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ORIGINAL RESEARCH – QUALITATIVE
Documenting
risk:
A comparison
of
policy
and
information
pamphlets
for
using
epidural
or
water
in
labour
Elizabeth C. Newnham*, Lois V. McKellar, Jan I. Pincombe
University of South Australia, School of Nursing and Midwifery, GPO Box 2471, Adelaide, South Australia 5001, Australia
‘At
the
simplest
level,
we
may
conclude
that
‘risk
is
in
the
eye
of
the beholder’.1
1.
Introduction
This article draws from the doctoral research of author EN, an
ethnographic
project
which
aims
to
examine
the
way
personal,social,
cultural and
institutional
influences
inform
women’s
choices
regarding
the
use
of
epidural
analgesia
in
labour.
As
midwifery
researchers, we were concerned with rising epidural rates and how
women were informed about epidural analgesia. The focus of this
paper
is
primarily
on
the
stark contrast
that
we
noticed
concerning
the information and use of epidural analgesia, compared with the
information and use of water in labour, which stood out from other
pain relief options because it was so contested, restricted and
controlled. First we discuss the evidence that lies behind our
concern, as we identify the ‘problem’ of epidural use, and present
some of the evidence regarding the use of water in labour and birth.
We then outline the use of critical medical anthropology as the
methodology for this study, and as the framework for analysis,
before moving into the ‘emergent concepts’ of the ethnographic
research findings. The central tenet—that the use of water in labour
and birth was constructed as a risky practice and that this affectedmidwifery practice and women’s choice—is then made, demon-
strated through a comparison of hospital and policy documents and
with reference to wider theoretical literature on risk. The findings
are discussed as they relate to, and further, current debates on the
position of risk in childbirth.
2. Background
Most Australian women (97%) give birth in hospital labour
wards,2 which are primarily obstetric-led units. These units are
Women and Birth 28 (2015) 221–227
A
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Article history:
Received 14 November 2014
Received in revised form 29 January 2015Accepted 31 January 2015
Keywords:
Risk
Choice
Epidural
Waterbirth
Childbirth
A
B
S
T
R
A
C
T
Background:
Approximately 30%of Australianwomenuseepiduralanalgesia forpain reliefin labour, and
its use is increasing. While epidural analgesia is considered a safe option from an anaesthetic point of
view, its use transfers a labouringwoman outof the category of ‘normal’ labour and increases her risk of
intervention. Judicioususeof epiduralmay bebeneficial in particularsituations,but its current common
use needs to be assessed more closely. This has not yet been explored in the Australian context.
Aim: Toexamine personal, social, institutionaland cultural influenceson women in their decision to use
epidural analgesia in labour. Examining this one event in depth illuminates other birth practices, which
can also be analysed according to how they fit within prevailing cultural beliefs about
birth.
Methods: Ethnography, underpinned by a critical medical anthropology methodology.
Results: These findings describe the influence of risk culture on labour ward practice; specifically, the
policies and practices surrounding theuse of epidural analgesia are contrastedwith those on the use of
water. Engaging with current risk theory, we identify the role of power in conceptualisations of risk,
which are commonly perpetuated by authority rather than evidence.
Conclusions: Aswemovetowards a risk-driven society, it is vital to identify both theconception and the
consequencesof promulgationsof risk. Theconstruction ofwaterbirthas a ‘risky’ practice had theeffect
of limiting midwifery practice andwomen’s choices, despite evidence that points to the epidural as the
more ‘dangerous’ option.
2015 Australian College of Midwives. Publishedby Elsevier Australia (a division of Reed InternationalBooks Australia Pty Ltd). All rights reserved.
* Corresponding author. Tel.: +61 8 83021156; fax: +61 8 83022168.
E-mail address: [email protected] (E.C. Newnham).
