Sometimes Doing The Right Thing Sucks: Frame Combinations and Multi-Fetal Pregnancy Reduction Decision Difficulty

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ARTICLE IN PRESS

Social Science & Medicine 65 (2007) 2342–2356


www.elsevier.com/locate/socscimed

Sometimes doing the right thing sucks: Frame combinations and


multi-fetal pregnancy reduction decision difficulty
David W. Britta,, Mark I. Evansb
a
Department of Health and Sports Sciences, College of Education and Human Development, University of Louisville, USA
b
Mt. Sinai Hospital, USA
Available online 14 August 2007

Abstract

Data are analyzed for 54 women who made an appointment with a North American Center specializing in multifetal
pregnancy reduction (MFPR) to be counseled and possibly have a reduction. The impact on decision difficulty of
combinations of three frames through which patients may understand and consider their options and use to justify their
decisions are examined: a conceptional frame marked by a belief that life begins at conception; a medical frame marked by
a belief in the statistics regarding risk and risk prevention through selective reduction; and a lifestyle frame marked by a
belief that a balance of children and career has normative value. All data were gathered through semi-structured interviews
and observation during the visit to the center over an average 2.5 h period. Decision difficulty was indicated by self-
assessed decision difficulty and by residual emotional turmoil surrounding the decision. Qualitative comparative analysis
was used to analyze the impact of combinations of frames on decision difficulty. Separate analyses were conducted for
those reducing only to three fetuses (or deciding not to reduce) and women who chose to reduce below three fetuses.
Results indicated that for those with a non-intense conceptional frame, the decision was comparatively easy no matter
whether the patients had high or low values of medical and lifestyle frames. For those with an intense conceptional frame,
the decision was almost uniformly difficult, with the exception of those who chose to reduce only to three fetuses.
Simplifying the results to their most parsimonious scenarios oversimplifies the results and precludes an understanding of
how women can feel pulled in different directions by the dictates of the frames they hold. Variations in the characterization
of intense medical frames, for example, can both pull toward reduction to two fetuses and neutralize shame and guilt by
seeming to remove personal responsibility for the decision. We conclude that the examination of frame combinations is an
important tool for understanding the way women carrying multiple fetuses negotiate their way through multi-fetal
pregnancies, and that it may have more general relevance for understanding pregnancy decisions in context.
r 2007 Elsevier Ltd. All rights reserved.

Keywords: USA; Framing; Decision difficulty; Multi-fetal pregnancies; Selective reduction; Medical frame

Introduction

Multifetal pregnancies are becoming more and


more common. The rule-of-thumb ‘‘law’’ proposed
Corresponding author. Tel.: +1 212 260 8418. by Hellin (that twins occurring in 1/90 births and
E-mail addresses: dwr2@nyu.edu (D.W. Britt), higher-order rates’ being estimable by multiplying
miegene@aol.com (M.I. Evans). the denominator by 90 with every increase) has been

0277-9536/$ - see front matter r 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2007.06.026
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D.W. Britt, M.I. Evans / Social Science & Medicine 65 (2007) 2342–2356 2343

rapidly obviated by the onset of ART (Mahowald, another and are rooted in the biographies of
2001). In the decade from 1989 to 1998, for patients (Table 1). Frames, as alternate ways of
example, the number of twin births increased by describing and thinking about decision options,
22.8% and the number of triplets increased by have become an important component of analyses
173.6% (Evans & Wapner, 2002). Further, we know in diverse fields. Kahneman and Tversky (1994)
from analyses of the Society for Assisted Repro- have used frames to compare normative (rational)
ductive Technology (SART) data base that for and descriptive (actual) aspects of decision making.
women conceiving from ART, the percentage of Schön and Rein (1994) made a similar argument
quadruplet pregnancies per the number of deliveries against criteria of technical rationality in their
has fallen dramatically from 1995 to 1999, while the analyses of intractable policy controversies. Goff-
percentage of triplet pregnancies has dropped only man’s (1963) pioneering work on frames has had an
slightly (Toner, 2002). What we do not know is impact on a number of fields, perhaps most notably
what is underneath these trends, as women and their in the social movement literature (Cress & Snow,
partners confront the realities and complexities of 2000; McVeigh, Bjarnason, & Welch, 2003; Snow,
carrying multiple fetuses and negotiating a safe Rochford, Worden, & Benford, 1986).
passage for their pregnancies. Central to our use of frames is the idea that moral
There are a modest number of studies and reviews or normative concerns are an essential part of each
that have focused on patient decision making and/ of the contending frames (Haley & Sidanius, 2006,
or psychological reactions to multifetal reduction Saguy & Riley, 2005; Scully, Banks, & Shakespeare,
(Britt, Risinger, Mans, & Evans, 2003; Garel et al., 2006). A conceptional frame draws its moral force
1997; Maifeld, Hahn, Titler, & Mullen, 2003; from a definition of life beginning at conception and
McKinney, Downey, & Timor-Tritsch, 1995; a sense that the taking of fetal life, no matter how
McKinney & Leary, 1999; McKinney, Tuber, & unviable, is wrong. As one becomes less committed
Downey, 1996; Schreiner-Engel, Walther, Mindes, to a definition of life beginning at conception, space
Lynch, & Berkowitz, 1995; Souter & Goodwin, is created for the development of more moderate,
1998; Wang & Yu Chao, 2006). There is marked situationally constrained moral reasoning, reason-
agreement across these studies, however, that the ing that permits the legitimate consideration of
period during which women are contemplating and reduction under certain circumstances (Chervenak
possibly having reductions is anxiety laden and & McCullough, 2002; Mahowald, 2001; Rudy,
stressful. This phenomenon appears to be associated 1996).
with the nature of the moral anxiety that is present
The medical frame draws its moral force from a
in multifetal pregnancies when multifetal reduction
consideration of the relative viability of fetuses.
is being considered as a pregnancy-management
Increasing the viability of some fetuses justifies
strategy (Britt, Mans, Risinger, & Evans, 2002).
the taking of other pre-viable fetal life. As
This brief period is bounded roughly by the point at
Chervenak and McCullough (2002) has pointed
which a woman and her partner (if applicable)
out, the embedded logic of the medical frame is
discover that she is carrying multiple fetuses (at
not simply the application of statistics to risk
about 8 weeks gestational age) and ends at about 12
reduction:
weeks gestational age, by which time the couple has
probably decided how to deal with the potential ‘‘The medical frame also assumes that (a) reduc-
difficulties of carrying multiples. Such a period is tion of mortality should be valued by the team and
both enormously stressful (Britt, Risinger, Mans, & the patient (and others involved in the decision with
Evans, 2002) and marked by a turning point (Britt her); (b) that some live births are better than none;
& Campbell, 1977) or disruption of equilibrium, (c) because of (b), reduction is preferable to not
during which the couple is forced to consider reducing a multifetal pregnancy; and (d), to achieve
alternative ways of thinking about and acting with (b), killing some fetuses is permissible.’’
respect to the problems presented by carrying This is not to say that there is unanimous
multiples. agreement among fetal surgeons regarding whether
In this paper, we seek to expand the framework and how far to reduce, but there does appear to
and analyses both conceptually and analytically. be agreement on the embedded logic. Finally,
Conceptually, we tentatively propose three contest- the lifestyle frame draws its moral force from the
ing, alternative frames that intersect with one achievement of normality in one’s culture. This
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Table 1
Frame comparison

