214
BIRTH 17:4 December 1990
Through a Glass Darkly: Ultrasound and Prenatal Bonding JudithLumley, M.A.,M.B.,B.S., Ph.D. ABSTRACT: Prenatal ultrasound scans are believed to enable mothers to f o r m an early affectionate bond to their child, to provide a reassuring image of the fetus, and to promote improvements in mothers’ health behaviors on the behalfof the fetus. Observational studies suggest that scans done early may slightly improve maternal-fetal bonding but that those done after quickening are not associated with attachment. Short-term effects on maternal health behaviors, including less smoking, less drinking of alcohol, and more visits to dentists, were detected in a randomized trial when detailed information was given during the scan. This trial also suggested that women’s anxiety was actually increased during scans, and then allayed by positive feedback f r o m the operator. Not all women considered scans reassuring in one interview study, and other authors found that mothers’ interpretations of scans depended on their personal and social circumstances. As used in everyday practice, ultrasound scans are not always accompanied by feedbuck, and when feedback occurs it is sometimes in the f o r m of slips of the tongue, incorrect diagnoses, identification of structures that cannot be deciphered, and language that is unfamiliar and alarming t o mothers. This “diagnostic toxicity” of ultrasound scans of the fetus has not been studied. (BIRTH 17:4,-December 1990)
In 1906 the Scottish obstetrician, Ballantyne, often credited with being the founding father of antenatal care, gave an inaugural address on the future of obstetrics. He took up the popular contemporary theme of time travel and imagined contacting his successor as President of the Obstetric Society in 1940 to learn about future key developments in obstetrics. His predictions included the development of a serum for safe and speedy induction of labor, and a revitalization of obstetric teaching by the clinical study of normal labor in hospitals. In addition, he foresaw the development of an exciting new technology: Could we throw upon the screen in kinematographic fashion the embryo as he passes from the simplicity of two or three rows of similar cells into the complexity of many interacting and interwoven systems of organs and tissues, all recognisedly different; could we see the un-
Judith Lumley is Consultant Epidemiologist, Perinatal Data Collection Unit, Health Department Victoriu, 555 Collins Street, Melbourne 3000, Australia. This paper was presented ut the Eighth Birth Conference, Murch 17, 1989, in Sun Francisco.
born infant as he quadruples his weight in one month of antenatal life and doubles his length in another month of the same marvelous time; could we watch the first performance of functions such as the circulation of the blood, the formation of the bile and the reflex actions of the brain and spinal cord, we should be compelled to cast away such ordinary expressions of surprise as “wonderful,” “amazing,” “incredible,” and “unsurpassed,” and seek to coin new terms to body forth the ideas which would be forming in our minds. (1)
Although Ballantyne underestimated the time it would take for this new technology to emerge-it was 1957 before the first paper reported the use of ultrasound in pregnancy- the last 25 years have confirmed his predictions. Routine ultrasound has made it possible to determine gestation with some precision, to identify faltering fetal growth, and to detect major fetal malformations. No longer does the obstetrician have to rely on the mother’s information about prior menstruation and fetal movements, or engage in the direct physical contact of abdominal palpitation and fetal heart rate auscultation. Ultrasonic equipment is an intermediary between the physician and the pregnant woman. There is little doubt that this development has
BIRTH /7:4 December 1990
