BIRTH 29:4 December 2002 225

Women’s Views of Pregnancy Ultrasound:

A Systematic Review

Jo Garcia, MSc, Leanne Bricker, MRCOG, Jane Henderson, MSc, Marie-Anne Martin,
BSc, Miranda Mugford, DPhil, Jim Nielson, MD, FRCOG, and Tracy Roberts, MPhil

ABSTRACT: Background: Ultrasound has become a routine part of care for pregnant
women in most countries with developed health services. It is one of a range of techniques used
in screening and diagnosis, but it differs from most others because of the direct access that it
gives parents to images of the fetus. A review of women’s views of ultrasound was commis-
sioned as part of a larger study of the clinical and economic aspects of routine antenatal
ultrasound use. Methods: Studies of women’s views about antenatal screening and diagnosis
were searched for on electronic databases. Studies about pregnancy ultrasound were then
identified from this material. Further studies were found by contacting researchers, hand
searches, and following up references. The searches were not intentionally limited by date or
language. Studies that reported direct data from women about pregnancy ultrasound were
then included in a structured review. Studies were not excluded on the basis of methodological
quality unless they were impossible to understand. They were read by one author and tabu-
lated. The review then addressed a series of questions in a nonquantitative way. Results: The
structured review included 74 primary studies represented by 98 reports. Studies from 18
countries were included, and they employed methods ranging from qualitative interviewing to
psychometric testing. The review included studies from the very early period of ultrasound use
up to reports of research on contemporary practice. Ultrasound is very attractive to women
and families. Women’s early concerns about the safety of ultrasound were rarely reported in
more recent research. Women often lack information about the purposes for which an
ultrasound scan is being done and the technical limitations of the procedure. The strong
appeal of diagnostic ultrasound use may contribute to the fact that pregnant women are often
unprepared for adverse findings. Conclusions: Despite the highly varied study designs and
contexts for the research included, this review provided useful information about women’s
views of pregnancy ultrasound. One key finding for clinicians was the need for all staff,
women, and partners to be well informed about the specific purposes of ultrasound scans and
what they can and cannot achieve. (BIRTH 29:4 December 2002)

Ultrasound scans have become an almost universal evidence about the clinical and economic impact of
feature of pregnancy care in countries with devel- pregnancy ultrasound (1), we carried out a system-
oped health services. As part of a larger study of the atic review of studies about women’s views of

Jo Garcia is Social Scientist and Jane Henderson is Health
Economist at the National Perinatal Epidemiology Unit, Oxford
University, Oxford; Leanne Bricker is Senior Lecturer, Department
of Obstetrics at the University of Liverpool, Liverpool; Marie-Anne
Martin is an Information Specialist in Broadway, Worcestershire;
Miranda Mugford is Professor of Health Services Research at the
University of East Anglia, Norwich; Jim Nielson is Professor of
Obstetrics and Gynaecology at the University of Liverpool, Liver-
pool; and Tracy Roberts is Lecturer in Health Economics at the
University of Birmingham, Birmingham, United Kingdom.
The work reported here is part of a larger project funded by a grant
from the National Health Service Health Technology Assessment
Programme, Southampton and London, and published by them in a
report and on their website.
Address correspondence to Jo Garcia, National Perinatal Epidemi-
ology Unit, Institute of Health Sciences, Old Road, Headington,
Oxford OX3 7LF, United Kingdom.

2002 Blackwell Publishing, Inc.
226
ultrasound use in pregnancy. Because another recent
review has explored the impact of ultrasound on
psychological variables like anxiety or attachment to
the baby, this topic is not addressed by the study
reported here (2).
Good reasons exist for doing systematic reviews of
people’s views of care. Trying to be inclusive, clear,
and systematic in what is included in a review can
give important new insights and limit the possibility
of a biased selection of studies. There are ethical
reasons, too; the effort already put into research by
pregnant women, partners, and researchers should
not be wasted. Methods for compiling the results of
research about people’s views are just being devel-
oped, and no standard approach is yet available.
Some recent reports include a synthesis of qualitative
research about experiences of diabetes (3), using a
technique called meta-ethnography (4); a review of
cancer patients’ preferences about place of care (5),
using methods for the review based on the recom-
mendations of the English National Health Service
Centre for Reviews and Dissemination (6); a review
of studies about life in acute psychiatric wards in the
United Kingdom, including study types ranging from
participant observation to questionnaire surveys of
patients (7); and a series of studies about health
promotion for young people that used reviews of
young people’s views alongside evidence of effective-
ness (8). All these studies had in common a desire to
find as much of the relevant research evidence as
possible, within specified boundaries of time and
space, and look at it systematically.
The review of women’s views of pregnancy ultra-
sound presented some particular challenges. Ultra-
sound is one of many methods used in pregnancy for
screening and diagnosis. Some of its features may be
special, for example, the chance to see the baby and
the immediacy of the knowledge gained, but it is not
unique and many questions we can ask about
ultrasound can also be asked about other screening
and diagnostic tests. The literature on these topics is
extensive. The experience of antenatal ultrasound is
likely to depend on several factors, such as the clinical
objective of the scan and what women know about
the purpose and likely outcomes. The setting for the
scan, women’s interaction with staff, and the way that
scan findings are passed on are also likely to have an
impact. Both the technique itself and the way in
which it is used have changed a great deal since
ultrasound was introduced, and they continue to
develop. Variation can be found between and within
countries in how ultrasound is used. In addition to
the inherent complexity of the subject, the review had
to consider studies using a wide range of research
approaches.
BIRTH 29:4 December 2002
Methods
The review of studies of women’s views was commis-
sioned as an addition to a project on the clinical and
cost-effectiveness of routine pregnancy ultrasound.
The research commissioners (the English National
Health Service’s Health Technology Assessment
agency) did not specify what they wanted from this
extra review. The approach was developed by the
lead author and then discussed and refined with the
other authors.
The initial search strategy was designed to find
material related to the views and experiences of
women about antenatal screening and diagnosis of all
types. The search of databases involved combining
the terms shown in Fig. 1, and searching for material
from 1981 onwards on Medline, CINAHL, EMBase,
and BIDS-SSCI. It picked up approximately 200
publications, many of them providing general back-
ground. Studies that were likely to be about ultra-
sound were then identified from the abstracts. Studies
of early miscarriage were excluded. Studies of the
experiences of ultrasound by male partners of preg-
nant women were included.
All papers about ultrasound, and the wider
reviews identified, were combed for additional rele-
vant publications about women’s views and experi-
ences of ultrasound. Many more were found this way,
perhaps because literature about ultrasound has been
published in such a wide range of journals. Forth-
coming papers and work in progress were also found
by contacting United Kingdom and French research-
ers to ask about new or key articles. The initial
searches were carried out during 1998 and updated in
2002. Unpublished work and studies published in
languages other than English are more likely to have
been missed. Publications obtained were read by one
author and sorted into three categories: relevant,
background, and not relevant.
Fig. 1. Search terms.
BIRTH 29:4 December 2002 227

