Background
Ultrasound is considered to be a beneficial tool in prenatal care, playing a central role to reveal pregnancy-related complications and optimize pregnancy outcomes [
1]. In Norway, all pregnant women are entitled to one ultrasound examination in gestational week 17–19 [
2]. This examination is offered at any level of public maternity care. The purpose of the examination is to determine the expected date of birth, the number of fetuses, the location of the placenta, and to observe the fetal anatomy and development [
3]. This examination is one of eight recommended consultations in the prenatal care programme [
2]. Any additional examinations are offered by public health care if clinically indicated [
3]. Ultrasound is also a tool to estimate fetal weight and growth, the amount of amniotic fluid and to confirm the fetal position. Ultrasound examinations that are not clinically justified are not eligible for reimbursement.
In Norway, the ultrasound examination in gestational week 17–19 is mainly performed by midwives with a postgraduate ultrasound qualification. In the following text, these midwives are referred to as “midwife sonographers”. A midwife sonographer in Norway has completed the Postgraduate Ultrasound Education for Midwives at the Norwegian University of Science and Technology (NTNU), which is a one-year full-time course. By 2019, 237 midwives had completed this course [
4]. Graduated midwife sonographers are qualified to perform independent obstetric ultrasound examinations. They are especially trained to perform the examination in gestational week 17–19 and other clinically indicated examinations. Their work also involves providing physical and mental care to the pregnant woman and her partner [
5]. They work in both public and private health care.
The Norwegian health service is organized into four regional health authorities [
6], and public maternity care is divided into three levels: birth rooms, maternity wards and women’s clinics. This classification is based on quality requirements, such as available qualified personnel and preparedness. Each regional health authority has at least one centre for fetal medicine located at the women’s clinics. These specialized centres are part of the public health sector. Norway is a country with considerable geographical distances and many isolated areas. The health service has agreed to comply with recommendations for decentralized and differentiated maternity care [
7]. Prenatal care is an important national preventative health programme [
6], which aims to promote a healthy lifestyle and reduce maternal and infant morbidity and mortality. The programme can help to reveal pregnancy-related complications, where pregnant women with an increased risk of complications are identified and referred to a hospital or clinic with the necessary expertise. Based on a professional assessment, pregnant women will be referred to the level in maternity care that is best suited the needs of the mother and fetus.
A previous study by Edvardsson et al. [
8] shows that midwives in Sweden acknowledged ultrasound as a vital tool in prenatal care, but felt that it could also lead to concern and ethical dilemmas. This is also emphasized by midwife sonographers in Norway in a recent study [
1]. Although they experienced high demands on their operational and counselling skills, they described performing obstetric ultrasound as very satisfying work [
1].
Midwife sonographers have a key role in referring pregnant women to a maternity facility with suitable expertise to address the needs of the pregnant woman and fetus. They often have large catchment areas, and work at a great distance from the nearest women’s clinics. At the time of this study, there were few previous studies to our knowledge that specifically described the work experiences of midwife sonographers in Norway. This study may contribute further insights into their work experiences. Knowledge of midwives’ work situation can enhance understanding of what their work involves and the challenges they encounter in their practice. This in turn can provide inspiration for organizational changes related to their work.
Discussion
This section discusses the results of this study in the order in which they are presented in the
results section.
Our study emphasizes that the work of midwife sonographers entailed a holistic approach to the fetus, the pregnant woman and her partner. The examination in gestational week 18 is stated by pregnant women in Norway to be the most important consultation during pregnancy [
11]. In the present study, the participants described their work as rewarding and satisfying. They pointed out that their expertise enabled them to calm and reassure pregnant women and answer their questions, which may be expected to enhance the quality of this type of pregnancy consultation. Good quality in prenatal care means that the care addresses individual needs [
12]. Such individualized care, accompanied by the opportunity to ask questions, an accommodating attitude, explanations and information, as well as sufficient time for the consultation, will impact the pregnant woman’s experience of the examination, as shown in several studies [
13‐
15]. In a study by Edvardsson [
16], midwives expressed concern that ultrasound may medicalize the pregnancy. Internationally, other professions often perform ultrasound examinations during pregnancy. It has been argued that midwives are well suited to perform the ultrasound examinations in gestational week 17–19, precisely because of their competence, communication skills and focus on psychosocial health and care [
17].