made antenatal care a great deal more rewarding for obstetricians. Providing this care without ultrasound has come to seem barbaric and regressive, even impossible. As I write this paper, independent nurse-midwives in Australia are lobbying for the right to order ultrasound scans directly as part of care for low-risk, healthy women. The technique has indeed increased prenatal bonding to the fetus, at least it has for caregivers. In the early years of ultrasound the pictures of the fetus were far from easy to interpret. Nor was this a friendly technology to begin with; the machines that produced the pictures were the size of grand pianos (2). When real-time scans became available, the ability of pregnant women to see the fetus became an issue, and comments about this aspect of the procedure and its impact began to be added to reports: In our experience all obstetricians provided with this service have found it most valuable; mothers have found fascinating and reassuring the sight of their fetus moving on the real time display. (3) When a mother undergoes ultrasound scanning of the fetus, this seems a great opportunity for her to meet her child socially and in this way, one hopes, to view him as a companion aboard rather than as a parasite. Doctors and technicians scanning mothers have a great opportunity to enable mothers to form an early affectionate bond to their child by demonstrating the child to the mother. This should help mothers to behave concernedly towards the fetus. (4)
These comments imply that the experience of having an ultrasound scan in pregnancy will be enjoyable and interesting, will reassure the pregnant woman about fetal well-being, will facilitate early bonding and attachment, and will promote healthy behavior change by the mother. Ultrasound Scans May Hasten but Not Change the Development of Maternal-Fetal Attachment It was about this time that the first three studies of the impact of ultrasound on maternal feelings toward the fetus were published, all carried out by midwives (5-7). They were small-scale, observational studies that concluded that maternal-fetal attachment increased after the procedure. They also reported that women seemed to have acquired a greater sense of fetal vulnerability. The largest study detailed some individual responses, both negative and positive, demonstrating that the mother’s interpretation of the scan depended on her whole personal and social situation. A more recent interview study confirmed the anxiety-allaying effect of ultrasound, but again reported that not all women found it reassuring (8).
215
A possibly critical aspect of the initial observational studies was that all of the research methods included a great deal of discussion, explanation, and interpretation of the ultrasound image as it was shown the mother. We do not know how typical this is of obstetric ultrasonography as it is usually carried out. Two groups of researchers assessed the impact of ultrasound on bonding by comparing the scores of women who did or did not have a scan on Cranley’s maternal-fetal attachment (MFA) scale (8). The first of these, which included both healthy and high-risk women, was carried out in the third trimester of pregnancy and could detect no association of ultrasound with attachment (9). The authors wondered whether ultrasound might accelerate the development of attachment, as the observational studies suggested, but make no difference by late pregnancy when other aspects of the relationship between mother and fetus had been in effect for several months. The second was carried out at some unspecified time of pregnancy that for almost half the participants was prior to quickening. It did find a significant association of ultrasound with attachment, although this was much smaller than the association of attachment with the presence, frequency, and strength of fetal movements (10). Unfortunately, the authors did not report the range of gestations among participants at the time of the study, or the timing of the ultrasound scans. A more basic problem about using the MFA scale in this context is that items in the subscales “attributing characteristics and intention to the fetus” and “interaction with the fetus” may be directly affected by the ultrasound information and the way it is given. The MFA score would be increased by the very process under investigation, with exposure (ultrasound) and outcome (increased attachment) inextricably confounded. One observational study of maternal-infant attachment in the first five days after birth was unable to detect any relationship between maternal behavior and the number and timing of scans performed during pregnancy (12). This raises again the possibility discussed by Kemp and Page (10) that ultrasound might hasten, but not substantially change in the longer term, the development of maternal-fetal attachment. These three papers cannot help raising questions about what is meant by prenatal attachment, and what values and assumptions are implicit in the ratings of it. In this regard, Richard’s critique is helpful ( 13).