The questions to ask of the material (listed in
Results below) were developed by a process of
reading and re-reading the articles. The questions
chosen were, to some extent, individual to the team,
and other reviewers might well come to this material
with a different agenda. Papers were initially tabula-
ted and categorized according to their relevance to
the questions. They were not graded in terms of
research quality, or removed from the review for
reasons of poor quality, although many had problems
of design and reporting.
Results
In all 74 studies were represented in the 98 reports
identified. The studies ranged widely in terms of the
questions addressed and the methods used. Table 1
shows the methods used; some studies used more
than one method so the total is greater than the
number of studies. Tables 2 and 3 show when and
where the studies were done. Some studies did not say
where they were done, and so we have guessed. Many
did not give a date when the work was carried out, so
we have used any information available to give a
likely date (Table 2). This means that the dates in the
table are probably later than they should be because
some studies may have been a few years old when
they were published.
The studies included in this review are shown in
Table 4. The decision was made to keep studies in
Table 4, even if they did not provide information
directly relevant to the questions posed in the review,
so that other researchers could locate the material
more easily. Fifteen studies fell into this category; 3
were about opinions on the appropriate national
policy about ultrasound screening (9–11), 1 was
about fetal gender identification during ultrasound
scans (12), and 12 were among the 22 studies
assessing the psychological impact of ultrasound. In
Table 4 we have tried to give information about the
way that ultrasound was being used in each study.
Several papers did not report this, however, which
makes it difficult to look at women’s views of
ultrasound in specific clinical contexts. Table 4 shows
the review questions to which each study was
relevant. Other background material, not included
in Table 4, is cited and listed in the references.
The data have been used to address a series of
questions:
• What do women know about reasons for using
ultrasound and what a scan can do?
• What do women like or value about scans?
• What are women’s views about the way the scan
was performed?
• What is the impact of the results?
• What might be the wider impact of ultrasound on
society?
What Do Women Know about Reasons for Using
Ultrasound and What a Scan Can Do?
A short personal account in the British Medical
Journal (13) told of the experience of a British family
doctor who received a nuchal translucency scan

Table 1. Numbers of Studies Using Different Methods (Studies Can Use More Than One Method)

Self-administered Psychometric Qualitative Structured Nonparticipant Randomized Other

Method Questionnaires Tests Interviews Interviews Observation Trials Trials Other*

Number of studies 31 20 21 10 7 8 3 5

* Willingness to pay, diaries, observation of mother/infant behavior.

Table 2. Estimated Date Work Was Carried Out for Studies Included in Review

Estimated Date Work Carried Out Not Later Than 1980 1981–1985 1986–1990 1991–1995 1996 or Later

Number of studies 3 14 22 23 12

Table 3. Countries Represented by Studies Included in Review

Scandinavia United United Australia and

Country and Finland Kingdom States France Canada New Zealand Italy Other*

Number of studies 11 23 17 4 3 4 3 9

* Austria, Belgium, Botswana, Croatia, Greece, Israel, Netherlands.

