Despite mainstream sociology being slow to apply the lens of risk to reproduction (Oakley, 2016) the language, knowledge, practices and negotiation of risk and uncertainty permeates childbirth and opens up a wealth of ideas and arguments about risk (Possamai-Inesedy, 2006). Indeed, Scamell (2011) argues that risk has come to underpin the development of maternity services through policymaking, the intensification of clinical governance, the production of standardised national guidelines and increased surveillance of women during pregnancy and birth.
Drawing on my wider PhD research into women’s childbirth preferences, decisions, and outcomes in England today, here I seek to explore the way in which some midwives negotiate risk and uncertainty as part of their everyday ‘risk work’ (Horlick-Jones, 2005; Brown and Gale, 2018). I focus in on a quote from one particular midwife interviewed as part of my PhD research to explore the concept of the “safe maverick”; what this means as an approach to managing risk and uncertainty, and its potential application to midwifery.
Rosa, 60 years old, worked as a midwife on the labour ward of a London hospital. When interviewed, Rosa spoke about her long and varied career in midwifery, her experience working under different maternity policies and the professional tensions that can arise on a maternity ward. As part of her role, Rosa worked with newly qualified midwives and was conscious of how the fear of litigation is becoming instilled into them as students;
I think there’s a great deal of fear, litigation you know and I do talk a lot to the midwives you know when they qualify, I do a session with them about litigation and they’ll say oh well how many times have you been to court? […] I’ve never been to court with a case I’ve been doing the report for, ever. So, I say you have to get that in perspective. I’m a maverick, I’m very proud of being a maverick, but I’m a safe maverick.
Fear of litigation amongst midwives is perhaps unsurprising when you consider that in recent decades the NHS maternity care services have faced multiple high-profile investigations and medical negligence claims following serious failings and seemingly unnecessary deaths of mothers and babies at NHS Trusts across England. The maternity care services has subsequently become one of the most heavily litigated areas of the NHS with the latest NHS Resolution Annual Report for 2019/20 stating that whilst maternity care constituted 9% of the clinical negligence claims made, it amounted to 50% of the cost of all claims, equating to £4.8bn. Furthermore, fear of litigation has been found to affect midwives’ practice; for example their ability to advocate for women, increasing requests for medical assistance, fostering a blame culture, causing midwives to avoid working in labour wards, creating self-doubt, isolation and low morale (Robertson and Thomson, 2016; Alexander and Bogossian, 2018).
Dahlen and Homer (2013) have suggested that the negligence culture is creating “litigation-based practice” in maternity care, where births are managed cautiously to avoid negligence claims, which in turn influences the information that maternity care providers give to women about their birth choices. The culture of litigation-based practice creates a fear in which risk is operationalised to manage uncertainty in birth, though in reality this often constrains providers’ practices and women’s choices. Indeed, one of the difficulties facing midwifery today is that midwives are caught between ideologies of birth; walking a fine line to support normal childbirth whilst managing (bio)medical risks and trying to protect their careers from litigation. However for Rosa, rather than adopting litigation-based practice, as an experienced midwife she was able to construct her own personal practice to managing risk and supporting women, which she refers to as the “safe maverick.”
Traditionally, approaches to risk and uncertainty have fallen into two dichotomous camps; rational and objective knowledge associated with ‘experts’, and non-rational beliefs and hopes associated with ‘lay’ people. More recently, Zinn (2008) has made a case for strategies in-between the rational and non-rational approaches such as trust, intuition, and emotion, which draw on tacit or experiential knowledge. I believe that Rosa’s concept of the “safe maverick” provides an example of how in practice, professionals are not just limited to rational, ‘expert’ knowledge but also draw on irrational/’lay’ knowledge as well as in-between approaches to risk and uncertainty. Indeed, Rosa’s approach is ‘safe’ because it draws on her rational and expert medical knowledge. It is also ‘maverick’ because she combines this knowledge with a belief in the abilities of herself and the women she cares for. Additionally, she uses the tacit knowledge she has developed from years of experience to manage different birth ideologies and perceptions of risk saying that “it’s about challenging what’s right to challenge in the right place”. Indeed, Zinn (2016) argues that in-between strategies to managing risk and uncertainty can be particularly useful when knowledge or time is limited and complexity overwhelming. As such Rosa uses her tacit knowledge as an in-between approach to gauge when and how far she should push the boundaries of conventional practice.
This integrated approach of the “safe maverick” illuminates the complexity of midwifery practice; staff are obliged to follow standardised, national guidelines but in practice midwives use their professional discretion to utilise tacit and experiential knowledge to subvert guidelines where necessary. Indeed, other research has shown that it is not uncommon for midwives to apply their experienced-based knowledge to override formalised guidelines when necessary, even if this deviation is performed secretly (Scamell and Stewart, 2014). This behaviour demonstrates that in practice, standardised guidelines do not always work, and pinpointing where midwives engage in subversive practices could identify areas where protocols can be improved.
By creating her own “safe maverick” approach to risk and uncertainty in birth, Rosa attempts to balance (bio)medical safety with a woman-centred care that tries to avoid iatrogenic risk, unnecessary interventions, and increased surveillance. Her statement that she is “very proud to be a maverick” and declaration that she has never faced litigation herself implies that she believes her actions as a maverick have always been appropriate and benevolent. However when positioning herself as a “safe maverick” to the newly qualified midwives (as above) it is interesting to consider how they might be able to apply this line to thinking to their own work.
Undoubtedly it is Rosa’s years of experience, as well as her reputation amongst colleagues, that allows her to work as a “safe maverick” and subvert normal workplace practices and hierarchies in this way. As such it seems likely that it takes time and experience to acquire the skills of the “safe maverick.” Indeed, one of Rosa’s concerns about the future of midwifery was that she believed younger midwives were less likely to question ‘doctor’s orders’ and as more midwives of her own generation retired from the profession there would be less “safe mavericks” like herself to challenge the dominant medical model of birth in labour wards. However, as an unconventional approach to midwifery, the “safe maverick” must be responsible for performing checks and balances on themselves in order to make sure that they are not becoming an unsafe maverick, which could lead to disciplinary action or litigation.
Thus when considering the application of “safe mavericks” to NHS maternity services, I believe that this approach could help midwives to walk the fine line between supporting normal childbirth whilst managing (bio)medical risks and avoiding litigation. Whilst it seems that Rosa could be trusted to hold risk as a “safe maverick”, it is also a privileged position which comes as result of accumulated knowledge, experience, and respect from colleagues. Midwives who are not in this position may struggle to intuitively know where the line between being a safe and unsafe maverick lies. Thus whilst I believe that there is value in the approach of the “safe maverick,” this approach and identity may be limited to those further along in their careers.
Georgia Clancy is a PhD candidate in the Centre for the Study of Women and Gender, Sociology, at the University of Warwick. Her ESRC funded doctoral research explores women’s childbirth preferences, decisions, and outcomes in England today.