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Viewing the unborn child – pregnant women's expectations, attitudes and experiences regarding fetal ultrasound examination
Sexual & Reproductive Healthcare 7 (2016) 8–13
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Sexual & Reproductive Healthcare j o u r n a l h o m e p a g e : w w w. s r h c j o u r n a l . o r g
Viewing the unborn child – pregnant women’s expectations, attitudes and experiences regarding fetal ultrasound examination Liv Øyen a,*, Ingvild Aune b a Post Graduate Programme on Obstetric Ultrasound for Midwives, St. Olavs University Hospital, Norwegian University of Science and Technology, Olav Kyrres gate 17, 7006 Trondheim, Norway b Department of Nursing Science, Midwifery Education, Faculty of Health and Social Science, Sør-Trøndelag University College, Mauritz Hansens gate 2, 7004 Trondheim, Norway
A R T I C L E
I N F O
Article history: Received 2 June 2015 Revised 24 August 2015 Accepted 5 October 2015 Keywords: Prenatal care Ultrasound Women’s view Expectation Experience
A B S T R A C T
Objective: To gain a deeper understanding of pregnant women’s expectations, attitudes and experiences regarding ultrasound examination during pregnancy. Methods: In-depth interviews were conducted with eight pregnant Norwegian women prior to their 18week scan. The data were analyzed through systematic text condensation. Results: The analysis generated three main themes: (1) I want to know if everything is fine, (2) Viewing the unborn child, (3) Holistic care. The women had a strong wish for ultrasound scanning and medical knowledge about their “baby” was their first priority interest. Visualizing the “baby” represented a strong emotional dimension for the parents-to-be and initiated the bonding process and the planning of a new life. The women wanted to be empowered and approached in a holistic way, where dialogic communication was needed. Conclusion: The women wanted medical knowledge about the fetal health. They considered the examination a visual experience together with their partner. The scan provided a personification of and an attachment to the fetus. This experience was the first step in the planning of a new life. The women had ambivalent feelings related to the ultrasound examination and they highlighted the importance of holistic care, where the sharing of information happens on an individual basis. © 2015 Elsevier B.V. All rights reserved.
Introduction Ultrasound examination during pregnancy is a frequently debated topic in Norway, which has led to two Consensus conferences. The first one, in 1986, discussed what at the time was seen as “overuse” of ultrasound scans during pregnancy, without resulting in any conclusions. In order to systemize and organize the use of it, one ultrasound examination became available to pregnant women across the country [1]. The second conference, held in 1995, discussed the ethical aspects of using ultrasound. Knowledge of the conditions in the womb could be lifesaving for some fetuses, while other conditions might lead to abortion. This conference resulted in a continuation of ultrasound scan at 18 weeks of gestation, which still is the only official offer available to pregnant women in Norway today [2].
* Corresponding author. Post Graduate Programme on Obstetric Ultrasound for Midwives, St. Olavs University Hospital, Norwegian University of Science and Technology, Olav Kyrres gate 17, 7006 Trondheim, Norway. Tel.: +47 72574667/+47 95888068. E-mail address: [email protected] (L. Øyen). http://dx.doi.org/10.1016/j.srhc.2015.10.003 1877-5756/© 2015 Elsevier B.V. All rights reserved.
Prenatal care is part of the primary health services and has a long tradition in Norway. The responsibility lies with the municipalities, while the specialist health services are responsible for care during birth and the early postnatal period. The ultrasound examination at 18 weeks is organized as consultation number two in the official prenatal care programme [3]. The scan takes place at the hospital and is carried out by midwives with professional competence on ultrasound. The ultrasound scan is mainly offered for medical reasons; fetal number, gestational age, location of the placenta and fetal anatomy [4]. As almost every pregnant woman in Norway undergoes this scan, it becomes an important part of prenatal care. The importance of informing the woman and her partner specifically about the purpose of the ultrasound examination, its possibilities and limitations has been emphasized [5,6]. The choice of prenatal screening should be conditioned by the access to correct, comprehensible and sufficient information and it is important that women are encouraged to choose according to their own values and wishes. The possibility of making a choice is affected by economic, political and ethical considerations. Apart from these factors, knowledge, combined with a reflective attitude, is the foundation of all informed choices [7]. Ebert et al. [8] claim that socially disadvantaged women do not feel confident to engage in discussions relating to choice. Situations such as inadequate contextualized
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information, perceived risks in not obeying routine procedures, as well as the actions and reactions of midwives may result in silent compliance. It may be interpreted as a way for the women to take responsibility for their baby’s well-being by delegating health care decision-making to professionals. According to Nicol [9], an informed choice related to ultrasound examination may be impossible to achieve because of the established routines in maternity care. Women also experience social pressure to undergo the examination in order to get a photo of the baby as part of a maternity package. They perceive the ultrasound scan as part of the antenatal care, and thus decide that receiving the offer is “the correct course of action”. Studies show that women feel anxious that something might be wrong with the fetus prior to the ultrasound scan [6,10]. However, normal developments during the ultrasound examination tend to reduce anxiety among pregnant women [10,11]. In her study, DiPietro [12] highlights that viewing a fetus on ultrasound involves a shortterm maternal psychological benefit, including reduction in anxiety following a reassuring scanning process. Several studies show that the ultrasound examination is highly desired by women, because it confirms a new life and a new family. Being able to see “the baby” on the screen creates overwhelming emotions and an attachment to the fetus [6,13,14]. Molander et al. [14] emphasize that pregnant women consider their first ultrasound scan as a way of approaching different goals during pregnancy. The goals are about meeting and connecting with the “baby”, and represent an important step toward parenthood. Objective The aim of this study is to gain knowledge and a deeper understanding of pregnant women’s expectations, attitudes and experiences regarding ultrasound examination during pregnancy. Methods Data collection A qualitative approach was chosen for data collection, and the data presented are from in-depth interviews prior to the ultrasound examination at 18 weeks of gestation. The informants were picked from a random sample taken from the hospital’s scanning list. The informants were healthy women with normal pregnancies of different ages and social statuses, and included both primiparous and multiparous women. They had to master the Norwegian language. 12 women were contacted by telephone and invited to participate in the study. Eight Norwegian women, with different backgrounds, aged 20–37, volunteered to participate. The educational level of the participants ranged from primary school to university education. Four women were primiparous and four were multiparous. The participants received written and oral information about the aim of the study, and were given assurances that all data would be treated confidentially. The informants provided a written informed consent to participate in the study. The project was approved by the Regional Research Ethics Committee (Ref. No. 2011/2046). All interviews were conducted at the hospital and lasted 45–60 minutes. Two of the eight interviews were
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conducted on the same day as the ultrasound scanning while the others took place two to three days before the scan. An interview guide was prepared in advance. The questions were derived from a literature review on the topic as well as from professional knowledge and experience. The interview guide was based on four main topics: (1) (2) (3) (4)
Informed choice Aim of the ultrasound scan Emotional state of mind Visualization
