Saturday, February 26, 2011

Risk-Taking As A Parent

My last post was about the risks involved in turning your baby's car seat so it faces forward.  One of the responses I received when I shared the link to the post with my mothers' group was: "What are we supposed to make of this - it's just a bunch of statistics?  The statistics don't say it never happens, so how are they relevant?"

This is an interesting question.  How do you make a decision in the face of uncertainty?  How do you evaluate a risk that has an 0.003% chance of occurring.  It does seem a little meaningless.

As parents, it is one of our roles to make fair decisions on behalf of our children.  And it is one of the stressful things about parenting that the best decision does not necessarily leap out at us.  I think new parents in particular feel pressured to make Absolutely The Best Decision For My Child Every Single Situation, and that we have failed if we don't.

The fact we feel this way is, I think, a result of being bombarded with well-meaning advice while soaked in anxious over-protective I-have-a-newborn hormones.

SIDS and Kids is undoubtedly a benevolent organisation.  They are trying to save your baby's life and your distress by letting you know simple steps you can take to reduce the risks to your baby.  Let's take the 'put your baby to sleep on her back' advice.  We are told that this is 'safer' or 'much safer', so most of us (me included) choose to do it.  But what if your baby just refuses to go to sleep on her back for longer than an hour at a time, and every time you try to put her down that way she screams with discomfort?  By contrast, she goes off to sleep quite easily and soundly if you put her on your tummy.

By this stage, you are desperately sleep deprived and you wonder: how much of a difference will it make really if I sleep my baby on her tummy?  A girlfriend confesses to you that she always slept her baby that way.  Your mother comments that in her day, everyone slept their babies on their tummies and she doesn't know any who died.

So you search around and come up with a figure - let's say you discover babies are 6 times more likely to die on their backs than their tummies.  Oh dear, you think, that seems like a lot.  I'd be an awful, irresponsible parent if I slept my baby on her tummy.  Then, if you are like me, you imagine coming in to find you baby has stopped breathing, and just imagining it is so horrible that you are quite willing to undergo further sleep deprivation to keep them on their backs.

But what if I were to tell you that you are not confused because you are sleep deprived, hormonal, or stupid.  You are actually confused because you don't have all the information.  Here's why:

Let's say God shows up on your doorstep tomorrow and gives you this choice:
Tricky dilemma.  But not because you're stupid.  The problem is that God has only told you about the relative risk.

Imagine how differently you'd answer the question if:

  • if you don't take the deal, your death tomorrow is almost certain, but God's offer can make it almost 70% likely you will survive (eek!); or
  • even if you don't take the deal, you have only have a one in a billion chance of dying tomorrow - God's offer only improves that to one in three billion (hmm...)
This extra information tells you what the absolute risk is.  It puts the risk in context.

We are always told about public health risks as relative risks not absolute risks, because they seem easier to understand, and because the relative risk is what the government or non-profit body is interested in.  By promoting the 'sleep baby on back' message, SIDS and Kids reduces the number of SIDS deaths significantly, because they look at the whole population and don't much care whether the baby that is saved is your baby or the one down the road.  

A relative risk is useful to know about if the cost of taking action to avoid the risk is small.  But as soon as the cost becomes large, you want to know the absolute risk.  If the cost of God's offer was $1, you'd probably pay it and not enquire further.  But if God was asking $10 million and you would have to rob a bank to pay, you might do this to save yourself from almost certain death, but probably not to improve your chances of not dying by only a tiny amount.

Which brings us back to the tummy sleeper dilemma.  When you hear that your baby is 6 times more likely to die on their tummy, this sounds like they are very likely to die that way.  This is not true.  They are very unlikely to die while sleeping at all.

SIDS and Kids claim to have reduced SIDS by 85% since the early 1990s, estimating they have saved over 6000 lives.  Sounds like a lot, stuck out there on its own.  6000 families not devastated by a preventable loss.  But then there have been something like 5 million babies born in Australia in that time, and the chance that your baby would have been one of the 6000 is about 0.1%.  By sleeping your baby on their tummy, you do not eliminate the risk of baby dying in their sleep, you just reduce it to about 0.015%.

This starts to put the risk in perspective.  You are not superhuman.  You need to sleep.   And what's more, if your baby is screamingly uncomfortable on their back, continually putting him in that position is not doing much for his quality of life.  Depending on how you value these things, you might decide that tummy sleeping is worth it, or you might decide that you and your baby can put up with a reduced quality of life for a while in order to make that small reduction in the chance of death.

But wait, it's not that simple.  We've only looked at the risks if you don't sleep your baby on her back, not the risks if you do.  If you sleep your refluxy screaming bub on his back, you will be chronically sleep-deprived.  When you are chronically sleep-deprived, what do you suppose happens to:
  • the risk you'll crash the car?
  • the risk you'll forget to check the temperature of the bath-water properly? 
  • the risk you'll develop PND and not be able to do much at all? and
  • the risk that you'll accidentally fall asleep with the baby somewhere unsafe on a sofa?
I don't have exact figures, but chronic sleep deprivation is equivalent to being a little intoxicated when it comes to driving a car, and with respect to the sofa sleeping I have seen studies putting the risk of the baby's death somewhere around 17-30 times higher than sleeping the baby in a cot.  You start adding up these risks and you haven't made your baby safer at all, you have just exchanged one kind of risk for a different set of risks.  In fact, tummy sleeping for some babies may even be safer.

