Resources for parents and providers

Framing Risk

What is risk?  How is it that the US culture at large has come to frame and gauge birth in general with this concept?  Risk inherently drives the idea of fear, and defines “what it is to be responsible.”  It can be used to convey, “You must __________ to be a good parent.”  And we all want to be good parents.  Such belief systems allow institutions to use ‘risk assessment’ as a tool to lessen or avoid liability, but it also justifies interventions including a rising cesarean birth rate.  Risk can be used as a means to give a particular type of service.  So we must look underneath this concept of risk and see what is really happening below the surface.

How do we stop and examine underlying belief systems as risk frames options and choices?  Risk is framed with an institutional and/or individual belief system, which can be the care provider or even the birthing mother.  Risk can be framed with statistics to minimize, so that a procedure seems “normal” or “routine,” or can be used to motivate families to comply with suggested procedures or emphasize its need.  A woman’s cultural views, perceptions, expectations, and experiences all serve as her framework during the decision making process.  Couple that framework with dialogue (with care providers, family, friends, etc.) about risk and responsibility surrounding birth decisions, and a woman in the midst of deciding her birth path has a lot to consider.

When are we going to shift the dialogue from the risks to relative options?  According to PREMODA and even the follow up Term Breech Trial of 2000, a vaginal breech birth with a skilled provider is just as safe as a cesarean.  If the aim is to reduce the overall perinatal mortality rate of 6.2 per 1,000 births (CDC 2014), why aren’t we holding the institution accountable for creating a higher sense of risk because they haven’t taken the initiative to hire competent skilled breech providers to minimize this risk?

As Barbara Katz Rothman points out when looking at the underbelly of risk assessment in birth:

“If safety were our real concern, if saving the lives of babies and of mothers were the driving force, then there are a number of changes we would make immediately.  We would require helmets for people in cars, something we know would save lives each week.  We would lower the speed limit in urban areas, and end driveway parking in suburbs. To suggest such things makes one look crazy – crazier than suggesting home birth.  But it most assuredly would protect children. If saving babies were our concern, we would invest in public housing, and in the food system.  These are large scale changes that would save far more people than anything that happens in those few hours of late labor to early neonatal period, the 24 or so hours of hospitalization that is now being debated.”

Dr. Stuart Fischbein addresses this issue quite well in a review of a study that framed vaginal breech as risky and yet the statistics showed that the concept of “risk” was quite subjective in interpretation:

There is risk and value to pretty much everything we do. It’s the balance between these that motivates decision making in every individual. And, obviously, there is no universality to the conclusion. It should not be expected that two people, given the same information, will always reach the same determination. Life experience and bias will always enter into the calculation. But we must always remember that in a free society the choice of what is risk and what is benefit belongs to an informed individual…

… It reminds me of the fallacy of words like “safer” and “riskier”. We must have more information to make reasonable decisions. What is the risk of doing something vs. not doing something? What do we surrender when always deferring to safety? How do we define safety? The safety argument is often misused as a means of coercion. As we have said, not everyone should be expected to define risk and safety the same way. Sometimes the risk of a choice may be greater but still small. Ultimately, we need to know specifically what those risks are in order to make an informed choice. For example, if the baseline risk of something is 1/10,000 and another method has a relative risk (RR) of 4, meaning it is 4 times more likely to happen, well, that sounds awful. Yet the risk is still only 1/2500 or 0.04%. For many, that is still a small risk. In statistics it matters what the denominator is.”