for personal decision making.  If you are called to be with women in birth, you must regard them as individual and their experience as their own.  Facts will be facts.  Birth will be birth.  While I appreciate and very much respect the studies and research being done in the name of evidence based care in childbirth, the torch we should be carrying during this time is the sanctity of the mother in birth, the rightness of personal experience, and the space for empowered decision making, for how can we accept responsibility for a decision we feel we did not make.