216
BIRTH 17:4 December 1990
Feedback During Scans and Change in Mothers’ Health Behavior
The possibility that ultrasound will “help mothers to behave concernedly towards the fetus” has been borne out to some extent in experimental studies, given certain preconditions for how the scan is carried out. Short-term effects on maternal health behavior (less smoking, less drinking of alcohol, more visits to dentists) were detected in a randomized trial when detailed feedback about the fetus was provided during routine ultrasonography (14). A small reduction in smoking was found in another trial of routine ultrasound (15). The way in which information is shared with parents seems to be crucial for excited reactions and reduced anxiety (16). Positive verbal interpretation is essential. Indeed, it seems from the randomized trial that scanning actually increased the women’s anxiety and then positive feedback reduced it, so that there were no significant differences in anxiety between the scanned and the unscanned groups (17). Slips and Shadows: The Diagnostic Toxicity of Prenatal Ultrasound Scans
The aspect of routine ultrasound that has not been studied systematically so far is the technique as it is actually used in everyday practice, including slips of the tongue, incorrect diagnoses, and identification of structures that cannot be deciphered. This hinterland of diagnostic toxicity involves both attachment and vulnerability issues. The relevant literature highlights in particular the obstetrician’s confusions and dilemmas. An Australian ultrasonographer emphasized that a scan suggesting anything atypical causes intense anxiety and distress (18). She mentioned as particularly stressful the use of words such as hydrocephalus; terms easily misunderstood such as excess amniotic fluid, growthretarded fetus, and missed abortion; and those that describe a current state that may or may not persist (breech, placenta previa). She stated that every machine update shows the observer features that have never been recognized before, features necessitating reappraisal of the range of normal, of artifacts, and of red herrings. She also pointed out that the referring doctor may not understand the limits of ultrasound. Two other papers and an editorial in the same issue of Lancet discussed some of the problems arising from artifacts, mistakes, and new visions (19-21). Many couples are now faced with enormous anxiety and dread about their unborn child, often long before delivery. The authors of one of these papers point out that:
Because of the nature of the investigation it is impossible, even if it were ethically justifiable, to conceal the diagnosis from the mother. . . . Thus the mother who may still have five months of pregnancy remaining, is faced with the certain knowledge that she is carrying an abnormal baby. Enormous feelings of fear, guilt and inadequacy develop and reassurance that the eventual outcome should be satisfactory may be to no avail. Rejection at birth, both of the baby and of the hospital, is not surprising. (1 1)
Further dilemmas arise when antenatal counseling as a result of the scan turns out to be incorrect. The parents’ initial confusion after delivery is then compounded by their subsequent skepticism about the information offered to them. This is the down side of the high-feedback scan. Routine scans may be even worse. The supplement published by Birth on ultrasound gave a number of disturbing examples of how the information has been shared with the pregnant woman in practice (22). One publication reported a longitudinal prospective study of 108 women referred to have ultrasound for problems of either fetal impairment or preterm delivery (23). All had some previous knowledge of ultrasound either through direct experience or through the experiences of friends or relatives. The women were divided into three groups on the basis of ultrasound findings: group 1 had normal findings and were reassured; group 2 had a fetal abnormality (impairment) diagnosed; and group 3 had equivocal findings of uncertain significance. At the time of their referral, anxiety, depression, and hostility scores were high in all the patients, and they decreased throughout the rest of pregnancy and the next three months. The women who received neither an unequivocal diagnosis of impairment nor reassurance of normality had higher levels of anxiety, depression, and hostility than those in the other two groups at the end of the study. Assessments of maternal-child interaction also showed that the so-called questionable group had a worse outcome on measures of the amount, quality, and appropriateness of interaction. The consistency of these findings, despite their small magnitude, is of some concern, especially since the women received a great deal of personal and professional support at the time of diagnosis. Besides verbal interpretations of the ultrasound, physicians introduced all the staff, described the ultrasound technique, and provided ‘‘individualized timing of interpretations.” The authors noted:
. . . in the case of impairments, private settings were used for interpretations and time was allotted for questions. Interpretations for the questionable and normal groups, however, were conducted in the imaging room in the presence of other professionals and family, an environment
217
BIRTH 17:4 December 1990 that subjects reported as unfamiliar and impersonal . . . parents with questionable status may require the same private attention as parents with diagnosed impairments. Parents with tentative physical findings anticipate definitive diagnosis from ultrasound. When these images are inconclusive, more careful explanation may be indicated. (23)
The increasingly routine practice of scheduling an ultrasound examination at around 18 weeks’ gestation, specifically to search for malformations, raises some difficult issues in prenatal attachment. Can earlier maternal-fetal attachment be suppressed until 20 weeks without untoward effects? What is the long-term impact of a not-proved diagnosis, remembering the earlier comment that “every machine update shows features never recognized before”? Even if the scan is totally reassuring, it provides other information that may be disturbing. What is the effect of knowing the sex of the infant at this stage of pregnancy? Does this knowledge alter the attitude of the mother to the fetus; increase stereotyping by sex; cause disappointment that is not molliiied by the reality of the infant, as it would be after birth? Are the attitudes of family and friends to the mother affected when more is known about the fetus, especially its sex? Is there a loss of interest in her, and more attention to the fetus? Is she seen to be more a container for the person of importance and of less importance herself? A survey of all the women who gave birth during one week last year in one Australian state found that 92% had received one ultrasound scan in pregnancy and a third of them had had more than one (Brown and Lumley, unpublished data, 1989). Clearly, it is too late to investigate whether ultrasound affects prenatal bonding. The case for investigating the procedure’s diagnostic toxicity has become more urgent. Even if only 1 in 100 or 1 in 1000 women experience “questionable” findings, at the current rate of ultrasound use we have a major problem. References
6.
