What If We Stopped Risk Assessing Women - and Started Risk Assessing Maternity Services?

There is something deceptively simple about the language we use in maternity care. It is so familiar, so embedded in everyday practice, that it almost disappears from view. We describe women as “low risk” or “high risk” as though these are neutral, clinical descriptors, objective observations about safety. However, language is never neutral, and these labels do much more than describe. They shape how care unfolds, what feels possible, and how decisions are made.

Over time, they begin to carry weight. Not just clinical weight, but relational weight. They enter conversations, subtly altering tone, emphasis, and expectation. They influence what is offered, how strongly it is recommended, and sometimes what is quietly withdrawn. Perhaps most significantly, they shape the experience of informed consent.

Because valid and true informed consent, for all its legal clarity, is not just something that lives on paper. It lives in conversations, in relationships, in moments that are often complex, emotional, and time pressured. 

It depends not only on what is said, but on how it is said and what sits behind it.

Legally, the position is clear. Following the ruling in Montgomery v Lanarkshire Health Board, the responsibility is not simply to provide information, but to ensure that a person is aware of material risks and reasonable alternatives, judged from their perspective, not the clinician’s. There is an explicit recognition here that decision making is personal, that what matters cannot be predetermined by clinical expertise alone. 

And yet, in practice, things are rarely so straightforward.

Because when risk is located in the woman, when she is described, formally or informally, as “high risk” that framing does not simply sit in the background. It shapes the entire interaction. It alters how information is presented, how uncertainty is conveyed, and how recommendations are positioned. It can create a sense, however subtle, that some choices are more acceptable than others, more responsible than others, more aligned with what good care looks like.

This is not about individual intent. It is not about clinicians deliberately directing or restricting choice. It is about something much more complex and far less visible, the way in which context influences communication.

We know, for example, that communication in maternity care is not always experienced as clear, balanced, or sufficient. Women and birthing people describe not being given enough information, not having time to ask questions, or feeling that risks were emphasised in ways that were difficult to fully process. We also know that informed decision making, while strongly endorsed in policy, does not always translate consistently into practice. It is shaped by time pressures, organisational culture, and uncertainty about how to navigate situations that do not fit neatly within established pathways. 

This is where risk framing becomes so significant.

How risk is described influences how it is understood. Research across healthcare has shown that even subtle differences in how risks are presented can lead to very different decisions. The same information, framed differently, can produce entirely different choices, not because people are ill informed, but because framing shapes perception. 

So, when a woman enters a conversation already positioned as “high risk,” the ground has shifted before the discussion even begins. The information she receives is not necessarily inaccurate, but it is not entirely neutral either. It is weighted, gently perhaps, but meaningfully.

This is where true informed consent becomes more fragile than it appears.

Consent is not just about information. It is about freedom. Freedom to think, to question, to weigh options, and to make a decision that feels genuinely one’s own. That freedom depends on the absence of undue influence, but influence is not always overt. It can sit in tone, in language, in what is emphasised and what is left unsaid.

This is particularly important in maternity care, where decisions are rarely purely clinical. They are also social, cultural, emotional, and deeply personal. They reflect values, priorities, beliefs, fears, and hopes, all of which sit alongside, rather than beneath, clinical considerations.

When risk is located solely in the woman, these dimensions can become secondary. The conversation narrows, even if no one intends it to. The focus shifts toward managing the perceived risk, rather than understanding the person in front of us.

There is another way of seeing this.

If we begin instead by asking not, “how risky is this woman?” but “how well can our service support this situation?”, the conversation changes in both subtle and profound ways.

Risk becomes something that arises in the interaction between the woman and the service, rather than something she carries alone. It includes not only clinical considerations, but also the realities of the system, staffing, environment, capacity, flexibility. These factors, which so often remain unspoken, are brought into view.

And with that, a different kind of honesty becomes possible.

It becomes possible to say: this is what we know clinically, this is what matters to you,
and this is what we can safely support right now, given the way our service is set up.

This does not reduce risk, nor does it simplify decision making. However, it does do something else, it redistributes responsibility. 

It acknowledges that uncertainty and limitation do not sit entirely with the individual but are shared.

This has implications for consent, because consent that is grounded in transparency, about both clinical evidence and service constraints, is qualitatively different from consent that is shaped by unspoken limitations. It allows for a clearer understanding of trade-offs, a fuller appreciation of context, and a more genuine offer of choice.

It also changes the dynamic of the conversation.

Instead of moving, almost inevitably, toward recommendation and direction, the interaction becomes more exploratory, more collaborative. Less about arriving at the “right” answer, and more about arriving at an answer that is informed, understood, and chosen.

This matters, because evidence consistently shows that women’s experiences of care are shaped not just by what happens to them, but by how involved they feel in what is happening. Greater involvement in decision making is associated with greater satisfaction, reduced anxiety, and a stronger sense of wellbeing in the aftermath of birth. 

Yet, there is also evidence that this involvement is not always fully realised in practice, that options can be constrained, sometimes invisibly, by the way care is organised and delivered. 

Reframing risk does not resolve all of this, but it does make it easier to see.

When risk is no longer something that sits within women, but something that emerges between women and services, the response cannot simply be to guide, persuade, or contain. It has to involve a willingness to acknowledge where systems and services fall short, and where they might need to change.

Then true informed consent begins to look less like a process and more like a relationship.

A relationship grounded not only in information, but in honesty. Not only in autonomy, but in respect. Not only in what is clinically indicated, but in what actually matters to the person at the centre of it all.



Sarah Wall, Service User Voice Representative, North East & Yorkshire, NHS England. June 2026 


References

Montgomery v Lanarkshire Health Board (2015) – Informed consent and material risk

Care Quality Commission (CQC) – Communication and informed decision-making in maternity care
https://www.cqc.org.uk/publications/maternity-services-2022-2024/communication

Royal College of Midwives – Informed decision-making guidance
https://rcm.org.uk/wp-content/uploads/2025/03/informed-decision-making_0604-1.pdf

NICE – Decision-making and consent (Mental Capacity and autonomy guidance)
https://www.nice.org.uk/guidance/ng108/chapter/Recommendations

NIHR – Shared decision-making during childbirth (VIP study)
https://journalslibrary.nihr.ac.uk/hsdr/FPFP4621

BMJ Open (2024) – Maternity professionals’ experiences of decision-making
https://pmc.ncbi.nlm.nih.gov/articles/PMC11057275/

NIHR / NCBI – Shared decision-making and women’s experience of childbirth
https://www.ncbi.nlm.nih.gov/books/NBK587610/

Birthrights – Coercion in maternity care report and campaign
https://birthrights.org.uk/campaigns-research/end-coercive-practices-in-maternity-care/

WHO – Respectful maternal and newborn care
https://www.who.int/publications/i/item/9789240110939

Respectful Maternity Care Framework (NICHQ)
https://nichq.org/wp-content/uploads/2026/03/RMC-Resource-Guide_March-2026-Revisions.pdf

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