The madness of modern measurement

Cassie, who has given me permission to tell her story and who chose her own pseudonym, became pregnant via IVF. She was thus one of those women who know the exact date when they conceived, and she and her midwife joked about this at her booking visit. They then calculated her estimated date of birth (EDB) together, using her conception date as the point from which to calculate her EDB. The date they came up with was September 1st.

The ultrasound appointment

Not long after her booking chat, Cassie attended an appointment for an ultrasound scan. Her reason for going was not the dating element of this procedure, but she wanted certain screening tests which were only available at this appointment. Cassie had read loads about pregnancy, birth and decision making and was well-informed even before she became pregnant, so she wasn’t entirely surprised when the ultrasonographer looked at her halfway through the scan and informed her that her due date was different from September 1st. According to the ultrasonographer, Cassie’s baby’s guesstimated due date was August 27th.

Smiling, Cassie told the ultrasonographer that, as this was an IVF baby, she was certain of the due date. Afterwards, Cassie told me that she relaxed again after imparting that information, thinking that she and the sonographer would share a laugh and move on, with her initial due date intact.

But no.

Preparing ahead

Initially, Cassie said, the sonographer seemed a bit flummoxed. ‘I wondered,’ Cassie wrote afterwards, ‘if she wasn’t used to women who had had IVF, but surely she sees lots of us – unless she’s new?’

We never found out how experienced the sonographer was, but that element of the story became less important as Cassie continued her tale. ‘Anyway,’ she told me. ‘I said to her that I didn’t want my due date to be changed. I didn’t want to be forced to have conversations about induction four or five days earlier than necessary.’ As a result of her reading, Cassie realised that one key element of avoiding unwanted pressure to have induction for so-called prolonged pregnancy was to ensure that any EDB calculated in early pregnancy is as accurate as possible.

Finding a solution

As Cassie explained this during the scan, she felt that the sonographer understood the problem and Cassie’s rationale for wanting to stick with her original EDB. At this point, Cassie told me, she assumed that the sonographer would simply make a note in Cassie’s notes that the original due date stood, and continue with the screening element of the examination.

No, again.

Cassie remembers the sonographer saying, ‘let’s see if I can make this right’, as she placed the transducer back on Cassie’s tummy. She then proceeded to continue to measure Cassie’s baby from a variety of directions, and it slowly dawned on Cassie what might be happening. A further chat with the sonographer confirmed Cassie’s suspicions. The sonographer knew that the final due date calculated by the scan procedure would be entered into the hospital computer and would usurp Cassie’s original due date. Without the ability to over-ride the authority of the computer-generated scan date, the sonographer was instead trying to re-measure Cassie’s baby in a way which would make the machine generate a due date to match the one worked out from the knowledge of when Cassie had actually conceived.

An isolated problem?

Sometimes, when I hear stories like Cassie’s, I wonder if I have accidentally entered an alternative reality. It wouldn’t surprise me at all to wake up and find that I had fallen asleep on the sofa while watching one of the Terminator movies, but that turned out not to be the case on this occasion.

However, it’s only fair that I add here that I am only able to report one side of this story and haven’t had a chance to speak to the sonographer who saw Cassie that day. So I was concerned that, before I wrote something on this and potentially missed an important point, I should check with a few colleagues. Amazingly, within a week of being contacted by Cassie, I had been told similar stories about three other women. I have also since talked to sonographers who confirmed that, like many other health professionals, they sometimes have to work with systems and machines whose programming prevents humans from trumping the decision of the appliance of the day.

Technological tenacity

I’ve encountered other examples of situations where technologies, machines or systems are limiting women’s decision making. In one area, midwives are not able to properly book women unless they record their height and weight so that the woman’s body mass index (BMI) can be calculated. Yet women have the absolute right to decline to be screened in this way, and some of them decline to be weighed and measured precisely because they know that they are better off (in terms of the options that will remain available to them) if they have an unknown BMI than if they allow their higher-than-average BMI to be documented. In fact, I know midwives who ensure that women know the pros and cons of consenting to BMI measurement before asking whether this is something the woman wants. But such a woman-centred approach leaves midwives in that region with a dilemma because, without a BMI, they can’t even get to page two, let alone complete the booking appointment.

In this situation, and many other similar ones where computer systems want information that women may not want to give or that midwives may not be able to provide, the midwife’s options are limited. Stopping the data entry isn’t really an option, and the impersonal, impenetrable stubbornness displayed by a computer is absolute and cannot be reasoned with. In some cases, practitioners have no option but to make something up in order to be able to get on with their work. (Fast forward, by the way, to the next audit or research study which draws on data gathered from these systems, and we have yet another reason to need to be extra vigilant about results based on medical records).

What can we do?

Often, when I write articles about things that aren’t working well within the maternity services, I know that there is nothing much that individual midwives can do about the problems. But, actually, in this case, there IS something that we can do. These machines, computers and systems are authorised and bought by people who work for health care systems and, if the machines are not serving the recipients of those health care systems well, then we should tell those responsible for their purchase. If you don’t want to do this as an individual, then there are a number of groups – such as MVPs and PALS – who may well feel able to take your concerns forward. Let’s not sit by and let machines dictate women’s experiences in this way.