Contents
lists
available
at
ScienceDirect
Women and Birth
jo u rn al h omep age: w ww.elsev ier .c o m/loc ate /wo mb i
http://dx.doi.org/10.1016/j.wombi.2015.01.012
1871-5192/ 2015 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
http://dx.doi.org/10.1016/j.wombi.2015.01.012http://dx.doi.org/10.1016/j.wombi.2015.01.012http://dx.doi.org/10.1016/j.wombi.2015.01.012http://dx.doi.org/10.1016/j.wombi.2015.01.012http://dx.doi.org/10.1016/j.wombi.2015.01.012http://dx.doi.org/10.1016/j.wombi.2015.01.012http://dx.doi.org/10.1016/j.wombi.2015.01.012http://dx.doi.org/10.1016/j.wombi.2015.01.012http://dx.doi.org/10.1016/j.wombi.2015.01.012http://dx.doi.org/10.1016/j.wombi.2015.01.012http://dx.doi.org/10.1016/j.wombi.2015.01.012mailto:[email protected]:[email protected]://www.sciencedirect.com/science/journal/18715192http://www.elsevier.com/locate/wombihttp://www.elsevier.com/locate/wombihttp://www.elsevier.com/locate/wombihttp://www.elsevier.com/locate/wombihttp://www.elsevier.com/locate/wombihttp://www.elsevier.com/locate/wombihttp://www.elsevier.com/locate/wombihttp://www.elsevier.com/locate/wombihttp://www.elsevier.com/locate/wombihttp://www.elsevier.com/locate/wombihttp://www.elsevier.com/locate/wombihttp://www.elsevier.com/locate/wombihttp://www.elsevier.com/locate/wombihttp://dx.doi.org/10.1016/j.wombi.2015.01.012http://dx.doi.org/10.1016/j.wombi.2015.01.012http://www.elsevier.com/locate/wombihttp://www.sciencedirect.com/science/journal/18715192mailto:[email protected]://dx.doi.org/10.1016/j.wombi.2015.01.012http://crossmark.crossref.org/dialog/?doi=10.1016/j.wombi.2015.01.012&domain=pdfhttp://crossmark.crossref.org/dialog/?doi=10.1016/j.wombi.2015.01.012&domain=pdf
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In order to manage the limitation of water use and facilitate
choice
for women
in
labour,
some
midwives used subtle, or
covert, mechanisms of resistance. As other midwifery research-
ers have found, midwives who are bound by highly regulated
policies that they consider too inflexible, particularly if not
evidence-based,
often find other
ways
to negotiate ‘risk’.30,31,47
For
example:
MW8 (coming out of a labour room): ‘Well, I didn’t see
that . . .she’s in the bath. We’re not really supposed to use them yet,
until
80%
of
the
staff
are
accredited.
But
who
knows
how
long
that’ll
take? She’s in orange [on the board – signifying antenatal – not active
labour] so she’s technically not in labour yet .’
Despite midwives attempting to offer water as a viable
choice,
whether a
woman
could
access this
option was
ultimately dependent on
the
midwife that the woman
had on
the day, and whether she was willing to undertake extra
paperwork, turn a blind eye to hospital policy, or find an
accredited
midwife
to support her
through
a
waterbirth—if
there
was
one available.
4.2. Risk culture and policy—epidural endorsement
The
cultural
emphasis
on
risk
meant
that
it
was
far
easier
to
get
an epidural than it was to get into a bath, but this was not only dueto the risk orientation of the labour ward. The South Australian
Department
of
Health
(DoHSA)
has
produced
three
policies
since
2005
regarding
the
‘alternative’
birth
practices
of
labouring
and
birthing in water. The initial policies were written as separate
documents for labour and birth respectively, but the latest
iteration
Policy
for
First
Stage
Labour
&
Birth
in
Water 32 combines
the
two.
Despite
the
capability
for
this
policy
to
‘legitimise’
the
practice of waterbirth, one of the effects of the introduction of the
Waterbirth Policy was the potential control and restriction of this
practice.50
Women who are contemplating a waterbirth in South Australia
need to read a DoHSA pamphlet based on the policy, which they then
sign.
A
waterbirth
consent
form
also
needs
to
be
signed
and
a
copy
goes into the case notes. By contrast, there is no corresponding state-wide policy requiring women to be fully informed antenatally about
epidural risk factors.
In the
fieldwork site, there
were
two
main documents
pertaining to
epidural
administration: a
hospital-specific
Epidural information handout and an anaesthetic checklist. The
women would also sign a Consent to medical treatment form.
The
Epidural handout
is
discussed below
in
contrast
with
the
Waterbirth [policy] pamphlet .
The following field note
excerpt
captures the inherent contradiction between the requirement
that women need to be fully informed and sign a document
before accessing water
in
labour, and
the consent
process
to
getting
an
epidural.
EN: ’What about epidurals? Do they sign a consent?’
MW13:
‘Yes,
they
sign
a
‘Consent
to
treatment’
form.’EN:
‘Why
is
it
easier
for
women
to
sign
an
epidural
consent
than
a
waterbirth
consent?’