228
without being aware of its purpose. She was angry
because she did not want to know if her fetus was
likely to have Down syndrome. The rapid changes in
the way that ultrasound is being used and the fact
that policies differ among hospitals in the United
Kingdom mean that a woman may well not know
what is scan is intended to do unless she has been
told. This lack of information can leave her vulner-
able to a painful shock if the scan shows a problem
when she was not aware that anomalies were being
looked for. On the other hand, lack of information
about what the scan can do may indicate that she
believes that the absence of anomalies detected means
that all is well.
Twenty-one studies in Table 4 are relevant to this
question, although researchers addressed these issues
from several angles. Most studies show some deficit
in women’s knowledge of the purpose of their scan,
and this tallies with studies of other aspects of
prenatal screening and diagnosis (14,15). A com-
mendably clearly reported study of women attending
for routine scanning at one United Kingdom hospital
found that few women were aware that one aim of the
scan was to look for markers associated with Down
syndrome (16). The paper describes in detail what the
scans were intended to do, but many other papers fail
to clarify the intent, which makes it hard to judge
how well women have understood what the scan is
for. One recent local study in England found that
two-thirds of women who had recently had a scan
including measurement of nuchal translucency
thought that they had not been adequately prepared
for the scan (17).
Two Swedish studies carried out in the 1990s of
women coming for routine midtrimester scan, asked
in different ways about women’s knowledge of what
the scan was for (18–20). The women (and partners)
in Uppsala (19,20) selected purposes for the scan that
seemed to match well with those described by the
authors, although the parents put more emphasis on
the detection of malformations than the authors
thought was appropriate, given the way the aims of
scanning were described in the hospital information
leaflet. In Lund women seemed less well informed,
with 62 percent thinking that the scan was compul-
sory, and one-third saying that they were not given
the information that the scan could detect malfor-
mations (18). A more recent Danish study of
women’s knowledge about midtrimester ultrasound
showed a high level of appropriate knowledge and
high satisfaction with the scan (21).
A French study carried out in 1990 addressed a
reported concern about women’s unrealistic expecta-
tions of ultrasound (22). Women were interviewed by
telephone after the birth. Most were well informed
BIRTH 29:4 December 2002
about the purposes of midtrimester scans. Only 9
percent thought that if no anomaly was found on
ultrasound, one could be sure that the fetus was
normal. This view was more common, however, in
women with the fewest years of education. In
Santalahti et al’s study in Finland, education levels
were also linked to knowledge about what the scan is
for and what it can detect (23).
Gaps in the provision of information have been
highlighted in some United Kingdom investigations.
A study that observed routine antenatal consultations
in six hospitals reported that information about
fetal anomaly scanning was extremely limited, with
approximately two-thirds of women receiving no
information in the consultation about the purposes of
scans (24). A survey of midwives and obstetricians
carried out by the same team found gaps in staff
knowledge about antenatal screening (25). A survey
of United Kingdom hospital practice reported that
just under one-half the maternity units surveyed
routinely gave women information about the poten-
tial of a scan to detect anomalies (26).
Researchers have tried to improve the information
provided to women, although only one randomized
trial has been identified (27). In a quasi-experimental
study in Sweden (not included in Table 4 because it
did not study women’s views), women at 7 clinics
were given extra information about antenatal screen-
ing, and then their uptake of tests was compared with
that of women in 10 control clinics (28). No women
in either group declined ultrasound, but 1 percent (11
women) in the clinics with extra information chose to
have only an early ultrasound and to avoid the
midtrimester scan for detecting malformations. In a
British study with historical controls, two surveys
were carried out (16). In the second survey, women
who were given extra written information about
ultrasound scored better on some aspects of know-
ledge than the group without the information. In a
trial of the offer of additional information (individu-
ally or in a group) about antenatal screening, the
uptake of ultrasound was not affected by the inter-
vention and was extremely high in all three groups
(99%). Uptake of screening for cystic fibrosis was
lower in the two intervention groups when compared
with the control group. The groups offered extra
information reported increased satisfaction with
information received and improved knowledge when
compared with the control group. Uptake of extra
information was relatively low—61 percent for
those offered individual sessions and 42 percent for
classes (27).
Further investigations could be done to improve
the understanding of staff attitudes to information-
giving about ultrasound (and other prenatal tests).
BIRTH 29:4 December 2002
Good communication about these complex issues
takes time, and requires considerable knowledge and
confidence on the part of staff. Procedures that are
seen as routine or no longer novel may not be
perceived by staff as needing as much explanation as
newer techniques. Explaining about ultrasound may
be viewed as less important because it is considered
noninvasive. Women, too, may put up barriers to
obtaining detailed information about the possible
outcome of a scan because of the strong attraction
exerted by ultrasound, discussed below.
What Do Women Like or Value about Ultrasound
Scans?
At the first scan I was only 11 weeks and didn’t feel very
pregnant, but it was a marvellous sight seeing this tiny thing
moving about and its heart beating. I felt pregnant then
(29).
The face, and heart beating. The closest you can imagine to
seeing or meeting your baby before you have him. You can
‘‘wave’’ to him. I would have them weekly if I could, and
take friends to meet baby (30).
Table 4 contains 25 studies that provide some
indication of what women like about ultrasound
and a further 2 that explore what women would be
willing to pay for it (31,32). Of the 25 studies, 11 gave
in-depth accounts, which help to clarify what is
attractive about ultrasound and also any fears that
women may have (29,30,33–42).
Taken together, the 25 studies we found show that
almost all the women included in these studies
reacted highly positively to ultrasound. Some were
unhappy about the way the scan was done (discussed
in the next section). Some women get bad news
during the scan and may regret having it; this is also
the subject of another section. A very few women
choose not to be scanned at all, or avoid scans that
are intended to detect anomalies. One or two women
are quoted in the studies we have reviewed who felt
uncomfortable seeing the image of the fetus during
the scan because they thought it intrusive, or because
they were worried that they may feel too much for the
fetus and then find it hard to cope if something went
wrong (30,37,40). In a Canadian study, however, 99
percent of parents asked if a scan was ‘‘an intrusion
into something very private that should have
remained hidden’’ said that it was not (43).
Only 9 studies referred to fears or worries about
ultrasound. In one early study from the United
States, some women were afraid, before the scan, that
it would be painful for them; in addition, one-half
expressed the fear that it might harm the baby (37). A
1995 study from Botswana, the only study found
229
from a poor country, reported that some women were
afraid that the scan might hurt or kill them. Ultra-
sound was not being used routinely and was an
innovation in maternity care there; women had been
given little information about what to expect (41). A
British study from the early 1980s found that over 85
percent of women reported the things they enjoyed
about the scan, whereas 15 percent reported worries
(29). Altogether, 77 percent of women in this study
mentioned only enjoyable aspects and 4 percent only
worries. The types of worries included fears of harm
to the fetus, and concerns about what the scan might
show. The enjoyable aspects were about seeing the
baby or details of the baby and seeing movements.
Women enjoyed the reassurance brought by the scan
and feeling that their pregnancy had become more real
to them. They also mentioned their partner’s presence
and increased involvement with the baby (29).
In a Swedish study carried out in 1991, women
interviewed before a scan had anxieties about what
the scan might reveal, but only 2 percent feared that it
might harm the baby (19,20). In Crang-Svalenius
et al’s study, 4 percent were apprehensive that the
scan might harm the baby (18). Few recent studies
have reported fears about the effects of ultrasound on
the baby, but that may be partly because few recent
qualitative studies have explored women’s views. One
exception is a study of Thai women in Australia,
done in the mid-1990s, which found some fears of this
kind among women who had received more than one
scan. Other women in this study were very positive
about the experience (38).
Four studies asked women to describe how they
felt about a scan using a list of adjectives from which
they had to pick one or more. Positive adjectives were
far more likely to be chosen (18,19,20,44). In addi-
tion, two trials compared the reactions of women to
scans where explanations were offered and a woman
could see the screen (high feedback) with scans where
only the operator saw the screen and the woman was
told at the end of the scan that all was normal (low
feedback). Women in the high-feedback groups were
more likely to choose very positive adjectives to
describe their feelings after the scan (45,46).
Only one study, a Swedish study of 10 women
pregnant for the first time, asked women to talk in
depth, before and after a scan, about their views about
