Experiences of interactive ultrasound examination among women at risk of preterm birth: a qualitative study

Pregnancy is one of the most significant transitional phases in life during which the pregnant woman goes through notable physical and emotional changes [1]. The psychological process of pregnancy has a dual focus: integrating one’s self as a parent into the current self-identity, and developing an emotional relationship with the unborn infant [2].

Pregnant women who are at risk of preterm delivery have elevated rates of depression (19–26%) and anxiety (13%) because of worries and fears related to the wellbeing of the unborn baby, their own health and uncertainty about the future [3‐5]. Maternal stress during pregnancy along with other risk factors, such as tobacco use, genital tract infections, previous preterm delivery and premature contractions, increases the risk of preterm birth [6]. Depressive symptoms have an association with poor prenatal attachment to the unborn infant [7‐10], which in turn predict low maternal involvement in the mother-infant interaction [11]. A high level of prenatal depressive symptoms has been shown to distort the representation of the infant and their own motherhood which, in turn, have been shown to predict dysfunctional mother-child interaction [12‐14]. Further, high levels of prenatal stress have been associated with adverse obstetric and neonatal outcomes such as preterm birth (< 37 gestational weeks), intrauterine growth restriction (IUGR), and low (< 2.5 kg) birth weight at delivery [15, 16]. Results concerning the effect of hospitalization on maternal depressive and anxiety symptoms have been inconsistent, possibly due to the use of various instruments of measurement. Decrease in depressive and anxiety symptoms has been reported in several studies [4, 17], but not all [18]. However, it is not known whether psychosocial support could relieve stress symptoms in patients at risk of preterm birth.

Several studies show that ultrasound examinations have a positive impact on maternal-fetal attachment [19, 20]. In risk pregnancies, ultrasound may strengthen the maternal-fetal attachment and make the fetus more real [21]. Ultrasounds using 3/4D technique reveal clearer images and more detailed facial expressions of the fetus. It has been shown to enhance parent’s mental images of the fetus and inspire the parents to reflect on the characteristics of their baby and feel a stronger bond with the baby [22]. In line with this, de Jong-Pleij et al. (2013) [23] discovered that the effect of the ultrasound on bonding is stronger with better visibility and recognition; however, according to some reports bonding increases equally after a 2-dimensional (2D)-ultrasound in comparison with 3/4D [24]. Most studies have been done in low risk pregnancies. There are only a few studies in risk pregnancies combining psychological support with prenatal ultrasound [21, 25] in order to reduce psychological stress, anxiety and depression.

An ultrasound consultation is a method, where the fetus is observed with mother initiated interaction [21] aiming to help the parents to comprehend that the fetus is an actively exploring infant with developing senses, not just a passive recipient of different stimuli. The ultrasound consultation has been reported to increase the maternal-fetal attachment and decrease anxiety [26]. Pajulo et al. (2016) [25] further developed this method by using 3/4D ultrasound and adding an interactive mentalization focus, as an intervention for pregnant women with substance abuse problems.

The aim of this study was to explore the experiences of women at risk of preterm birth of an interactive ultrasound and the applicability of an interactive ultrasound as antenatal support. In addition, pregnant women’s need for psychological support during hospitalization was examined.

A total of twelve pregnant women participated in the study (Table 3). Their median age was 28 years (range 22–31) and pregnancy duration 30 + 2 (range 28 + 0–32 + 3) gwks and eight of the participants were primiparas. The women’s experiences of the interactive ultrasound examination were compiled under three main themes: 1) Pregnant woman as an active and equivalent participant, 2) The fetus as a real person and 3) Strengthened mental image of the baby.

We found that pregnant women with an imminent preterm birth experienced the interactive ultrasound as supporting their active and equivalent participation which also enabled them to consider the fetus as a real person and strengthen the mental image of the baby. Any need for additional emotional support depended on the woman’s social network and should, therefore, be provided on an individual basis. The interviews revealed the women’s appreciation of their thoughts and questions being valued during the ultrasound sessions. Most importantly, they experienced that they were able to participate actively and equally in contrast to their previous ultrasound examinations, which they described as professional-centered. Professional-centered care may lead to a passive role during the ultrasound examination and subsequent decision-making. Allowing and encouraging the pregnant women to participate actively in the observation of the fetus may have empowered them to present questions and their concerns. Our finding is in line with previous results showing that the responses of pregnant women to the ultrasound examination is more favorable when it is performed in an interactive way [26]. Because the women were active participants and their babies were seen as real persons, the women’s mental images of their fetuses were strengthened.

The maternity care in Finland strives to be patient-centered. Thus, it was surprising that some of the women had not understood the reason for their hospitalization and had not dared to ask the hospital staff about it. This implies that informing the patient about decisions based on any medical examination should be done explicitly without using professional terms and by involving the patients in the decision-making. Active participation has been related to increased empowerment and dignity and the loss of powerlessness in family-centered care [28]. Early interventions activating parents’ participation in neonatal setting have been shown to facilitate parenting and parental well-being [29, 30] as well as the development of the preterm infants [31]. It is possible that active participation in prenatal treatment has similar effects, as the women reported that seeing the baby during the ultrasound aroused emotions, such as feelings of closeness and deeper attachment. The first trimester ultrasound screenings already confirm the forthcoming parenthood [32, 33].

