Here’s an interesting article and some food for thought. An Australian study – which was published in BMC Pregancy and Childbirth and is thus freely available if you’d like to read it in full for yourself – explored midwives’ experiences and views of the role of obstetric ultrasound, with a focus on where this is used in complicated pregancies and in situations where maternal and fetal health interests conflict.
Now let me just pause for a moment and say that, if you’re wondering about the definitions of ‘complicated pregnancy’ and ‘situations where maternal and fetal health interests conflict’ and are thinking that those areas are ripe for debate, then so am I. This is part of a wider study and the authors note that participants raised and discussed other aspects of this topic area, for instance the use of ultrasound in early pregnancy screening. Other interesting features and noted limitations of the study include that a third of the midwives interviewed had training in undertaking ultrasound examination and participants all worked in tertiary referral hospitals. The authors described these as “highly specialised and intervention-rich environments”.
Let’s look at the results…
“Overall, ultrasound was seen as having many advantages in maternity care; however, it was also seen as contributing to increased medicalisation of pregnancy, to complex and sometimes uncertain decision-making and to parental anxiety. The use of routine ultrasound was described as normalised and unquestioned in health care and in wider society. Midwives were concerned that this impacts negatively on informed consent processes, and at a societal level, to threaten acceptance of human variation and disability. Further, the use of ultrasound was seen to have led to increased ‘personification’ of the fetus, though a variety of views were expressed about when the fetus ‘becomes a person’. Protection of maternal health was the first priority for midwives, but they felt that women often put fetal health interests ahead of their own.” (Edvardsson et al 2015).
This theme was built on three categories:
“First, the category ‘Experiencing pros and cons of ultrasound’ highlighted that ultrasound was seen as having many advantages; however, it was also seen as contributing to increased medicalisation of pregnancy, to complex and sometimes uncertain decision-making and to parental anxiety. Second, ‘Viewing ultrasound as a normalised and unquestioned examination’ illuminated how the use of ultrasound has become normalised and unquestioned in health care and in wider society. Midwives were concerned that this impacts negatively on informed consent processes, and at a societal level, to threaten acceptance of human variation and disability. Third, ‘Reflecting on the fetus as a person in relation to the pregnant woman’ described views on that ultrasound has led to increased ‘personification’ of the fetus, and that women often put fetal health interests ahead of their own.”
The issue of anxiety is one that really bothers me, perhaps because it is the one that I have dealt with most often as a midwife, so I couldn’t agree more with this summary and the words of one particular participant:
“Ultrasound findings falsely indicating that something was wrong were described as having significant consequences in terms of unnecessary worry and anxiety for expectant parents…
‘…you tell parents that there’s something not quite right with the baby’s brain, well it doesn’t matter how you expand that up, it’s going to create a lot of anxiety… and at the end they’ve got a normal baby and we’ve just wrecked that pregnancy really. I see it quite often…’ (FGD 3)”
It is now a number of years since Barbara Katz Rothman wrote her monograph and then book chapter (in Birth By Design) on ‘Spoiling the Pregnancy: prenatal diagnosis in the Netherlands’, but the issues that she raised are still relevant today and, indeed, are echoed by the Australian midwives interviewed for this study. The authors conclude by arguing that, “Further discussion about the use of ultrasound is needed, both among health professionals and in the community, in order to protect women’s rights to informed decision-making and autonomy in pregnancy and childbirth and to curb unnecessary medicalisation of pregnancy.”
I welcome thoughts on that discussion…
Edvardsson K, Mogren I, Lalos A et al (2015). A routine tool with far-reaching influence: Australian midwives’ views on the use of ultrasound during pregnancy BMC Pregnancy and Childbirth 2015, 15:195 doi:10.1186/s12884-015-0632-y
photo credit: our little girl via photopin (license)