Medical frame Conceptional frame Lifestyle frame

Intensity of commitment to High High High


having children
Intensity of training in High Low Modest
medicine, dentistry, hard
sciences and the law
Intensity of commitment to Modest High Modest
belief that life begins at
conception
Intensity of commitment to High Low High
balance of career and children
Source of moral authority for Relative survivability of fetuses Minimization of damage to Having a ‘‘normal’’ life in a
resolution moral beliefs culture that values both careers
and family for women
Implications for reduction Dependent upon the medical For those carrying 4+ fetuses, Depending on the financial
choices status of the patient, the choice the choice typically is between situation, career demands,
for the patient who is trying to reducing to three or two. For availability of hands-on
maximize the chances of a those carrying three fetuses, the support from one’s spouse, and
successful pregnancy is between choice typically is between not whether or not there are other
reducing to 2 and reducing to 1 reducing and reducing to two children in the family, the
choice typically is between
reducing to two and reducing to
one

would include augmenting resources devoted to The central question of this analysis is what are
surviving fetuses and permitting more complex the implications of the contest among these frames
female identities, identities that permit the integra- has on the difficulty and associated emotional
tion of career and maternal identities for women. turmoil of the decisions faced by these women and
The moral struggles of these women and their their spouses. There appears to be near-universal
spouses are skewed in different directions depending agreement among those that have studied decision
on their circumstances—circumstances that are difficulty for multifetal pregnancy reduction
often the result of previous life choices in their (MFPR) patients from a variety of countries and
biographical experience. There are certain existen- using different methodologies on at least two points:
tial facts in these experiences that need to be morally first, the decision is difficult, and second, there is a
reconciled in a way that restores some equilibrium high level of emotional turmoil associated with the
to their lives (Britt, 2001). If they are in a career that decision that appears attributable to moral reserva-
requires a relatively high degree of numeracy (Peters tions about the reduction (Britt et al., 2003; Garel
et al., 2006), have received prior medical advice to et al., 1997; Maifeld et al., 2003; McKinney et al.,
reduce from their physicians, or have high preg- 1995; McKinney & Leary, 1999; McKinney et al.,
nancy risk due to past pregnancy outcomes or 1996; Schreiner-Engel et al., 1995; Souter & Good-
current complications, they are more likely to be win, 1998; Wang & Yu Chao, 2006).
framing their choices in medical terms. On the other While we agree that reduction is, on average, a
hand, if they are very active in religious organiza- difficult and morally charged decision, we also have
tions—especially those that believe that abortion is observed considerable variation in the level of
a sin—they are more likely to be framing their assessed difficulty and the attendant emotional
choices using a conceptional frame. Finally, if they turmoil. Further, the careful analysis of the condi-
have expectations of continuing to work at some tions that generate easier vs. more difficult decisions
level after the birth of their children, then they are should have implications for both patients and, at a
likely to be actively negotiating with themselves and level of policy, for centers where such procedures
others how many children they can raise as good take place. We ask whether different combinations
parents. of medical, conceptional and lifestyle frames have
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an impact on the difficulty and attendant emotional assured us that the role of escort was welcomed and
turmoil surrounding these decisions. More specifi- that we were neither undermining the integrity of
cally, we ask whether frame contests (Becker, 2000; the clinical process nor impeding the gathering of
Britt, 2001; Rudy, 1996)—operationalized as having valid and reliable data. During the first week of our
a relatively intense conceptional frame in combina- data gathering, a time when we were actively de-
tion with either, or both, a relatively intense medical briefing one another on the success of these
or lifestyle frame—affect decision difficulty. potentially conflicting roles, there were strong
indications that the combination was a success.
Methods We routinely escorted patients back to the elevator,
where it was common to have them thank us for our
Data were gathered by the lead author and two help in negotiating the process and giving us an
female graduate assistants on 54 patients and their opportunity to thank them for their participation in
partners after counseling at a North American our study. There was also one epiphany when, as
Center specializing in MFPR during their first visit one of the graduate assistants was escorting the
for evaluation and management of multiple preg- couple down a long hallway to the sonographic
nancies. Patients and their partners were met by the rooms, trailed by a visiting fetal surgeon and a
fetal surgeon in his office and given the option of medical student on obstetric rotation (both of
having someone sit in who would escort them whom had been introduced by the fetal surgeon
through the process and ask some questions about by name, title and reason for being in attendance),
what they were going through. The counseling of the husband inclined his head toward the graduate
patients always included the risks of continuing the assistant and asked, ‘‘Who are these people again?’’
pregnancy with their number of fetuses, including While we continued to monitor the possibility that
the risks of loss and prematurity and then a our presence might be making things more difficult
comparison of those numbers of expected deliveries for the patients, at this point we felt that the data-
to outcomes following reduction. Patients were told gathering process was working while protecting the
that the changes in risk were specific to both the clinical process and the rights of the parents. We
starting and finishing number and were net effects, should note as well that some of the missing data in
i.e. take home baby rates that included the our data set is attributable to our being as sensitive
improvement by reduction and whatever procedural as possible to parental wishes not to talk about
risks might exist. Twenty-four weeks was used as the certain issues.
threshold for a ‘‘delivery’’, as compared to 20 weeks Only data from the patients are considered in this
in standard American literature, because a 22 week analysis. Table 2 gives a breakdown of some of the
‘‘delivery’’ is still a dead baby and counting such as patient characteristics. They averaged 33 years of
a success is misleading. Patients were also told that age (with 12 at least 35) at the time of the interview,
overall, only a very small number of pregnancies and all were carrying at least triplets, with 19
were lost within one to 2 weeks of the procedure, patients carrying four or more fetuses. Their
and that most losses were likely due to background education level was much higher than the popula-
and not procedural issues. Three couples opted out tion at large, with only one patient having stopped
at this point, and one couple opted out later in the at high school and 19 having a professional or
process—an opportunity created by our re-empha- graduate degree. They (and typically, their spouses)
sizing that if there were any questions that the traveled quite a distance to be consulted and poten-
patients did not which to discuss, the interview tially undergo the procedure. As many patients
would stop—saying I would just rather not talk came from distant states and foreign countries as
about that now.’’ The combination of being an came from a narrow catchment area defined by local
escort through the process and also being an telephone codes. Net of missing data, 36 had
observer and interviewer was potentially fragile achieved pregnancy through IVF, 11 through
and intrusive even though we had spent consider- ovulation induction and only one natural preg-
able time working out the procedures for informed nancy. Their occupations were quite diverse, with a
consent and subsequent data gathering. Our guiding small number of homemakers and a large number of
premises here were that we should not intrude on managers and professionals. Of these, slightly over
the patient’s rights and should not undermine the half had data-centric careers, careers that had
clinical process. Early feedback from the patients training in and/or required the use of statistics to
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Table 2
Sample characteristics (N varies due to missing data on some variables)

