Risk and risk assessment in pregnancy - Do we scare because we care?

Objective: To assess whether being labelled 'high-risk' affects women's psychosocial state in pregnancy. Design: Prospective, cross-sectional, non-experimental, case-control study. Setting: A large city in Germany. Participants: Women between 22 and 41 weeks gestation were identified at antenatal classes and invited to participate in the study. Of the 147 women who were given a questionnaire, 82% (122) responded but only 75% (111) were eligible for inclusion in the study. Of these 111 women, 57 were classified as 'labelled high-risk' and 54 as 'no-risk' according to the risks documented in their antenatal records. Measurements: Women's psychosocial state was assessed using a validated, anonymous, self-completed questionnaire, the Abbreviated Scale for the Assessment of Psychosocial State in Pregnancy (Goldenberg et al. 1997). Analysis of covariance (ANCOVA) was performed to test the effect of the risk label on psychosocial state. The effect of other variables, such as parity or education, was also tested. Findings: The effect of the risk label on psychosocial state after adjusting for age was statistically significant (R ²=0.07, F=7.59, df=1, p=0.001). No significant differences were found for the other independent variables. The data showed that a large number of women had one or more risk factors and that 71% were booked for obstetrician-led care. A high variability in obstetrician's documentation of women's risk factors was also found. Conclusion: The data suggest that labelling women to be 'at risk' may negatively affect their psychosocial state. The findings highlight the need to re-evaluate the risk catalogue in the German antenatal record (Mutterpass) as well as the German maternity guidelines (Mutterschaftsrichtlinien). Although this study was conducted within the German system of antenatal care, the findings raise questions about the effects of risk labelling in maternity care wherever it is practised. Further research is needed to assess women's psychosocial state in a more representative sample, to explore women's experiences and satisfaction with the practice of risk assessment and to investigate the reasons for the high variability in documenting women's risk factors.