MW13: ‘Because they have to understand the [waterbirth]
policy and all that. I don’t think they can do a true informed consent
if
they’re
in
labour.
I
suppose the
same goes for epidural . I
don’t
know.’
However, in practice, the ‘same’ did not apply to epidural
consent; specifically, there was no policy handout for a woman
to
read and sign.
There
was
no way
of
gauging how much
information
women had received about
epidurals
antenatally.
Many midwives discussed the fact that consent was often gained
verbally prior to the epidural being placed, with the woman
not signing the Consent
to
medical treatment form until after the
epidural had taken
effect.
5. Water versus epidural: risk versus safety
Table 1 contains section titles and information given in the two
leaflets. There is a clear difference in language use and how each
practice
is
framed.
The
language
in
the
Waterbirth
pamphlet
signals
restrictions and conditions. For many women, the fact that
‘hospitals, doctors and midwives. . .generally do not advocate
waterbirth’ would be enough to deter them in making this choice
as
they
negotiate
mainstream
ideas
of
risk
and
responsibility.
Although the Waterbirth pamphlet does not give the source of this
information—indeed it would appear to be completely anecdotal—
it does later appeal to the lack of evidence in support of waterbirth.
However, the evidence actually cited (column 1, row c) identifies
promising outcomes with water use, resulting in an incongruity
between the evidence and the claim that waterbirth is not
supported by midwives and doctors. Still under the ‘Evidence’
section, rare events such as drowning are discussed, leading to the
conclusion that it ‘demands extra care both of who can give birth in
water and how’. It then follows with who is allowed access to water
and the conditions for using a bath. In this section (column 1, row
d) there is a reiteration of the need for safety; implicitly reinforcing
the ‘dangerousness’ of water use as well as appealing to the
woman’s sense of responsibility in the face of such risk. There is not
such a call to consider safety concerns within the Epidural handout .The Epidural handout , which is a hospital specific document, but
also carries a DoHSA logo has none of the cautious tone adopted for
waterbirth. In fact epidurals appear almost to be recommended
(column 2, row a) as a common and effective analgesic choice. The
obstetric
risks
associated
with
epidurals
are
acknowledged,
but
downplayed, and possible negative effects on the baby are
completely ignored; in fact having an epidural is discussed as
being potentially beneficial to the baby (column 2, row e).
The
anaesthetic
risks
(column
2,
row
f)
are
quite
comprehen-
sive, listing rare complications. What is surprising, given this, is
that the overall tone of the Epidural handout —compared to the
Waterbirth pamphlet —is pleasant, conciliatory, and formulated to
facilitate
the
process.
As
can
be
seen
throughout
Table
1, the
overall language of the Epidural handout is that of safety while theWaterbirth pamphlet is couched in terms of risk. There are no
‘conditions’ for who can use an epidural (see column 1, row f).
Particularly
telling
is
the
language
(row
g):
‘you
can
only
give
birth
in
water
if’
as
compared
to
‘can
I
definitely
have
an
epidural?’—
these women are only advised if an epidural is not ‘recommended’,
whereas the women choosing water are ‘told’ if they have a
condition
that
‘prevents’
them
from
using
water
(see
column
1,
row
d).
The
epidural
pamphlet
is
all
about
access—who
can
have
one, while the water birth pamphlet is all about restriction—who
cannot.
5.1. Policy and practice
Restrictions
on
the
use
of
water
in
labour
and
birth
may
bereasonable
enough,
for
example
if
a
woman
has
had
pethidine,
or
indeed an epidural—two of the conditions for not using a bath. But
this judgement, as with much midwifery practice, has usually been
left
to
the
midwife’s
discretion,
in
consultation
with
the
woman,
and
forms
part
of
safe
and
competent
practice
in
line
with
a
multitude of professional practice and ethical guidelines provided
by the Nursing and Midwifery Board of Australia. Government
health
policy
has
not
usually
intervened
at
this
level
of
practice
and
there
is
no
corresponding
concern
about
epidural
use
despite
rare occurrences that happen, ‘casting’ a potential ‘cloud’ over its
use; however, these are not referred to, even though two cases
of
extremely
rare
complications
from
epidural
analgesia
have
occurred
in
the
last
decade
in
Australia.
Adverse
events
have
also
occurred
in
the
US
and
the
UK.
33
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Table 1
Comparison of main headings and content: waterbirth pamphlet and epidural handout.