Variable Mean (SD) Median Breakdown

Patient age 33.13 (4.41) 33 Younger than 35 28 (70%)


35 or older 12 (30%)
Patient education HS, some college 10 (19%)
College grad 24 (45%)
Grad or Prof school 19 (36%)
Patient race-ethnicity Caucasian 49 (92%)
Other (Asian 2; Indian 2) 4 (8%)
Distance traveled Local area codes (AC’s) 14 (28%)
Surrounding AC’s and 21 (42%)
states
Distant states and foreign 15 (30%)
Religious preference Roman Catholic 15 (31%)
Protestant 18 (38%)
Jewish 2 (4%)
Muslim 1 (2%)
Hindu 2 (4%)
None 10 (21%)
Religious attendance Never 10 (21%)
A few times a year 8 (17%)
Several times a year 12 (25%)
More than once a month 3 (6%)
At least weekly 14 (30%)
Pregnancy route IVF 36 (72%)
Ovulation induction 11 (22%)
Natural 1 (2%)
Prior voluntary abortion No 50 (98%)
Yes 1 (2%)
Pregnancy riska Relatively low 34 (67%)
Relatively high 17 (33%)
Presenting Number 3 32 (60%)
4 or more 19 (40%)
Job status Homemaker or unemployed 6 (12%)
Public school teacher or 6 (12%)
mgr
Med technician 3 (6%)
Physician, dentist, nurse 4 (7.5%)
Non-technical manager or 14 (26%)
prof
Engineer, accountant, 10 (19%)
systems
College prof, graduate 4 (7.5%)
student
Lower-level salaried 6 (12%)
b
Data-centric career No 25 (47%)
Yes 27 (51%)
Prior medical advice to No 31 (60%)
reduce Yes 21 (40%)
a
Based on presence of any of the following: prior pregnancy problems or current relevant medical condition.
b
Defined as a career in the medical sciences or being characterized by decisions based on statistics.
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analyze decisions. Religious preferences and fre- Table 3


