Risk Management

I have struggled with how to write this post. I have thought about the issue from a multitude of different directions, and I still have 10 puddles of discrete thought, and no idea of how to collect these thoughts into one body of water. And I need some help.

1. In my professional life, I spend a large part of my time managing risk for the organization I work for. Managing risk is handled in a variety of different ways, through policy, through training staff to be aware of and address risks, through computer systems that flag certain things or don’t let staff perform certain functions, through identification, through common sense. Much of what I do is about identifying a risk, quantifying it, and determining what, if anything, should be done about it.

2. How do we quantify risk? We use a measure of Probability (P), Impact (I) and Cost (C). In other words, we take the likelihood that this will happen (P), the impact to the organization (I) and then we try to figure out what it would cost the organization to fix it (C). Which turns the entire question into a number and a mathematical equation, that we can apply some certainty too. Part of the risk tolerance business is trending. Just getting a number doesn’t help much. You need to compare the number against something. Options include doing nothing, using another solution, outsourcing the work to someone more experienced. That’s how you take the risk number, and start getting somewhere with it.

3. What does the risk number actually mean? If I told you that there was a risk of 1 in 1800 that an asteroid would hit the earth and wipe out your entire country, you are very likely to shrug your shoulders and say ‘oh well, gotta go sometime’. This is because while the I (wipe out your entire country) is very high, the probability (1 in 1800 chance each century) is very low. There are much more likely things to happen. If I told you that the probability that you would change jobs is very great, but in all likelihood you will make more money when you change jobs, you are also equally likely to shrug your shoulders. The P is great, but the I is likely low.

4. So, I come back to my conversation last night – where someone asked how likely it was that “it” would happen again. It, of course, meaning, will another baby die. 30% I answered. I have a 30% chance of developing pre-eclampsia between 23-26 weeks, before the threshold of “real” viability. Which means, a 30% chance of another baby dying. Invariably people respond that “oh, so a 70% chance of another baby living – that’s good news, focus on that.” And invariably, I want to scream.

5. Part of it is the numbers. I am 60 times more likely to loose a baby. The average woman has a 99.5 percent chance of being presented with a screaming, wiggling baby at the end of her labour. I have, at best a 70 percent chance, and that doesn’t take into account the risks of a premature baby. You see, if we say the impact (I) is “dead baby”, and my probability is much greater, it’s just not something I can ignore.

6. So then, we might ask what the medical experts and I can do to reduce either the probability or the impact, or both. That’s what you would usually do to manage risk. And the answer is: a whole lot of not much. Low Dose Aspirin, which might help, although there are no large studies. There are also no large studies about the risk of the drug to a foetus. Blood pressure medications, which don’t halt the progression of the disease, but may buy some more time. Diuretics, which may help my kidneys. Magnesium Sulfate, which prevents seizures and saves lives. Serial ultrasounds, which will at least tell us if something is up. Putting me on bed rest. “We’ll watch you very closely”, the Doctor’s say. And I have this wonderful and terrible image of roadrunner watching Wylie E. Coyote going over the cliff with the acme jet engine strapped to his back. Really, not a whole lot of things to do. And it’s not that my doctor’s are bad, it’s just that truly, there isn’t much they can do about a disease that they don’t know how to cure, because they don’t know what causes it.

7. I come back to those words, “a 70 percent chance the baby won’t die”. And I have heard this from so many people. Now, some of them are the “sunshine and roses” brigade, any disturbing news upsets them, so they focus on the positive. I have to confess, I’m generally speaking, a focus on the positive kind of person. Up until the moment that they told me that they had to induce me, I was positive, I held on to Gabriel living. I would rather dwell on the good than the bad. But in this case, the risk is higher, and the bad, well it’s just so very bad, and it’s a bad I know so excruciatingly well.

8. Now, I want to take their heads, and beat them around a bit. I want to tell them, if you think a 70 percent survival rate is so wonderful, you take a look at the three people you love most, and tell me which one you think should die. And I will happily tell you that “hey, at least the other two lived!”. Because these odds, they totally suck. Totally, absolutely, completely.

9. And I don’t know why their optimism bothers me. Obviously Mr. Spit and I have looked at the odds, and we are willing to try again. Obviously we are hopeful for that screaming baby. I don’t think we are blindly stupid, ignoring the risks. But we are obviously hopeful that this time it’s our turn to win on the giant roulette wheel of life. (In which your odds are 35:1)

10. But please, and this is the help part of the question if you are still with me. What do I say to people who only talk about the 70%? How do I communicate how concerned we are about the 30%. How do I communicate that my risk is way higher? Should I even do that? I don’t want a medal for getting pregnant, I don’t want to be told I’m brave, but I do want everyone to know it won’t be easy, and it may not turn out as planned? I need people to understand that everything is not “ok”, and it may not turn out well, and I have a much higher risk of it not turning out well.