Column 1 – Waterbirth pamphlet Column 2 – Epidural handout
a Background Introduction
Hospitals, doctors and midwives in South Australia generally do not
advocate waterbirth.
Those who allow the use of water need to adhere to the policies of the
Department of Health for labour and birth in water to occur safely.
Epidurals are commonly used in labour for pain relief. Nearly one in
two women in South Australia has an epidural during labour.
Epidurals provide very good pain relief, and you may want one
when you are in labour.
b
Arguments
for
and
against
the
use
of
a
bath
What
is
an
epidural?Enthusiasts for baths in labour and birth argue that it enhances
relaxation, reduces pain and promotes supportive care.
Critics are concerned about the potential harm to the baby mainly
through getting water in the lungs and the risk of infection.
An epidural is a special form of pain relief . . .Local anaesthetic and
other drugs are given into the epidural space via the catheter. The
drugs help take away the pain from the uterus, cervix and birth
canal by numbing the nerves to these areas.
c Is there good evidence on the use of a bath? How is my epidural put in? Does it hurt?
There is a lot of opinion and anecdote on the use of baths, but little is
substantiated by good scientific evidence. . .Studies have shown. . .less
pain and fewer epidurals. No effects on the duration of labour or on the
condition of the baby have been demonstrated.
Giving birth in water has resulted in some serious incidents that do not
occur outside water, including drowning. . .While these situations have
been rare they have cast a cloud over waterbirth.
First your anaesthetists will assess you to make sure there are no
reasons why you should not have an epidural, and to make sure you
understand the risks and benefits involved.
You will feel a sting as some local anaesthetic is put into the skin at
the area of your lower where the epidural needle will be inserted.
You might feel a dull pressure as the epidural needle is inserted, but
this is usually not painful.
d Who can use a bath? Will I be completely numb? Does an epidural always work?
In or outside the bath, safety for you and your baby are the main
concerns. You should not use the bath at all:
If there is a state of altered consciousness. . .
If you have an epidural. . .
If either you or your baby need a level of monitoring that is difficult to
achieve in a bath. . .
Your doctor of midwife will tell you if there is a condition that would
prevent you from using the bath during labour or for the birth.
Different strengths of local anaesthetic solution can be used.
Stronger solutions used to relieve stronger pain will cause more
numbness, heavy legs and less pushing sensation. About 1 in
20 women maynot get adequate pain relief. You may feel some pain
in the 2nd stage of labour if the epidural is allowed to wear off for
pushing.
e Conditions for using a bath during labour Will I be able to push mybaby out? Will the epidural affect my
baby?
You must not have a condition that makes use of the bath too risky
You must never be alone in the room when using the bath. . .
You can leave the bath at any time you wish.
You must leave the bath to urinate.
You must also leave the bath when advised to do so for safety reasons.
You cannot have pain killers or an epidural when using the bath.
Having an epidural can make the second stage of your labour longer,
and there is a slightly higher chance you will need help delivering
your baby, either with forceps or the suction cup (Ventouse). Some
studies suggest you have a slightly higher chance of needing
Caesarean delivery, but this is not definite.
As long as your blood pressure is well maintained during labour
there is little effect on your baby from an epidural. In fact an
epidural may be better for your baby than other types of pain relief
as it minimises the effects of painful labour.
f Conditions for giving birth in a bath Are epidurals safe? Can I be paralysed?
All conditions for using a bath during labour must be met.There must be no medical reasons against giving birth in water.
You must be prepared to leave the bath when necessary for reasons of
safety.
You may need to stand up to facilitate the birth.
The baby must be brought to the surface as soon as it is born. . .
The baby’s cord must not be cut underwater.
After birth the baby must be protected against heat loss (a wet baby
loses heat 25 times faster than a dry baby).
You must leave the bath for the delivery of the placenta after the baby is
born.
Epidurals are very safe, but there are some common minor sideeffects. Serious problems do occur, but are very rare. Common side
effects include discomfort. . .a drop in blood pressure, and
occasionally the need for a catheter in the bladder. . .If the epidural
needle is unintentionally inserted too far it can puncture the
membrane containing the spinal fluid, causing severe
headache. . .Less common side effects include the epidural working
too high up your body, leading to some difficulty breathing. Rarely,
local anaesthetic gets into your circulation and can cause problems
with your heart, or directly affects your brain, leading to a fit or
convulsion. . .with prompt medical attention should cause no long-
term harm.