quency of attendance varied widely, with large Variable distributions
percentages of Protestants and Catholics and Variable Characteristics Mean Standard
varying degrees of participation. With respect to deviation
their pregnancies, although all of these women are
at a higher level of risk by virtue of carrying Medical frame Low ¼ 33
dichotomy High ¼ 21
multiples, we also coded the extent to which they
had medical conditions and or prior problem Conceptional frame Low ¼ 31
pregnancies that would exacerbate their risk. intensity High ¼ 23
Roughly two-third of the patients in this sample Lifestyle Frame Low ¼ 35
did not have such conditions. Most of them (60%) Intensity High ¼ 19
had not received prior medical advice to reduce. Self-assessed decision Low ¼ 34
A focused qualitative data-gathering approach difficulty High ¼ 20
was chosen for both epistemological and ethical
Emotional turmoil Low ¼ 34
reasons as it maximized the chances for valid and High ¼ 20
reliable data, minimized the disruption to the
treatment process, and respected what the patients
were going through. The challenge was to design a of embryos the patients thought they were present-
data-gathering approach that would have these ing with and the number to which they decided to
attributes and permit the assessment of variables reduce. We paid attention to what patients said and
of interest while the couples who agreed to did not say, how they acted in different situations
participate were in the process of making their final (counseling, waiting room, initial ultrasound, re-
decisions, and if deciding to go through the process, duction itself and after the reduction), and how they
accompanying them. On average, we were with the spoke about their lives and their families both
patients and their spouses for about 2.5 h. All of the before and their expectations for after the reduction.
couples in our sample had decided to at least go All of the variables in the analysis are dichot-
through a final sonographic scan to assess whether omized. In part this is driven by the tradeoff in
or not there had been any changes in their situation, QCA (as opposed to fuzzy set analysis) in sacrificing
such as emerging risk factors, changes in the more precise measurement in order to maximize the
number of fetuses being carried, and the possibility ability to examine combinations of conditions. This
of genetic anomalies in the fetuses that were being tradeoff turned out not to be much of a sacrifice for
carried. The data we report was on the patient only. us. We had experimented in mapping frame
This is something of a simplification since in many intensities onto 7-point scales and spent much time
cases, the decisions to pursue a reduction and how and effort engaging in inter-rater reliability ana-
far to reduce are jointly determined by both lyses. In none of these exercises did our reliability
partners. The variation among couples is interest- scores exceed .65, owing to difficulties in differ-
ing. In our sample, for example, we had three entiating among levels 5 and 6 on the one hand and
women whose partners were against reduction, one 2 and 3 on the other. By focusing only on a
woman who appeared to not be involved in the dichotomy, there was only a single case in which
decision at all (the father and his family were there was disagreement regarding scoring (the case
making all the decisions), and at least eight women in which the decisions seemed to be being made by
who were being deferred to by their husbands the patient’s husband and his family with only
regarding the decision. To explore these variations, minimal consultation of the wife).
however, is beyond the scope of the present paper.
Data were gathered (Table 3) on the following Decision difficulty
(with all variables being dichotomized into high and
low, represented as uppercase letters and uppercase Building on previous research, we incorporated
letters preceded by a cedilla (), respectively): two approaches to the assessment of decision
medical frame intensity [M vs. M], intensity of difficulty: (1) a patient self-assessment of decision
conceptional frame [C vs. C], intensity of lifestyle difficulty; and (2) field notes regarding levels of
frame [L vs. L], and decision difficulty [hard vs. emotional turmoil surrounding the decision. We
easy]. Additionally, we gathered data on the number asked patients how difficult the decision was for
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2348 D.W. Britt, M.I. Evans / Social Science & Medicine 65 (2007) 2342–2356

them. We thought it might be useful to examine two or one. These distributions speak to the
both aspects so as to minimize the potential for recognition among those coming to the center that
socially desirable responses with respect to assess- the risk of carrying multiples is considerable.
ment of difficulty or for miscodings of emotional Our task in mapping what patients said about
turmoil that are plausibly attributable to pain statistics and the probable health of the surviving
reactions or procedural anxiety. fetuses was to capture variation in the intensity of
Neither of these possibilities is plausible. Patients the medical frame without blurring the boundaries
and their spouses seemed open and honest in their between the medical frame and the other concepts
responses, though in some cases this amounted to that might be related to it—following the dictum
saying to us that talking about specific things was that before one can analyze relationships among
too upsetting or requesting that we let them be concepts one must differentiate among them (Britt
alone for a few minutes in the procedure room so & Campbell, 1977; Soulliere, Britt, & Maines, 2001).
that they could gather themselves together. And it Table 4 presents examples of our high and low
turned out to be relatively easy to differentiate pain medical frame intensity codings.
reactions and anxiety over procedures (one patient Two aspects of what patients said with respect to
had expected a transvaginal method of reduction the substance of the medical frame were especially
rather than a transabdominal method, and that was helpful in discriminating high and low medical-frame
anxiety provoking, for example) from moral anxi- intensity (Table 4). The first of these is simply the
ety. Further validating this conclusion is the fact extent to which medical frame language dominated
that the relationship between the dichotomized patient discussions of their decision-making process,
versions of these two indicators of decision difficulty both in terms of what they said and did not say and
have a X2 of 38.92 (sig.o.000), with only two cases the extent to which a medical frame was separable in
falling off the diagonal, one on each side. their minds from other frames. A second feature was
Looking in Table 4, those who had comparatively the extent to which the focus of their discussions was
easy decisions were both relatively at ease and able to on the relative health of the surviving fetuses. It is this
articulate just why the decision was relatively easy. In focus that best captures the goals of the medical
some cases the reasons were financial. In others it was frame. On occasion, not dwelling on something—
career development or maintenance. In others, it was such as having (but ignoring) a medical condition that
the overwhelming sense of how divergent the out- could have been used to construct a medical frame—
comes were for reduced and non-reduced pregnancies. led us to a low-intensity medical frame code.
This was anything but true for those for whom the
decision was more difficult. They were typically in Conceptional frame intensity
much more emotional turmoil and unable to articulate
the reasons why the decision was so hard. The assessment of conceptional frame intensity was
multifaceted. There were no open references to life
Medical frame intensity beginning at conception. There were no specific
references to selective reduction as being potentially
All of the patients in our sample had accepted the sinful. Nor was there any mention of casuistry as a
credibility of the risks associated with carrying guiding principle in such matters. There were,
multiples (relative to those involved in the proce- however, numerous instances in which the language
dure) to a degree sufficient for them to have made of the patients and their spouses was squarely focused
an appointment to talk to a reduction specialist. on the fetuses that were being reduced—as opposed
Hence, they all have at least some minimal to the fetuses that were to survive. In some cases this
acceptance of the importance of considering medical took the form of patients saying that ‘‘there is no way
data and advice. Having established that, however, that you can overlook the fact that none of the babies
two points should be noted: (1) not all of the is being sacrificed,’’ or attention was focused on the
patients decided to reduce (in our sample, three fact that some of the fetuses were being sacrificed so
women decided not to reduce after the first that the others had a better chance of viability. In
sonogram, with all patients who had come in for other cases, we used post-reduction observations to
consultation going at least as far as the first validate our assumptions about whether patients had
sonogram); (2) of those that decided to reduce, a high or low conceptional frame. There were five
one decided to reduce only to three as opposed to instances in which patients, looking at the monitor
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Table 4
Examples of high and low codes for concepts in the analysis (presenting # and reduction-decision number in parentheses)

