1.3 Risk Approach in Maternity Care

An assessment of need and of what might be called “birthing potential” is the foundation of good decision making for birth, the beginning of all good care. What is known as the “risk approach” has dominated decisions about birth, its place, its type and the caregiver for decades now (Enkin 1994). The problem with many such systems is that they have resulted in a disproportionately high number of women being categorised as “at risk”, with a concomitant risk of having a high level of intervention in the birth. A further problem is that, despite scrupulous categorisation, the risk approach fails signally to identify many of the women who will in fact need care for complications in childbirth. By the same token, many women identified as “high risk” go on to have perfectly normal, uneventful births. Nonetheless, some form of initial and ongoing evaluation of a woman’s likelihood of giving birth normally is critical to preventing and/or identifying the onset of complications and the decisions which have to be made about providing appropriate care.

This report therefore starts with the question of the assessment of the woman embarking on labour. The assessment of risk factors starts during prenatal care. This can be attained in a relatively simple way by determining maternal age, height and parity, asking for complications in obstetric history such as previous stillbirth or caesarean section, and searching for abnormalities in the present pregnancy, such as pre-eclampsia, multiple pregnancy, ante partum haemorrhage, abnormal lie or severe anaemia (De Groot et al 1993). The risk assessment can also differentiate more extensively between individual risk factors and levels of care (Nasah 1994). In the Netherlands a list of medical indications for specialist care has been devised, distinguishing between low, medium and high risk (Treffers 1993). In many countries and institutions where a distinction is made between low-risk and high-risk pregnancies, comparable lists are in use.

The effectiveness of a risk scoring system is measured by its ability to discriminate between women at high and low risk, that is by its sensitivity, specificity, positive and negative predictive value (Rooney 1992). Exact figures about the discriminatory performance of these risk scoring systems are difficult to obtain, but from the available reports we may conclude that a reasonable distinction between low and high risk pregnancies can be made in developed and developing countries (Van Alten et al 1989, De Groot et al 1993). Defining obstetric risk by demographic factors such as parity and maternal height has a low specificity and therefore results in many uncomplicated deliveries being labelled as high risk. The specificity of complications in the obstetric history or in the present pregnancy is much higher. However, even high quality antenatal care and risk assessment cannot be a substitute for adequate surveillance of mother and fetus during labour.

During prenatal care a plan should be made, in the light of the assessment, which identifies where and by whom labour will be attended. This plan should be prepared with the pregnant woman, and made known to her husband/partner. In many countries it is also advisable that the plan is known to the family, because they ultimately take the important decisions. In societies where confidentiality is practised other rules prevail: the family can only be informed by the woman herself. The plan should be available when labour starts. At that moment a reevaluation of the risk status takes place, including a physical examination to assess maternal and fetal well-being, fetal lie and presentation and the presenting signs of labour. If no prenatal care has been provided, an assessment of risk should be made at the time of the first contact with the caregiver during labour. Low-risk labour starts between 37 and 42 completed weeks. If no risk factors are identified labour can be considered as low-risk.