The data collected were rich in content as all informants talked freely about the topics and offered thorough descriptions of their experiences. After 8 interviews, data saturation was achieved. Data analysis The interviews were tape-recorded and transcribed verbatim. The transcribed interviews were carefully analyzed through systematic text condensation. This method, developed by Malterud [15], is a modified version of Giorgi’s [16] phenomenological analysis. The purpose of the phenomenological analysis is to gain knowledge about the informants’ experiences within a particular field. The researcher tries to identify the essence or the themes emerging from the data. The method of analysis followed a four-step process [17]. First, all the interviews were read in order to obtain an overall impression; the broad picture being more important than the details. The researchers looked for themes that reflected the women’s thoughts about ultrasound scanning and an effort was made to bracket hypotheses, preconceptions and the theoretical framework of reference. In the second step, meaning units representing the different aspects of the ultrasound scan were identified and coded. In the third step, the content of each of the coded groups was condensed, abstracted and summarized. The last step of the analysis involved re-contextualization. The women’s expectations, attitudes and experiences regarding ultrasound scanning were summarized in re-contextualized versions that provided the basis for new descriptions or concepts. Table 1 shows one example of the analyzing process. Results Three themes emerged during the review of the material: “I want to know if everything is fine”, “Viewing the unborn child” and “Holistic care”. Quotations from the informants are used to support the findings. I want to know if everything is fine This theme describes the women’s satisfaction with receiving an offer of ultrasound examination during prenatal care. They identified this scan as the most important form of consultation they received during pregnancy. Together with their partner, they looked forward to getting information about the pregnancy and their new baby. The women preferred to get this as early as possible during pregnancy in order to avoid the possibility of receiving bad news
Table 1 One example of the analyzing process. Theme
Sub-theme
From code to meaning
Code
Quotation
Viewing the unborn child
Parenthood and attachment
The visual experience strengthened the relationship and connection to the baby
Experience
“Experiencing another human living inside you, and simultaneously being able to see it – that is impressive!”
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at the time of birth. The women knew that it is impossible to discover everything; nothing is guaranteed. Their feelings switched between joy and anxiety, while hoping that everything would be fine. Knowledge about fetal health The women wanted all available information in order to find out if their baby seemed healthy, or discover things that could have an impact on its life. First and foremost, the informants experienced that ultrasound examination was based on medical considerations. The women expressed themselves in this way: The aim must be to detect physical damage, that is the medical…/ …/You have so many thoughts, and then you wonder if it’s all imagination. We are really lucky to have the possibility to find out about our baby’s health. (E) All the women in the study expressed their main motivation for taking the ultrasound scan in the same way: “I want to know if everything is fine”. The women also expressed: It’s important for me to know if there is life inside; if everything looks fine. (D) They can see if the baby is healthy and calm things down if something is wrong; maybe help me get to know what can be done. (C) The women sought dialog with the person responsible for the scan, and wanted the midwife to understand how important it was for the pregnant woman and her partner to receive information about their specific baby:
The waiting time for the ultrasound scan was experienced differently for women with children compared to those without children. The women who were primiparous found the ultrasound scan at 18 weeks of gestation to be too long a wait: You experience a sense of unreality before you get the ultrasound scan. I yearn for the scan and I’m counting the days. (E) Being able to see reassures and calms you down. You need it when you are struggling a bit emotionally. (G) The women also found there was too little time for midwifery care during the first part of pregnancy. Then you feel alone and you know nothing about what’s inside. (D) Then you are just waiting for a sign that all is well. (A) The women who had children found that time flew by. They did not focus as much on pregnancy as the first time. Shocking how fast time flies! Have been busy, so it’s from now on I begin to have contact with the baby in the womb. (E) Viewing the unborn child This main theme describes the first visual meeting between the parents-to-be and their baby. This meeting caused a strong emotional experience which marked the beginning of parenthood, attachment to the baby, and the planning of a new life.
Last time I heard what they said. But if it could be possible to share some of our own thoughts and concerns, it would be another type of examination. (E)
Parenthood and attachment The women highlighted that the ultrasound examination is a common experience for the mother and father-to-be. They also pointed out that this type of examination in pregnancy involves live images of their baby, enabling a visual experience and a strengthening of the relationship and connection to the baby.
Emotional ambivalence The women experienced an ambivalent feeling of pleasure and anxiety when considering the ultrasound examination. The fear that something could be wrong was always there, but they tried not to focus on this in the present. Ultrasound examination generates strong emotions, and the women wished the midwife to take this into consideration.
The most important is to create a bond between the father, mother and baby. Imagine seeing the head, four limbs and a beating heart, and at the same time realizing that this is ours! – And then it can be our secret for a little while. – It’s so good to experience such wonderful feelings. (E)
It’s too long to wait for something you are looking forward to, but then you don’t know if it’s something to look forward to either. (C)
The visual images confirms life, you just know that it’s real. (E)
But one should not take sorrow in advance. (D) The women knew that the ultrasound examination might reveal abnormal developments or disease affecting the fetus, but leading up to the examination the women tried to keep their hopes alive, and did not want to spend time on negative thinking. They neither saw the importance of having a lot of information in advance about possible anomalies that may be detected, as they would not be able to deal with it at that point anyway. Sub-consciousness works and prepares you. Last night I had such a horrible dream that reality can only be better./…/I should have a predictability that is not there, but I must believe that all is well. It’s a small chance that it would not be so. We take it as it comes./…/I want to know now rather than at birth because preparation is important. (A) I do not think it’s possible to prepare for something that may go wrong, but you must deal with it. (B) It’s just the way things go. If only the baby will be healthy, I think. (H)
Experiencing another human living inside you, and simultaneously being able to see it – that is impressive! (A)
The women felt that the ultrasound examination enabled the pregnancy and the baby to become more real for the partner, who is not able to experience this in the same way as the woman does through her body. The women claimed that they, during the ultrasound examination, took their partner for a journey full of visual images of their baby. They highlighted that this half hour was full of impressions with strong mental and emotional dimensions. When I think of ultrasound I see a small intimate, cosy room where I hold my husband’s hand and together we get to see our baby, a small human being with a beating heart. (E) Planning a new life The women and their partners used the ultrasound examination in planning the pregnancy process leading toward birth and a new life with the baby. They emphasized that the scan would leave unique memories that would benefit the phase before birth as well as the future. Knowing who is in there will help the preparation, as it makes it possible to plan how to take the pregnancy process forward. (E)
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It’s very special to see the one who will be with us in a while. I feel happiness about what is coming. (C)
The women wanted concise, understandable and user-friendly information.