Decision difficulty Medical frame intensity Conceptional frame Lifestyle frame intensity
intensity

High (4/2) [In response to a (3/2) This was definitely (3/2) When my fertility (3/2) It would have been
discussion during a medical decision. We doctor told us that I was much too much to raise 3
consultation regarding wanted to do anything carrying 3 fetuses, I small children and our 2-
what other women have we could to take home 2 started crying year old at the same
done] She reduced to 2?! healthy babies and immediately. It was time.
I couldn’t do that. I just reduce the risk of losing especially hard because I (3/2) I’m an engineer and
want you to know that I all 3. found out I was carrying my husband has a Ph.D.
am not here (3/2) I don’t want to give a third during Rosh Our careers are
willinglyyI’m not birth to 3 babies that are Hashana. important to us
happy about being here 2 lbs, each. There is no way that you Sometimes it might be
and I’ll never be happy (3/2) I was amazed to can overlook the fact necessary to have an
about being here. I find how little the local that one of the babies is abortion because it just is
would not wish this on Planned Parenthood being sacrificed. not advantageous to
anyone. This is really chapter knew about the have a child at that point
hard, I think harder than risks involved in in your life.
my miscarriage before. multiple-gestation (3/2) Triplets are just
(4/2) It seemed to us that pregnancies and the unacceptableyWe want
the statistics for 3 were possibilities of lowering to keep the situation
pretty close to the those risks through contained so that we can
statistics for 2, and it was reduction. lead a sort-of semi-
only after talking to a lot normal life.
of people that we became
convinced that reduction
to 2 increased their
chances of success.

Low When you consider (4/2) We’ve had a hard (3/1) The religious aspect (4/2) It’s really hard to
having 4 unhealthy time separating the of all this just does not focus on the medial
babies versus 2 healthy medical facts from the apply. aspects this and not let
babies, the decision was moral issues My (4/2) The only thing that everything else y come
easy for us, coupled with (patient) mother said matters is how healthy into play.
observations noting how that we should look at the kids might be; (3/2) Yes, I’m a college
at ease the patient and this as a necessary everything else is besides professor. I enjoy it and
her spouse were during medical procedure that I the point. will continue to teach,
the counseling, waiting need to undergo rather but maintaining my
room and during the than as an career is not a big issue
procedure. abortionyand we are as far as the decision
(6/3 or 2) [On finding out trying to so that. goes.
that 3 of the embryos (3/2) This is a tough
had spontaneously decision medically, but a
aborted] What!? What!? lot of this is based on my
I’ve been praying for prior medical history, my
this! I said that if there prior lumpectomy. If it
were only 3 I was going had not been for that, we
to keep 3. might have gone for it.

after the reductions, apologized to and thanked the of the fact that it runs the risk of blurring the line
fetuses(es) that had been reduced for their sacrifice. between cause and effect.
To engage in such behavior requires that one have Those with a low conceptional frame were often
attributed personhood to these fetuses at the time of explicit about how little religious and/or ethical
the reduction (Chervenak & McCullough, 2002), and factors played a role in their decision. The two
we used this information in our assessments in spite examples of low conceptional frame codes in Table
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4 reflect this. In other cases, however, we coded (and stop at three) and those who were carrying
conceptional frames as being low when there was four+ fetuses who decided to reduce only to three.
simply no mention of ethical or religious factors in We present the data on the 50 patients first. The
their decision-making process. results for emotional turmoil and self-assessed
difficulty are exactly the same—which should not
Lifestyle frame intensity be surprising given how highly correlated they are.
We present the data only for self-assessed difficulty,
There were a couple of different scenarios using it as a proxy for both indicators. Table 5
associated with patients’ were being coded as having reports the results of this analysis in the form of a
a high lifestyle frame. Not all of these scenarios are slightly modified ‘‘truth table’’ (Ragin, 1987). A
represented in Table 3. One scenario focuses on truth table is simply a collection of the different
career development and maintenance, such as the combinations of conditions with their associated
woman who is an engineer and her partner who has outcomes. Since there are three causal conditions,
a Ph.D. was illustrated in Table 4. A second representing each of the frames that we deem
scenario focuses primarily on the difficulty of relevant, there are 23 ¼ 8 combinations of dichot-
raising three children of the same age, especially omized conditions. Each of these combinations is
when there is at least one older child. A third represented as a row in Table 5. The frequencies
scenario focuses primarily on the financial burden associated with these different combinations are
of raising three children of the same age. In our reported in the fourth and fifth columns, with the
coding scheme, any of these was sufficient to code last column summarizing the discrete outcome that
the patient’s lifestyle frame as high. Often, more we believe is associated with each combination of
than one of these scenarios came into play. conditions. So, for example, in row 3 of the table, a
Some of the patients whom we coded as having non-intense conceptional frame (C) is paired with
low lifestyle frames were explicit in rejecting lifestyle an intense medical frame (C) and a non-intense
elements as having anything at all to do with their lifestyle frame (L). This combination of conditions
decision, as with the second example of a non- is associated with a ratio of 9/0 of easy to difficult
intense lifestyle frame presented in Table 3. In other decisions. On the basis of this outcome ratio, we
cases, there was discussion such as that represented conclude that an easy decision is a discrete outcome
in the first example, with an explicit acknowl- for this combination.
edgement that there were other things—either moral Qualitative comparative analysis is deterministic
or medical—that were driving the decision rather rather than probabilistic, having been designed by
than anything having to do with lifestyle. Ragin (1987) to facilitate the analysis of small
numbers of cases for rarely occurring events like
Results revolutions, strikes, and coups d’Etats. As data sets
become somewhat larger and chance enters into the
We analyze the impact of frames separately for outcomes of cases to a greater extent, some decision
the 50 patients who reduced to two or one fetus and rules are necessary for deciding just when an
those four patients that either decided not to reduce outcome is truly discrete. In other work (Britt &

