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Risk scoring
1 Introduction
2 Theoretical considerations
3 Usefulness of scoring
4 Conclusions
1 Introduction
One of the primary objectives of antenatal care is to identify factors
that might put mother or baby at an increased risk of an adverse
outcome, at a time when interventions can be undertaken to prevent
or ameliorate the harmful consequences. Other chapters in this book
address the process of screening for specific problems. In this chapter
we consider a quite different aspect, the overall risk status of the woman
and the pregnancy.
Caregivers have long recognized that some women are more likely
than others to develop problems during their pregnancies. Factors in
their family history, past medical history, past obstetrical history, or
findings that are noted in their physical or laboratory examination,
may increase their risk of serious sequelae. Clinicians, consciously or
subconsciously, formally or informally, attempt to identify these
women, and provide them with increased surveillance and care. Ques-
tions remain, however, as to whether assessing risk status in a formal,
quantitative manner, is more effective than the informal methods
traditionally used, and whether the labels and interventions that arise
from risk assessment improve the outcome for mother or baby.
2 Theoretical considerations
The primary purpose of a risk-scoring system is to classify individual
women into different categories, for which specific actions can be
planned, advised, and implemented. A number of scoring systems have
been proposed, in which a womans putative risk factors are identified
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SOURCE: Murray Enkin, Marc J.N.C. Keirse, James Neilson, Caroline Crowther, Lelia Duley, Ellen Hodnett, and
Justus Hofmeyr. A Guide to Effective Care in Pregnancy and Childbirth, 3rd ed. Oxford, UK: Oxford University
Press, 2000.
DOWNLOAD SOURCE: Maternity Wise website at www.maternitywise.org/prof/
Oxford University Press 2000
and summed to produce an overall risk score. In some, the process has
been refined (or complicated) by allotting a weighting factor to each
risk, so that relatively minor risks add little to the score, while more
serious risks are given greater emphasis.
In theory, a process of rationally based risk scoring should be more
accurate than the rather nebulous process of clinical impression that
is part of daily clinical practice. There are, however, a number of
problems with this approach. First, it is difficult to make quantitative
estimates of the exact risk associated with a given factor. That infor-
mation is available only for certain factors, usually the most serious
factors, which in themselves are enough to alert the clinician. Second,
there is no evidence to suggest that assigning a number or weight to a
feature allows it to be added to others to arrive at a valid overall
measurement of risk status. A combination of three similar risk factors
does not provide three times the risk of one of them.
There are difficulties also in the definition of risk factors. Does
bleeding, for example, also include spotting, or bleeding from a local
lesion in the vagina or cervix? The need to dichotomize continuous
variables that are as different from each other as blood pressure (how
high?) or smoking (how much?), imposes a rigidity that can often be
counterproductive. With formalized risk scoring, a woman may be
assigned to a high-risk group because of fixed definitions of the risk
markers, whereas a capable clinician or the woman herself could
have assessed the situation more sensitively with clinical judgement or
common sense.
Scoring is more predictive of outcome in second or later pregnan-
cies, than when used for women pregnant for the first time. The poor
predictive value of the scoring systems for nulliparae is, at least in part,
inherent in the choice of risk markers, many of which relate to char-
acteristics of past obstetric history.
Some scoring systems require women to be scored only once, at the
initial visit, while others may require reassessment at each antenatal
visit. Reassessment allows the inclusion of complications appearing
in the current pregnancy, and revision of the score upwards or, less
typically, downwards depending on new circumstances. A useful scor-
ing system should allow ascertainment of risk in time for appropriate
action to be taken. Scoring systems correspond better to outcomes if
they are implemented late in pregnancy, or allow for readjustment
during pregnancy. This leads to the paradox, that the most precise
predictions are made at a time when there is less need or opportunity
to influence the course of events, whereas the potentially more useful
early risk identification is imprecise.
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3 Usefulness of scoring
In essence, risk scoring is a screening test, and should be required to
conform to the criteria required for all good screening tests. The test
should be able to discriminate clearly between those who are, and those
who are not, at high risk, and effective management should be avail-
able for those who are identified as at high risk. Both the positive and
the negative predictive values of all scoring systems are poor.
Depending on the cut-off point and the test chosen, only between 10
and 30% of the women who are allocated to the high-risk groups actu-
ally experience the adverse outcome for which the scoring system
declares them to be at risk. Between 20 and 50% of mothers who deliver
preterm or low-birthweight infants have low risk scores. As for many
other tests, the sensitivity, specificity, validity, and utility of risk-scoring
systems remain to be determined.
It may be useful to the clinician to know which pregnancies under
his or her care are most likely to result in an adverse outcome. To the
individual woman, however, being labeled as high-risk will be bene-
ficial only if something can be done either to decrease the risk or to
reduce its consequences. If, on the other hand, the label results in the
use of an intervention that was not needed, it will have caused more
harm than good.
Although often referred to as risk factors, most of the elements that
are incorporated in the scores are merely risk markers, indicating that
there is a statistical association with a particular outcome. These risk
markers do not cause the outcome. The most important of them, such
as parity, prepregnancy weight, height, and past reproductive perfor-
mance, cannot be altered by any intervention. For the individual
woman who is labeled as high risk, both the threat of adverse outcome
and the inability to change its markers may create anxiety. As well,
being labeled low risk does not guarantee a good outcome. It is too
easy to fall into the trap of thinking that risk implies a fate, rather than
a frequently incorrect prediction.
The most powerful way to test the effectiveness of formal risk-scoring
systems is to mount randomized, controlled trials in which formal risk
scoring is a component of the antenatal care of one group of women,
while a control group receive the usual antenatal care without formal
risk scoring. No such trials have been carried out.
A number of observational studies have claimed a reduction in
preterm births following the introduction of systematic scoring. They
attributed this improvement to better selection of those women
who require treatment, and to better systematization of interventions.
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In many settings there was an increase in the frequency with which
interventions of dubious value were performed. Although some
authors expressed the belief that their prevention policy had played a
part in the overall reduction of preterm birth rates, most of the
improved results occurred in the women scored to be at low risk.
4 Conclusions
Formal risk scoring systems are a mixed blessing for the individual
woman and her baby. They may help to provide a minimum level of
care and attention in settings where these are inadequate. In other
settings, however, formal risk scoring and labeling may result in a
variety of unwarranted interventions. The introduction of risk scoring
into clinical practice carries the danger of replacing a potential risk of
adverse outcome with the certain risk of dubious treatments and inter-
ventions.
The potential benefits of risk scoring have been widely publicized,
but the potential harm is rarely mentioned. Such harm can result from
unwarranted intrusion in womens private lives, from superfluous
interventions and treatments, from creating unnecessary stress and
anxiety, and from allocating scarce resources to areas where they are
not needed.
Sources
Effective care in pregnancy and childbirth
Mohide, P. and Grant, A., Evaluating diagnosis and screening during
pregnancy.
Alexander, S. and Keirse, M.J.N.C., Formal risk scoring during preg-
nancy.
Other sources
Chard, T. and Carrol, S. (1990). A computer model of antenatal care:
relationship between the distribution of obstetric risk factors in
simulated cases and in a real population. Eur. J. Obstet. Gynecol.
Reprod. Biol., 35, 5161
Hall, P. (1994). Rethinking risk. Can. Fam. Physician, 40, 123944
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