The women also considered the baby’s gender as a preparation for parenthood, even if this was not the most important thing.
Much of the information is written in such a poor language that it’s useless. (E)
It’s not for my own sake I want to know, but it’s a person living in my belly. The relationship becomes more personal if you know whether it’s a boy or girl and you can give it a name. (G) Others felt guilty about reflecting on the baby’s gender. One day I became excited when thinking of whether it was a boy or girl. The next moment I thought that it’s not allowed to think so. I have always heard that it doesn’t matter, what matters is that the baby is healthy. (C) The women were concerned about the great responsibility that comes with pregnancy, childbirth and the postnatal period. They highlighted that they had to make sure to take care of themselves during pregnancy; doing exercise, eating healthy food, not drinking alcohol, enabling the baby to feel well in the mother’s womb. It’s a great gift and a huge responsibility. It turns your life upside down. You have to realize that there is another person to care for. (B)
Individual needs during pregnancy The women would have wanted several ultrasound scans during pregnancy, if this had been possible. They perceived the offer of one ultrasound scan as an official recommendation and that this recommendation was based on safety considerations concerning the fetus. The women were uncertain about the risks associated with ultrasound technology and whether the risk would increase with several examinations. I might have wished several ultrasound scans, but don’t want to expose my baby more than is recommended. (E) I hear the rumours … I don’t know if they are justified … that it can be harmful to take more than one scan. At the same time, you can pay for an ultrasound scan whenever you want. (C)
He thinks more of practical things when the kid is born, and is eager to look for equipment. (H)
The informants also commented on the social pressure related to ultrasound scans during pregnancy. There were great expectations from family and friends that they would accept the offer. Those who had been informed about the “big news” shared the joy with the couple and the pregnant woman was often asked: “Have you had an ultrasound scan?” or “when are you going to have an ultrasound scan?”, as it was taken for granted that she would have one.
He has already started talking about taking the kid out for fishing. (F)
I feel some pressure from the environment. My girlfriends were surprised that I hadn’t demanded a 12-week scan. (A)
According to the women, the partner’s preparation and planning were different:
Holistic care This main theme describes how pregnant women experience receiving information about ultrasound scanning and their need for individualized care. Information about the ultrasound scan All women in this study wanted the ultrasound scan strongly. They wanted to be followed up by the public services during pregnancy, but claimed that information about the public prenatal care, as well as the choices and rights of pregnant women, was difficult to get hold of. The women highlighted that the information leaflet from The Directorate for Health and Social Affairs contains information they should have had already at their first consultation during prenatal care involving their general practitioner (GP) or midwife. The women also sought information about the ultrasound scan at the hospital. They responded negatively to the information leaflet, which they received in connection with the appointment for scanning. They felt that the information only focused on the person performing the scan, who was not to be disturbed. The important dialog during the scan was not given any emphasis. We have the right to get information from the public health services, but this information is so “machine-like”, it doesn’t address the whole process. It lacks the emotional and human dimensions. (G) The women claimed that the Internet is the most important source of information today. They experienced various degrees of professionalism, and said that they had to be critical to the information. Friends and family were also cited as important sources of information. The women felt that there is too much information during pregnancy. Apparently, the women want information adapted to their own context. They found it hard to read large amounts of information before they finally discover what they are looking for.
The women believed that visualization of the fetus is not emphasized in the official medical examination. This is despite the fact that the women emphasized the importance of “seeing their baby”. The public health services mostly focus on the physical examination of the baby, in order to see if it’s healthy. The emotional experience and the individualized care that we need are not emphasized. But body and mind cannot be separated. (E) Discussion The pregnant women in this study had a sincere desire to undergo the ultrasound examination at 18 weeks of gestation because they wanted medical knowledge about the fetal condition. They wanted to know if the fetus was viable and whether it had developed as it should. The ultrasound scan was considered the most important examination during pregnancy. Several other studies highlight that the ultrasound examination provides valuable information about the condition of the fetus, which in turn brings reassurance and relief to the parents-to-be [10–12,18]. When women show up for the ultrasound examination, the midwife expects that they have received information about the examination’s purpose and content, as this is specified both in Guidelines for the use of ultrasound in pregnancy [4] and Guidelines for prenatal care [3]. The informed consent of the women should be ensured before the examination. The informants in the present study considered the information given prior to the examination to be insufficient. Several other studies support this finding [9,18–20]. Ekeland [21] argues that the problem in today’s health services is not too little information but too poor communication. Martin et al. [22] highlight that the focus on giving information may prevent midwives from establishing a real dialog on a daily basis during the antenatal counseling. The study by Martin et al. [23] provides insight into the midwives’ perception of their own prenatal counseling performance. The midwives found the client–advisor relation and the