the unborn child (34). Ultrasound was reported by
these women as having a considerable impact on them,
and of increasing their awareness of bearing a child.
One woman said in the interview after the scan:
It becomes obvious that it is actually in my belly, that it
exists. I have realized more that it is my child that is lying in
there. It made it more real, even if you won’t understand it
until it comes out (34).
230
They were all positive about the experience of the
scan, and liked the detailed explanation given to them
at the time. They were relieved that no problems had
been detected. Women in Black’s study (47), who
were interviewed about the scan after they had lost a
pregnancy through miscarriage or termination, also
emphasised the powerful effect of the scan. One said:
I tried to protect myself from the eventuality of losing this
baby. Even from the minute I knew I was pregnant it was
almost like, OK I’m pregnant, so what? I didn’t really feel
much joy because I was too anxious about having the test
done, and when I saw the sonogram it was sort of a shock
because, yes, there was a very vigorous heart beating and it
was a baby there; and it just made me more keenly aware
that I didn’t want to lose it... (47)
Summing up this section: what women like about the
scan has been described by Clement et al as having
three main elements: meeting the baby, sometimes
with other family members; having a visual confir-
mation of the reality of pregnancy; and gaining
reassurance about the well-being of the fetus (33).
Ultrasound is different from other types of tests
because it provides the first two of these alongside the
third.
What are Women’s Views about How the Scan is
Performed?
Before looking at some of the issues that women
raised about the scan procedure itself, it is worth
mentioning the findings of the 6 studies (of 17
relevant to this question) that reported direct obser-
vation of ultrasound clinics and scans (35,37,41,48–
50). These, again, are highly time and context specific.
Several authors emphasised the extent to which the
mother’s experience was mediated through the person
carrying out the scan. Because the image was difficult
to recognize, the doctor or ultrasonographer needed
to explain what was being seen. For example, in an
early French study (48) the following exchange was
observed:
Doctor: A single fetus, head down.
Woman: Oh, I can’t see anything.
Doctor: Yes, there. It’s the head.
Woman: Which side? I can’t see.
Doctor: Good, OK. BIP 4.4, cardiac activity noted, placenta
in posterior position…
Woman: Is that the heart I can see?
Doctor: What? It’s the baby. Good, there is the stomach,
umbilical vein…
Woman: It’s a shame. I saw nothing.
In another early study the women’s reactions are
described in detail (37). At first most women were
extremely tense (one thought she was going to be
‘‘opened up’’ for the procedure). The technician
BIRTH 29:4 December 2002
doing the scan reassured them with general phrases
about the baby looking fine. During the phase of the
scan where the dynamic image was shown, women’s
attention became fixed on the screen. When they
recognized some part of the baby their reactions were
strong: ‘‘Oh, I see it!’’ The contribution of the
technician was crucial to this recognition. In the
account of the way scanning was carried out in a
hospital in Botswana, the researchers observed that
most women were unable to communicate with the
person doing the scans due to lack of a common
language, and only a few women saw the screen and
had the images explained to them (41). The room was
darkened for the scan, and women were unprepared
for this and found it frightening.
In a Greek study conducted from 1990 to 1991
(35,50), more than 80 scans were observed in a large
teaching hospital in Athens and a hospital in a small
city. In general, the doctor did not speak during the
scan except to say if the fetus was male or female and
to read off the gestation from a chart. If the doctor
did not say that the baby was all right, the woman
usually asked (no malformations were detected in the
scans she observed). Mitchell, who observed scans in
Canada during 1995, put more emphasis on the social
assumptions revealed in the ways that the sonogra-
phers talked about the fetus. One, for example, told a
father not to say ‘‘fetus’’: ‘‘Your fetus? Ugh! Don’t
say that. It’s your baby’’ (50).
With the exception of the study in Botswana (41),
we lack more recent observation studies of the way
that ultrasound is being used. It would be helpful, for
example, to know what explanations about the
purposes of the scan are being given by the person
doing the scan. This would complement the evidence
referred to earlier about lack of information given in
antenatal clinics about the purposes of ultrasound
(24). It also would be useful to know more about how
much women are told before the scan by the person
doing it and how any problems detected during the
scan are talked about. This is mentioned in Baillie’s
interview study with women with potential problems
detected at a scan. Some women in that study
reported that they picked up a worried or serious
reaction from the ultrasonographer before anything
had been said about a problem (51,52).
Women need to know what to expect during the
scan itself, although few women now would expect
the scan to be painful (37,41). In Barton et al’s
study of women referred for fetal echocardiography
because of concerns or risk factors, some women
found the long silent period at the start of the scan
very unsettling, and the authors recommended that
women be told that this does not mean that an
anomaly has been found (53). In other studies women
BIRTH 29:4 December 2002
have commented about the discomfort of a full
bladder or uncomfortable couches (30,54). Women
need to know about such practical aspects, and also
be told who can accompany them (29).
The key issue for most women, however, is the
part played by the person doing the scan. Women
respond badly to unspoken tensions, muttered com-
ments, lack of explanation, or dismissive answers
(29,36,51,55,56). In this aspect of care, as in others,
women appreciate being treated kindly and respect-
fully (57). Ultrasound creates extra tensions because
of the immediate knowledge gained and the possibil-
ity of worrying news. It is likely that practice has
changed over time, so that women are given more
feedback now during the scan and sonographers are
more aware of how women feel. However, no
evidence is available about this fact.
In the early days of ultrasound, some user groups
raised the problem of having to wait for the scan
results to be given by a doctor (55,56,58). Other
studies have tended not to mention this issue, which
may be because scans were done by obstetricians in
many studies, or because ultrasonographers now
provide information about the outcome of the scan
directly to women. Dissatisfaction with the lack of
direct feedback was a feature of the Botswana study
referred to earlier (41).
What Is the Impact of the Results?
From a woman’s point of view a scan can have the
following outcomes:
• No adverse findings
• News, for example, twins, or finding out the sex of
the baby
• Failure to see or measure what was intended,
leading to further tests or scans
• A worrying finding leading to further tests or scans
• A clear bad outcome, such as a diagnosis of death
or serious malformation
What is the likely impact of each of these outcomes?
Nine studies were relevant to this question.
No Adverse Findings
Some women who are told that nothing bad has been
found may still be worried by something they heard
or saw during the scan (29,37). In addition, a
proportion of women will experience a poor outcome
of pregnancy and may think that the scan should
have picked it up (38). A small number of genuine
false-negatives will also happen, so that a baby with
an anomaly may be born after a negative test result.
231
A recent general review of the impact of false-
negatives in screening programs suggested that better
information about the limitations of screening pro-
grams should be provided so that participation in
screening is more fully informed (59). The authors
point to evidence of gaps in public understanding of
screening and limited perceptions of risk, and recom-
mend the development and testing of better approa-
ches to information-giving. A study of false-negative
results after antenatal screening for Down syndrome
showed a limited adverse impact on parental adjust-
ment detected between 2 and 6 years after the birth,
and emphasized the need for better information for
parents about the limitations of screening tests (60).
News, for Example, Twins, or Finding Out the Sex
of the Baby
Examples of individual women’s responses to news
from scans, such as the presence of twins, or learning
the baby’s sex, have been quoted in some studies.
Women may be upset if the baby’s sex is revealed to
them when they did not want to know it (33).
Failure To See or Measure What Was Intended
Scans that fail to obtain the necessary information
can be difficult for women (30,33). They miss the
hoped-for reassurance, and have to spend time on
another visit. They may also be extremely anxious in
case something that is wrong with the baby was the
cause of the failed scan. For example, one woman
said:
They could not see all the spine. It was not fully developed.
We had to go back in two weeks to be checked. I was quite
worried. It would have been shattering without my husband
(30).
The findings of an audit of the use of ultrasound in
Liverpool Women’s Hospital showed that 7.6 percent
of women had a repeat anomaly scan, mostly because
some aspect of the scan could not be completed (1).
A Worrying Finding
If the ultrasound finding indicates a possible prob-
lem, the woman is likely to find herself involved in
extra tests and scans. For example, if her placenta
appears low, she will be scanned again regularly.
Some low placentas will resolve spontaneously,
although the woman may still be anxious about her
labor (30). An early paper reporting a short case
series of false-positive results from ultrasound
warned of the potential costs to the service and stress
on women (61). A woman in Oakley’s New Zealand
232
study, who had a routine scan at 18 weeks’ gestation
that indicated a kidney problem in the fetus, com-
