A few moments ago I was sitting on my deck in the morning sun with a coffee in my hand, looking at the wallaby grazing nearby and wondering about what I was going to write about for this week’s blog. None of the ideas I had written down were begging to be written. I pulled up Twitter and distractedly scrolled through and my eye landed on the term “high-risk obstetrics”. It is a term that makes me feel uncomfortable each time I see it, as does its counterpart “high risk women”, and a whole pile of other phrases that are fairly commonplace in maternity care that start with “high risk”. Today’s blog post explains why these phrases make my eyebrows twitch.
Being a writer helps me think
One of the gifts I was given during my PhD years was to realise that writing ALL THOSE DRAFTS, much of which didn’t make it anywhere near the final thesis – was the opportunity to play with language and to think deeply about how I wanted to express myself. The approach I used for my research (Institutional Ethnography) had its roots in what is known as the linguistic turn in philosophy, where people started paying more attention to the relationship between language and power. Consequently, I was often bumping up against words and phrases I was familiar with as an obstetrician, and finding myself saying ‘ just hang on a moment, what is really going on here?’ in a way that had never happened for me before. This meant I could explore the history of term, understand how it related to obstetric power, and decide whether it served me well in my writing or not.
Who is the risky one?
The term risk has multiple meanings (if you are academically interested in understanding the concept, I can recommend Deborah Lupton’s excellent book Risk, linked in the reference list). In obstetric circles, it gets tossed about enthusiastically without much critical thought, and is meant to convey the concept that because a woman has a particular thing (a test result, part of their previous pregnancy experience, an aspect of who they are) they or their fetus / baby are more likely to experience a poor outcome.
Let’s back up for a moment and look at the way “high risk” is used on non-healthcare communication. The other social institution where the term “high risk” is used a lot is the legal / judicial / policing / carceral world. A high risk offender or prisoner is a person who is likely to offend again, or to behave in a manner that puts other people at risk. They are the source of the risk. High risk families are families considered likely to abuse or harm children. Again the family is the risky thing here. A high risk environment is one in which a person in that environment is more likely to end up being harmed.
In healthcare, the relationship between the high risk label and what it is attached to is different and variable. “High risk women” could be women who are more likely to have a poor health outcome for themselves. This isn’t the most common meaning of the term as I encounter it though. More often I see it used to mean that the fetus or baby is at higher risk of a poor outcome because of a factor that belongs to the woman (her age, her body mass index, her fasting blood glucose). This is like the use of high risk in the legal world – the woman is risky for someone else.
The label “high risk woman” is also a marker for a person who generates risk for the healthcare organisation. Typically speaking the risk here is to the organisation’s reputation. Healthcare organisations are meant to identify “high risk women” and manage that risk, thereby preventing the poor outcome the risk factor predicted. Failing to avoid that risk by breaking social rules about how to manage risk, brings the organisation into the firing line for criticism (look at every investigation into the safety of maternity services ever conducted).
Therefore “high risk women” become a focus for maternity care providing organisations. To avoid criticism, the organisation and their healthcare providers need systems to identify “high risk women” and provide ways to manage this risk. This works well when there are effective mechanisms to actually bring down the chance of a bad thing happening to the woman, her fetus, and / or her baby. It doesn’t work so well when there is no effective mechanism, leaving the organisation to perform “safety theatre” – that is to provide forms of healthcare that are socially accepted and believed to make a difference, while there is no actual proof they really do reduce risk. (I’m looking at you, CTG machines.)
Safety theatre is a great show, but when you pull pack the curtains, it is all made up.
Why we need “high risk clinics” run by “high risk obstetricians” who practice “high risk obstetrics”
In our current risk focussed maternity care systems, once a woman has picked up the “high risk” label, the expected response is that these women get different care to women without this label. This has worked very effectively for obstetrics starting from the time when “male midwives” (aka obstetricians) emerged and started shifting birth into the hospital environment. Obstetrics got to define the terms by which women were labelled “high risk”, and obstetrics was presented as the best solution to resolve the risk. Midwives get the left overs – the very small proportion of women who manage to escape this risk labelling. This is why I find the idea that “midwives are the experts in normal birth” problematic – but I’ll leave that discussion for another day!
A clear demonstration that the maternity care organisation takes risk management seriously is to create a “high risk clinic” and staff it with “high risk obstetricians” who practice “high risk obstetrics”. All these labels are like set dressing in the safety theatre show. Look at us! We are doing risk management and that makes us a great maternity care provider! If the bad thing still happens, the organisation can now (mostly) escape criticism, because the risk was identified and managed in ways that are considered appropriate by obstetrics. If the bad thing still happened, that’s now not the organisations fault. Bad stuff still happens because you can reduce risk but not eliminate it, right?
Not everyone speaks “healthcare”
For people who aren’t insiders in the world of healthcare, the phrases I have used here can be read in a different way. And that way that is completely opposite to how they are read in maternity care. For example:
- A high risk obstetrician is one who is highly likely to get things wrong and do something that leads to harm to the people they are caring for or are working with
- High risk obstetrics is a set of knowledges and practices that when applied, are highly likely to lead to poor outcomes
- A high risk clinic is where high risk obstetricians apply their high risk obstetric ideas and techniques and people get harmed
A woman who has spent her earlier life being told to avoid high risk situations and environments might therefore be very anxious about attending a high risk clinic – because it is dangerous right?!
Why maternity professionals should “unlearn” language
The term “professional” refers to a group of people who have mastered the use of a specific “discourse” – a way of using language. Maternity professionals must become fully fluent in obstetric ways to knowing and thinking about risk in order to become maternity professionals. Overtime, it is easy to take for granted that everyone else speaks the same language in the same way. But most people don’t.
I urge maternity professionals to spend time thinking about they language they use, why it has come to mean what it means, who it is benefitting and protecting, and who is on the losing side of the equation. A focus on adopting woman-centred language has helped to start to shift the balance of power but there is more work to be done!
What bits of language commonly used in maternity care are getting under your skin this week and why? Let me know!
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References
Lupton, D. (2024). Risk. Routledge. Available here.
Categories: CTG, EFM, Language, Reflections, Writing
Tags: high risk, Institutional Ethnography
Birth Small Talk 
There are so many fear-mongering labels in maternity care when there should be encouraging and empowering conversations with a woman who is doing what she is made to do! This book tells of the impact of a change of mind and direction! https://www.penguin.com.au/books/joyous-childbirth-changes-the-world-9781609805241
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