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health education aspects of counseling during the prenatal phase to work well, whereas decision-making support was insufficient. The authors conclude that midwives should focus more on decisionmaking support to optimize the counseling in connection with prenatal screening. On the other hand, in a midwifery model of care, Dixon and Burton [24] found that midwives provide adequate information and promote informed choice in relation to prenatal screening, with high levels of client knowledge and satisfaction. In this model of care, the principle of informed choice is central and the time spent on counseling long enough to enable in-depth discussions. Farrell et al. [25] highlight the need to ensure that professionals have both the knowledge and communication skills to effectively support pregnant women’s informed decisionmaking regarding the use of prenatal tests. Nicol [9] points out that leaflets are often used instead of verbal communication; the women choose to read what they want and they interpret written information about ultrasound scanning in a way that fits their coping strategies. None of the women in this study were given written information about the ultrasound examination at 18 weeks, and only one of the eight women was asked whether she wanted to accept the offer. It seems that midwives and general practitioners during prenatal care take it for granted that women want an ultrasound scan, and therefore fail to ask the women about it. The women instead received the following statement from the GP: “I will send a referral for ultrasound scanning to the hospital”. For pregnant women who want a different choice, such statements may be perceived as a pressure. Several studies show that the ultrasound examination is perceived as a part of the prenatal care and necessary for a successful pregnancy [9,26,27]. Heyman et al. [27] consider this view to be based on an inclination to trust the health service providers and an idea that health care services offered ought to be accepted. Nicol [9] claims that when pregnant women find themselves in a stressful situation, they respond by complying with what they believe is the recommendations of the health professionals. Social pressure is also clearly evident in several other studies [28–30]. Health professionals who work with prenatal care should encourage informed choice by parents with regard to routine ultrasound examination [11]. The women in this study wanted information during the examination in order to understand the ultrasound images and the purpose of the examinations. They welcomed dialog with the midwife, including the opportunity to express their own thoughts, concerns or questions. The women wanted the midwife to understand the significance of the examination for the parents-to-be. Garcia et al. [5] and Lalor and Devane [6], who emphasize the necessity of specific information about the ultrasound examination, support this finding. The experience of the ultrasound scan depends on the treatment and information the woman and her partner receive [31]. During the examination, the midwife, the pregnant woman and her partner will enter a relationship. The relationship with the midwife builds bridges through the sharing of information, enabling the pregnant woman to make sense of the communication. This represents what Ekeland [21] understands as “helping communication”. A successful ultrasound examination depends on how the helper relates to those seeking help, and whether the person receiving help feels acknowledged. For women who accept the offer of ultrasound examination, trust and good communication skills from the midwife are essential for the ultrasound scan to be meaningful. Communication is at the heart of the entire ultrasound examination, as information from the images on the screen is conveyed to the parents-to-be. When accepting the offer of ultrasound examination the women put their trust in the hospital as a system. The midwife herself depends on being trusted by the couple in order to be able to provide individualized care [32]. The examination starts when the midwife
puts the ultrasound probe on the woman’s abdomen. This is a very vulnerable situation for the woman because she leaves her pregnant body in the midwife’s hands, and expects to be cared for. The women in this study described an alternating sense of pleasure and anxiety prior to the ultrasound scan. For some women there is a growing tension before the examination, with physical and emotional discomfort [18]. Brudal [33] points out that our emotions are guided by increased vulnerability when moving from one phase of life to another. Women’s vulnerability during pregnancy means that memorized coping strategies are often not useful. Usually, the way we think follows rational logic, which is characterized by common sense. During pregnancy, a new kind of logic arises – the emotional logic. Such emotions dominate the mind, and Brudal’s theories may help us understand how this logic influences the woman’s experience of the scan. Ekelin et al. [11] and Aune and Möller [18] stress that women are mentally affected by the ultrasound scan. They emphasize the advantage that all caregivers who are involved in the ultrasound examination are aware of this fact, both in relation to the information given before the offer is accepted and in connection with the scan itself. Midwives should provide useful information and understand the factors that influence women’s concerns [34,35]. The women in this study considered the examination to be a visual experience, involving personification and attachment to “their baby”. The visual images resulted in a strong emotional experience, which was the starting point for planning a new life with a baby. According to Aune and Möller [18], the ultrasound examination enables visualization and personification of the fetus, and the women develop a stronger connection and different relationship to it. Several studies indicate that the ultrasound scan confirms a new family, and the ability to see the fetus causes overwhelming emotions and attachment [6,13,14,18]. The women in the present study also wanted to prepare themselves in case something wrong was detected during the scan. According to Aune and Möller [18], preparedness was considered an important factor. This also implied that health professionals during the examination get to know about the condition of the fetus, which better prepares them to take care of the baby after the birth. Limitations In this study, the thoughts and experiences of a small group of pregnant women in Norway were examined. We do not suggest that these women are representative of all other pregnant women. However, the small sample size does not mean that the findings are irrelevant. The women gave comprehensive descriptions of their expectations, needs and attitudes using their own words. This study enables us to understand some key factors that influence pregnant women’s experience of ultrasound scanning during pregnancy. Conclusions The women had an independent, sincere desire for ultrasound examination at 18 weeks of gestation, as they wanted information about the fetal health. At the same time, they considered the examination a visual, shared experience with their partner, including a personification of and attachment to “their baby”. The visualization led to a strong emotional experience, which marked the beginning of a new life with the baby. The women experienced both happiness and anxiety about the ultrasound examination. They emphasized holistic care, where individually adapted information is an important factor. Acknowledgements We would like to thank the eight pregnant women who participated in this study.
