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.
The WRISK Project has started a conversation which encompasses many different views and disciplines. In our latest blog Dr Ariane Critchley, who is a Lecturer in Social Work at Edinburgh Napier University, offers her perspective.
Protecting babies from risk of harm whilst in the womb and in their first year of life is an important aspect of the work of health professionals who work with pregnant women and young families. Within more targeted child welfare and protection services it is also a priority. In this blog I offer a perspective from social work, based on my doctoral research into pre-birth child protection and on my previous practice as a social worker with children and families.
For my ESRC (Economic and Social Research Council) funded doctoral project (Critchley, 2019a), I observed 20 pre-birth child protection meetings and interviewed 31 participants including expectant mothers and fathers, social workers, and related professionals. The 12 families who participated in the research were all experiencing current difficulties or had a history of behaviour seen as potentially risky for their expected baby. Identified difficulties included diagnosed mental health problems, substance misuse, neglect or poor care of older children, having had an older child or children removed through previous care proceedings, and domestic abuse.
Infants can be understood as particularly vulnerable to harm from within their families due to their high levels of dependency on care givers for their physical and emotional wellbeing and development, and their pre-verbal nature. Child protection involvement during pregnancy may be due to concerns about risks to the baby once born, for example of parental neglect. However, it may also be due to concerns about risks to the baby within the womb, for example substance misuse by the mother causing worries about adverse impact on the baby’s development in utero.
In the English context, Broadhurst and colleagues (2018) have found stark increases in recent years in the removal of newborn babies and infants from their families due to risk of harm. Increases in the numbers of very young children being assessed as in need of care and protection have also been identified within Scotland (Biehal et al. 2019; Woods and Henderson, 2018). In many cases, the risks to babies will have been identified during the pregnancy itself and a great deal of work may have taken place with families before the baby is born.
The science of risk to infants
Scientific claims about the risks to the physical development of babies from their environment have been popularised through ideas of a ‘critical window’ of development, or the idea of the importance of ‘the first three years’. This has created a strong agenda about creating and supporting the conditions for healthy development of babies. This agenda is difficult to argue with: as parents, as communities and as a society we want the healthiest start for our babies. This can tend to silence critical analysis of how this agenda is driven forwards and who is most impacted by a preoccupation with risk to babies. Featherstone and colleagues describe the problem as follows.
‘Complex and abstract vocabularies of risk, science, evidence and economics have been melded together to deliver increasingly persuasive stories that apparently beguile policy makers and appear to be very compelling for practitioners. Who can possibly want a vulnerable baby’s brain to be damaged beyond repair by our lack of early and resolute intervention?’
(Featherstone et al. 2018, 65).
However, the ways that risk in pregnancy is constructed deserves our attention. In terms of social, epigenetic and neurodevelopmental risks to the development of babies there has been a strong concentration on mothers. Although the causes of human health and illness are complex, studies have focused strongly on exposure to health risks in the womb and therefore on the mother.
‘This interest manifests as an abundance of studies on the potential effects of the health and lifestyle of mothers around the time of pregnancy on the health of their children. We argue that this focus reflects deeply-held assumptions, among researchers, clinicians, policy makers, the media and the public, that maternal pregnancy exposures are the most important, causal determinants of offspring health’
(Sharp et al. 2019: 1).
This skewed research agenda leads ultimately to an assumption that intervening with mothers in pregnancy in order to protect children can be an effective way of preventing harm. This in turn keeps the focus firmly on the behaviour and choices of women. Despite the fact that risks to babies arise not only from their mothers. Expectant parents themselves highlighted this in the research interviews within my study (Critchley, 2019b), and this theme will be further explored in forthcoming publications. These highly gendered dimensions of our approach to risk can be teased out through thinking about domestic abuse and risk during pregnancy.
Domestic Abuse: a risk case study
Domestic violence and associated ‘self-medication’ through for example anti-depressant and cigarette use have long been found to lead to increased risks for mother and baby in pregnancy (Mezey and Bewley, 1997; Webster et al. 1996). For two families in the sample of twelve in my doctoral study, there was a strong professional focus on the risks of domestic abuse to the baby. In both cases the known or suspected perpetrator was the father of the baby. Yet the focus in terms of risk was primarily on the mother. In one of the families, a child protection case conference to decide the plan for safe care of the baby once born happened in the absence of the father, although he was the clear source of risk. The chair of the meeting reflected on this in a research interview.
‘So I was trying to operate from a sort of perpetrator based ethos you know? That he’s responsible. That’s why it would have been better. Because he wasn’t there. So it would have been good if he’d come in for at least part of it [pause]. Then we could have said, “Well we’re here because of your behaviour towards her and you need to hear that”. Kind of gets into what responsibility he was taking, and what work he would engage in. But anyway, he didn’t. So she was left carrying the can as it were’
(Extract from research interview with Case Conference Chair Person)
The responsibility for risk remained with the mother although it was the father of the baby who presented a risk. He had seriously assaulted a previous partner to the abdomen in pregnancy and in this pregnancy had threatened to ‘kick the baby out’ of the mother of his unborn baby.
