Background
Obstetric ultrasound has come to play a significant role in obstetrics since its introduction in clinical care [
1]. For some time now most pregnant women in the developed world have been exposed to ultrasound examinations in pregnancy, even though the timing of the examination and the number of scans vary considerably between countries and settings [
2]. The use of obstetric ultrasound is also rapidly increasing in developing countries, particularly in urban areas [
3,
4]. Ultrasound has broad application in obstetrics, including screening, diagnostics, and fetal surveillance during the course of pregnancy. The examinations are generally conducted by obstetricians or generalist physicians, radiologists, sonographers [
3], or specially trained midwives [
5].
The benefits of routine (screening) ultrasound include gestational age assessment, detection of multiple births, placenta localisation, assessment of fetal wellbeing, and detection of fetal anomalies [
6]. Further, ultrasound plays an important role in surveillance and management of high-risk pregnancies, where its use has been shown to reduce obstetric interventions and also the risk of perinatal deaths [
7]. There is no doubt that the advantages of obstetric ultrasound technique have led to improvements in pregnancy outcomes. At the same time however, it has been argued that continuing medico-technical progress has led to an increased medicalisation of pregnancy [
8]. Its use has also raised many ethical challenges, especially in relation to non-medical provision [
9], and its role in the practice of sex-selective abortions [
10,
11], and fetal reduction in multiple pregnancies [
12].
Ultrasound is generally very appealing to expectant parents [
2,
13]. Expectant parents’ experiences of ultrasound examinations have been described as a confirmation of new life, meeting and connecting with the baby, and as an important step towards parenthood [
14,
15]. Expectant parents in general expect a confirmation that the ‘baby’ is well and that the pregnancy is real [
2,
16]. However, unpreparedness for adverse findings has been reported as common, as well as lack of knowledge about the purpose of the ultrasound examination and the limitations of the procedure [
2,
13,
17]. While different aspects of expectant parents’ experiences of the use of ultrasound in pregnancy have been explored previously, there is still a gap in the literature with regards to obstetricians’ views and experiences in relation to the use of ultrasound.
We report findings from the initial stage of the CROss-Country Ultrasound Study (CROCUS) which aims to explore issues related to the use of obstetric ultrasound in both low-income and high-income countries. The specific aim of the present study was to explore obstetricians’ experiences of the significance of obstetric ultrasound for clinical management of complicated pregnancy and their perceptions of expectant parents’ experiences.
Methods
Outline of the CROCUS study
The CROCUS-study is a two-phase project, with qualitative and quantitative components, being undertaken in a number of low-income and high-income countries in Europe, Africa, Asia, and Oceania. This study was the first exploratory sub-study of the qualitative phase. The countries involved in the CROCUS-study have been selected to represent a variety of contexts, including culture, religion, gender perspectives, legislation, organisation of obstetric and maternal health care, and organisation of and access to ultrasound examinations during pregnancy.
The local study setting
The Australian health care system consists of both public and private funders and providers. Medicare, the compulsory tax-funded national health insurance scheme, offers patients free public hospital treatment and access to subsidized medical services and pharmaceuticals. Voluntary private health insurance assists people with access to hospital treatment as private patient and with access to allied health services and dental services. Private medical practitioners provide most community-based medical treatment, and general practitioners (GPs) are normally the first point of medical contact in the health care system [
18,
19]. Pregnant women in Australia have a range of choices for model of health care during pregnancy, birth and the postpartum period [
20]. All pregnant women are offered dating ultrasound examinations, although the screening approach varies across the country [
21]. In the state of Victoria, 98% have at least one ultrasound examination, with 94% having the routine anomaly ultrasound scan [
22]. Women may undergo a number of ultrasound examinations during the course of pregnancy if pregnancy-related complications occur. According to the researchers’ knowledge, ultrasound examinations are in Australia predominantly performed by obstetricians or sonographers.
