Risk Discourses and Model One

At the beginning of the 20th century, risk calculations and predictions regarding health outcomes became a central tenant of scientific understanding and discovery (Conrad, 1992; Tardy, 2000). During this time, pregnancy, previously considered as something normal and natural came to be seen as a time of illness which threatens both maternal and fetal health (Parry, 2008). This new understanding of illness and disease shifted healing from the private domain to the public domain of medicine and experts (Tardy, 2000). This placed an expectation on pregnant women to turn to expert sources of information regarding risk in pregnancy in favor of personal experiences (Miller, 2005). This has had the effect of pushing the women to the periphery of the pregnancy

experience (Lupton, 1999; Mackenzie Bryers & van Teijlingen, 2010; Murphy, 2000). Model 1 can be understood as the influence of expert risk discourses on

participants’ perceptions of phthalates and other household chemical risks in pregnancy. The first model maps out the relationships the women and clinicians interviewed

What was immediately striking was the emphasis both women and clinicians put on the value of their relationship together. Women looked to healthcare providers to provide accurate and relevant information regarding risk and pregnancy. Obstetrical care providers also felt that it was their role to provide information regarding risks in pregnancy. Obstetrical care providers were relied on to have an expert knowledge over pertinent information in pregnancy and provide women with sound scientific evidence regarding risk information. By having the pregnant woman-healthcare provider

relationship as the central relationship in the model, Model 1 resonates with current thought regarding expert discourses of risk and the need for expert advice during pregnancy.

An interesting finding from this study was that neither the obstetrical care providers (with the exception of Midwife 1) nor the women had previous knowledge of phthalates. Upon learning about phthalates in the interview, women immediately expressed a concern regarding phthalates, desired to learn more, and expected their obstetrical care providers to provide information. Conversely, clinicians were not particularly concerned about the risks of phthalates or other household chemicals during pregnancy. This added another layer of complexity and tension to the pregnant woman- healthcare professional relationship. Specifically, it suggests a tension between women’s expectation to receive information on a wide range of risks from her healthcare provider and a lack of concern from clinicians as a result of a lack of evidence.

These tensions likely emerge from the differing orientations towards risk between women and healthcare professionals. Linell and colleagues (2002) summarize this

Although health care professionals can talk about risk in scientific terms amongst themselves, they must, in their clinical practices, ‘recontextualize’ (Linell, 1998) something that is meaningful only at the statistical level of probability within a population in such a way that it applies to the individual patient (pp. 197). For women, risk perceptions are danger-oriented and experienced based (Hunt, Castaneda, & de Voogds, 2006; Lupton, 1999; Miller & Solomon, 2003). This was evident throughout at the study as women expressed concern regarding a wide variety of risks including air quality, exercise, and work-related risks.

For healthcare professionals, risk carries more scientific connotations consistent with expert risk discourses (Linell, Adelsward, Sachs, Bredmar, & Lindstedt, 2002; Miller & Solomon, 2003). That is, clinicians look for statistically expressed probabilities of a particular occurrence within a population (Mackenzie Bryers & van Teijlingen, 2010). This was demonstrated in Family Practitioner 2’s (FP-2) interview when she explained that she would require an evidence-based risk assessment of phthalates before she would counsel women about phthalates in her practice. FP-3s need for statistical probabilities regarding the risk of phthalates can be seen to be in conflict with lay understandings of risk and an example of the tension between clinicians and pregnant women in Model 1.

Although obstetrical care providers relied on statistical and scientific calculations to determine the legitimacy of a particular risk, this study found that clinicians were not initially judging the significance of risks themselves. Instead, clinicians depended on the government reports and their governing professional bodies (such as Health Canada the Society of Obstetricians and Gynaecologists of Canada [SOGC]) for rigorous and

systematic reviews of the appropriate scientific literature to report any significant risks. Lack of scientific evidence regarding risks by these bodies was implicit confirmation to the clinicians that household chemical risks, such as phthalates, were not significant and provided sufficient reason to not provide counselling.

These findings resonate with sociological research studying uncertainty in medical practices (Atkinson, 1984; Katz, 1984; Light, 1979; Timmermans & Angell, 2001). Uncertainty refers to both the unknowns in medical knowledge as well as the impossibility of mastering all of the ever-expanding medical knowledge (Timmermans & Angell, 2001). Studies have found that in the face of uncertainty, medical practitioners tend to lean heavily on the dogmatic medical paradigms while downplaying and disregarding uncertainties (Katz, 1984). Accordingly, health professionals turning to their governing bodies to resolve the uncertainty regarding the risk of phthalates can be seen as clinicians dogmatically relying on medically based risk discourses. That is to say those obstetrical care providers manage uncertainty by neglecting it and shifting the focus to risks that can be known and controlled (Light, 1979).

By taking a wide scope to examine women’s social networks during pregnancy, Model 1 highlights the influence of expert risk discourses in pregnancy. Participants’ perception of the pregnant women-healthcare professional relationship as the central relationship in the model is likely the best demonstration of this finding. The lack of trust women and clinicians placed in relationships with the media and manufacturers to

provide reliable information also gives credence to the dominance of medical discourses. The model gives insight into the pervasiveness of the expert discourses and decreasing control women play in their own pregnancy (Horton-Salway & Locke, 2010; MacKenzie

Bryers & von Teijlingen, 2010). Although women expected clinicians to provide as much information regarding risks as possible, clinicians often took a paternalistic stance on providing information regarding household chemical risk. This resulted from a lack of evidence provided from the Canadian government and other regulating bodies. Again, this resonates with expert discourses of risk that assumes no risk exists until scientifically determined (Timmermans & Angell, 2001). Taken cumulatively, Model 1 demonstrates the interdependency of pregnancy and how medical discourses influence perceptions of household chemical risk and phthalates.