But this is still not the end of the story.  It's one thing to discuss dry statistical risks, but that is not how humans think.  I was at a dinner a few months back where I mentioned I was co-sleeping, and one of the other girls looked at me in horror.  She was working at the coroner's office, and she had just been dealing with the family of a baby who had died during co-sleeping.  I talked about the statistics and how it really was safe if you followed safe co-sleeping guidelines, but she shook her head and said, 'Maybe, but it would just be so horrible to know you killed your own baby.'

No kidding.  This illustrates two points - and psychologists have actually shown these points in studies.  We tend to feel worse when something bad happens because of something we did than when it happens because of something we failed to do.  Secondly, a risk seems much worse when we can vividly imagine the unpleasant consequences than when they all seem kind of vague and wishy-washy, regardless of whether the statistical risk is the same.

So if you feel cot-sleeping is the norm, and you come in to find your baby dead on his back in the cot, it's devastating but you at least feel you did everything you could do.  On the other hand, if you have deliberately decided to co-sleep instead (despite being told this is unusual and risky) if your baby dies in the bed, you will partly feel it was your fault for co-sleeping.  You feel this way because you didn't just adopt the status quo but made an active choice to do things differently.  In co-sleeping coronials in Australia, there is an assumption that the baby was smothered even if there is absolutely no evidence of this.  Whereas in cot-death coronials in Australia, there is an assumption that the baby died from natural causes.  Why?  Because it's so easy to imagine how smothering could occur during co-sleeping, but hard to visualise how a baby could die from being left alone, notwithstanding that studies show babies are less likely to die when they sleep in the same room as their parents.  We just don't know how or why being in the same room makes a difference, exactly, so it just doesn't 'feel' relevant.

By contrast, women from cultures where co-sleeping is the norm feel the opposite - they feel it would be unbearably horrible if they deliberately chose to leave their baby in a cot alone and away from their protection then came in to find the baby dead.  They would blame themselves for not keeping the baby close.  Whereas if the baby dies in the bed, it's horrible, but they feel they were as present to protect their baby as possible.

Your own peace of mind is relevant here, when you choose which risks you will live with.  It makes sense trying to avoid even a very tiny risk if it's easy to do, and if you didn't you would be so anxious and unhappy you can't think straight.  Academics speak of this psychological aspect of risk-taking as risk salience.  A risk is more salient (seemingly important and relevant) when you can vividly imagine the horrible consequences that might result.

It never seemed that risky to have a second drink on Friday nights, even though I knew it might well put me over the limit.  I could still drive pretty well so it didn't seem such a big deal.  But then I went and worked in the magistrate's court for a while, listening to people being publicly humiliated as they lost their licence over that second drink - and suddenly the thought of being dragged up for public humiliation in front of all my colleagues seemed extremely unattractive.  Unattractive enough to refuse a second drink or get a taxi.  The risk hadn't changed at all - I always knew I would have to go to court and lose my licence if I was caught drink driving - but seeing all the drink driving cases made me feel that this risk was salient and worth avoiding.

Some of the mothers in my mothers group read the post about forward / rear facing car seats and said: that's nice the risk is small, but it still worries me so my baby is going to stay rear-facing for as long as possible.  One of these mums made the point that she had recently been in a car crash, so the thought of her baby being in a car crash was all too real for her.  On the other hand, other mums (me included) who had very nearly crashed the car because their baby was so unhappy in the rear-facing car seat felt that the risks caused by an unhappy baby were more vivid - and were prepared to turn the car seat forward even before knowing whether the statistics offer us any support.  

Neither of these choices are right or wrong.  They just remind us that we are not robots, and that in real life decisions, unless the risks are very large, salience is usually more important than the bare statistics.

Initially as a new parent, I felt trapped and a little overwhelmed by all the warnings.  And for me, it did not help to have well-meaning friends tell me that "I was just overthinking things." or "My parents did that and we turned out all right."  

What did help was to come up with a more structured way of thinking about the possible dangers than just reacting and feeling guilty.  Now, when I'm confused or worried making a decision that seems risky, I try to run through the following points:
  • Do I actually know how likely this awful thing is to happen - meaning, a percentage or approximate percentage figure?  Or am I just reacting to the fact that someone has told me it's more risky?  (If I can't figure out the approximate figure, I pick the highest figure that seems likely then run through the rest of the questions.)
  • How hard / unpleasant is it to avoid taking the risk?
  • Can the risk actually be avoided or just delayed? (eg. giving finger foods to a baby poses a risk of choking whether you start them at 6 months or 10 months - unless I want her to stay on milk / purees forever, we have to brave this choice at some time.)
  • How much of a difference (in absolute terms) do the steps I'm taking actually make - what risk still remains?
  • How horrible would I feel if the horrible thing actually happened?
  • How do the steps I take to avoid the risk create other pressures and strains on my life and those around me?  Do these pressures and strains actually create other risks that are more risky?
  • How horrible would I feel if the other risks actually happened?
  • Are people going to judge me for taking this risk?  Do I feel I can live with my decision despite their disapproval?  (Usually for me, this involves being clear on what my reasons are.)
Using this way of thinking, I was able to come comfortably to the decision to toss out my baby's alphabet foam play mat after reading this article about the possible risks.  No, I don't know exactly how risky it is.  Some countries have left them on the shelves, other countries have pulled them.  But the cost of avoiding the risk is so low (baby has plenty of other toys to chew on and rugs to crawl on, the playmat won't really be missed) that I'm happy to chuck it out, even if the risk turns out not to be significant.  On the other hand, I have decided to keep my baby's Sophie the Giraffe toy, even after knowing that other babies have either choked or gagged on it.  