7.
8. 9.
10.
11.
12. 13. 14.
15.
16.
17.
18. 19.
20. 21. 22. 23.
1.
Ballantyne JW. Inaugural address on the future of obstetrics. Obstet Trans Edinburgh 1906;7:3-28.
Donald ID. Interview with A Oakley. The Captured Womb. Oxford: Blackwell, 1984:161. Neilson JP, Whitfield CR. Ultrasound in obstetrics [letter]. Lancet 1981;2:94. Dewsbury AR. What the fetus feels [letter]. Br Med J 1980;11:481. Kohn CL, Nelson A, Weiner S. Gravidas’ responses to realtime ultrasound fetal images. JOGN Nurs 1980;9:7780. Milne LS, Rich OJ. Cognitive and affective aspects of the response of pregnant women to sonography. Maternal Child Nurs 1981;110:5-39. Garel M, Franc M. Reactions des femmes a l’echographi obstetrical. Eur J Obstet Gynaecol Reprod Biol 1979;9: 347-354. Hyde B. An interview study of pregnant women’s attitudes to ultrasound scanning. SOCSci Med 1986;22:587-592. Cranley M. Development of a tool for the measurement of maternal attachment during pregnancy. Nurs Res 1985;30: 281 -284. Kemp VH, Page CK. Maternal prenatal attachment in normal and high-risk pregnancies. JOGN Nurs 19873 16: 179- 184. Lerum CW, LoBiondo-Wood G . The relationship of maternal age, quickening, and physical symptoms of pregnancy to the development of maternal-fetal attachment. Birth 1989;16: 13- 17. Grace JT. Prenatal ultrasound examinations and mother-infant bonding [letter]. N Engl J Med 1983;309:561. Richards M. Commentary. Fishing for facts: Some reflections on reading a scientific paper. Birth 1989;16:27-31. Reading AE, Campbell S, Cox DN, Sledmere CM. Health beliefs and health care behavior in pregnancy. Psycho1 Med 1982;12:379-382. Waldenstrom U , Axelsson 0 , Nilsson S, et al. Effects of routine one-stage ultrasound screening in pregnancy: A randomised controlled trial. Lancet 1988;2:585-588. Cox DN, Witman BK, Hess M, Ross AG, Lindah S. The psychological impact of diagnostic ultrasound. Obstet Gynecol 1987;70:673-676. Reading AE, Cox DN. The effects of ultrasound examination on maternal anxiety levels. J Behav Med 1982;5:237247. Furness ME. Reporting obstetric ultrasound. Lancet 1987; 1~675-676. Hudson JM, MacKenzie JR, Young DG, McNay MB, Whittle MJ, Raine PAM. Antenatal diagnosis of surgical disorders by ultrasonography. Lancer 1985;1:621-623. Griffiths DM, Gough MH. Dilemmas after ultrasonic diagnosis of fetal abnormalities. Lancet 1985;1:623-624. When ultrasound shows fetal abnormality. Lancet 1985;l: 618-619. Stewart N. Women’s views of ultrasonography in obstetrics. Birth 1986;13(suppl):34-38. Sparling JW, Seeds JW, Farran DC. The relationship of obstetric ultrasound to parent and infant behavior. Obstet Gynecol 1988;72:902-907.