Participant recruitment process
Participants for this study were recruited from two large hospitals in Victoria, Australia, each hospital with over 4000 births per year. Approval to involve obstetricians was sought from the heads of each department of obstetrics and gynecology. Inclusion criteria for participation were being an obstetrician working with obstetric ultrasound examinations as a major work task, or doing obstetric ultrasound examinations as part of their general obstetric care, or using the results of obstetric ultrasound in clinical management of pregnant women. Names and contact details of obstetricians were obtained via the department heads, who also mediated bookings of appointments for interviews. All participants were provided written information about the study aim and procedures. A convenience sample of 14 obstetricians meeting the inclusion criteria was assembled and no one approached declined participation in the study. Verbal and written informed consent was obtained prior to the start of each interview.
Participant characteristics
Fourteen obstetricians agreed to participate; ten females and four males. Their ages ranged between 33 and 59 years (mean 43.7 years) and their experience as an obstetrician varied between 4 and 30 years (mean 15.5 years). A few of the participants were of non-Australian origin and had previously practised obstetrics overseas. All were qualified in performing obstetric ultrasound examinations.
Data collection procedures
All interviews took place in November 2012 and were held at the hospitals during, or in close connection with, the obstetricians’ normal work shifts. An interview guide, developed by the research group and linked to the overall aims of the CROCUS study, was used to guide the interviews. The following key domains were included (topics addressed in this paper are shown in italic).
The obstetricians’ views/experiences of:
-
The importance/value of obstetric ultrasound for clinical management of complicated pregnancy.
-
Clinical situations where the interests of maternal and fetal health have been in conflict.
-
Whether the woman may be considered to act as an instrument for fetal treatment.
-
The importance of obstetrical ultrasound in comparison to other surveillance methods during complicated pregnancy.
-
If/when the fetus can be regarded as a person.
-
Situations where the fetus has been regarded a patient with his/her own interests.
-
Their professional role in relation to other occupational groups working with obstetric ultrasound examinations or the outcomes of these examinations.
-
Other issues in relation ethical aspects of the use of obstetric ultrasound.
The individual interviews were performed by two of the authors (IM and MP). All participants were asked to complete a short anonymous questionnaire with demographic questions including sex, age, qualifications and professional experience of obstetrics and obstetric ultrasound. The interviews lasted between 22 and 65 minutes (mean 37 minutes) and were all digitally recorded. After performing 14 interviews, the whole research group met to discuss whether further data collection was needed. The authors concluded that further interviews were unlikely to provide any new information and that saturation of data had been reached [
23]. The interview discussions were broad-ranging and it is not possible to report all findings here. We describe those findings of central relevance to our stated aim. Remaining findings will be reported in forthcoming papers.
Data analysis
Data were analysed using qualitative content analysis [
24]. First, three members of the research group read all interviews to get a sense of the whole (KE, RS and IM). The researchers then discussed general impressions and emerging content areas. Data addressing the aim of this study were then coded by KE and selected parts were also coded by RS and IM. KE compared the codes for similarities and differences, grouped them into content areas and subsequently into preliminary categories and sub-categories. These were then reviewed by RS and IM, and uncertainties in interpretations were thoroughly discussed between the three researchers until consensus was obtained. An overall theme emerged during these discussions. All five researchers then reviewed the categories and theme against the original transcripts, which resulted in minor adjustments to the labelling and the order of categories.
The researchers’ backgrounds
The research group represents various professional disciplines and research traditions including obstetrics and gynecology, midwifery, nursing, behavioral science, maternity services and maternal health research, public health, epidemiology, and qualitative methods. The authors’ diverse experiences added complementary perspectives in interpretation of data, something we believe enriches the overall trustworthiness of the study.
Ethical considerations
All participation was voluntary and based on informed consent. Ethics approval was obtained from the Faculty Human Ethics Committee at La Trobe University in Melbourne (reference FHEC12/135) and the Human Ethics Committees of the two participating hospitals. To ensure confidentiality, characteristics of participants are presented only with means and ranges and the participants are referred to with individual numbers where quotations are presented.
Discussion
The aim of this study was to explore obstetricians’ experiences of the significance of obstetric ultrasound for clinical management of complicated pregnancy and also their perceptions of expectant parents’ experiences. Although the aim was to focus primarily on complicated pregnancy, participants raised dilemmas in relation to all aspects of use of ultrasound.
