Effects of framing on teratogenic risk perception in pregnant women JD Jasper, Rakhi Goel, Adrienne Einarson, Michael Gallo, Gideon Koren We examined the effects of Information presentation (framing) on women's perception of fetal risk, and their intention to use. a safe drug during pregnancy. Half the women received negatively-framed Information (1-3% chance of having a malformed child), the other half received positively-framed information (97-99% chance of having a normal child). Women In the negative group had a significantly higher perception of teratogenic risk (14-9%) than those In the positive group (8-3%), p=0-0484, and were less likely to want to take the drug. These findings suggest that health professionals and policy makers need to carefully consider how Information is best presented. Lancet 2001; 358: 1237-38 Since the thalidomide disaster, every drug has been perceived as potentially harmful for the fetus. In fact, less than 30 medicinal drugs have been shown to be teratogenic if used in the recommended doses. Services such as Motherisk attempt to distribute this information to the public. The Motherisk Program is a counselling service based in Toronto, Canada, which provides evidence-based information to pregnant women (or women contemplating pregnancy) and their health-care professionals about fetal and maternal safety, and risks associated with drug, chemical, radiation, and infectious exposures in pregnancy and lactation. We impart this information daily to 150-200 women, mostly by telephone, by trained counsellors or information specialists. One of the main objectives of Motherisk is to assist women and their health-care professionals to understand risk information in the hope that they will make better and more informed decisions. The consequences of poor decisions can be severe and include fetal malformations (if women are exposed to a teratogenic agent), psychological and physiological maternal harm (eg, if women choose to abruptly discontinue medication),' and termination of healthy and otherwise wanted pregnancies. Therefore, presentation of accurate information in an understandable and convincing form is very important. Slight changes in the way information is presented can have large effects on behaviour. For example, information framing can affect perceptual judgment, and decisions in patients and physicians. In a classic study of attribute framing, ground beef labelled "75% lean" (the positive frame) was seen as better tasting and less greasy than the same meat labelled "25% fat" (the negative frame). Furthermore, people asked to choose between surgery or radiation therapy for lung cancer view surgery as the more attractive option if life expectancy for surgery is framed in terms of the probability of living rather than of dying.' Thus, a similar manipulation might affect perceptions and decisions of pregnant women inquiring about teratogenic risk. We aimed to assess these effects by comparison of groups of women who received baseline fetal-risk information in a positive or negative form. Participants were successive female Motherisk callers (already, or planning to be, pregnant) seeking information THE LANCET- Vol 358 October 13, 2001 about use of allergy-related drugs during pregnancy. Drugs included oral formulations, nasal sprays, and injections; none had been shown to increase teratogenic risk above baseline. For a complete list of drugs please contact the first author. 125 participants were included: 64 in the positive frame and 61 in the negative frame. However, only 105 participants were successfully contacted in follow-up. All women successfully contacted in follow-up agreed to participate. Table 1 shows their demographic characteristics. After completing a standard intake form, callers were invited to participate in a study assessing "different ways of presenting information to callers". After giving verbal consent, callers were randomly assigned to baseline teratogenic-risk information in the positive (55 women) or negative (50) frame. Callers who received negatively-framed baseline information (the standard form of counselling at Motherisk) were told: "In every pregnancy, there is a 1-3 % chance that a woman will give birth to a child who has a major birth defect. This/these drug(s) [insert applicable drug name] has/have not been shown to change that." Callers receiving positively framed baseline information were told: "In every pregnancy, there is a 97-99% chance that a woman will give birth to a child who does not have a major birth defect. This/these drug(s) [insert applicable drug name] has/have not been shown to change that." Follow-up calls to participants were made 1-4 days after the first call. During follow-up, women were asked to (1) rate their likelihood of having a child with a birth defect as a result of using allergy-related drugs on a 5-point scale ranging from 1, "very low", to 5, "very high", with 3 being "moderate"; (2) rate their likelihood of having a child with a birth defect as a result of using allergy-related medications on a 100-point scale ranging from zero, "0% or absolutely no chance", to 100, "100% or definite chance"; and (3) indicate whether or not they were going to take the drug(s) in question. Data were compared between the framing groups with the Mann-Whitney U test (question 1), unpaired test (2), and x (3). In terms of risk perception, the two scales gave almost the same information. Binomial tests and one-sample z tests against the values of 3, 4, and 5 together (five-point scale) and 50 (100-point scale), respectively, showed that both groups estimated their risk of having a child with a birth defect as a result of allergy-related drug use as being low (all p values