Devaney (2004; 2008) has questioned whether the use of child protection measures is a constructive response to the problem of intimate partner violence. Identifying confused underlying messages about women’s own vulnerability and simultaneous capacity to protect their vulnerable children from harm (Devaney, 2008). One danger identified through research with women being that child protection measures compound women’s sense of personal failure (Lloyd et al. 2017). Thereby potentially increasing rather than reducing the risks for children. Women’s Aid (2019) have sought to address the tendency for professionals’ exclusive focus to be on the relationship between the mother and baby when women successfully leave situations of domestic abuse with their babies. Their work in conjunction with the University of Stirling highlights how pressure on women to provide everything that their infant needs while recovering from abuse is neither realistic nor helpful. Since babies are cared for in social contexts beyond the dyadic mother-infant bond. This pressure was evident within the research I conducted with pregnant women and their partners who were going through child protection processes in relation their unborn babies.
Towards a broader understanding of risk in pregnancy?
Our continued focus on the choices, behaviour and capacity of women in relation to their unborn, newborn and infant children obscures the role of men as fathers. It obscures the risk the men place babies at through their behaviour. It also obscures the positive contribution that fathers make to the development, health and care of their young children. As Waggoner has suggested,
‘men matter, but reproduction talk is almost always about women. It is a human creation that women’s bodies are often solely tied to reproductive responsibility, yet such an arrangement appears as “common sense”, as simply “the way things are”. This sentiment is perhaps slowly changing’
(Waggoner, 2017: 21).
Widening our thinking about risk to infant health and well-being beyond the mother is a necessary first step in recognising that risk in pregnancy is not situated only within the womb but can be externally located: within the family, the community and the environment.
Biehal, N., Cusworth, L., Hooper, J., Whincup, H., Shapira, M. (2019). Pathways to permanence for children who become looked after in Scotland. Stirling: University of Stirling. Available at: https://www.stir.ac.uk/media/stirling/services/faculties/social-sciences/research/documents/permanently-progressing/Pathways-Final-Report.pdf
Broadhurst, K., Alrouh, B., Mason, C., Ward, H., Holmes, L., Ryan, M. and Bowyer, S. (2018). Born into care: Newborns babies subject to care proceedings in England. The Nuffield Family Justice Observatory, Nuffield Foundation: London.
Critchley, A. (2019a) Quickening Steps: An Ethnography of Pre-birth Child Protection in Scotland. Doctoral thesis. Edinburgh: The University of Edinburgh.
Critchley, A. (2019b) Jumping through hoops: Families’ experiences of pre-birth child protection. Chapter 8 in Murray, L., McDonnell, L., Hinton-Smith, T., Ferreira, N. and Walsh, K. (Eds.) (2019) Families in Motion: Ebbing and Flowing through Space and Time. Bingley: Emerald Publishing, 135-154.
Devaney, J. (2004). Relating outcomes to objectives in child protection. Child and Family Social Work, 9(1), 27-38.
Devaney, J. (2008). Chronic child abuse and domestic violence: Children and families with long-term and complex needs. Child and Family Social Work, 13(4), 443-453.
Featherstone, B., Gupta, A., Morris, K. and White, S. (2018). Protecting Children: A social model. Bristol: Policy Press. Kindle Edition.
Lloyd, M., Ramon, S., Vakalopoulou, A., Videmšek, P., Meffan, C., Roszczynska-Michta, J., … Devaney, J. (2017). Women’s Experiences of Domestic Violence and Mental Health: Findings from a European Empowerment Project. Psychology of Violence, 7, 3, 478-487.
Mezey, G. and Bewley, S. (1997). Domestic violence and pregnancy. BJOG: An International Journal of Obstetrics and Gynaecology, 104 (5), 528-531.
Sharp, G.C. Schellhas, L. Richardson, S.S. Lawlor, D.A. (2019) Time to cut the cord: recognizing and addressing the imbalance of DOHaD research towards the study of maternal pregnancy exposures. Journal of Developmental Origins of Health and Disease doi: 10.1017/ S204017441900007.
Waggoner, M.R. (2017). The Zero Trimester. Pre-Pregnancy Care and the Politics of Reproductive Risk. Oakland, CA: University of California Press.
Webster, J., Chandler, J. and Battistutta, D. (1996). Pregnancy outcomes and health care use: Effects of abuse. American Journal of Obstetrics and Gynaecology, 174 (2), 760-767.
Woods, R. and Henderson, G. (2018). Changes in out of home care and permanence planning among young children in Scotland, 2003 to 2017. Adoption and Fostering, 42, 3, 282–294.
Women’s Aid (2019). Supporting women and babies after domestic abuse. A toolkit for domestic abuse specialists. Available at: https://www.womensaid.org.uk/information-support/downloads-and-resources/children-young-people/