mented after the scan:
I regret having a scan. I preferred my baby the way things
were (30).
The woman went on to have further scans, which did
not confirm the presence of an anomaly, and the baby
showed no kidney problems at 6 weeks.
A recent British study looked at the experiences of
women who had had false-positive results from
screening or from nuchal translucency scanning
(51,52). Those who had a worrying finding were
unprepared for adverse findings. Ultrasound was, for
them, a high spot in pregnancy. One said:
We were thinking—brilliant! We’ll be able to know if it’s a
boy or a girl and all things like that, not that anything
would be wrong.
Parents in this study found it difficult to understand
the idea that the scan finding indicated an increased
risk rather than a definite finding, and also reported
their confusion and difficulty in asking further
questions. Some women were not fully reassured by
the later test findings that ruled out the abnormality.
They also experienced a more generalized anxi-
ety—now that something had gone wrong with the
pregnancy other disasters might follow.
A Bad Outcome
For a small number of women the scan leads to a
clearcut bad outcome. Findings of fetal death in early
pregnancy scans must be common, but little has been
written about the impact on women, or the way the
news is conveyed (62). Later in pregnancy ultrasound
may detect serious malformations. The impact on
women is likely to be similar whether ultrasound is
involved or some other screening technique. They
may be less prepared for untoward findings, however,
when having a routine scan. The issues facing women
in these situations have been considered in reviews
about prenatal testing (14,63).
Only 5 studies about women’s experiences after the
detection of malformations were identified (47,64–
67). Three deal mainly with the pain and grief
experienced by parents and the decision to have a
termination, not with the process of ultrasound
(64–66). Black’s paper, however, which examined
the experiences of 105 women who had lost their fetus
through miscarriage or termination for abnormality,
provided evidence about their views of ultrasound
(47). Women had received at least one scan, and an
average of two by the time the pregnancy ended.
Nearly one-half of the women (44%) said that seeing
BIRTH 29:4 December 2002
the fetus on ultrasound made it harder to cope with
the loss. On the other hand, some women also talked
about the paradoxical benefits of ultrasound in terms
of giving the loss some reality for them, sometimes in
terms of clear evidence that the pregnancy had ended
(no heartbeat visible) and sometimes by providing an
image of a person to mourn.
What Might Be the Wider Impact of Ultrasound on
Society?
Writers and researchers have raised several issues
about the potential wider impact of antenatal ultra-
sound.
A Psychoanalytical Approach
The French language literature refers to a concern
arising from psychoanalytical theory about the poss-
ible adverse effect of ultrasound on a woman’s own
image of the fetus. The ultrasound image, seen by the
woman, is thought to interfere with the ‘‘child of the
imagination’’ that she needs to develop in the course
of her pregnancy (68,69). Of the 6 studies in Table 4
addressing these issues (34,43,55,68–71), 3 explicitly
reject the theory on the basis of their findings
(34,43,69). Well-designed comparisons of ultrasound
with no ultrasound have not looked for an impact on
the relationship between the parents and the baby, or
at other aspects of psychological or psychoanalytical
well-being in the short or long term.
Bonding and the ‘‘Pro-Life’’ Agenda
A survey of 50 sonographers working in an American
city (72) suggested that their experience with ultra-
sound had made them feel less favorable to abortion,
and all but 4 believed that ultrasound with feedback
‘‘strengthened maternal-fetal bonding.’’ Nine studies
were identified that explicitly addressed the issue of
bonding. The decision was made to omit from this
review evidence for the psychological effects of
ultrasound, and it is covered briefly in the Discussion.
In Europe the possibility that ultrasound increases
attachment to the fetus has been raised either as a
general benefit or as a potential problem for parents
who may have an anomaly diagnosed and then find it
difficult to consider termination. The emphasis has
tended to be different in the United States, and some
writers have expressed concern that ultrasound is
being used as part of an anti-abortion agenda (73).
The use of ultrasound pictures in the anti-abortion
film, The Silent Scream, is also discussed by Petche-
sky, who suggested that visual images of the fetus can
strengthen the emphasis on the rights of the fetus as
BIRTH 29:4 December 2002
an individual (73). This theme is also discussed by
Mitchell and Georges, who contrast the North
American individualisation of the fetus with a very
different Greek perspective that emphasises the com-
munity or nation (50).
Other Feminist Concerns
Feminist writers and researchers have raised several
interlocking issues about the impact of ultrasound.
Mitchell, in her paper with Georges referred to in the
previous section, described her impression of the
scan as an opportunity for messages to be given to
pregnant women about appropriate behavior and
language (50). This fits in with the work cited earlier
that showed how dependent the woman is on the
interpretation of the person doing the scan (37,48).
Ann Oakley expressed the concern that ultrasound
was a further way of reducing the importance of
women’s own knowledge about their bodies in favor
of ‘‘objective’’ measures (74), and this is echoed by
other writers (50,75). This ‘‘direct’’ access to the fetus
and the use of images of the fetus detached from the
mother’s body are linked back to the individualiza-
tion of the fetus and the political debates that have
arisen when the rights of the fetus and the woman
come into conflict (73). All these concerns have to be
viewed in the light of the general popularity of
ultrasound, and the lack of evidence of widespread
unhappiness among those who experience it. These
apparent dissonances are helpfully discussed by
Petchesky in the concluding section of her article
(73).
Conclusions
The most striking finding from this review is how
very attractive women and partners find ultrasound
during pregnancy, which may not surprise some
readers. For the authors of this paper, however, the
concerns of the childbirth movement about the safety
of ultrasound, issues about medicalization, and the
overlapping worries about routine and excessive use
of this technology ahead of evidence of effectiveness
may have predisposed to a somewhat negative
expectation.
The attractiveness of ultrasound may be because,
unlike other forms of prenatal screening, it provides
people with early visual confirmation of pregnancy
and contact with their unborn babies in addition to
reassurance about fetal well-being. These features,
however, may augment the potential for feelings of
anxiety, shock, and disappointment when the scan
shows a problem. Recent changes in the use of
ultrasound may lead to more findings of uncertain
233
clinical significance, and this is likely to have
important psychological and social consequences
for women.
Early studies reported that some women feared
that ultrasound might harm the fetus. Concerns of
this type are not a feature of later research, although
this may be partly because researchers in more recent
studies have not asked about fears. It is important to
investigate women’s experiences of the introduction
of ultrasound into care in countries or regions where
it has not been available.
Because a recent review had explored the psycho-
logical impact of ultrasound (2), this topic was not
addressed in our review, although, for completeness,
22 relevant studies are included in Table 4. It is likely
that the reductions in anxiety after a scan, reported in
some studies, are mainly due to increased anxiety just
before the scan rather than a real benefit of ultra-
sound. The Australian trial of a routine scan at first
antenatal visit showed lower anxiety in women
having the early scan, but the outcome was only
measured at that visit, and so we do not know what
the longer term impact might be (76). Evidence about
ultrasound and attachment to the fetus or baby is
inconclusive. Early suggestions of improved attach-
ment to the baby after an ultrasound scan and
women’s comments in qualitative studies led to an
assumption in much of the literature that this was a
real effect. Prospective studies, however, showed a
trend to increased attachment over the course of
pregnancy. The only randomized trial to look at
attachment showed no impact of high-feedback
ultrasound on attachment (77). This outcome has
not been assessed in trials comparing ultrasound with
no ultrasound. Studies of pregnancy loss do raise the
issue of whether the experience of having seen an
ultrasound image has an impact on subsequent
bereavement (47,78,79). There is no evidence from
trials of an impact of ultrasound on smoking, or of
high feedback on smoking and other aspects of health
behavior.
Methodological issues were raised by this review.
Ways of reviewing studies of people’s views of care
are not well established. Some issues under discus-
sion include the need for quality criteria for inclusion
in a review and the extent to which review questions
can be pre-specified. Our review did not grade the
studies using quality criteria, and studies were not
rejected on the grounds of poor quality. In addition,
the review question was not pre-specified in any
detail and the material—the body of included stud-
ies—was treated in an exploratory and qualitative
way to arrive at several themes. It would be
interesting to find out if different methods would
have led to different findings.
Table 4. Studies Included in the Structured Review of Women’s Views of Ultrasound, Key to Review Questions
234
1. What do women know about reasons for using ultrasound and what a scan can do?
2. What do women like or value about scans?
3. What are women’s views about the way the scan was performed?
4. What is the impact of the results?
5. What might be the wider impact of ultrasound on society?
PsI. What is the psychological impact of ultrasound? Other (specified in table)