The results of this study also show that the participants had the perception that pregnant women did not always have realistic expectations of the content of the ultrasound examination. Other studies have emphasized this [
8,
16,
18,
19]. Further, our study shows that the participants felt that informing couples about all possible abnormalities that could be detected by ultrasonography might create unnecessary anxiety. For the same reason, pregnant women themselves have also stated in other studies that they do not want such information [
11,
20,
21]. Expectant mothers appreciate pregnancy being considered a normal event [
20], and preparation for an ultrasound examination in the form of information about possible abnormalities may adversely affect this. Furthermore, pregnant women have reported being aware that the examination cannot guarantee that their baby will be healthy, as shown in another study [
11]. It would also seem unrealistic to expect that a couple’s reaction to adverse findings would be eliminated if they received advance information about the possibility of such findings. How well prepared pregnant women should be for an ultrasound is subject to debate. It should be possible to ensure both the joy of future parenthood and the medical objectives of the examination.
At an ultrasound examination, the midwife sonographer is the first person to experience the spontaneous reaction of the couple when abnormal findings are discovered. Our study shows that such situations could be challenging, as do other studies [
1,
18,
22]. As previously described in the literature [
18,
23], such situations leave little time to prepare how to communicate the bad news. Although pregnant women express a desire for quick answers in such situations, they also emphasize the importance of the quality of the information provided [
24,
25]. Any unusual findings detected at the ultrasound examination often require further examination at a centre for fetal medicine. Although the participants found it challenging not to be able to give the couple immediate answers, it may also seem unrealistic to expect such a practice. The participants also highlighted that they appreciated supporting the couples in such situations, as described in a previous study [
19]. Providing follow-up support to the couple was underlined by the participants as an important part of their work. Other studies show that such factors will have a positive influence on the couple’s experience [
24,
25]. Following up the couple in such situations provides continuity in health care, which pregnant women also have called for in several studies [
25,
26]. Based on the above, follow-up care of the couple should be considered an important aspect of the work of midwife sonographers. Our results show variation in the participants’ practice regarding follow-up care, which suggests that implementation of such a practice may be an important focus area for the future.
This study demonstrates that the participants experienced great responsibility and increasing demands as to what they should detect during ultrasound examinations. The fear of failing to detect deviations, or other factors of importance, during the ultrasound examination has also been described by midwives performing obstetric ultrasound in Norway in a recent study [
1]. Many Norwegian maternity facilities are located at great distances from each other and have different requirements for expertise and preparedness. In this context, our study emphasizes the responsibility of midwife sonographers for referring pregnant women to the most suitable level in maternity care to give birth, in order to ensure optimal health care for mother and baby during childbirth and in the postnatal period. This responsibility was especially emphasized by participants who performed obstetric ultrasound in smaller facilities. Prenatal discovery of certain congenital heart defects is crucial for transfer of the unborn child to a higher level of care to ensure the necessary expertise and preparedness at birth, as several studies illuminate [
27,
28], rather than an emergency transportation of a sick neonate [
29]. This example clearly demonstrates the role of midwife sonographers in detecting fetal anomalies prenatally and underlines the importance of performing high-quality ultrasound examinations in all geographical areas and at any level of maternity care.
Findings of unclear significance were pointed out as challenging in our study and the participants emphasized their experience of worrying the couple unnecessarily in such situations. This has also been found in other studies [
8,
16,
19,
30]. Findings of soft markers were mentioned as an example of such situations. Such findings may create unnecessary worry among pregnant women and affect their attachment to the unborn child [
21,
31,
32]. In the study by Åhman et al. [
21], women diagnosed with soft markers in pregnancy stated that they would have preferred not to have known, or were hesitant about receiving, this information. The clinical value and management of soft markers are described in a number of articles [
33‐
35]. These vary as to the type of follow-up care recommended, and how far soft markers should be considered significant or normal variants. Information regarding the assessment and importance of observed soft markers has been shown to vary among Swedish clinics [
36]. Assessment of clinically uncertain ultrasound findings in a “grey area” may be a stressful task, especially without clear guidelines on how to deal with such findings [
8]. National Norwegian guidelines could enhance the confidence of midwife sonographers when assessing such situations and prevent pregnant women from worrying unnecessarily. This would also promote equal treatment of pregnant women, in line with the strong emphasis on fairness and providing safe health care in the Norwegian welfare state.