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[19] Gottfredsdottir H, Bjornsdottir K, Sandall J. How do prospective parents who decline prenatal screening account for their decision? A qualitative study. Soc Sci Med 2009;69:274–7. [20] Georgsson Öhman S, Grunewald C, Waldenstrom U. Perception of risk in relation to ultrasound screening for Down’s syndrome during pregnancy. Midwifery 2009;25:264–76. [21] Ekeland T-J. Kommunikasjon som helseressurs (Communication as a health resource). In: Ekeland T-J, Heggen K, editors. Meistring og myndiggjering. Reform eller retorikk? (Coping and empowerment. Reform or rhetoric?). Oslo: Gyldendal akademisk; 2008. p. 29–52. [22] Martin L, Hutton EK, Spelten ER, Gitzels-van der Wal JT, van Dulmen S. Midwives’ views on appropriate antenatal councelling for congenital anomaly tests: do they match clients’ preferences? Midwifery 2014;30:600–9. [23] Martin L, Gitsels-van der Wal JT, Pereboom MTR, Spelten ER, Hutton EK, van Dulmen S. Midwives’ perceptions of communication during videotaped counseling for prenatal anomaly tests: how do they relate to clients’ perceptions and independent observations? Patient Educ Couns 2015; http://dx.doi.org/10.1016/j.pec.2015.02.002. [24] Dixon V, Burton N. Are midwifery clients in Ontario making informed choices about prenatal screening? Women Birth 2014;27:86–90. [25] Farrell RM, Nutter B, Agatisa PK. Patient-centered prenatal counseling: aligning obstetric healthcare professionals with needs of pregnant women. Women Health 2015;doi:10.1080/03630242.2014.996724. [26] Moyer A, Brown B, Gates E, Daniels M, Brown HD, Kuppermann M. Decisions about prenatal testing for chromosomal disorders: perceptions of a diverse group of pregnant women. J Womens Health Gend Based Med 1999;8: 521–31. [27] Heyman B, Hundt G, Sandall J, Spencer K, Williams C, Grellier R, et al. On being at higher risk: a qualitative study of prenatal screening for chromosomal anomalies. Soc Sci Med 2006;62:2360–72. [28] French S. Perceptions of routine nuchal translucency screening. Br J Midwifery 2000;8:632–8. [29] Lou S, Dahl K, Risor MB, Hvidman LE, Thomsen SG, Jørgensen FS, et al. A qualitative study of pregnant women’s choice of nuchal translucency measurement. Ugeskr Laeger 2007;169:914–18. [30] Gottfredsdottir H, Sandall J, Bjornsdottir K. This is just what you do when you are pregnant: a qualitative study of prospective parents in Iceland who accept nuchal translucency screening. Midwifery 2009;25:711–20. [31] Ekelin M. Parents’ expectations, experiences and reactions to a routine ultrasound examination during pregnancy. Doctoral thesis. Department of Health Sciences, Faculty of Medicine, Lund University, Sweden; 2008. [32] Grimen H. Profesjon og tillit (Profession and trust). In: Molander A, Terum LI, editors. Profesjonsstudier (Professional studies). Oslo: Universitetsforlaget; 2008. p. 197–215. [33] Brudal LF. Psykiske reaksjoner ved svangerskap, fødsel og barseltid (Emotional reactions during pregnancy, birth and postnatal period). Bergen: Fagbokforlaget; 2000. [34] Murakami K, Tsujino K, Sase M, Nakata M, Ito M, Kutsunugi S. Japanese women’s attitudes towards routine ultrasound screening during pregnancy. Nurs Health Sci 2012;14:95–101. [35] Rapp R. Testing women, testing the fetus. The social impact of amniocentesis in America. New York: Routledge; 2000.
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Sexual & Reproductive Healthcare j o u r n a l h o m e p a g e : w w w. s r h c j o u r n a l . o r g
Viewing the unborn child – pregnant women’s expectations, attitudes and experiences regarding fetal ultrasound examination Liv Øyen a,*, Ingvild Aune b a Post Graduate Programme on Obstetric Ultrasound for Midwives, St. Olavs University Hospital, Norwegian University of Science and Technology, Olav Kyrres gate 17, 7006 Trondheim, Norway b Department of Nursing Science, Midwifery Education, Faculty of Health and Social Science, Sør-Trøndelag University College, Mauritz Hansens gate 2, 7004 Trondheim, Norway
A R T I C L E
I N F O
Article history: Received 2 June 2015 Revised 24 August 2015 Accepted 5 October 2015 Keywords: Prenatal care Ultrasound Women’s view Expectation Experience
A B S T R A C T
Objective: To gain a deeper understanding of pregnant women’s expectations, attitudes and experiences regarding ultrasound examination during pregnancy. Methods: In-depth interviews were conducted with eight pregnant Norwegian women prior to their 18week scan. The data were analyzed through systematic text condensation. Results: The analysis generated three main themes: (1) I want to know if everything is fine, (2) Viewing the unborn child, (3) Holistic care. The women had a strong wish for ultrasound scanning and medical knowledge about their “baby” was their first priority interest. Visualizing the “baby” represented a strong emotional dimension for the parents-to-be and initiated the bonding process and the planning of a new life. The women wanted to be empowered and approached in a holistic way, where dialogic communication was needed. Conclusion: The women wanted medical knowledge about the fetal health. They considered the examination a visual experience together with their partner. The scan provided a personification of and an attachment to the fetus. This experience was the first step in the planning of a new life. The women had ambivalent feelings related to the ultrasound examination and they highlighted the importance of holistic care, where the sharing of information happens on an individual basis. © 2015 Elsevier B.V. All rights reserved.
Introduction Ultrasound examination during pregnancy is a frequently debated topic in Norway, which has led to two Consensus conferences. The first one, in 1986, discussed what at the time was seen as “overuse” of ultrasound scans during pregnancy, without resulting in any conclusions. In order to systemize and organize the use of it, one ultrasound examination became available to pregnant women across the country [1]. The second conference, held in 1995, discussed the ethical aspects of using ultrasound. Knowledge of the conditions in the womb could be lifesaving for some fetuses, while other conditions might lead to abortion. This conference resulted in a continuation of ultrasound scan at 18 weeks of gestation, which still is the only official offer available to pregnant women in Norway today [2].
* Corresponding author. Post Graduate Programme on Obstetric Ultrasound for Midwives, St. Olavs University Hospital, Norwegian University of Science and Technology, Olav Kyrres gate 17, 7006 Trondheim, Norway. Tel.: +47 72574667/+47 95888068. E-mail address: [email protected] (L. Øyen). http://dx.doi.org/10.1016/j.srhc.2015.10.003 1877-5756/© 2015 Elsevier B.V. All rights reserved.