Am I loosing my mind for expecting, hoping, wanting people to understand this?

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22 Responses to Risk Management

  1. c. says:

    The thing is, Mrs. Spit, there is nothing you can say to the 70 per cent people. They don’t get it. They will never get it. It’s just not in their frame of reference. I became the 1% when C died. Fabulous odds, but I lost. And until you lose, it’s easier to live in probability and possibility than in reality.

  2. Julia says:

    You know, I get why you are frustrated with the 70% people. They want to look at the answer in the back of the book, and they want to get to pick that answer. And as long as it is about you and not them, they get to do that, and then go home to their warm and cozy life. I mostly tend to not be very nice to people like that. I don’t feel that I owe them anything, and, in fact, I feel that I owe more to my sisters out there who might get hit with this bullshit optimism/”wisdom” from the same source. So I think what they need is to personalize it for them, make it very uncomfortable. They may not like it, they may even think you are rude for doing that, but for me personally it’s psychologically worse to let them spew their bullshit than to shove it right back at them. Your mileage, of course, may vary.
    So what I might say is something like “well, would you take a plane flight to the best place on Earth, where you would never want for money, or security, or anything else, if your odds of surviving that plane trip were 70%? What if you were sure that you would survive the trip, but one of your children would only make it with the 70% probability?”
    Yes, I am mean like that, I would totally ask it. And for idiots who would tell me that it’s different because they already know and love their kids, and mine was a baby and I can have another, to them I would ask whether their children are indeed interchangeable, and which one of them would they be willing to give up for a 70% chance of having another, some day? Or even a 99.5% chance? 100% chance?
    Like I said, I feel no obligation to be nice to people who say stuff like that, mostly because I don’t think they are being nice to me. They are saying things that make them feel better, and that is a chickenshit thing to do when in the company of someone who has actually been hurt, who needs support and abiding, not bullshit smiles.

  3. Sam says:

    You said it yourself – most people are naturally optimists and don’t want to think about the alternative. However, you also said the average woman has a 99.5 percent chance of having a wiggly baby.

    Perhaps when faced with the postivity brigade, you should gently point out “yes, but most women have an 99% percent chance, mine is 30% lower than that – and this risk needs to be managed”.

    But…at the end of the day, they need to remember (as I am sure you definitely do) that the choice (and risk) is yours, along with the attendant strategies that you will have to deal with it.

    I don’t quite know what else to say!! Except that I have ordered the chocolate!!!

  4. Ya Chun says:

    I think what you may be craving is for people to realize you are going to be very nervous and worried for this whole pregnancy. You won’t be bouncing around, carefree. But I don’t think you can “make” anyone realize this or understand or have additionally caring. This will sort the “friends” from the “people wasting your time”.

    I like how you constructed this post. It’s like an essay I read. Number paragraphs can be very powerful.

    and the logic still flows. But risk for a company to lose some money vs the risk of another health problem and child’s death are not on the same continuum, so it is not so easy to use the same metrics.

    30% is 1 in 3. Triple S, Ya Chun, Serenity. Someone got the short stick.

  5. Carbon says:

    There are some that just won’t get it of course. Few of those who are optimistic by nature are going to take the risks as seriously as you are. But, you should have the right to their love and support as you weigh your own risks.

    You might just say that 1/3 of the time (approximately of course) the outcome will not be good, and you have to be mindful of that risk on your journey. You may need some extra love and support to make it through, regardless of the outcome!

  6. Glo says:

    I would also use the probability. It brings the risk more into focus.

  7. Niki says:

    Well Mrs. Spit you and I are in the same boat. I too had severe, early-onset PE that resulted in Myles being born at 26wks. I have seen 3 different MFMs searching for someone to tell me that all would be well in a subsequent pregnancy. Of course the realistic, logical me knew that it’s impossible to guarantee anything, but the emotional, illogical side of me of me kept hoping for some guarantee that the next time things would be different. All of the doctors I’ve seen assessed my risk around 30% as well, but all reassured me that typically when it reoccurs that it’s less severe and occurs later (like that’s consolation!). Despite the risk we are also trying again. In fact we are doing IVF/FET next week. For us our desires are stronger than our paralyzing fears!