BIRTH 17:4 December 1990
Through a Glass Darkly: Ultrasound and Prenatal Bonding JudithLumley, M.A.,M.B.,B.S., Ph.D. ABSTRACT: Prenatal ultrasound scans are believed to enable mothers to f o r m an early affectionate bond to their child, to provide a reassuring image of the fetus, and to promote improvements in mothers’ health behaviors on the behalfof the fetus. Observational studies suggest that scans done early may slightly improve maternal-fetal bonding but that those done after quickening are not associated with attachment. Short-term effects on maternal health behaviors, including less smoking, less drinking of alcohol, and more visits to dentists, were detected in a randomized trial when detailed information was given during the scan. This trial also suggested that women’s anxiety was actually increased during scans, and then allayed by positive feedback f r o m the operator. Not all women considered scans reassuring in one interview study, and other authors found that mothers’ interpretations of scans depended on their personal and social circumstances. As used in everyday practice, ultrasound scans are not always accompanied by feedbuck, and when feedback occurs it is sometimes in the f o r m of slips of the tongue, incorrect diagnoses, identification of structures that cannot be deciphered, and language that is unfamiliar and alarming t o mothers. This “diagnostic toxicity” of ultrasound scans of the fetus has not been studied. (BIRTH 17:4,-December 1990)
In 1906 the Scottish obstetrician, Ballantyne, often credited with being the founding father of antenatal care, gave an inaugural address on the future of obstetrics. He took up the popular contemporary theme of time travel and imagined contacting his successor as President of the Obstetric Society in 1940 to learn about future key developments in obstetrics. His predictions included the development of a serum for safe and speedy induction of labor, and a revitalization of obstetric teaching by the clinical study of normal labor in hospitals. In addition, he foresaw the development of an exciting new technology: Could we throw upon the screen in kinematographic fashion the embryo as he passes from the simplicity of two or three rows of similar cells into the complexity of many interacting and interwoven systems of organs and tissues, all recognisedly different; could we see the un-
Judith Lumley is Consultant Epidemiologist, Perinatal Data Collection Unit, Health Department Victoriu, 555 Collins Street, Melbourne 3000, Australia. This paper was presented ut the Eighth Birth Conference, Murch 17, 1989, in Sun Francisco.
born infant as he quadruples his weight in one month of antenatal life and doubles his length in another month of the same marvelous time; could we watch the first performance of functions such as the circulation of the blood, the formation of the bile and the reflex actions of the brain and spinal cord, we should be compelled to cast away such ordinary expressions of surprise as “wonderful,” “amazing,” “incredible,” and “unsurpassed,” and seek to coin new terms to body forth the ideas which would be forming in our minds. (1)
Although Ballantyne underestimated the time it would take for this new technology to emerge-it was 1957 before the first paper reported the use of ultrasound in pregnancy- the last 25 years have confirmed his predictions. Routine ultrasound has made it possible to determine gestation with some precision, to identify faltering fetal growth, and to detect major fetal malformations. No longer does the obstetrician have to rely on the mother’s information about prior menstruation and fetal movements, or engage in the direct physical contact of abdominal palpitation and fetal heart rate auscultation. Ultrasonic equipment is an intermediary between the physician and the pregnant woman. There is little doubt that this development has
BIRTH /7:4 December 1990