Year Carried Country, Setting, Comments and Relevance

Study Out Participants, Sample Size Methods Results to Review Questions

Allen (1996) (80) 1995 UK, hospital clinics in Trent
Region
44 pregnant women
Anderson (1995) 1994 UK, West Midlands, maternity
(81) unit
50 consecutive pregnant women
attending for antenatal care
Baillie (1997) 1995–96 UK, Leeds
Baillie et al Pregnant women referred to fetal
(2000) (51,52) assessment unit for amniocen-
tesis because of triple test re-
sults, or a suspicious ultrasound
scan. Those with no problem
detected on further testing;
‘‘false positives’’ formed the
study sample (36 after triple test
and 24 after ultrasound)
Barton et al Not later than UK, specialist center, probably
(1989) 1988 in London (not stated)
Study 1 (53) Cases: 24 women referred for
fetal echocardiography
because identified as at
increased risk
Controls: 26 women selected at
random from antenatal clinics
Self-administered questionnaire;
no details of how or when.
Women asked to select, from a
list, reasons for use of ultrasound
and rank them in order of im-
portance.
Aim was to find out about wo-
men’s views and knowledge to
improve information provided;
short self- completion question-
naire given at the clinic.
Study of impact of being a ‘‘false
positive’’ using psychometric tests
at 3 points in time (after amnio-
centesis but before result; after
result; at about 34 wk) and a
qualitative interview at same time
as second questionnaire.
Prospective interview study with
cases and controls. All scanned,
with immediate feedback. All
interviewed before and after scan.
Topics: knowledge, views, anxi-
ety, experience of scan.
95% of women selected ‘‘to see if Very little detail is given of
the baby has any abnormality’’ as methods or findings and
one of their four reasons. sample very small
One-half ranked this as the most Review question—1
important reason.
Women’s answers about reasons for Very small sample
scan tallied fairly well with infor- Review question—1
mation leaflet sent out to them.
They tended to underestimate
scan’s ability to detect problems.
Women were unprepared for ad- One of the few studies of
verse findings from scan. Many impact of false positives
continued to be anxious even after Review questions—3, 4
amniocentesis found no anomaly
No abnormalities were detected. Early use of scanning to
‘‘High-risk’’ group more anxious detect fetal abnormality
before scan. State anxiety was Review question—PsI
lower in both groups after scan,
with ‘‘high-risk’’ score falling
further, to same level as controls.
Similar finding for attitude to
baby and baby’s health.

Barton et al Not later than UK, specialist center probably Prospective interview study— cases No abnormalities were detected. Review questions—3, PsI
(1989) 1988 in London (not stated) only. Pre-scan interview covered State anxiety was lower after scan.
Study 2 (53) 48 women referred for fetal psychological and social issues Anxiety and changes in anxiety
echocardiography (as above); and attitudes. Post-scan: experi- varied greatly within sample.
no controls ence of scan, level of information Aspects of scan procedure were
anxiety. Follow-up questionnaire commented on.
at 2 wk (by mail)—satisfaction
Berwick & Not later than USA, Harvard Community Focus groups with 8 pregnant Authors emphasise value attached Method used for economic
Weinstein 1984 Health Plan women who had ultrasound to to nondecisional information. analyses. How do findings
(1985) (31) 43 women currently pregnant, discuss valued aspects of infor- Information on health and relate to real choices?
all ‘‘considered normal’’; 37 mation from ultrasound. normality of baby was valued Ultrasound not named in
BIRTH 29:4 December 2002

had ultrasound most highly. questionnaire—scenarios


Black (1992) (47) 1985–88 USA
Women enrolled in national
study of CVS and amnio-
centesis; they then had a
miscarriage or termination
for abnormality (approxi-
mately half and half). 121
women took part in one or
both interviews. Study
women were relatively well
educated and affluent.
Gestation at pregnancy
loss: 7–27 wk. All women
had had a scan at 7–10 wk
at entry to main study;
many had further scans.
Boyer & Porret Not later than France, Grenoble
(1988, 1991) 1987 630 pregnant women in
(69,82) course of antenatal care
Braithwaite & Not later than UK, London teaching
Economides 1996 hospital
(1997) (54) 160 pregnant women com-
ing for routine dating scan
at 12–13 wk
Brown GF (1988) Not later than USA, Los Angeles
(83) 1987 Couples attending antenatal
appointment at office of 3
obstetricians in private
practice
35 men saw scan; 32 men
did not see scan
Brown S et al 1989 Australia, Victoria
(1994) (84) All women giving birth in
the state over a fixed time
period (n ¼ 790/1107)
Questionnaire then developed to
assess ‘‘willingness to pay.’’ Admin-
istered by interview. Analyzed quan-
titatively.
Women were approached at 1 and 6
months after pregnancy loss. Partly
structured telephone interviews were
carried out and tape-recorded.
Semistructured interview study carried
out before women’s second ultra-
sound at 20 wk.
Comparison of transabdominal (TA)
and transvaginal (TV) ultrasound
using self-completion questionnaires
After TA scan (routine), women were
asked if they would be willing to have
a TV scan.
Quasi-experimental study. Some fa-
thers saw image of baby; others
attended visit but did not see scan.
Completed range of psychological
tests before and after woman’s scan
on anxiety, stress, and attitudes to
pregnancy. For those who witnessed
scan, some questions on what they
had seen. No information on level of
feedback during scan.
Questionnaire study of all aspects of
maternity care. Postal survey sent out
6 months after birth.
describe information from
an unnamed test.
Review question—2
Results from first interviews with 105 Review questions—4, 5
women; discusses the impact of the
scan, positive and negative, in
women’s own words. For 44%,
seeing fetus at a scan made coping
with the loss more difficult. One
woman reports her thoughts about
BIRTH 29:4 December 2002
scan image during the termination.
Other women found ultrasound
images helpful; e.g., in providing
confirmation that the fetus had died,
or in giving the woman something
more real to grieve for.
77% of women said that scan had Focus on psychoanaly- tical
helped them to imagine the baby; concerns about parents’
43% said that they had dreamed image of fetus/baby.
more since having scan. Review question—5
All women had TA scan and 88% Review questions—3, other
agreed to have TV scan. Some women (views of TV ultrasound)
found TA scan uncomfortable because
of full bladder. Twice as many women
reported mild discomfort with TV
scans than with TA scans. Marked
discomfort reported by 6 women with
TA scans (all had full bladders) com-
pared with 1 woman with TV scan.
Slightly greater reduction in stress No mention of why some
scores after procedure for fathers fathers saw scan and not
who saw scan. others, but implication is
that fathers chose.
Review question—PsI
Over 70% of women rated ultrasound Review question—2
as one of the best aspects of their
antenatal care.
235
Table 4. Continued
236