    Many have asked us how we are able to try again knowing the risks (a question I frequently ask myself too) while others are among the “optimism brigade.” I like you get very irritated with those 70% people, but typically choose to bite my lip. This decision is not to ease their discomfort, but rather to save my energy, which happens to be in short supply these days. Like others have mentioned no one understands and they never will. I really want to say the same things that Julie says, but I feel like it’s not worth it for me. They will hear me, get super uncomfortable, make me uncomfortable, and in the end will likely continue to focus on the 70%. They cannot and will not look beyond their unrealistic ideal of this world where these things don’t happen. Really who can blame them for not wanting to accept this reality?! I’d much rather live in their world, wouldn’t you?!

    Anyway I’m there with you facing the reality of a subsequent pregnancy that no one else seems to be able to face. I wish you strength and courage in your journey!

  8. loribeth says:

    It’s easy to ignore or downplay statistics when you’ve always been on the right side of them. Also, to me, saying the outcome is negative 1/3 of the time somehow sounds more weighty to me than saying 30%, for some weird reason.

    I do know several women (IRL & cyberspace) who lost babies through pre-eclampsia but went on to have healthy subsequent pregnancies. They were monitored very closely, though!

    You know that we’ll all be here for you if/when you decide to take the plunge again!

  9. Reese says:

    Mrs. Spit,

    All you can say is that you held your born-to-soon baby once, and you have to be able to deal with the 30% chance that it could happen again.

    Some women talk about doing whatever it takes to get a baby. I read a crazy story about a couple who were carriers of a fatal genetic illness that lost 4 (16-18wks) until they magically came up with 2 children that were not affected by their disease. I asked myself, would I be like that woman? Is that woman crazy or just determined?

    I try not to judge, because everything is such a personal decision. Just like this one will be. I wish you well–Reese

  10. Candid Engineer says:

    I am trying to think about this from my own perspective as your standard woman who has not yet tried to get pregnant and who is relatively unfamiliar with these things. I don’t think that it’s necessarily people’s optimism getting in the way (because God knows I am not particularly optimistic). It is just that people are conditioned to treat the state of pregnancy with delight and happiness. Typically, it is a very joyful thing, and that is the scripted response.

    If I was not part of your family or good circle of friends, I admit that it would be hard for me to say “Yeah, your pregnancy situation totally sucks. 30% chance of losing the baby sounds horrible.” At least in my case, this would be hard for me to say because I would not want to draw the mother’s attention to the negativity of the situation (not knowing her very well).

    So, my long answer to your short question is that I would not really bother with the socially-conditioned optimists. Don’t talk to them about it. If they press, say you are concerned, but try to leave it where you can. It is hard to press this kind of understanding into ignorant people on the fly.

  11. Heather says:

    I tend to agree with Candid Engineer’s perspective. While my baby didn’t die (and this may completely discount my opinion — and that’s okay), I did have PE/HELLP with him. I dragged about with PE for six weeks, had an abruption, and the wheels blew off the bus. But he was 36 weeks and we made it to the hospital in time. It very easily could have turned out *very* differently.

    When we decided to try again, it was a hard decision to arrive at. We both wanted people to appreciate the risk, the absolute tightrope that the pregnancy would be – and was, and the bare truth that it was not going to be easy or fun or light. That I would be prodded, poked, and scanned to oblivion. And I knew that my doctors would not let me die, but that *if* I got sick, it would be my baby.

    I can tell you that not ONE single person in my life besides my husband can share that perspective. No amount of talking, explaining, and illustrating will get people to grasp reality here. My solution? To try to avoid discussing it with anyone because I inevitably ended up in tears. I felt it was a very personal matter and one that I didn’t want to invite people into.

    Our culture very much views pregnancy as something benign, and unless that statistical anomaly touches your life – your baby’s life, you don’t get it. Women who don’t fit that picture are marginalized. And being marginalized is a horrible, horrible feeling.

    Personally, finding online support carried me through in a way that my family and close friends, despite their best intentions, wouldn’t have been able to.

    Thinking of you, Mrs. Spit.

    Sorry this became so wretchedly long.

  12. Geohde says:

    People would say to me (and I was operating on much lower risk numbers of 5-10%)that 90% chance it’ll be fine!! Rainbows! Puppy dogs!! Kittens!!

    I used to point out that I’d fallen in the unlucky % once, and you know what? WHen that happens, then risk is immaterial- it’s 100%. Or to put it another way, would YOU get on a plane that had a 30% chance of crashing and the passengers dying?

    J

  13. Trish says:

    Don’t answer. Just punch them in their ovaries. It’s justifiable.