Temporary nerve injury. . .happens about 1 in 1000 deliveries.
Nerve damage causing permanent paralysis can also happen after
an epidural, but is extremely rare (less than 1 in 100,000 epidurals).
Infection or bleeding around the spinal cord. . .are very serious
problems, but both are very rare.
If
you
are
worried
about
any
of
these
side
effects
you
should
discussthem with an anaesthetist well before your delivery day.
g You can only give birth in water Can I definitely have an epidural?
If you have a normal pregnancy and normal labour
If you explicitly ask for a waterbirth
If you accept to leave the bath when advised to do so. . .
You have been informed of the Department of Health policies on the use
of water for labour and birth
If you have read this leaflet, understood it and discussed it with your
midwife or doctor and signed the consent form below; and
Ifyou are attended throughout by a midwife or doctor who is confident
and experienced in conducting waterbirths.
Your epidural will be difficult to insert if you are overweight or have
certain back problems. . .
If you have a bleeding problem or are taking medication to thin the
blood, you might be advised not to have an epidural.
h I confirm that I have received a copy of the Labour and Birth in Water
information, have read it, understood it and discussed the management
of labour and birth with the person whose signature appears below.
If you ask for an epidural when you are in labour you will be asked
to sign a consent form to show that you have read and understood
this information.
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In addition, in this and other venues across South Australia,
midwives
are
not
required
to
undertake
extra
training
or
accreditation to monitor and safely manage epidural analgesia,
although it is likely as necessary, given the complexities
introduced by this intervention. Women are not informed that
they
‘must
be
attended
throughout
by
a
midwife
or
doctor
who
is
confident
and
experienced
in
conducting’
epidural
management
(see column 1, row g) despite this surely being optimal; neither are
they required to read a policy document which outsets the practice
they
are
desiring
for
their
labour
in
clear
terms
of
risk
and
restriction,
and
have
it
signed
before
labour.
6. Discussion
In
comparing
these
two
documents
we
have
drawn
attention
to
the way in which practices are framed as risky or safe depending on
their acceptance by hospital culture, rather than their actual level
of
risk.
In
Beck’s34 description
of
risk
society,
a
self-reflexive
era
of
modernity
where
ideas
of
certainty
are
no
longer
possible,
he
identifies the ‘power game of risk’ acknowledging that power rests
with whomever gets to define risk in the current environment of
‘manufactured
uncertainties’.
So,
while
risk
analysis
may
contrib-
ute
to
the
diminishment
of
certain
real
dangers,
the
construction
of
particular practices as risky—and certain individuals as ‘at risk’—also serves to maintain existing authoritative social structures.34
As
we
move
increasingly
towards
a
risk-driven
society,
it
becomes
more
important
to
critically
assess
our
cultural
meanings
and
understandings of particular practices and the way in which risk is
assigned. As in our example above, the ‘manufacturing’ of
waterbirth
as
an
‘uncertain’
(risky)
practice
is
evident.
Yet,
the
inculcation
of
risk
discourse
into
the
everyday
language
and practice of midwives is of concern. It can impact on midwifery
practice,
even
for
those
midwives
who
see
themselves
as
coming
from
a
midwifery
philosophy,
and
it
restricts
choices
for
women
in
ways that are imperceptible, or at least not necessarily overt,
exampled by the difference in language between the two
pamphlets.
6.1. Theorising risk
Smith,
Devane
and
Murphy-Lawless35 argue
that
risk
as
a
concept
is
both
abstract
and
unstable.
Its
changeable
boundaries
mean that the constitution of risk varies over periods of time and
is not always based in evidence,36,37 implicating it as an inexact
frame
of
reference.
The
placement
of
evidence
and
anecdote
within
the
two
leaflets
demonstrates
how
the
language
of
risk
in
this
case is manufactured to uphold acceptable medical practices and
discourage the ‘alternative’. Anecdotal evidence suggesting cata-
strophic
possibilities
are
included
in
the
information
on
waterbirth
to
further
dissuade
women
from
this
choice,
while
adverse
events
associated with epidural analgesia are not mentioned.
Despite
society’s
current
obsession
with
risk,
its
use
as
amanagement
tool
is
fallible
because
its
primary
deductive
methods—statistics
and
probability—are
abstract
concepts
which
are inexact predictors of pregnancy outcomes; women designated
at low-risk may have an acute, emergency event, and women
designated
as
high-risk
can
birth
without
experiencing
a
complication.38,39 And
this
is
the
final
dilemma:
risk
factors
as
identified through probability, mediated by guidelines, and
internalised by women can inspire fear and alienation without
necessarily
safeguarding
against
the
uncertain
event,
which
in
any
case
may
never
happen.