made antenatal care a great deal more rewarding for obstetricians. Providing this care without ultrasound has come to seem barbaric and regressive, even impossible. As I write this paper, independent nurse-midwives in Australia are lobbying for the right to order ultrasound scans directly as part of care for low-risk, healthy women. The technique has indeed increased prenatal bonding to the fetus, at least it has for caregivers. In the early years of ultrasound the pictures of the fetus were far from easy to interpret. Nor was this a friendly technology to begin with; the machines that produced the pictures were the size of grand pianos (2). When real-time scans became available, the ability of pregnant women to see the fetus became an issue, and comments about this aspect of the procedure and its impact began to be added to reports: In our experience all obstetricians provided with this service have found it most valuable; mothers have found fascinating and reassuring the sight of their fetus moving on the real time display. (3) When a mother undergoes ultrasound scanning of the fetus, this seems a great opportunity for her to meet her child socially and in this way, one hopes, to view him as a companion aboard rather than as a parasite. Doctors and technicians scanning mothers have a great opportunity to enable mothers to form an early affectionate bond to their child by demonstrating the child to the mother. This should help mothers to behave concernedly towards the fetus. (4)
These comments imply that the experience of having an ultrasound scan in pregnancy will be enjoyable and interesting, will reassure the pregnant woman about fetal well-being, will facilitate early bonding and attachment, and will promote healthy behavior change by the mother. Ultrasound Scans May Hasten but Not Change the Development of Maternal-Fetal Attachment It was about this time that the first three studies of the impact of ultrasound on maternal feelings toward the fetus were published, all carried out by midwives (5-7). They were small-scale, observational studies that concluded that maternal-fetal attachment increased after the procedure. They also reported that women seemed to have acquired a greater sense of fetal vulnerability. The largest study detailed some individual responses, both negative and positive, demonstrating that the mother’s interpretation of the scan depended on her whole personal and social situation. A more recent interview study confirmed the anxiety-allaying effect of ultrasound, but again reported that not all women found it reassuring (8).
215
A possibly critical aspect of the initial observational studies was that all of the research methods included a great deal of discussion, explanation, and interpretation of the ultrasound image as it was shown the mother. We do not know how typical this is of obstetric ultrasonography as it is usually carried out. Two groups of researchers assessed the impact of ultrasound on bonding by comparing the scores of women who did or did not have a scan on Cranley’s maternal-fetal attachment (MFA) scale (8). The first of these, which included both healthy and high-risk women, was carried out in the third trimester of pregnancy and could detect no association of ultrasound with attachment (9). The authors wondered whether ultrasound might accelerate the development of attachment, as the observational studies suggested, but make no difference by late pregnancy when other aspects of the relationship between mother and fetus had been in effect for several months. The second was carried out at some unspecified time of pregnancy that for almost half the participants was prior to quickening. It did find a significant association of ultrasound with attachment, although this was much smaller than the association of attachment with the presence, frequency, and strength of fetal movements (10). Unfortunately, the authors did not report the range of gestations among participants at the time of the study, or the timing of the ultrasound scans. A more basic problem about using the MFA scale in this context is that items in the subscales “attributing characteristics and intention to the fetus” and “interaction with the fetus” may be directly affected by the ultrasound information and the way it is given. The MFA score would be increased by the very process under investigation, with exposure (ultrasound) and outcome (increased attachment) inextricably confounded. One observational study of maternal-infant attachment in the first five days after birth was unable to detect any relationship between maternal behavior and the number and timing of scans performed during pregnancy (12). This raises again the possibility discussed by Kemp and Page (10) that ultrasound might hasten, but not substantially change in the longer term, the development of maternal-fetal attachment. These three papers cannot help raising questions about what is meant by prenatal attachment, and what values and assumptions are implicit in the ratings of it. In this regard, Richard’s critique is helpful ( 13).