Prenatal care is part of the primary health services and has a long tradition in Norway. The responsibility lies with the municipalities, while the specialist health services are responsible for care during birth and the early postnatal period. The ultrasound examination at 18 weeks is organized as consultation number two in the official prenatal care programme [3]. The scan takes place at the hospital and is carried out by midwives with professional competence on ultrasound. The ultrasound scan is mainly offered for medical reasons; fetal number, gestational age, location of the placenta and fetal anatomy [4]. As almost every pregnant woman in Norway undergoes this scan, it becomes an important part of prenatal care. The importance of informing the woman and her partner specifically about the purpose of the ultrasound examination, its possibilities and limitations has been emphasized [5,6]. The choice of prenatal screening should be conditioned by the access to correct, comprehensible and sufficient information and it is important that women are encouraged to choose according to their own values and wishes. The possibility of making a choice is affected by economic, political and ethical considerations. Apart from these factors, knowledge, combined with a reflective attitude, is the foundation of all informed choices [7]. Ebert et al. [8] claim that socially disadvantaged women do not feel confident to engage in discussions relating to choice. Situations such as inadequate contextualized
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information, perceived risks in not obeying routine procedures, as well as the actions and reactions of midwives may result in silent compliance. It may be interpreted as a way for the women to take responsibility for their baby’s well-being by delegating health care decision-making to professionals. According to Nicol [9], an informed choice related to ultrasound examination may be impossible to achieve because of the established routines in maternity care. Women also experience social pressure to undergo the examination in order to get a photo of the baby as part of a maternity package. They perceive the ultrasound scan as part of the antenatal care, and thus decide that receiving the offer is “the correct course of action”. Studies show that women feel anxious that something might be wrong with the fetus prior to the ultrasound scan [6,10]. However, normal developments during the ultrasound examination tend to reduce anxiety among pregnant women [10,11]. In her study, DiPietro [12] highlights that viewing a fetus on ultrasound involves a shortterm maternal psychological benefit, including reduction in anxiety following a reassuring scanning process. Several studies show that the ultrasound examination is highly desired by women, because it confirms a new life and a new family. Being able to see “the baby” on the screen creates overwhelming emotions and an attachment to the fetus [6,13,14]. Molander et al. [14] emphasize that pregnant women consider their first ultrasound scan as a way of approaching different goals during pregnancy. The goals are about meeting and connecting with the “baby”, and represent an important step toward parenthood. Objective The aim of this study is to gain knowledge and a deeper understanding of pregnant women’s expectations, attitudes and experiences regarding ultrasound examination during pregnancy. Methods Data collection A qualitative approach was chosen for data collection, and the data presented are from in-depth interviews prior to the ultrasound examination at 18 weeks of gestation. The informants were picked from a random sample taken from the hospital’s scanning list. The informants were healthy women with normal pregnancies of different ages and social statuses, and included both primiparous and multiparous women. They had to master the Norwegian language. 12 women were contacted by telephone and invited to participate in the study. Eight Norwegian women, with different backgrounds, aged 20–37, volunteered to participate. The educational level of the participants ranged from primary school to university education. Four women were primiparous and four were multiparous. The participants received written and oral information about the aim of the study, and were given assurances that all data would be treated confidentially. The informants provided a written informed consent to participate in the study. The project was approved by the Regional Research Ethics Committee (Ref. No. 2011/2046). All interviews were conducted at the hospital and lasted 45–60 minutes. Two of the eight interviews were
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conducted on the same day as the ultrasound scanning while the others took place two to three days before the scan. An interview guide was prepared in advance. The questions were derived from a literature review on the topic as well as from professional knowledge and experience. The interview guide was based on four main topics: (1) (2) (3) (4)
Informed choice Aim of the ultrasound scan Emotional state of mind Visualization
The data collected were rich in content as all informants talked freely about the topics and offered thorough descriptions of their experiences. After 8 interviews, data saturation was achieved. Data analysis The interviews were tape-recorded and transcribed verbatim. The transcribed interviews were carefully analyzed through systematic text condensation. This method, developed by Malterud [15], is a modified version of Giorgi’s [16] phenomenological analysis. The purpose of the phenomenological analysis is to gain knowledge about the informants’ experiences within a particular field. The researcher tries to identify the essence or the themes emerging from the data. The method of analysis followed a four-step process [17]. First, all the interviews were read in order to obtain an overall impression; the broad picture being more important than the details. The researchers looked for themes that reflected the women’s thoughts about ultrasound scanning and an effort was made to bracket hypotheses, preconceptions and the theoretical framework of reference. In the second step, meaning units representing the different aspects of the ultrasound scan were identified and coded. In the third step, the content of each of the coded groups was condensed, abstracted and summarized. The last step of the analysis involved re-contextualization. The women’s expectations, attitudes and experiences regarding ultrasound scanning were summarized in re-contextualized versions that provided the basis for new descriptions or concepts. Table 1 shows one example of the analyzing process. Results Three themes emerged during the review of the material: “I want to know if everything is fine”, “Viewing the unborn child” and “Holistic care”. Quotations from the informants are used to support the findings. I want to know if everything is fine This theme describes the women’s satisfaction with receiving an offer of ultrasound examination during prenatal care. They identified this scan as the most important form of consultation they received during pregnancy. Together with their partner, they looked forward to getting information about the pregnancy and their new baby. The women preferred to get this as early as possible during pregnancy in order to avoid the possibility of receiving bad news
Table 1 One example of the analyzing process. Theme
Sub-theme
From code to meaning
Code
Quotation
Viewing the unborn child
Parenthood and attachment
The visual experience strengthened the relationship and connection to the baby
Experience
“Experiencing another human living inside you, and simultaneously being able to see it – that is impressive!”
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at the time of birth. The women knew that it is impossible to discover everything; nothing is guaranteed. Their feelings switched between joy and anxiety, while hoping that everything would be fine. Knowledge about fetal health The women wanted all available information in order to find out if their baby seemed healthy, or discover things that could have an impact on its life. First and foremost, the informants experienced that ultrasound examination was based on medical considerations. The women expressed themselves in this way: The aim must be to detect physical damage, that is the medical…/ …/You have so many thoughts, and then you wonder if it’s all imagination. We are really lucky to have the possibility to find out about our baby’s health. (E) All the women in the study expressed their main motivation for taking the ultrasound scan in the same way: “I want to know if everything is fine”. The women also expressed: It’s important for me to know if there is life inside; if everything looks fine. (D) They can see if the baby is healthy and calm things down if something is wrong; maybe help me get to know what can be done. (C) The women sought dialog with the person responsible for the scan, and wanted the midwife to understand how important it was for the pregnant woman and her partner to receive information about their specific baby:
The waiting time for the ultrasound scan was experienced differently for women with children compared to those without children. The women who were primiparous found the ultrasound scan at 18 weeks of gestation to be too long a wait: You experience a sense of unreality before you get the ultrasound scan. I yearn for the scan and I’m counting the days. (E) Being able to see reassures and calms you down. You need it when you are struggling a bit emotionally. (G) The women also found there was too little time for midwifery care during the first part of pregnancy. Then you feel alone and you know nothing about what’s inside. (D) Then you are just waiting for a sign that all is well. (A) The women who had children found that time flew by. They did not focus as much on pregnancy as the first time. Shocking how fast time flies! Have been busy, so it’s from now on I begin to have contact with the baby in the womb. (E) Viewing the unborn child This main theme describes the first visual meeting between the parents-to-be and their baby. This meeting caused a strong emotional experience which marked the beginning of parenthood, attachment to the baby, and the planning of a new life.
Last time I heard what they said. But if it could be possible to share some of our own thoughts and concerns, it would be another type of examination. (E)
Parenthood and attachment The women highlighted that the ultrasound examination is a common experience for the mother and father-to-be. They also pointed out that this type of examination in pregnancy involves live images of their baby, enabling a visual experience and a strengthening of the relationship and connection to the baby.