Table 5
QCA analysis of frame combinations and decision difficulty

Conceptional frame Medical frame Lifestyle frame Number with easy Number with Outcome
salience salience salience decision difficult decision

C M L 3 0 Easy
C M L 11 1 Easy
C M L 9 0 Easy
C M L 5 0 Easy
C M L 1 8 Difficult
C M L 0 1 —
C M L 0 9 Difficult
C M L 0 0 —
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Evans, 2006) we have used a rule of thumb of a ratio having children. We had two cases in which women
of 3 for deciding upon a discrete outcome. In this reduced their involvement in religious activities and
analysis some of the outcome ratios are impressive, moderated the extent to which such precepts
but there are a few others in which the number of become the sole source of moral force in their lives,
cases is so small that a change in one case might presumably in an attempt to deal with the moral
alter the conclusion of whether or not a discrete pressures regarding reduction. These women have
outcome was associated with a particular combina- been actively creating a reality to live in (Britt &
tion of frame conditions. This is in part attributable Campbell, 1977) that may be less stressful for
to the limited diversity of cases in particular raising children.
combinations. Ragin (1987) has argued that limited The combinations of conditions with their out-
diversity is to be expected with social phenomena comes from Table 5 may be gathered together as
because in real life (as opposed to experiments), summary equations. We use the following conven-
there are clusters of things that go together for one tions for these equations (Ragin, 1987): (1) each
reason or another. Rothman (1976) also makes this term consists of a set of combined concepts; (2) a
observation with specific reference to the relation- tilde ‘‘’’ in front of a term in a combination
ship among causes of an illness. Rather than being indicates ‘‘absence’’ or ‘‘low,’’ while terms without a
an artifact of a particular study, such combinations tilde indicate ‘‘present’’ or ‘‘high’’; (3) alternative
are an ‘‘unalterable fact of nature.’’ combinations of conditions are separated by ‘‘+’’
Being able to deal effectively with such lumpiness sign and should be read as ‘‘or.’’ Gathering terms
is a real advantage of QCA, but it is incumbent associated with easy decisions (easy) from Table 4
upon the researchers to explain as best they can the yields the following equation:
occurrence of null sets and clustering in their data,
Easy ¼ CML þ CML
and to that we turn before looking at our more
substantive results. þ CML þ CML: ð1Þ
We can use QCA to facilitate this distributional Using simplification rules (Ragin, 1987) to reduce
analysis by taking the occurrence of null (and near- these equations to a more parsimonious form,
null) sets as the outcome we wish to explain. Doing Eq. (1) reduces initially to
so for our data set we find that the combination CL
(simultaneously holding an intense conceptional Easy ¼ CM þ CM: (2)
and lifestyle frame) is almost completely absent Eq. (2) reflects the fact that the first two terms and
from our data. This is the simplified equation the second two terms in Eq. (1) each share two
derived from the observation that row 6 and 8 in common elements and differ only in one. Eq. (2) can
Table 5 have a total of one case. Among those who be further simplified to:
reduced to two or one fetus, we had 18 women
whom we coded as having an intense lifestyle frame. Easy ¼ C (3)
In most of these cases, these are women whose Eq. (3) tells us that for those patients who have
desire to continue working, but only one of them decided to reduce to two or one fetuses as a
had the CL combination. Another way of looking at pregnancy management strategy for carrying multi-
this is that women with this combination of frames ples, if they do not have a well-developed or intense
are unlikely to make a reservation to consider multi- conceptional frame, the decision will be relatively
fetal reduction (at least at our Center), and perhaps easy for them and they will not have much residual
even to consider going though IVF. It is conceivable emotional turmoil associated with the decision.
that some of the women in our sample at one point Thirty-one of the women in our sample were able
in their lives had a CL frame combination, but as to make a fairly easy decision with not too much
their choices regarding careers, mates, religious emotional turmoil. This C scenario picks up 28%
involvement and the importance of children in their of 29%, or 96%, of all easy decisions.
lives have concatenated over time, this potentially What are the identifiable conditions under which
incongruous pattern has transmuted into other patients will find the decision difficult and fraught
patterns. For example, we had 10 women who with emotion? Collecting terms from Table 5 for a
placed their work commitments ‘‘on the back difficult decision, we have
burner’’ or ‘‘on cruise control’’ (giving them a
CL combination) in order to create more space for Difficult ¼ CML þ CML: (4)
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2352 D.W. Britt, M.I. Evans / Social Science & Medicine 65 (2007) 2342–2356

