BOX 3-1
Assessment of Risk in Pregnancy:
Key Points Made by Individual Speakers

  • Kimberly Gregory noted while the steady declines in maternal and neonatal mortality across the United States are among the greatest public health achievements of the 20th century, the maternal mortality rate has been increasing in recent years.
  • Gregory emphasized the dynamic nature of low risk: the risk associated with childbirth can change at any point, often unexpectedly. She also emphasized the contextual nature of risk, for example with risks of both maternal and neonatal events being low in collaborative care situations where events are triaged appropriately.
  • Gregory urged a greater focus on identifying conditions that call for different levels of care. Just as high-risk women need to be cared for in appropriate facilities with appropriate resources, the same may be true of low-risk women given that care of low-risk women in high-risk or high-intervention sites is associated with increased adverse events.
  • Elizabeth Armstrong observed that numerous sociological and anthropological studies have identified control and safety as being especially important for the birth experience. However, control and safety have different meanings for different women. For some women, a technology-intensive birth in a hospital imparts a desired sense of control. For others, the same situation makes them feel out of control.
  • Armstrong described contemporary American culture as a “risk society,” one that views birth as a high-risk and dangerous endeavor. Some social scientists believe that the attempt to classify births into varying levels of risk itself emphasizes the pathology inherent in birth rather than the normal physiology of birth.
  • As described by Kathryn Menard, the purpose of risk assessment is to predict which women are most likely to experience adverse events, to streamline resources to those who need them most, and to avoid unnecessary interventions.
  • Identifying low obstetric risk is a difficult challenge. Menard elaborated on how low risk is defined differently by different researchers, making it difficult to compare outcomes across settings. She emphasized the need for more consistent and evidence-based criteria of low obstetric risk and called for a greater understanding of predictors of both neonatal and maternal complications to guide decisions about level of care and a better understanding of predictors that should prompt maternal transfer.

(from greater than 800 per 100,000 in 1900). However, more recently, based on data from the Maternal, Child and Adolescent Health Division of the California Department of Public Health, there is very clear evidence that the maternal mortality rate is increasing (see Figure 3-2). In the mid-



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