Year Carried Country, Setting, Comments and Relevance

Study Out Participants, Sample Size Methods Results to Review Questions

Cappa et al Not later Italy (location and sample Interview study of two groups of This was a preliminary paper and We have not found a main
(1987) (70) than 1987 size unknown) pregnant women– one ‘‘normal,’’ suggested (authors’ abstract) that report.
All primigravida other with ‘‘pathological events’’ in women in higher risk group needed Review question–5
the first 3 months of pregnancy reassurance about health of fetus.
studied around first (10–16 wk) and Those with normal pregnancies were
second (25–30 wk) scans. Focus more interested in description of their
mainly qualitative. child.
Caverzasi et al 1989 Italy, University hospital From authors’ abstract: aim was to From authors’ abstract: ‘‘ultrasound Review question—5
(1991) (71) in Pavia look at relationship between woman has a deep impact on the pregnant
60 women having routine and sonographer; questionnaire be- woman’s images, affecting the elab-
second trimester scan fore scan, observation of scan, inter- oration of her ‘imaginary child’.’’
view after scan with request to draw
what she sees as her ‘‘internal space’’
and further questionnaire at unspec-
ified point after scan.
Clement et al 1993–95 UK, South East London, Part of a trial of different schedules of Ultrasound came 2 nd among best This chapter is mainly a re-
(1998) (33) 3 hospitals antenatal visits. Data came from things mentioned by women about view, with data from trial
Subsample of 700 women analysis of free-text written answers their antenatal care. Women liked and women’s comments to
who returned question- to questions about best and worst seeing the baby, liked confirmation illustrate themes.
naires and wrote some- aspects of antenatal care in a postal that they were pregnant, and it reas- Review questions—2, 4
thing in response to at questionnaire completed approxi- sured them that baby was well. They
least one open question mately 34 wk of pregnancy. liked involving partner and family,
and having a picture.
Colucciello Not later USA, Midwest, mater- Self-completion questionnaire was gi- Differences in perception scores before Numbers small; data not fully
(1998) (85) than 1998 nal/fetal health clinics ven to women before and after an and after the scan are reported, but presented; significance of
50 pregnant women age 19 ultrasound scan, during a routine no tables and directions of any dif- any changes in perceptions
yr or younger antenatal visit. Aim was to find out ferences are not given, except that not discussed. Does the scan
about their perception of the fetus young women had more accurate have any impact on how
perception of babies’ lie after the young women get on with
scan. their babies later?
Review question—5
Cox et al (1987) Not later Canada, Vancouver Women randomly assigned to high or High-information groups were much Review questions–PsI, 2
(45) than 1986 100 women with ‘‘low and low information during the scan. more likely to say they felt ‘‘wonder-
high-risk’’ pregnancies Tests before scan and after to look at ful’’ during scan. Anxiety fell further
(50 in each), 8–16 wk anxiety, etc. in the high- information group, post
scan, but only for low-risk women.
Crang-Svalenius Not later Sweden, University Hos- Semistructured interview just after a One-third could not recall having been Discussion raises the links
et al than 1995 pital, Lund scan, to ask about information, told that the scan could detect some between prior information
(1996) (18) 50 nulliparas, 50 knowledge, and choices. Every 4th types of malformation. 62% thought and reactions in women who
multiparas woman booked for an appointment a scan was compulsory; 95% were have a problem diagnosed.
Interviewed after routine was asked to take part, unless they satisfied with information during and Review questions—1, 2
scan at 17–18 wk had received fetal diagnosis or previ- after scan. 90% of women reported
Was scan mainly for da- ous malformed fetus/baby. Interview feeling better after scan than before.
ting? by one person–a midwife/ultraso-
nographer.
BIRTH 29:4 December 2002
Crowther et al 1991–95 Australia, Adelaide
(1999) (76) Women attending antenatal care
before 17 wk of pregnancy
648 women were randomized
Detraux et al Not later than Belgium, 2 maternity units in
(1998) (67) 1994 Brussels, 2 in Liege
Study 1: 4 categories of women
a. 26 pregnant, no abnormal-
ity or previous problem
b. 17 pregnant with diagnosed
fetal abnormality
c. 30 mothers of normal baby
d. 30 mothers of baby with
malformation
Study 2: 48/120 gynecologists
approached
Study 3: 11 mothers of child with
cardiopathy
Dixon (1994) (16) Not later than UK, Leeds, St James’s Hospital
1994 Routine 18 wk scan performed for
dating, placental site, soft mark-
ers, structural abnormalities
200 consecutive pregnant women
attending 18 wk scan; 100 women
attending scan who had been
given information sheet at
booking
Draper et al 1983 UK, Cambridge, hospital and
(1984) (29) community antenatal clinic
170 unselected pregnant women
Dykes & Not later than Sweden, University Hospital, Lund
Stjernqvist 1999 Women pregnant for first time,
(2001) (34) who had not received ultrasound
before
12 women approached, 10 agreed
Randomized controlled trial of
ultrasound scan at first antenatal
visit.
Three-part study: Study 1: Inter-
views with women (including
some self-completion question-
naires) Study 2: Questionnaire
study of gynaecologists Study 3:
Small interview study of women
with a child who had cardiopathy
diagnosed before birth (age
1–6 yr).
Two surveys:
200 women interviewed briefly
before scan by ultrasonographer
to assess knowledge of purpose of
scan. 100 women given informa-
tion sheet at booking then inter-
viewed before scan in same way as
first group.
Questionnaire and interview pros-
pective study of antenatal care.
Questionnaires given at 24 wk,
37 wk, and after birth. Different
aspects of ultrasound covered in
questionnaires.
Aim was to provide insights into
effect of ultrasound on women’s
thoughts about their unborn
child. In-depth interviews 1 wk
before and 1 wk after a woman’s
first scan at around 17 wk of
pregnancy. Interviews were tape
recorded and transcribed.
Scan improved accuracy of Review question—PsI
gestational dating, and reduced
proportion of women who
reported feeling worried about
their pregnancy at end of that
first visit.
Findings relevant to ultrasound: Review question—4
Pregnant women who had an
abnormality detected were less
satisfied with scan and less likely
to want further ultrasound
BIRTH 29:4 December 2002
examinations. Gynecologists
discussed difficulties they faced
in telling parents about prob-
lems detected with ultrasound.
Emphasizes how few women Highlights need for women
were aware of possibility that to be aware of purpose of
scan would show pregnancies scan. One of the few
with increased risk of Down papers that states, expli-
syndrome. citly, what the scan is for
in that setting.
Review question—1
Over 2/3 of women reported only Review questions—1, 2
enjoyable aspects of scan, and
4% reported only worrying
aspects. Enjoyable aspects:
seeing and feeling the baby and
reassurance. Worries: the effect
on the baby, and on concerns
that followed from the scan.
Comments on the way the scan
was done are useful.
Ultrasound was reported by these One of the few studies done
women as having a considerable before and after a scan
impact on them and of increas- that allows women to des-
ing their awareness of bearing a cribe the impact on them,
child. They were all positive rather than using preset
about the scan, and liked the scales.
detailed explanation given to Review questions—2, 5
them at the time. They were
relieved that no problems were
detected. No sign that the scan
had an impact on their imagi-
nings of what the baby/child
would be like.
237
Table 4. Continued
238