216
BIRTH 17:4 December 1990
Feedback During Scans and Change in Mothers’ Health Behavior
The possibility that ultrasound will “help mothers to behave concernedly towards the fetus” has been borne out to some extent in experimental studies, given certain preconditions for how the scan is carried out. Short-term effects on maternal health behavior (less smoking, less drinking of alcohol, more visits to dentists) were detected in a randomized trial when detailed feedback about the fetus was provided during routine ultrasonography (14). A small reduction in smoking was found in another trial of routine ultrasound (15). The way in which information is shared with parents seems to be crucial for excited reactions and reduced anxiety (16). Positive verbal interpretation is essential. Indeed, it seems from the randomized trial that scanning actually increased the women’s anxiety and then positive feedback reduced it, so that there were no significant differences in anxiety between the scanned and the unscanned groups (17). Slips and Shadows: The Diagnostic Toxicity of Prenatal Ultrasound Scans
The aspect of routine ultrasound that has not been studied systematically so far is the technique as it is actually used in everyday practice, including slips of the tongue, incorrect diagnoses, and identification of structures that cannot be deciphered. This hinterland of diagnostic toxicity involves both attachment and vulnerability issues. The relevant literature highlights in particular the obstetrician’s confusions and dilemmas. An Australian ultrasonographer emphasized that a scan suggesting anything atypical causes intense anxiety and distress (18). She mentioned as particularly stressful the use of words such as hydrocephalus; terms easily misunderstood such as excess amniotic fluid, growthretarded fetus, and missed abortion; and those that describe a current state that may or may not persist (breech, placenta previa). She stated that every machine update shows the observer features that have never been recognized before, features necessitating reappraisal of the range of normal, of artifacts, and of red herrings. She also pointed out that the referring doctor may not understand the limits of ultrasound. Two other papers and an editorial in the same issue of Lancet discussed some of the problems arising from artifacts, mistakes, and new visions (19-21). Many couples are now faced with enormous anxiety and dread about their unborn child, often long before delivery. The authors of one of these papers point out that:
Because of the nature of the investigation it is impossible, even if it were ethically justifiable, to conceal the diagnosis from the mother. . . . Thus the mother who may still have five months of pregnancy remaining, is faced with the certain knowledge that she is carrying an abnormal baby. Enormous feelings of fear, guilt and inadequacy develop and reassurance that the eventual outcome should be satisfactory may be to no avail. Rejection at birth, both of the baby and of the hospital, is not surprising. (1 1)
Further dilemmas arise when antenatal counseling as a result of the scan turns out to be incorrect. The parents’ initial confusion after delivery is then compounded by their subsequent skepticism about the information offered to them. This is the down side of the high-feedback scan. Routine scans may be even worse. The supplement published by Birth on ultrasound gave a number of disturbing examples of how the information has been shared with the pregnant woman in practice (22). One publication reported a longitudinal prospective study of 108 women referred to have ultrasound for problems of either fetal impairment or preterm delivery (23). All had some previous knowledge of ultrasound either through direct experience or through the experiences of friends or relatives. The women were divided into three groups on the basis of ultrasound findings: group 1 had normal findings and were reassured; group 2 had a fetal abnormality (impairment) diagnosed; and group 3 had equivocal findings of uncertain significance. At the time of their referral, anxiety, depression, and hostility scores were high in all the patients, and they decreased throughout the rest of pregnancy and the next three months. The women who received neither an unequivocal diagnosis of impairment nor reassurance of normality had higher levels of anxiety, depression, and hostility than those in the other two groups at the end of the study. Assessments of maternal-child interaction also showed that the so-called questionable group had a worse outcome on measures of the amount, quality, and appropriateness of interaction. The consistency of these findings, despite their small magnitude, is of some concern, especially since the women received a great deal of personal and professional support at the time of diagnosis. Besides verbal interpretations of the ultrasound, physicians introduced all the staff, described the ultrasound technique, and provided ‘‘individualized timing of interpretations.” The authors noted:
. . . in the case of impairments, private settings were used for interpretations and time was allotted for questions. Interpretations for the questionable and normal groups, however, were conducted in the imaging room in the presence of other professionals and family, an environment
217
BIRTH 17:4 December 1990 that subjects reported as unfamiliar and impersonal . . . parents with questionable status may require the same private attention as parents with diagnosed impairments. Parents with tentative physical findings anticipate definitive diagnosis from ultrasound. When these images are inconclusive, more careful explanation may be indicated. (23)
The increasingly routine practice of scheduling an ultrasound examination at around 18 weeks’ gestation, specifically to search for malformations, raises some difficult issues in prenatal attachment. Can earlier maternal-fetal attachment be suppressed until 20 weeks without untoward effects? What is the long-term impact of a not-proved diagnosis, remembering the earlier comment that “every machine update shows features never recognized before”? Even if the scan is totally reassuring, it provides other information that may be disturbing. What is the effect of knowing the sex of the infant at this stage of pregnancy? Does this knowledge alter the attitude of the mother to the fetus; increase stereotyping by sex; cause disappointment that is not molliiied by the reality of the infant, as it would be after birth? Are the attitudes of family and friends to the mother affected when more is known about the fetus, especially its sex? Is there a loss of interest in her, and more attention to the fetus? Is she seen to be more a container for the person of importance and of less importance herself? A survey of all the women who gave birth during one week last year in one Australian state found that 92% had received one ultrasound scan in pregnancy and a third of them had had more than one (Brown and Lumley, unpublished data, 1989). Clearly, it is too late to investigate whether ultrasound affects prenatal bonding. The case for investigating the procedure’s diagnostic toxicity has become more urgent. Even if only 1 in 100 or 1 in 1000 women experience “questionable” findings, at the current rate of ultrasound use we have a major problem. References
6.