I think the absolute risk must be quite small, particularly if I don't let her play with it unsupervised, and Bethany really enjoys the toy.

That said, I tend to just ignore risks if I haven't had the time to look into them properly.  I don't really know about the risks from non-organic foods or plastics, for example - and just try to choose organic / natural material if it's available but not worry to much if it's not.  If you are keen to know about more choices you can make to reduce risks to your baby, SafeMama provides a run-down particularly on risks from common baby and household products, with alternatives you can select instead.  Mind you, there is not much here on absolute risks - it just helps you select a safer option when the options are otherwise fairly equal.  Want to know why you see "BPA-free" on products - look at the glossary of this site.

But the truth is that if you avoided every last risk you were warned about as a parent, you'd wrap your baby in (organic, non GM) cotton wool and never leave the house.

I do think those who warn parents about risks (SIDS and Kids, Kidsafe, the ABA, your child health nurse etc.) are doing a good thing.  I certainly want to know what are the safer options.  But I think they would be doing parents more of a favour if they helped them evaluate the risks in context rather than creating black and white choices that don't necessarily fit with the complexities of real life.  Without context, the warnings save lives, but they lead to much unnecessary angst and guilt, not to mention unfair judgements of parents who make one of the 'blacklisted' choices.


  1. True, very true. And I think the personal experiences of each parent plays a huge part in how "risky" you perceive something to be. If you know someone whose baby choked to death, you are much more likely to freak about choking than someone who has never had any personal experience with it. One of the women in my "online" Mum's group lost her baby to SIDs at the age of 4 months, a truly terrible thing to happen. She had him in his own bed following all the SIDS recommendations and it still happened... and it prompted a mass of SIDs hysteria throughout the rest of the group. Suddenly everyone was buying angelcare monitors and other breathing monitors, and moving their babies back to their bedroom if they previously put them into their own room.. it was crazy.. the risks of that happening to their own child hadn't gone up.. but suddenly the risk seemed more real because it had happened to someone they know. Ultimately, at the end of the day everyone needs to make the decision they feel most comfortable with in their own personal situation.

  2. Great info, something I think of often when weighing up decisions. Risk and chance are two different things aren't they? There is often fear surrounding risk but it doesn't increase the chance of something actually happening - yet it feels like it does. Like the risk of sharks when swimming in the ocean. We focus on the risk and fail to remind ourselves of the actual chance of being attacked by a shark...

  3. I agree about the sleep deprevation and the baby-crying-being-distracting-causing-crash things. :) oh, just to throw a spanner in the works, never leaving the house is not recommended as it is not good for babies immune systems and can lead to autoimmune disease :p. I think conflicting advice is a major problem, there is so many different warnings that we don't know which ones to heed

  4. "In co-sleeping coronials in Australia, there is an assumption that the baby was smothered even if there is absolutely no evidence of this."
    So does this mean a baby's unexplained death when co-sleeping is never SIDS - it is always 'smothered'??? This is very scary and unhelpful for parents who want to do the best for their child.

  5. Jen - I probably should have written that better. There is no legal rule which creates a presumption of smothering in co-sleeping. It's just that the people doing the coronials tend to interpret the evidence as accidental smothering, because it's an 'obvious' possible explanation for the death. When a baby dies from lack of oxygen, there are usually no physical signs on the baby's body. Unlike with an adult it can happen with little force. So really the only clue to how the baby died is the circumstances surrounding the death. Probably many co-sleeping cases are death by smothering - statistics support this - deaths occur at a higher rate for co-sleeping arrangements. But this is not because co-sleeping per se is unsafe - deaths only occur at a higher rate when mum is drunk, there are other people in the bed, the bedding is unsafe, mum smokes etc. Take care of these factors and co-sleeping is not any more risky. It is therefore a rare co-sleeping coronial where the baby was in a safe arrangement, and I am not sure I even know what the finding would be in such a case.

    I ought to mention that the purpose of coronials is not to assign blame and punish - but to check for foul play, make recommendations for public policy etc. And I should also say my comment is based on conversations with various people who have had first-hand experience with coronials, not on any kind of systematic study of the findings. And in my experience they do not think the mothers in co-sleeping coronials were neglectful or anything like that - they just think the situation is very sad.