Which can be further reduced to down to two. In doing so, they brought the medical
risks down—not to the minimum, but a clear
Difficult ¼ CL:
reduction in risk from carrying six. The decision
What keeps us from reducing this equation even was apparently very easy for them, with no trace of
further is the fact that there is only one patient in residual emotional turmoil and their only trepida-
our sample of reduction patients who had a CL tion coming before talking with their Pastor, whom
combination, at least as it was reported to us. We they feared would take a harder line on reduction to
do, however, pick up 17/19 (90%) of the patients for three than he actually did.
whom the decision to reduce was difficult using a The Ferlinnis also presented with six embryos.
combinatorial approach. Importantly, seven of the Like the Fosters, they were also very involved in a
19 cases in which difficult decisions were manifest Church that has strong anti-abortion beliefs. Unlike
involved women who had both an intense medical Mrs. Foster, however, Mrs. Ferlinni is just over 5
frame and an intense conceptional frame. feet tall and weighs more than 225 lbs, making
How do these results compare with those from carrying multiples even more risky than for Mrs.
the four patients who decided either to reduce only Foster (Berkowitz & Papiernik, 1993). The couple
to three or who decided not to reduce at all? With had decided to reduce to two after discussion with
only four patients and three predictive variables, it the fetal surgeon, pending the outcome of the initial
does not make sense to present these patients in ultrasound examination, but reducing to two was a
table form, but there are patterns that should be difficult decision for them and both the patient and
examined. The results for all four of these patients her spouse were emotionally distraught by the
are compatible with our results for reduction to two. situation. During this initial ultrasound examina-
We discuss here only two of the cases because of tion it was discovered that three of the embryos had
space limitations. Two patients presented with six spontaneously aborted. Mrs. Ferlinni’s very excited
embryos, the first of whom had decided to reduce response was to exclaim:
only to three and the second of whom had decided
What!? What!? I’ve been praying for this! I said
to reduce to two or three depending on the results of
that if there were only 3 I was gong to keep 3.
the first ultrasound exam.
Mr. and Mrs. Foster (a pseudonym) are very The intensity of Mrs. Ferlinni’s excitement at
involved with their Church and the community built finding that three of the embryos that she had been
up around that Church—a Church that has a carrying had spontaneously aborted is predictable,
proscription against abortion. Hence, they are given how difficult the decision was for them and
immediately thrust into a moral dilemma. On the how relieving the finding of genetic anomalies and
one hand, they were confronted with the seemingly spontaneously aborted fetuses tends to be in multi-
undeniable risks associated with carrying six em- ple pregnancies (Britt et al., 2003). After the
bryos. On the other, they also faced the apparently ultrasound session was over, Mrs. Ferlinni indicated
absolute and inflexible ethical norms of their that she had interpreted the loss of three embryos as
Church, norms that are shared by all of their a ‘‘sign from God’’ that she should not reduce
friends and family. On the surface this situation further.
might seem hopeless and terrifying (As the mother These two cases are perfectly compatible with the
said, ‘‘When I found out I was carrying multiples, results from our previous analysis. Both of these
my anxiety shot through the roof.’’). Yet the women had an intense conceptional frame. The
Fosters, with the help of their Pastor and their decision to reduce only to three was easy for
families, were able to resolve the dilemma by someone with a non-intense medical frame and an
concentrating on how to minimize the damage to intense conceptional frame (the Fosters). Had the
their ethical principles. Mrs. Foster received addi- Fosters felt that they had to reduce to two, however,
tional support and advice from a high-school we would have anticipated that the decision would
teaching colleague who had reduced to three and have been much more difficult for them. The
from the triplet connection, a non-profit organiza- situation of the Ferlinnis is instructive here, for
tion providing resources for patients carrying while it appeared to have been very hard for the
triplets and above. After discussing their options Ferlinnis to decide, even tentatively, to reduce to
with several people, including their Pastor, they two given the same frame, they were pulled back
choose to reduce only to three rather than going from the brink by the three spontaneous abortions
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D.W. Britt, M.I. Evans / Social Science & Medicine 65 (2007) 2342–2356 2353

that took place, allowing them to not reduce below that patients going through the process experience
three, and making the decision much easier for (Evans & Wapner, 2002). Perhaps the best we can
them. The dictates of the medical frame to reduce to say is that just less than half of MFPR patients are
two or one to maximize the medical probabilities likely to find the decision very difficult.
are being bent so as to be compatible with the We are able to go a little further than that, tracing
dictates of their conceptional frames. decision difficulty to particular elements in the
biographical experience of women’s lives as they
Discussion are captured by the alternate frames that these
women have in varying intensities. Schreiner-Engel
Such findings are intriguing in a couple of et al. (1995) traced continued emotional problems
respects. For some the world of MFPR is terrifying after an MFPR to those who were younger, more
and threatening. For others, it is yet another religious, and those who had viewed their pregnan-
technique for helping them to achieve a family, a cies on ultrasound screens more often. These last
technique that can be appreciated as such. Disen- two patterns are compatible with one of the main
tangling those for whom the decision to reduce is identifying characteristics of the conceptional
difficult and fraught with emotion from those for frame: that all of the fetuses are endowed with the
whom it is comparatively easy requires considera- moral status of personhood at conception. That
tion of two things: (1) how far the patient and her such a position is compatible with a conceptional
spouse have decided to reduce, if at all (down to frame does not mean that patients are actually
three or down to two or one); (2) the combination of thinking about it in such a formal fashion (Brau-
medical, lifestyle and conceptional frames that the nack-Mayer, 2001). But it does mean that whether
patient uses to consider her options. formally articulated or not, how they view what
Do these results take us beyond the existing they are going through and the implications that has
literature? The literature on multifetal reduction is on the decisions with which they are struggling
relatively sparse and scattered across a variety of (whether to reduce and if so, how far) is appreciable.
cultures and societies, making generalization of For our study, those without an intense concep-
prior findings somewhat difficult. The two bench- tional frame found the decisions relatively easy,
mark research projects in the United States that though their reasoning differed depending on the
bear on decision difficulty were done by McKinney, intensity of their medical and lifestyle frames.
Leary and their colleagues (McKinney et al., 1995, Reasoning that embraced lifestyle-related issues,
1996; McKinney & Leary, 1999) and Schreiner– for example, only showed up where there was not an
Engel, Walther and their colleagues (Schreiner- intense conceptional frame. In some cases, the
Engel et al., 1995). These studies estimated that medical frame was dominant, but the lack of an
between 30% and 70% of women undergoing intense conceptional frame created legitimate space
MFPR in their studies had acute feelings of for the discussion of lifestyle-related issues. One
emotional pain, and 33% even verbalized that the dual-physician couple in which the wife was
procedure was tantamount to killing or murder carrying three fetuses, for example, spoke matter-
(McKinney & Leary, 1999). Such a range, though of-factly about the health risks to the wife and
broad, is compatible with the smaller studies that fetuses from carrying three fetuses and the changes
have been done here and elsewhere (Garel et al., in risk from reducing down to two—just as one
1997; Maifeld et al., 2003; Wang & Yu Chao, 2006), would expect with a CM combination. But they
and our own experience, with 38% finding the went on to describe the stresses and problems that
decision to reduce very difficult and fraught with they felt they were avoiding by not trying to raise
emotion, fits within that range. Precise estimates are three children of the same age while they were going
not possible for a variety of reasons, but the most to be opening a new medical practice. It should be
important sources of variation may be cultural emphasized, however, that the determining factor
differences (societies with higher percentages of was not whether an intense medical frame was
shared norms against abortion should differ from operative, but only whether an intense conceptional
more liberal societies), characteristics of patient frame was operative.
populations, a sampling bias toward those that have The issue of whether to emphasize the most
chosen reduction, and the cultures of clinics that parsimonious, simplified scenarios or those that
have grown over time to help moderate the anxiety embody more terms is interesting for those with
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2354 D.W. Britt, M.I. Evans / Social Science & Medicine 65 (2007) 2342–2356