Results from the present study show that obstetric ultrasound was an essential tool (‘third eye’) for obstetricians in surveillance of maternal and fetal health. More importantly however, the study highlights some issues and dilemmas that arise with its use; obstetricians’ and expectant parents’ differing perspectives and expectations of obstetric ultrasound examinations and the challenges related to uncertain findings, and how the obstetricians try to balance this in their counselling and discussions with expectant parents prior to, during, and following an ultrasound examination. This is to our knowledge the first study to explore these experiences and views among obstetricians, contributing new knowledge to the field.
It is clear from this study that ultrasound is a highly valued tool for obstetricians in their everyday practice and for managing complicated pregnancy. However, they experienced public confidence in obstetric ultrasound to be somewhat misguided and saw a gap between their own and expectant parents’ knowledge about the possibilities and drawbacks of the use of obstetric ultrasound. These findings seem consistent with those from previous studies. For example, a systematic review of women’s views of pregnancy ultrasound in 18 countries including Australia, revealed that women are often unprepared for adverse findings, and often lack information about the purposes of the examination and about the technical limitations of the procedure [
2]. Several studies have also shown that women’s understanding of ultrasound often does not meet the requirements of informed choice [
2,
25‐
27], which includes the three components information, comprehension and voluntary choice [
28]. While women may be familiar with the practical aspects of prenatal examinations, their understanding of the drawbacks and other consequences of the tests are often insufficient [
26]. Probably, these issues are more related to routine antenatal ultrasound use (screening) than the use of ultrasound in the management of complicated pregnancy. The present study has illustrated how the obstetricians experienced and tried to deal with challenging circumstances when pregnant women may lack understanding or have unrealistic expectations.
Results of this study also illuminate the difficulties obstetricians can encounter in clinical situations characterised by uncertainty. Communicating uncertainty was depicted as one of the most demanding aspects of obstetric practice. During routine pregnancy ultrasounds, expectant parents in general expect reassurance that everything is fine [
2,
16]. The obstetricians are obliged to provide objective information, however, as indicated by our participants, this information may be difficult for them to formulate appropriately and hard for the expectant parents to interpret and put into perspective. This may create an unbearable situation for some women and men, characterised by anxiety and worry for the wellbeing of the fetus/the future child. While previous studies investigating obstetricians’ experiences of communicating uncertainty following ultrasound examinations are lacking, communicating uncertainty and assessing expectant parents’ understanding have been pointed out as among the most challenging aspects in other areas of obstetric care [
29]. Obstetricians are expected, as are doctors in general, to cope with the complexity of diagnoses and decisions, while simultaneously being sensitive to the feelings of the pregnant woman and her partner when communicating uncertainty or breaking bad news. This is a demanding task in which the obstetrician also needs to be in possession of emotional competence and good communication skills. The pregnant woman deserves to be managed by an astute and empathetic obstetrician and a skilled team. As some diagnoses may cause a psychological crisis, there is often need for psychological and social support in parallel with the obstetric investigation and treatment, as the obstetricians also pointed out. When communicating uncertainty or breaking bad news, the obstetrician and the rest of the team have a responsibility to help the couple to put the problem into perspective and navigate their way forward. Following expectant parents through this journey was depicted by the participants as a difficult task, but at the same time as one of the most rewarding aspects of being an obstetrician. Despite both doctors and patients likely agreeing on the importance of information provision and support, there can however, be discordance in the approach health care providers have, and the approach preferred by pregnant women and their partners [
30]. For example, while providing ‘hope’ and supplementary information were emphasised as important to expectant parents who were at risk of giving birth to an extremely premature infant, health care providers expressed the importance of ‘objectivity’ and emphasised the desire not to provide ‘false hope’ [
30].