Our study shows that the participants referred pregnant women to experts at a higher level in cases of abnormal findings. This suggests that midwife sonographers have a well-established and well-functioning system when deviations are suspected. Good cooperation with centres for fetal medicine was reassuring and promoted professional discussions, which was especially mentioned by participants working in small maternity facilities and in private clinics. Being part of a professional environment was stated to be important for one’s professional development. Colleagues and education generate knowledge, and providing good care is dependent on collaboration and the exchange of experiences among health care professionals [
37]. Our participants working in small facilities also expressed the desire for mandatory study visits to a centre for fetal medicine. Such schemes can provide professional development and updating, as well as promoting collaboration in health care. Some participants in our study found it lonely being a midwife sonographer and study visits may also enhance the feeling of belonging.
A further point emphasized by the participants was the desire to enhance their knowledge in the field. Pregnant women should have equal access to high-quality health services ([
38], § 1–1) and in order to achieve this, practitioners must also develop professionally [
37]. The challenge of decentralized health services is to maintain quality and strength in small professional communities. Financing of further education and participation in professional events will enhance the knowledge, skills and confidence of midwife sonographers, which again will improve the quality of health services.
To share experiences and learn from good results and adverse incidents are fundamental factors in enhancing quality and patient safety in health care [
39]. The participants in our study wanted to receive discharge summaries and feedback related to their work, which may be expected to improve their work quality. The Health Personnel Act ([
40], § 21a) stipulates that it is forbidden to acquire information unless this is justified in terms of health care for the patient. The Health Personnel Act [40, § 29c] permits information to be disclosed to health professionals referring the patient, if the purpose is quality assurance of health care or learning for health professionals. The results of this study suggest that this legislation is interpreted and handled differently in practice. Lack of feedback may be a practice that prevents workplace learning and constrains professional development and confidence, which may again adversely affect the quality of health care.
The study shows that the participants wanted variety in their work and the opportunity to use their holistic competence when meeting pregnant women for the ultrasound examination. Work variety and autonomy are factors that affect job satisfaction [
41]. According to The International Confederation of Midwives [
42], holistic care is an important part of midwives’ work. Time pressure can, however, limit the possibilities to provide holistic care as desired by pregnant women, thus adversely affecting the quality of health services. Our results show that the participants enjoyed their work as midwife sonographers, although their practice of the profession was subject to organizational factors that affected their job satisfaction. Further, our study shows that it was important for the participants’ motivation and well-being to be given work variety within obstetric ultrasound, to be able to influence their own work situation and to be allocated sufficient time for the ultrasound examination to provide holistic care. These factors were prominent, independently of where they worked. Despite the small number of participants in our study, there was a clear tendency that midwives who had chosen to work in private facilities had done so because they felt that this would give them greater opportunity to work holistically.
Limitations of the study
Our professional background as midwife sonographers and expertise in the field may have enhanced our ability to ask the participants relevant follow-up questions in the interviews. At the same time, this may also have influenced the design of the study. The obstetric ultrasound environment in Norway is somewhat limited and we cannot ignore the fact that our familiarity with this environment may have influenced our data. In order to limit the use of participants with whom we had a close relationship, we carefully chose the workplaces to contact during recruitment, even though we were aiming for a purposeful sample. To accomplish our desire to include midwife sonographers living in outlying areas, three interviews were conducted by telephone, due to time and financial constraints, which again may have influenced the quality of the interviews. After completing the first telephone interview, we considered the data to be sufficiently rich and therefore conducted two further interviews by telephone. Further, to enhance trustworthiness, quotations have been presented in the text. In addition, data were analysed and discussed among the authors. Also, to provide greater transparency when translating and writing the research manuscript, the authors collaborated and a native English speaker made the necessary corrections [
43].
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