Heather Trickey, Clare Murphy, and Rebecca Blaylock 

The WRISK project is a Wellcome-funded collaboration between the British Pregnancy Advisory Service (bpas) and Heather Trickey at the School of Social Sciences at Cardiff University. WRISK engages expert stakeholders and draws directly on women’s experiences to develop recommendations to ensure effective and respectful public health messages for women in pregnancy.

Public health messaging in pregnancy

In public health terms, health protection and promotion in pregnancy is understood to have significant and lasting impact on population health outcomes. A growing public health agenda focuses on reducing risk to developing foetuses as well as supporting the health of babies and children throughout the early years.  Public health messages about decision-making in pregnancy form one aspect of an agenda to give babies and children a better start during ‘the first 1000 days’. These messages tend to be based on an understanding that improved information and clear direction will lead expectant parents (primarily mothers) to make decisions that reduce the chance of their babies experiencing adverse health outcomes.

One consequence of an increased focus on delivering public health messages for pregnancy, is that women who are planning a pregnancy, or who are pregnant, find themselves subject to a wide range of messages about how to eliminate or manage a multitude of risks. As part of antenatal care, midwives are responsible for advising women about what not to eat or drink, stopping smoking and substance misuse, managing their weight, monitoring their emotional and mental health, avoiding exercise that puts their baby at risk, managing pre-existing conditions and medications, building attachment to their growing foetus, as well as learning to monitor their baby’s movements and other pregnancy symptoms. Family members, friends, and parenting sites contribute their own (sometimes contradictory) opinions, experiences, and interpretations. Meanwhile, reporting of ‘latest study findings’ introduce an ever broadening range of risks and benefits – from avoiding air pollution to eating more broccoli. Scientific findings are often transformed into press statements and distorted into  headline, creating a bewildering onslaught of alarm.

Unintended harms

There is growing concern, in the public health community and beyond, that the sheer weight and intensity of instruction may be leading to unintended negative effects – including, on the one hand undue and excessive maternal anxiety and, on the other, a failure to appropriately prioritise serious risks to maternal health. Furthermore, there is concern that risks are not always communicated in a way that reflects or explains the evidence base (or its limitations), and that messages are not always constructed in ways that acknowledge either the context of women’s lives or their capacity to weigh up risks  in relation to their own circumstances.

Elements of current advice have been challenged on the basis that they are insufficiently nuanced or unrealistic. For example, recent research, which considered women’s experiences of the current guidance to abstain from drinking any alcohol in pregnancy, raised concerns relating to the communication of the precautionary principle (the ‘better safe than sorry’ approach). Other concerns highlighted were the risk of irresolvable anxiety among women who had drunk alcohol before they knew they were pregnant, the encouragement of social surveillance (other people’s sense that they are entitled to comment or interfere), and a failure to address wider cultural and social constraints on decisions. Concerns have also been raised around a tendency to extend pregnancy risk messaging to all women of childbearing age. For example, it has been argued that restrictions on the use of sodium valproate for treatment of epilepsy for women aged 15-45, regardless of whether or not they are pregnant or planning a pregnancy, indicates that ‘the potential for pregnancy has now become a dominant consideration when treating women’. Furthermore, some social scientists and women’s/parent’s rights organisations hold that the current risk messaging context may be exacerbated by, and sometimes driving, a wider culture of parenting that tends to hold mothers responsible for any and all ills that befall their children.

Uneven impact

The challenges inherent in negotiating a complex risk message landscape disproportionately affect women who have pre-existing conditions, who develop conditions in pregnancy, or whose social circumstances mean that they are more vulnerable in other ways. Women who are taking medications, who are overweight, older mothers, mothers at risk of domestic violence, or who are heavy smokers or  who misuse substances substance misusers can all find themselves under pressure to change their decisions on multiple fronts, and may also find risks more difficult to avoid. For example, an overweight woman taking medication for pregnancy sickness may find risk messages about weight and medication to be anxiety-inducing, but ultimately beyond her control. For women whose pregnancy circumstances fall short of a risk-free ideal, a multiplicity of messages can prove challenging to negotiate safely. Mothers themselves, and the health professionals responsible for their care, sometimes struggle to balance and prioritise competing risks. The latest confidential inquiry into maternal mortality found cases of women who had been inappropriately discouraged from taking medication for depression on the basis that it might be harmful to their baby.

The WRISK project

The WRISK project builds on the recommendations from a Wellcome funded workshop involving invited stakeholders with an interest in understanding and improving the way that public health messages are communicated to parents.  Our findings highlighted concerns about a culture of blame associated with public health messages, an over-emphasis on an individualised approach to improving public health in pregnancy, the erosion of the concept of a ‘normal’ pregnancy, increasing focus on the foetus at expense of maternal health and autonomy, increased surveillance in pregnancy and pre-pregnancy, and the over-simplification of risk messaging. The workshop group recommended the development of a set of shared principles about how risk messages for pregnancy should be constructed and communicated.

WRISK builds on this recommendation and sets out to develop shared principles to inform the work of public health researchers and practitioners, health professionals, third sector organisations, and the media. The research considers recommendations in relation to every phase of message creation and delivery – from scientific enquiry to message reception. Research and engagement will be underpinned by principles of coproduction and public engagement. The WRISK methodology combines three core strands, to be developed in parallel.

  • Public engagement methods will be used to explore the current wider context for risk messaging and to consider ways in which the conversation about pregnancy and risk might be nuanced and changed.
  • Qualitative research will be undertaken with recently pregnant women from a range of backgrounds and with different experiences in relation to pregnancy and risk.
  • An expert consensus methodology, involving stakeholders with cross-sector expertise in maternal and child health, public health, risk communication, women’s experiences of fertility, pregnancy and parenthood, will iterate with public engagement and qualitative research to develop recommendations to support future public health messaging

The WRISK project combines engagement and research. We aim to engage the wider public in conversation about public health messages and pregnancy. We also aim to develop and disseminate recommendations – and other outputs – that incorporate principles of maternal autonomy to improve both the experience and effectiveness of public health messaging.

Whether you are a recently pregnant woman, a public health professional, clinician, or journalist, we would very much like to hear from you. If you would like to be involved in our research or public engagement activities, please get in touch