7.
8. 9.
10.
11.
12. 13. 14.
15.
16.
17.
18. 19.
20. 21. 22. 23.
1.
Ballantyne JW. Inaugural address on the future of obstetrics. Obstet Trans Edinburgh 1906;7:3-28.
Donald ID. Interview with A Oakley. The Captured Womb. Oxford: Blackwell, 1984:161. Neilson JP, Whitfield CR. Ultrasound in obstetrics [letter]. Lancet 1981;2:94. Dewsbury AR. What the fetus feels [letter]. Br Med J 1980;11:481. Kohn CL, Nelson A, Weiner S. Gravidas’ responses to realtime ultrasound fetal images. JOGN Nurs 1980;9:7780. Milne LS, Rich OJ. Cognitive and affective aspects of the response of pregnant women to sonography. Maternal Child Nurs 1981;110:5-39. Garel M, Franc M. Reactions des femmes a l’echographi obstetrical. Eur J Obstet Gynaecol Reprod Biol 1979;9: 347-354. Hyde B. An interview study of pregnant women’s attitudes to ultrasound scanning. SOCSci Med 1986;22:587-592. Cranley M. Development of a tool for the measurement of maternal attachment during pregnancy. Nurs Res 1985;30: 281 -284. Kemp VH, Page CK. Maternal prenatal attachment in normal and high-risk pregnancies. JOGN Nurs 19873 16: 179- 184. Lerum CW, LoBiondo-Wood G . The relationship of maternal age, quickening, and physical symptoms of pregnancy to the development of maternal-fetal attachment. Birth 1989;16: 13- 17. Grace JT. Prenatal ultrasound examinations and mother-infant bonding [letter]. N Engl J Med 1983;309:561. Richards M. Commentary. Fishing for facts: Some reflections on reading a scientific paper. Birth 1989;16:27-31. Reading AE, Campbell S, Cox DN, Sledmere CM. Health beliefs and health care behavior in pregnancy. Psycho1 Med 1982;12:379-382. Waldenstrom U , Axelsson 0 , Nilsson S, et al. Effects of routine one-stage ultrasound screening in pregnancy: A randomised controlled trial. Lancet 1988;2:585-588. Cox DN, Witman BK, Hess M, Ross AG, Lindah S. The psychological impact of diagnostic ultrasound. Obstet Gynecol 1987;70:673-676. Reading AE, Cox DN. The effects of ultrasound examination on maternal anxiety levels. J Behav Med 1982;5:237247. Furness ME. Reporting obstetric ultrasound. Lancet 1987; 1~675-676. Hudson JM, MacKenzie JR, Young DG, McNay MB, Whittle MJ, Raine PAM. Antenatal diagnosis of surgical disorders by ultrasonography. Lancer 1985;1:621-623. Griffiths DM, Gough MH. Dilemmas after ultrasonic diagnosis of fetal abnormalities. Lancet 1985;1:623-624. When ultrasound shows fetal abnormality. Lancet 1985;l: 618-619. Stewart N. Women’s views of ultrasonography in obstetrics. Birth 1986;13(suppl):34-38. Sparling JW, Seeds JW, Farran DC. The relationship of obstetric ultrasound to parent and infant behavior. Obstet Gynecol 1988;72:902-907.