Emotional ambivalence The women experienced an ambivalent feeling of pleasure and anxiety when considering the ultrasound examination. The fear that something could be wrong was always there, but they tried not to focus on this in the present. Ultrasound examination generates strong emotions, and the women wished the midwife to take this into consideration.
The most important is to create a bond between the father, mother and baby. Imagine seeing the head, four limbs and a beating heart, and at the same time realizing that this is ours! – And then it can be our secret for a little while. – It’s so good to experience such wonderful feelings. (E)
It’s too long to wait for something you are looking forward to, but then you don’t know if it’s something to look forward to either. (C)
The visual images confirms life, you just know that it’s real. (E)
But one should not take sorrow in advance. (D) The women knew that the ultrasound examination might reveal abnormal developments or disease affecting the fetus, but leading up to the examination the women tried to keep their hopes alive, and did not want to spend time on negative thinking. They neither saw the importance of having a lot of information in advance about possible anomalies that may be detected, as they would not be able to deal with it at that point anyway. Sub-consciousness works and prepares you. Last night I had such a horrible dream that reality can only be better./…/I should have a predictability that is not there, but I must believe that all is well. It’s a small chance that it would not be so. We take it as it comes./…/I want to know now rather than at birth because preparation is important. (A) I do not think it’s possible to prepare for something that may go wrong, but you must deal with it. (B) It’s just the way things go. If only the baby will be healthy, I think. (H)
Experiencing another human living inside you, and simultaneously being able to see it – that is impressive! (A)
The women felt that the ultrasound examination enabled the pregnancy and the baby to become more real for the partner, who is not able to experience this in the same way as the woman does through her body. The women claimed that they, during the ultrasound examination, took their partner for a journey full of visual images of their baby. They highlighted that this half hour was full of impressions with strong mental and emotional dimensions. When I think of ultrasound I see a small intimate, cosy room where I hold my husband’s hand and together we get to see our baby, a small human being with a beating heart. (E) Planning a new life The women and their partners used the ultrasound examination in planning the pregnancy process leading toward birth and a new life with the baby. They emphasized that the scan would leave unique memories that would benefit the phase before birth as well as the future. Knowing who is in there will help the preparation, as it makes it possible to plan how to take the pregnancy process forward. (E)
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It’s very special to see the one who will be with us in a while. I feel happiness about what is coming. (C)
The women wanted concise, understandable and user-friendly information.
The women also considered the baby’s gender as a preparation for parenthood, even if this was not the most important thing.
Much of the information is written in such a poor language that it’s useless. (E)
It’s not for my own sake I want to know, but it’s a person living in my belly. The relationship becomes more personal if you know whether it’s a boy or girl and you can give it a name. (G) Others felt guilty about reflecting on the baby’s gender. One day I became excited when thinking of whether it was a boy or girl. The next moment I thought that it’s not allowed to think so. I have always heard that it doesn’t matter, what matters is that the baby is healthy. (C) The women were concerned about the great responsibility that comes with pregnancy, childbirth and the postnatal period. They highlighted that they had to make sure to take care of themselves during pregnancy; doing exercise, eating healthy food, not drinking alcohol, enabling the baby to feel well in the mother’s womb. It’s a great gift and a huge responsibility. It turns your life upside down. You have to realize that there is another person to care for. (B)
Individual needs during pregnancy The women would have wanted several ultrasound scans during pregnancy, if this had been possible. They perceived the offer of one ultrasound scan as an official recommendation and that this recommendation was based on safety considerations concerning the fetus. The women were uncertain about the risks associated with ultrasound technology and whether the risk would increase with several examinations. I might have wished several ultrasound scans, but don’t want to expose my baby more than is recommended. (E) I hear the rumours … I don’t know if they are justified … that it can be harmful to take more than one scan. At the same time, you can pay for an ultrasound scan whenever you want. (C)
He thinks more of practical things when the kid is born, and is eager to look for equipment. (H)
The informants also commented on the social pressure related to ultrasound scans during pregnancy. There were great expectations from family and friends that they would accept the offer. Those who had been informed about the “big news” shared the joy with the couple and the pregnant woman was often asked: “Have you had an ultrasound scan?” or “when are you going to have an ultrasound scan?”, as it was taken for granted that she would have one.
He has already started talking about taking the kid out for fishing. (F)
I feel some pressure from the environment. My girlfriends were surprised that I hadn’t demanded a 12-week scan. (A)
According to the women, the partner’s preparation and planning were different:
Holistic care This main theme describes how pregnant women experience receiving information about ultrasound scanning and their need for individualized care. Information about the ultrasound scan All women in this study wanted the ultrasound scan strongly. They wanted to be followed up by the public services during pregnancy, but claimed that information about the public prenatal care, as well as the choices and rights of pregnant women, was difficult to get hold of. The women highlighted that the information leaflet from The Directorate for Health and Social Affairs contains information they should have had already at their first consultation during prenatal care involving their general practitioner (GP) or midwife. The women also sought information about the ultrasound scan at the hospital. They responded negatively to the information leaflet, which they received in connection with the appointment for scanning. They felt that the information only focused on the person performing the scan, who was not to be disturbed. The important dialog during the scan was not given any emphasis. We have the right to get information from the public health services, but this information is so “machine-like”, it doesn’t address the whole process. It lacks the emotional and human dimensions. (G) The women claimed that the Internet is the most important source of information today. They experienced various degrees of professionalism, and said that they had to be critical to the information. Friends and family were also cited as important sources of information. The women felt that there is too much information during pregnancy. Apparently, the women want information adapted to their own context. They found it hard to read large amounts of information before they finally discover what they are looking for.