The women appreciated that the baby was seen as a person during the interactive ultrasound examination. Indeed, most women (92%) experience the fetus as a separate individual during the third trimester of pregnancy, and some already during the second (63%) or even the first (30%) trimester [34]. Between the fourth and seventh month of pregnancy women also create rich and specific mental representations of the baby [2] that are related to a stronger emotional bond to the unborn baby. This progress in mental representations is initiated by the moment when a woman senses the movements of the baby. Because all the participating women were between 28 and 32 gestational weeks, they were likely to imagine the baby as a real person and an individual. The women reported, that seeing the 3/4D view of the baby and observing the baby’s behavior in the womb made the baby more concrete and real for them. Previously, women’s representations of the unborn baby have been shown to be complementary to their representations of their own care giving role [35]. For example, if a woman imagines herself as a loving and caring mother, she imagines the baby as calm and happy. With ultrasound the representations related to the baby are enriched by observation of the real infant and slowly separated from the representations related to their care giving role [1, 2]. Importantly, the mothers also reported that the session awakened positive emotions, such as closeness and a deeper attachment, towards the baby. Interactive ultrasound is a unique way to approach pregnant women. It has not previously been applied to pregnant women with a risk of preterm birth. The women’s overall experience of 3/4D-ultrasound examination as positive in the present study is in line with previous findings [19, 22‐24, 36‐38]. Most of the previous studies regarding the impact of 3/4D-ultrasound on maternal-fetal bonding are relatively outdated and the method evaluating the bonding varied. However, 3/4D ultrasound has been shown to improve maternal fetal-bonding in the third trimester [23] and in first and second trimesters as well [19, 24, 36, 38]. Due to advanced technology, the quality of the 3/4D-images have improved and thus enables more realistic images of the fetus. The joint observation probably intensifies the effect of the 3/4D ultrasound image as regards maternal bonding to the infant.

Maternal prenatal attachment predicts the postnatal mother-infant interaction [11]. A low level of attachment is associated with negative emotions, depression and weak support from the family and partner [14, 39]. In preterm delivery, bonding to the infant is at risk because of early interruption of the psychological preparation for parenthood [40, 41]. The psychological influence of 3/4D ultrasound should be further investigated in risk groups [19, 22, 24, 25, 36] because there is increasing evidence that prenatal distress may be detrimental to the cognitive, psychomotor and behavioral development of the infant [42]. Thus, active and non-pharmacological prenatal interventions are needed.

An interactive ultrasound requires some training and personnel resources, but is feasible in clinical setting [25]. The presence of both the maternal fetal specialist and the psychologist enabled them to give full input. While the psychologist concentrated on joint observations with the woman, the obstetrician had the freedom to focus on the ultrasound view of the fetus. This study highlights the importance of communication between health care professionals and pregnant women as regards the fetus during an ultrasound examination. However, it is difficult to determine whether the advantages of the interactive ultrasound examination are due to improved communication or the method itself. Thus, the core issues of the intervention, listening to the mother, personalizing the fetus and giving emotional support, can easily be reached. Even though 3/4D- images give more realistic view of the fetus, this method may also be applied within the 2D-technique. Looking at fetus’ actions during routine ultrasound examinations with better communication and treating the pregnant woman as an active participant may strengthen the mental images in daily clinical setting.

It is also important to consider potential disadvantages of the interactive ultrasound method. The image of the 3/4D ultrasound may affect negatively on the pregnant woman’s developing mental images about her baby, but there is not enough knowledge available about diverse effects on the 3/4D-images on parental representations. However, the risk of negative impact is probably smaller when the image is properly explained and explored together with a parent. A strengthened emotional bond to the unborn infant after interactive ultrasound could also be considered a potential risk in the case of a woman losing the fetus or newborn infant. However, the literature shows [20, 43] that mothers’ well-being after a neonatal death is associated with their satisfaction with the support they received from the hospital staff after the death of the infant and the opportunities to create special and concrete memories of their baby. The interactive ultrasound can be seen as an opportunity for a pregnant woman to create memories of the unborn infant.

The small sample size is a limitation, although data saturation, indicated by repetitive responses in the interview was reached. In addition, the data provided a coherent understanding of the topic. The interviews were conducted based on a pre-designed interview guide which confirmed the dependability. The interviews were performed by the psychologist who was present at the ultrasound sessions, and this might have affected the participants’ responses. The transferability of the results may be limited. The aim of this pilot study was to map the women’s experiences of the interactive use of a 3/4-ultrasound in a group of women at risk of preterm birth. The results provide promising information about the interactive use of the ultrasound and encouragement to continue studying the topic.

The results of the qualitative pilot study imply that an interactive way of looking at the fetus during an ultrasound examination supports pregnant women at risk of preterm birth. It is a potentially new way to awaken maternal mental images, and thus increase maternal attachment to the infant as well as reducing worry during pregnancy. The method is relatively easy to implement into public healthcare and thus, may be a promising clinical practice in treatment of women with risk pregnancy. However, the effectiveness of this method needs rigorous further evaluation.