The obstetricians in the present study believed that the increased stress and anxiety as a result of not knowing the significance of abnormal findings affected the pregnancy experience very negatively for some women. These findings are congruent with findings from previous studies in pregnant women that have shown that unpreparedness for adverse findings can make this information traumatic [
2,
31,
32]. Interestingly, in a Swedish interview study, it was found that the majority of women who had soft markers detected via routine ultrasound would rather not have known, or were hesitant about getting this information [
17]. On the contrary, in a prospective Canadian survey of women booked for a (routine) anatomy ultrasound examination in second trimester, only 6% of women were hesitant or clearly did not want to know about soft markers if they were seen. However, 23% of the study participants stated that soft markers should be reported only after the woman has been counselled and given her consent [
33]. Our study, which is the first to report obstetricians’ views on the use of ultrasound, in conjunction with the number of publications that report on women’s limited understanding of the purpose and potential of the scan [
2,
13,
17], provides evidence for the utter importance of appropriate counselling prior to the examination. Thus, improved information about the ultrasound examination, including possibilities and limitations, seems to be the most appropriate way for obstetricians and other caregivers to minimise the psychological impact of uncertainty, as well as to establish informed consent to the scan. This is becoming increasingly important considering the effects of the rapid technical advances, the growing diagnostic possibilities, and the more widespread use of ultrasound.
Our findings also highlight the obstetricians’ perception of their own and their patients’ perspectives and expectations of obstetric ultrasound examinations, and how these at times conflicted. Most evident was the clash between the obstetricians’ medical approach to ultrasound and their opinion that some expectant parents viewed pregnancy ultrasound as not only a medical procedure, but also a social event or even as entertainment. This finding is consistent with previous research [
17,
34]. Taylor (2008) [
35] describes the ultrasound examination as a ‘hybrid practice’, by having nonmedical meanings and functions commonly incorporated into medical ultrasound practice. This ‘hybrid practice’ is exemplified through the way ultrasound equipment is often designed to facilitate the ‘entertainment’ aspect through swivel monitors to enable expectant parents to follow the examination, and special printers available for providing keepsake photos [
35]. The growing phenomenon of non-medical or so-called ‘entertainment’ ultrasound was raised as a concern among obstetricians. Non-medical use of obstetric ultrasound can be defined as situations where the purpose of the examination is solely to view the fetus, take its picture or determine its sex without medical indication [
36]. An ethical analysis of non-medical fetal ultrasound concludes that obstetric ultrasound practice is ethically justifiable only if the indication for its use is based on medical evidence [
9]. Furthermore, the practice of non-medical or ‘entertainment’ ultrasound is discouraged by governments and professional bodies [
9,
37‐
41]. Reasons for seeking non-medical fetal ultrasound have been reported as dissatisfaction with the medical imaging, (including factors such as not learning the sex of the fetus), insufficient length of the obstetric ultrasound appointment, poor visual quality of images or unfriendly staff [
34]. Other non-medical reasons for participation in ultrasound screening include to experience the pregnancy as more real and also to give the partner the opportunity to experience and see the pregnancy [
42], as undergoing ultrasound provides an excellent opportunity for the expectant father to meet and connect with the fetus [
14].
