Pregnancy and risk


Pregnancy is often heralded as a time of hope and happiness. But when issues of risk enter—as they always do—pregnancy also challenges our ability to reason well. There is a tendency to think of safety in ways unmoored from evidence.

The above quote comes from a fascinating new paper in this month’s issue of a leading bioethics journal, The Hastings Center Report. Risk and the Pregnant Body by Lyerly, Mitchell , Armstrong , Harris, Kukla , Kupperman , and Little. The paper explores what the authors describe as “historical cultural themes around pregnancy and birth.”

These include themes about purity in pregnancy and control in birth—both of which can lead to reasoning about risk that is oriented more by magical thinking than evidence—as well as themes about the roles and responsibilities of motherhood. As many have noted, pregnancy can refract and intensify the already demanding moral standards of sacrifice we apply to mothers. In the present context, this can lead to a tendency to unreflectively judge any risk to the fetus, however small or theoretical, to trump considerations that may be of substantial importance to the woman herself.

The authors consider the impact of these themes on pregnant women and on medical professionals. In this post, I’d like to focus on pregnant women and other lay people.

I have argued in the past that thinking about risk in general, and pregnancy in particular, is plagued by the habit of ignoring the magnitude of risk. In pregnancy; women will express horror of trivial or merely theoretical risks and ignore real risks. This defect is enhanced by the tendency of lay people to vastly overestimate trivial risks and vastly underestimate real risks, which is more pronounced among advocates of “natural” childbirth and homebirth. Hence the avoidance of the theoretical and unsubstantiated risk of caffeine during pregnancy while simultaneously embracing the very real risk of homebirth.

The authors offer an intriguing explanation for the obsession with the trivial, theoretical and often unsubstantiated risks attending the behavior of pregnant women: the emphasis on purity in pregnancy.

… [C]oncerns about purity reflect a form of magical thinking rather than evidence-based reasoning about actual harms and dangers. As psychologists point out, magical thinking is the tendency to see causality in coincidence and to substitute rituals and taboo for empirical evidence. In the context of pregnancy, magical thinking can turn an innocuous exposure into a dangerous one—a sip of beer to poison, a bite of sushi to contamination. Such thinking is considered a familiar and natural response to uncertainty and the unimaginable… The temptation is to tell ourselves that if we can only find and follow the right set of “musts” and “mustn’ts,” all will be well …

The perception of risk has also been profoundly influenced by the contemporary view of mothering:

The dominant idea of a “good mother” in North America requires that women abjure personal gain, comfort, leisure, time, income, and even fulfillment; paradoxically, during pregnancy, when the woman is not yet a mother, this expectation of self sacrifice can be even more stringently applied. The idea of imposing any risk on the fetus, however small or theoretical, for the benefit of a pregnant woman’s interest has become anathema. A second cup of coffee, the occasional beer, the medication that treats a woman’s severe allergies but brings a slight increase in the risk of cleft palate, the particular SSRI that best treats a woman’s severe recalcitrant anxiety disorder but brings a small chance of heart defects—all are off limits, or nearly so, to a “good mother.”

Yet this professed belief is belied by the ways that we actually behave and the fact that we sanction many potentially “risky” behaviors when it is convenient for us to do so:

We accept small risks to our children for our own sakes every day. We believe it reasonable to impose the small risk of fatality introduced every time we put our children in the car (safely restrained in a car seat), even if our errand is mundane and optional… To be sure, balancing such risks can be among the most challenging tasks of parenthood. But we recognize that reasoning about risk is inevitable, that thoughtful, responsible trade-offs are a fact of life …

Lyerly and colleagues have given us a cultural framework within which we can situate current view of risk in pregnancy. Consider the issue of epidurals for pain control in labor. According to “natural” childbirth advocates, the “good mother” will forgo and epidural, an “achievement” considered remarkable because so many women “give in” to the pain.

But this view of epidurals is at odds with the scientific evidence of their safety. Rather it reflects the cultural obsession with purity of the pregnant body. Everything introduced into the pregnant body in any way must be tightly controlled. Moreover, the “good mother” must endure agonizing labor pain since she is not entitled “personal gain, comfort, leisure, time, income, and even fulfillment” let alone pain relief.

In other words, “natural” childbirth reflects cultural preoccupations, not scientific evidence. The “natural” childbirth advocate’s understanding of risk in pregnancy and the range of “acceptable” responses to risk has almost nothing to do with the actual magnitude of the risks under consideration, and everything to do with how she wishes to view herself and other mothers.