The women believed that visualization of the fetus is not emphasized in the official medical examination. This is despite the fact that the women emphasized the importance of “seeing their baby”. The public health services mostly focus on the physical examination of the baby, in order to see if it’s healthy. The emotional experience and the individualized care that we need are not emphasized. But body and mind cannot be separated. (E) Discussion The pregnant women in this study had a sincere desire to undergo the ultrasound examination at 18 weeks of gestation because they wanted medical knowledge about the fetal condition. They wanted to know if the fetus was viable and whether it had developed as it should. The ultrasound scan was considered the most important examination during pregnancy. Several other studies highlight that the ultrasound examination provides valuable information about the condition of the fetus, which in turn brings reassurance and relief to the parents-to-be [10–12,18]. When women show up for the ultrasound examination, the midwife expects that they have received information about the examination’s purpose and content, as this is specified both in Guidelines for the use of ultrasound in pregnancy [4] and Guidelines for prenatal care [3]. The informed consent of the women should be ensured before the examination. The informants in the present study considered the information given prior to the examination to be insufficient. Several other studies support this finding [9,18–20]. Ekeland [21] argues that the problem in today’s health services is not too little information but too poor communication. Martin et al. [22] highlight that the focus on giving information may prevent midwives from establishing a real dialog on a daily basis during the antenatal counseling. The study by Martin et al. [23] provides insight into the midwives’ perception of their own prenatal counseling performance. The midwives found the client–advisor relation and the
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health education aspects of counseling during the prenatal phase to work well, whereas decision-making support was insufficient. The authors conclude that midwives should focus more on decisionmaking support to optimize the counseling in connection with prenatal screening. On the other hand, in a midwifery model of care, Dixon and Burton [24] found that midwives provide adequate information and promote informed choice in relation to prenatal screening, with high levels of client knowledge and satisfaction. In this model of care, the principle of informed choice is central and the time spent on counseling long enough to enable in-depth discussions. Farrell et al. [25] highlight the need to ensure that professionals have both the knowledge and communication skills to effectively support pregnant women’s informed decisionmaking regarding the use of prenatal tests. Nicol [9] points out that leaflets are often used instead of verbal communication; the women choose to read what they want and they interpret written information about ultrasound scanning in a way that fits their coping strategies. None of the women in this study were given written information about the ultrasound examination at 18 weeks, and only one of the eight women was asked whether she wanted to accept the offer. It seems that midwives and general practitioners during prenatal care take it for granted that women want an ultrasound scan, and therefore fail to ask the women about it. The women instead received the following statement from the GP: “I will send a referral for ultrasound scanning to the hospital”. For pregnant women who want a different choice, such statements may be perceived as a pressure. Several studies show that the ultrasound examination is perceived as a part of the prenatal care and necessary for a successful pregnancy [9,26,27]. Heyman et al. [27] consider this view to be based on an inclination to trust the health service providers and an idea that health care services offered ought to be accepted. Nicol [9] claims that when pregnant women find themselves in a stressful situation, they respond by complying with what they believe is the recommendations of the health professionals. Social pressure is also clearly evident in several other studies [28–30]. Health professionals who work with prenatal care should encourage informed choice by parents with regard to routine ultrasound examination [11]. The women in this study wanted information during the examination in order to understand the ultrasound images and the purpose of the examinations. They welcomed dialog with the midwife, including the opportunity to express their own thoughts, concerns or questions. The women wanted the midwife to understand the significance of the examination for the parents-to-be. Garcia et al. [5] and Lalor and Devane [6], who emphasize the necessity of specific information about the ultrasound examination, support this finding. The experience of the ultrasound scan depends on the treatment and information the woman and her partner receive [31]. During the examination, the midwife, the pregnant woman and her partner will enter a relationship. The relationship with the midwife builds bridges through the sharing of information, enabling the pregnant woman to make sense of the communication. This represents what Ekeland [21] understands as “helping communication”. A successful ultrasound examination depends on how the helper relates to those seeking help, and whether the person receiving help feels acknowledged. For women who accept the offer of ultrasound examination, trust and good communication skills from the midwife are essential for the ultrasound scan to be meaningful. Communication is at the heart of the entire ultrasound examination, as information from the images on the screen is conveyed to the parents-to-be. When accepting the offer of ultrasound examination the women put their trust in the hospital as a system. The midwife herself depends on being trusted by the couple in order to be able to provide individualized care [32]. The examination starts when the midwife
puts the ultrasound probe on the woman’s abdomen. This is a very vulnerable situation for the woman because she leaves her pregnant body in the midwife’s hands, and expects to be cared for. The women in this study described an alternating sense of pleasure and anxiety prior to the ultrasound scan. For some women there is a growing tension before the examination, with physical and emotional discomfort [18]. Brudal [33] points out that our emotions are guided by increased vulnerability when moving from one phase of life to another. Women’s vulnerability during pregnancy means that memorized coping strategies are often not useful. Usually, the way we think follows rational logic, which is characterized by common sense. During pregnancy, a new kind of logic arises – the emotional logic. Such emotions dominate the mind, and Brudal’s theories may help us understand how this logic influences the woman’s experience of the scan. Ekelin et al. [11] and Aune and Möller [18] stress that women are mentally affected by the ultrasound scan. They emphasize the advantage that all caregivers who are involved in the ultrasound examination are aware of this fact, both in relation to the information given before the offer is accepted and in connection with the scan itself. Midwives should provide useful information and understand the factors that influence women’s concerns [34,35]. The women in this study considered the examination to be a visual experience, involving personification and attachment to “their baby”. The visual images resulted in a strong emotional experience, which was the starting point for planning a new life with a baby. According to Aune and Möller [18], the ultrasound examination enables visualization and personification of the fetus, and the women develop a stronger connection and different relationship to it. Several studies indicate that the ultrasound scan confirms a new family, and the ability to see the fetus causes overwhelming emotions and attachment [6,13,14,18]. The women in the present study also wanted to prepare themselves in case something wrong was detected during the scan. According to Aune and Möller [18], preparedness was considered an important factor. This also implied that health professionals during the examination get to know about the condition of the fetus, which better prepares them to take care of the baby after the birth. Limitations In this study, the thoughts and experiences of a small group of pregnant women in Norway were examined. We do not suggest that these women are representative of all other pregnant women. However, the small sample size does not mean that the findings are irrelevant. The women gave comprehensive descriptions of their expectations, needs and attitudes using their own words. This study enables us to understand some key factors that influence pregnant women’s experience of ultrasound scanning during pregnancy. Conclusions The women had an independent, sincere desire for ultrasound examination at 18 weeks of gestation, as they wanted information about the fetal health. At the same time, they considered the examination a visual, shared experience with their partner, including a personification of and attachment to “their baby”. The visualization led to a strong emotional experience, which marked the beginning of a new life with the baby. The women experienced both happiness and anxiety about the ultrasound examination. They emphasized holistic care, where individually adapted information is an important factor. Acknowledgements We would like to thank the eight pregnant women who participated in this study.
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