Findings in the present study suggest that ultrasound was sometimes used liberally in clinical practice and not always according to medical criteria for reasons such as risk-averseness, lack of clinical experience, or expectant parents’ need of reassurance. It is plausible that this is not unique to this specific study context. Although the benefits of ultrasound are well established in relation to clinical management and maternal and fetal health outcomes [
6,
7], its use also carries some risks. These can broadly be categorised into diagnostic errors (e.g. overdiagnosis/underdiagnosis) and possible biological effects [
43]. The obstetricians in our study repeatedly described experiences related to the former: the psychological harm caused due to false positive or false negative findings, or the stress caused when the information obtained from an examination was too difficult to grasp or manage for expectant parents. Interestingly, in this study the possible biological fetal effects were not given much attention by the participating obstetricians, the implications of too liberal use was exclusively discussed in relation to diagnostic errors. This may have several explanations, including the fact that ‘risks’ was not raised as a separate topic for discussion by the interviewers or that ultrasound may be considered safe, as some of the participants stated. That pregnancy ultrasound does not pose any risk to a pregnant woman or fetus has been suggested by others to be a common perception among clinicians [
43]. Further studies from the US and Europe have shown poor knowledge among those performing obstetric ultrasound examinations regarding aspects of fetal safety during pregnancy [
44,
45]. However, to our knowledge, there is no such data for Australian obstetricians and further studies into this area seem needed. There is to date not sufficient evidence about the absolute safety of pregnancy ultrasounds. Although previous systematic reviews regarding safety have been unable to find evidence of significant adverse maternal, perinatal, or childhood outcomes [
6,
46], an association between exposure to ultrasound in pregnancy and non-right handedness has been found [
46,
47]. More studies around safety are warranted [
46,
48], especially since experimental studies on fetal mice have shown adverse effects [
49], and as the most recent systematic review on safety is based predominantly on ultrasound exposures before the mid 1980s, when the acoustic potency of the ultrasound equipment was much lower than today [
46], and the use of ultrasound less frequent. The uncertainties regarding safety are evident in the recommendations of prudent use and adherence to the ALARA (As Low As Reasonably Achievable) principle [
41,
46].
One of the relatively novel aspects that emerged in our study was the issue of pregnant women’s body weight in relation to imaging performance. This is an escalating issue in obstetrics due to the increasing trends of overweight and obesity in childbearing women [
50]. It has been shown that image quality substantially decreases with increasing BMI, which in turn negatively impacts on the detection rate of congenital anomalies [
51]. This is problematic especially considering that the risk for adverse fetal and pregnancy outcomes also increases with increasing BMI [
52,
53], as pointed out by the participants in our study. Previous research has shown a low level of awareness of maternal and offspring risks linked to overweight and obesity [
54‐
57]. However, research into women’s understanding of the influence of BMI on image quality, and obstetricians’ experiences of counselling overweight or obese women in relation to pregnancy ultrasounds is lacking. A study conducted in the UK showed that the ultrasound examination was a significant source of distress in women who were obese if difficulties imaging the fetus were not clearly explained during the examination [
58]. Thus, skirting around the issue because of fear of upsetting, stigmatising or blaming women [
59] may be an unfortunate strategy, especially when overweight or obese women expect the same outcome of the examination as their normal weight peers, as indicated in our study. Obese pregnant women are in general sensitive about their size [
58], however, caregivers’ vagueness and inconsistent messages can make women feel even more uneasy about their weight [
60]. Thus, providing adequate and consistent information [
60], and having an affirmative approach are ways for care providers to alleviate discomfort and increase wellbeing in obese women during consultations [
61].
Strengths and limitations
Factors increasing credibility in this study include that obstetricians with varying characteristics in relation to gender, age, length of experience in obstetric practice, and work settings (two hospitals with different characteristics) were recruited, and that none of the approached obstetricians declined participation. Furthermore, the participating obstetricians were highly engaged and reflected extensively on their work during the interviews. This contributed to a broad range of topics and perspectives being raised with us, providing a comprehensive picture of the phenomenon under study [
24]. We aimed to increase dependability by consistency in data collection and analysis. The use of an interview guide ensured coverage of all topics, at the same time as it prevented interruption in the obstetricians’ narratives, as questions were not asked in a predefined order. All interviews were performed by two researchers (IM and MP) within a two week period, which further increased dependability in data collection. The authors also collaborated closely during data analysis and reporting to further strengthen the dependability and credibility of the study [
24]. It is important, however, to bear in mind that the findings presented in this study are only representative of the experiences and views expressed by the participating obstetricians. Although it is likely that many of the aspects discussed are transferable to obstetricians working in other high-income settings, context-specific factors such as organisation of services, culture, gender perspectives, religion, legislation, and economy may influence experiences with pregnancy surveillance, clinical management and utilisation of obstetric ultrasound.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
KE, RS, MP, AL and IM designed the study and contributed to the data collection. KE conducted the analyses in close collaboration with IM and RS, and KE drafted the manuscript with input from IM and RS. All authors contributed to revising the manuscript and approved the final version.