    I really don’t have an answer for you, but thought I’d share that the night Robbie was born.. while I was still laying in the hospital bed completely doped up and wondering every 15 seconds or so if NOW was the minute he was dying, my MIL said something to me about “when you have a little sister for Robbie..”

    I don’t clearly remember what I said in response, but I know there was a LOT of sputtering.

    People just assume we’ll have another baby. It blows my mind.

    We didn’t have an easy time conceiving, I had 2 miscarriages and my 3rd pregnancy only last 6 months and almost killed both of us.

    I’m not saying we WON’T try again, but I’m sure not saying we will either.

    People are idiots.

  14. Azaera says:

    I’m kind of one of those avoid it and leave it where it is kind of people. I hate that everyone assumes that I am going to have a live baby by January. I want to of course, but when they start being rude to me about things that they clearly take for granted and they don’t understand that nothing is definite and I have lost one before I may very well lose one again. I tend to just kind of say yeah whatever and walk away. Like I will simply go along with whatever they are saying so that I can get away from the conversation quickly, because usually arguing with these kinds of people is pointless. Until they experience it themselves they have no clue. (not everyone has to experience it to be sympathetic, I mean the people who are super optimistic, think you are being overdramatic etc, those people just don’t get it.)

  15. niobe says:

    Well, I got same 30% number quoted to me and you know what I decided to do.

    But anyway, the way I explained the odds to people is “I have a 2/3 chance that the baby will either die or be extremely premature” — adding together the 30% chance of very early onset PE when the baby isn’t viable and the 30% chance of onset at a viable gestational age, but still, by anyone’s count, very early.

    People seemed to understand when I put it like that.

  16. JamieD says:

    I don’t have any advice that is politically correct. To be honest, I vote for punching them in the ovaries.

    It is easy for people to be all ‘Raindrops on roses and whiskers on kittens’ when they haven’t lived through the 30%

  17. luna says:

    well you’ve heard lots of good replies so far. of course these people just don;t get it. they never will. and they want you to look at the bright side because their babies never died.

    as you and others have said, the numbers don’t mean crap until you’re on the wrong side of the equation. and then it’s 100%. so your experience has been 100% bad, right? you could always say something like, unless you have been in that 30% I don’t think you can possibly know how to weigh those odds…

  18. SAHW says:

    I think you should say back, yes, but that is still a 30% chance of a baby not living – almost 1/3 – which is still quite a big chance, and that is why you are so concerned.
    But unfortunately, life is such that rarely do people understand what they haven’t experienced.

  19. Emily (Apron Strings) says:

    Because I can’t think of anything witty enough to say right now (I blame it on the cold …), I’m all for the punching in the ovary bit as well.

    Hugs, Mrs. Spit. Whatever the outcome, just know that you do have a lot of love and support here in cyberspace.

  20. Jill says:

    I agree that most people just don’t get it. I’ve never lost a child. I’ve never been pregnant. I don’t get it, quite honestly, but I try my best. From my own struggles, I know that it is hard to accept other people’s optimism for your situation- especially when you’re SO afraid that the worst might actually happen. But on the contrary, when you hear someone is afraid, it’s a natural reaction to try and cheer them up and help them get through the hard times with something positive. I’m SO sorry that you have to go through this. I wish I had something better to say, but all I have are((hugs))

  21. Nicky says:

    Some of what you’re fighting is other people’s optimism, but I think that a lot of it is just mathematics. Most people do not understand probabilities well. People are crappy at estimating odds, they make irrational decisions when faced with known odds, and they don’t understand risk/reward calculations at all. 70% sounds like a big number to them because hey, it’s over 50!

    I was a math major in college, but I quickly learned that while most people do not understand numbers, they do understand comparatives.

    When faced with someone thinking that 70% sounds great, I would switch to a non-mathematical, more emotional approach. Something along the lines of, “I’ve faced this before, and there’s a good chance that I’ll have to face it again, so sadly, I really do have more to be worried about than most people.”

  22. Erin says:

    I hope you don’t mind, but I linked this post to a recent one I did in my private blog. I developed preeclampsia/HELLP syndrome and gave birth to my son at just over 25 weeks.

    I thank God everyday that he survived, but he did sustain considerable brain damage and has cerebral palsy and is significantly impacted. I have decided to do a gestational carrier cycle with my sister as the carrier (suppressing right now), and thought your post was the perfect explaination of the risk analysis.

    If you would rather I not link, please let me know and I will be happy to remove it (you can leave a comment on my public blog, but please don’t specifically mention the gestational carrier cycle as I don’t want it to be public knowledge quite yet).

    Best of luck to you.

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