non-intense conceptional frames, but important life-threatening, and had very bad morning
both theoretically and practically for those with sickness, yet who attend their Protestant Church
intense conceptional frames. Both Maines and Britt several times a week and whose (supportive)
(2002) and Ragin (1987) discussed the tradeoffs father is a minister] ‘‘Frankly, we don’t know
between parsimony and richness of detail that may how other people, people who do not have
be theoretically and practically useful. An impor- medical necessity to rely on, get through it.’’
tant issue in fertility studies more generally is the
extent to which women feel as if they are being Here again, the construction of medical necessity
pulled in at least two directions simultaneously. The eases the burden of the choice to reduce below three.
work of Britt (2001), Rudy (1996) and others attest For those without a well-developed medical frame
to the frequency of this claim. With particular and an intense conceptional frame, the language of
reference to MFPR, Schreiner-Engel et al. (1995) necessity just did not arise. A Hindu woman
expressed it most concretely. While 65% of the presenting with three is a case in point. Several of
patients in their sample remembered feelings of her friends (who happened to be doctors) urged her to
pain, stress and fear during the procedure, 93% of reduce, and they spent hours on the internet trying to
them felt as if they would make the same decision do some research, but a theme of medical necessity—
again if faced with it. or even thinking in terms of the medical implica-
For the women with an intense-conceptional- tions—just did not come across. Instead, the patient
frame in our sample, we found two scenarios in began praying as soon as the procedure started and
which women experienced difficult decisions: continued to pray throughout, stopping only when
CML and CML, scenarios that can be the surgeon announced that it was over and asked if
simplified to CL. To simplify to the most they wanted to ‘‘see their twins.’’ Medical necessity
parsimonious level possible loses some of the does not show up either for those with an intense
practical and theoretical richness of the experiences medical frame paired with a non-intense conceptional
of these women, however, specifically with respect frame. The closest to the construction of medical
to the question of whether and how these women necessity in this CM group was a family who
are feeling as though they are being pulled in two initially said that this ‘‘was not a decision,’’ but then
directions. They are being pulled in two directions quickly went on to add: ‘‘When you consider having
by their conceptional frame and their medical four unhealthy babies vs. two healthy babies, the
frames, but it is also the case that those with a decision was easy for us.’’ Hence, it is only in the CM
CML combination were using the medical frame group that medical necessity becomes apparent. This
to carve out a justification for medical necessity, is an important finding, for the very frame that is
thus easing their burden somewhat. Consider the pushing towards reduction to two or one to maximize
following: the chances of ‘‘take-home babies’’ and tearing at
their ethical beliefs is being subtly transformed so that
[a couple that started out at 4/2, a situation they the decision is not really theirs. Having to reduce
described as a ‘‘no brainer,’’ but after one of the reduces the voluntarism, reduces the choice, and
fetuses had spontaneously aborted, they found reduces the blame and guilt that could result. Such a
themselves in a much more ethically challenging shift in the sense of ‘‘whom to blame’’ is akin to a
situation] ‘‘Sometimes doing the right thing ‘‘frame transformation’’ (Snow et al., 1986), or what
sucks! The hardest part is that you try so hard Goffman (1963) referred to as ‘‘keying,’’ but it is
to get pregnant, and then have to turn around relatively subtle. The major characteristics of the
and yuhyabort some of the embryos to medical frame stay the same. The only thing that
increase the chances that everything will turn appears to change is the extent to which the reduction
out ok.’’ is not seen as a voluntary decision but rather as one
that is so over-determined that the patient and her
The sense of having to reduce, and not having a partner feel they have no choice in the matter.
choice in the matter is also present in other CM
cases, as in the following:
Conclusion
[for a woman carrying 4 who was also on
medication for kidney failure, had been warned Frames exert a powerful influence on the nature
by her doctor that to try and carry 4 would be and difficulty of decisions regarding pregnancy
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D.W. Britt, M.I. Evans / Social Science & Medicine 65 (2007) 2342–2356 2355

management. For those considering multi-fetal Berkowitz, G. S., & Papiernik, E. (1993). Epidemiology of
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