Risk analysis in maternity care is therefore a fragile science.
While the science of risk is essentially based on probability, Lane40
observes
that
‘under
the
medical
model
of
childbirth,
risk
has
been
assigned
to
individuals
rather
than
structural
and
social
conditions.
The individualisation of risk has, therefore, legitimated the routine
use
of
interventions’.
The
paradoxical
nature
of
how
risk
manage-
ment can work against individuals is lucidly illustrated in the
following example:
formal risk management schedules too frequently protect the
interests of hospitals, health authorities, and ultimately, the
state
through
its
regulatory
bodies.
If,
for
example,
a
woman
wants
to
birth
at
home
because
the
birth
of
her
previous
baby
in
an overcrowded, understaffed public hospital, with too fewmidwives experienced in sustaining the birth process without
intervention,
and
a
heavy
reliance
on
routine
CTG
as
part
of
the
local
protocols,
leading
to
an
emergency
caesarean
section,
a
common enough occurrence, that event itself now precludes
the woman from giving birth at home as a VBAC. The woman
has
already
sustained
a
traumatic
and
damaging
outcome
physically
and
psychologically.
The
state
and
its
institutions
will take no responsibility whatsoever for the lack of ‘best
practice’ leading to this outcome; indeed the woman may well
have
been
told
or
been
encouraged
to
infer
that
the
emergency
Caesarean
section
‘saved’
her
baby,
yet
the
conditions
of
care
and poor clinical management of her labour will not be ‘seen’, as
problematic, let alone documented as ‘risk factors’. Her decision
to
have
a
subsequent
baby
at
home
will
be
blocked
because
of the obstetric belief that any birth which happens beyond the
borders of a hospital constitutes a greater ‘risk’ compared with
birth inside a hospital simply because it lies beyond that border,
and therefore beyond its control.37
Risk society encourages the constitution of the self as an
individual;
the
responsibility
to
avoid
risk
is
placed
firmly
on
the
self.34Women
are
thus
positioned
as
choosing
agents,
and
there
is
pressure to succumb to social norms that define risk, thereby
avoiding the stigma of risk-taking behaviours, and there was an
appeal
to
this
sense
of
responsibility
throughout
the
Waterbirth
pamphlet .
Women
can
participate
in
‘purchasing’
freedom
from
risk35 by utilising private obstetricians, or consenting to interven-
tion, and this is the main thrust of obstetric discourse in
Australia.41,42 However, the obstetric model is an unreliablesafeguard
against
risk,
as
interventionist
practices
can
increase
the
risk of adverse outcomes.38,41,43,44Nevertheless, medicalised birth
practices are continually promoted as the safest option,51 while
midwifery
models
and
non-interventionist
practices
are
still
framed
as
occupying
a
position
of
risk.
Bryers and van Teijlingen38 raise the concept of tolerable risk,
whereby individual perceptions of what constitutes a risky
practice
are
weighed
up
and
some
freedoms
or
compromises
are
made
in
order
to
feel
safe.
These
individual
meanings
of
risk
differ according to prior experience and beliefs about birth
practices,
and
will
vary
depending
on
whether
one
is
committed
to
a
model
of
childbirth
as
inherently
risky,
or
inherently
normal.
Women therefore make their own interpretation of risk and safety
according
to
their
own
parameters,
which
may
differ
from
those
of the
medical
establishment.35,45–47Operating
from
a
‘risk
manage-
ment’
perspective,
women’s
understanding
and
experience
of
pregnancy and birth can be overlooked by the medical model. The
use of the risk model of birth serves to maintain medical authority
and
control
over
birth
processes,
often
working
against
current
evidence.35,37,38,41,42,47 Interestingly,
Bryers
and
van
Teijlingen38
use the very example of water use and epidural analgesia to
illustrate their point of how tolerable risks come to be accepted:
when a woman who has had a previous caesarean section
chooses to have a waterbirth, the midwife is put in a difficult
position:
she
may
wish
to
support
the
woman,
but
to
do
so
will
mean
that
she.
.
.is practising
outside
the
agreed
clinical
guide-
lines.
Both
the
midwife
and
the
woman
will
face
considerable
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