The WRISK project regularly asks contributors to share their perspectives on a range of issues related to risk communication in pregnancy to further understanding of the challenges faced by scientists, clinicians, policy makers and of course women themselves when trying to navigate risk messaging. These represent individual and personal viewpoints, and are aimed at encouraging reflection and discussion, rather than reaching conclusions. In our latest guest blog Janelle Wagnild shares how her perception of ‘risk’ and pregnancy changed during the course of her PhD.
My name is Janelle Wagnild, and I recently completed my PhD in Biological Anthropology at Durham University. My thesis focused on sedentary time during pregnancy and gestational diabetes risk (publications from which are forthcoming). While doing a PhD causes most to think critically about their topic of interest, my PhD journey caused me to critically question the very paradigm in which my research questions were situated.
Sedentary time as a predictor for gestational diabetes?
My thesis tested the hypothesis that sedentary time (time spent sitting or lying down during waking hours) during pregnancy would predict gestational diabetes risk. This hypothesis was initially informed by my assumption that health and pregnancy-related outcomes (and ‘risk’ of adverse outcomes) could be largely explained and predicted by women’s everyday ‘behaviours’ during pregnancy. Such an approach is not unusual in the disciplines of human and evolutionary biology, areas in which I earned degrees prior to starting my doctorate. I assumed not only that the link between sedentary time and gestational diabetes would exist, but also that this link was important to identify because, as the biomedical literature frequently suggests, the ‘trans-generational’ effects of women’s health and behaviour during pregnancy have important lifelong consequences for their offspring’s health.
Over the course of completing my PhD, my perspective on the research questions my thesis was aiming to address dramatically shifted. The primary aim/hypothesis of the thesis didn’t change, but I began to interrogate the way that I thought about ‘risk’ and its prediction, especially during pregnancy, and began to question the assumptions upon which my initial (biomedical) approach was based.
It is difficult to pin down exactly when and how this evolution took place. Much of it can probably be attributed to conversing with colleagues in the anthropology department and reading a vast array of literature coming out of anthropology and critical public health, both of which discuss critiques of the biomedical paradigm, as I tried to put my thesis together. While I can’t locate when and where the shift happened, I can identify two key, interrelated critical changes in thought that took place.
First, I began to realise there are problems with the way in which ‘risk’ is often statistically interpreted. In particular, epidemiology seeks to identify the frequency and distribution of disease (including gestational diabetes) within populations and identify factors that are related to the development of such health outcomes. The results of statistical models, often framed in terms of ‘odds’ or ‘risk’ of disease incidence, tend to be mistakenly interpreted as the likelihood of an individual within that population to develop the disease. In actuality, the statistics only describe patterns and predictors at the population level; they do not refer to an individual’s personal risk of developing a given outcome (see Chapter 5 of The Obesity Epidemic: Science, Morality and Ideology by Michael Gard and Jan Wright for a fantastic in-depth explanation of this problem).
Second, and related to the previous point, since ‘risk’ statistics are often interpreted as outcomes of individual-level factors, the biomedical paradigm tends to implicate individuals as key determinants of their own risk. In the case of pregnancy (and indeed, child-rearing as a whole), women are often held personally responsible for the health and development of their fetuses/babies/children, and ‘good mothers’ are those who do everything they can, both through behavioural modification and heeding ‘expert’ advice, to avoid posing risks to their offspring (see Risk and Sociocultural Theory by Deborah Lupton). This projection of responsibility is apparent in lay interpretations; for example, in my study, one participant who was diagnosed with gestational diabetes stated that her diagnosis made her feel like ‘a failure’ because, despite what she had tried to do to do ‘bring this baby in safely’ (she mentioned not smoking or drinking during pregnancy), she felt her diabetes was ‘kind of putting them at risk.’ This projection of responsibility also underpins entire research paradigms, such as DOHaD and epigenetics. This is not to say that individual-level ‘behavioural’ factors during pregnancy never effect outcomes; for example, there is substantial evidence linking folic acid supplementation during pregnancy to lower likelihood of congenital abnormalities. However, pinning responsibility for (all) fetal outcomes squarely on the mother disregards the broader factors that contribute to health, such as social and structural inequalities, and the fact that problems with fetal development can be caused by a wide variety of complex (and sometimes unexplained) factors.
Contextualising women’s experiences
Consideration of these issues (among others) led me to reframe my thesis as I realised that the assumptions on which I had framed my original hypothesis were seriously flawed. Rather than constructing a thesis around identifying factors that predict risk of gestational diabetes (which would have presumably concluded with suggestions for interventions to ‘reduce risk’), I instead used ideas surrounding risk during pregnancy to contextualise women’s experiences of sedentary time and gestational diabetes. For example, I argued that the public perception of the fetus as continuously ‘at risk’ of harm may underpin the social context of physical activity and sedentary time (‘resting’) during pregnancy. I still tested the hypothesis that sedentary time would predict gestational diabetes (the association was not significant), but I framed the hypothesis and the interpretation of the null findings with a much greater emphasis on the broad and complex factors that can contribute to health and pregnancy outcomes.
Now that I have completed my PhD, I find myself in a complicated but important position, straddling two paradigms (i.e., public health and critical public health) that are often assumed to be in conflict with other. However, awareness of both approaches not only provides multiple perspectives on pregnancy-related issues, but also has made me realise that, despite the major differences between them, both paradigms are united by their shared ultimate aim: to improve the health of the population. Both approaches can be used in a complementary way to work toward broadening our understanding of health on all levels.