Year Carried Country, Setting, Comments and Relevance

Study Out Participants, Sample Size Methods Results to Review Questions

Esen & Olajide Not later than UK, South Tyneside District Questionnaire study of women Some women turned down serum Very limited detail of what
(1997) (86) 1996 General Hospital who declined serum screening screening because they would not was done in this study.
154 pregnant women who de- in pregnancy, having accepted consider a termination. For some the Review question—2
clined serum screening an ultrasound. scan was preferred because it gave
opportunity to see baby and because
it was seen as more accurate. Thus
even women who reported that they
would not consider a termination
may be willing to have a scan.
Eurenius et al 1991 Sweden, Uppsala University Questionnaires given to each Paper 1 (1996): Smoking and Review questions—1, 2, PsI
(1996, 1997) 393 unselected, consecutive woman and her partner. One ultrasound. Scan had little effect on
(19,20) women and their partners before scan (while waiting) proportion of men or women who
coming for a midtrimester and one to be completed at thought that their ability to stop
scan home and returned. Questions smoking was more than 50%. Paper
Exclusion, no Swedish lan- included knowledge about 2: Details of views about purpose of
guage purpose of scan, desire for scan and their expectations, including
Part 1 completed by 299 women information, smoking plans. some differences between women’s
and 255 men; part 2 by 271 and men’s views. Anxieties before
women and 228 men scan related to baby’s health and
possible malformations. Only 2% of
women feared that scan might harm
the baby. Feelings about scan were
far more positive than negative for
both women and men, when a series
of adjectives were offered.
Field et al (1985) Not later than USA (presumed, not stated) Women were randomly assig- All results are presented as means, split Review question—PsI
(87) 1984 40 pregnant women referred for ned to low- or high-feedback between first-time mothers and oth-
ultrasound assessment of group (n ¼ 20 each). Ultra- ers. Authors concluded that birth-
gestational age sound performed 3 times in weight and Brazelton scores are
pregnancy. Assessment after better for babies of first-time mothers
each scan with psychological in high- feedback group, but very
tests, a fetal activity schedule small numbers and large standard
to complete at home for 30 deviations make this less than con-
min for 5 nights, and a record vincing.
of sleep and dreams. Follow-
up within 2 days of birth to
look at infant behavior.
Fleeman & 1994 UK, Liverpool Health Authority Postal questionnaire study of In response to questions about infor- Review questions—1, 2
Dawson Women resident in the area all aspects of maternity care mation needs, 35–40% of women said
(1995) (88) gave birth during a fixed time 7–8 wk after birth. they had wanted more information
period before, during, or after the scan. 96%
Questionnaires ¼ 526/701sent reported that the scan had been a
out pleasant experience.
French (2000) Not later than UK (unspecified maternity unit Interview with mixture of Women’s knowledge of Down syn- A small sample but useful in
(89) 1999 and primary care setting) structured and unstructured drome and of NT scanning varied relation to this new area of
Convenience sample of 10 first- questions, with aim to investi- greatly. There were misunderstand- practice.
time mothers, 8 had nuchal gate women’s experiences of ings about scan’s ability to detect Review question—1
translucency (NT) scan, 1de- routinely offered, first Down syndrome and about implica-
BIRTH 29:4 December 2002

clined, and 1 not done trimester NT scans. tions of results.

Garel & Franc 1978–89 France, large maternity hospi-
(1980) (48) tal in Paris
75 women; data used here refer
only to 54 first-time mothers;
scans routine at months 3 and
6 of pregnancy
Georges (1996) 1990–01 Greece, public hospital in a
(35) small city
Formal interviews with 26 wo-
men at 3 days after delivery;
additional observation in a
teaching hospital in Athens
Grace (1983) (90) Not later than USA (presumed, not specified)
1983 81 healthy mother-infant pairs
Harrington et al Not later than UK, 1 (or more?) London
(1996) (12) 1996 hospitals
472 women attending for a
routine 20 wk anomaly scan
Heidrich & Not later than USA (location and setting not
Cranley (1989) 1988 given)
(91) 91 pregnant, midtrimester
women; 2/3 were multiparas
19 had amniocentesis, 37 had
ultrasound, 35 had neither
Hunfeld et al 1990–91 Netherlands, Dijkzigt University
(1993) (66) Hospital, Rotterdam
46 women with diagnosis of se-
vere/lethal malformation.; by
2nd interview, all but 5 babies
had died
Hyde (1986) (36) 1984 UK, 2 hospitals in Manchester,
one (R) where scan at 16 wk
routine; other (S) where scan
only for clinical indications
97 women at Hospital R, 307
women at Hospital S
All pregnant, no indication of
gestation; 78% had received
scan already in this or previ-
ous pregnancy
Janus & Janus 1979 USA, New York, Mount Sinai
(1980) (92) Hospital
204 patients (134 female) who
had pelvic/abdo- minal
ultrasound (i.e., not just
pregnant women); number
pregnant not given
Ultrasound exams were observed,
and then women were inter-
viewed. This paper reports results
of analysis of observation data.
Observation and interview study of
antenatal care including ultra-
sound exams.
Comparison of mother’s behavior
toward baby, in postnatal ward,
between women who had received
different numbers of ultrasound
scans in pregnancy.
Questionnaire study, completed by
sonographer just before scan, to
find out whether woman wanted
to know fetal gender.
Assessment of maternal-fetal
attachment before and after a
scan or amniocentesis. Control
group had no intervention. Data
collection at (mean) 16 wk and
(mean) 20 wk, using 2 psycho-
metric scales.
Reactions to severe malformations
diagnosed by ultrasound. In
depth study with interviews 2–6
wk after diagnosis and then 3
months after birth.
Interviews carried out in hospital
while women were waiting for a
scan (Hospital R) or for an ante-
natal check (Hospital S).
Patients were given questionnaires
before and after ultrasound.
Women experience the scan An early and detailed look
‘‘through’’ the doctor, who at how ultrasound was
explains and interprets the image. being used.
Reactions are varied and Review questions—3, 5
complex.
Results of this descriptive study are Review questions—2, 3, 5
difficult to summarize, but it
illustrates the way that ultrasound
is used in different contexts, and
the role it plays in doctor/woman
BIRTH 29:4 December 2002
relations.
No association was found between A very short report (a letter)
numbers of scans and mother’s of a study using inappro-
behavior toward the baby. priate methods for the
question being explored.
Review questions—PsI, 5
Three-fourths of women wanted to Review question—other
know fetal gender. Gender was (views on gender of fetus)
determined in 89% of fetuses. In
3% gender was incorrectly deter-
mined.
Women who reported feeling fetal Small numbers in sub-
movements scored higher on the groups; not a trial so find-
attachment scale, but direction of ings difficult to interpret.
causation, if any, is unclear. No Reviewquestions—PsI,5
suggestion that attachment
increased more between the two
assessments in the ultrasound
group.
Results are about grief and not Review question—4
about use of ultrasound to diag-
nose the malformation.
Women’s views about ultrasound Discussion raises issue of
varied between the two hospitals, how findings should be
and seemed to reflect the way that told to women and by
ultrasound had been presented to whom.
them. Some women were unhappy Review questions—2, 3
about level of feedback during the
scan.
Generally, patients were poorly Study included nonobstetric
informed about purpose of scan ultrasound.
and the way that ultrasound Review question—2
works. 90% of pregnant women
commented favorably on the
experience.
239
Table 4. Continued
Year Carried Country, Setting,
Study Out Participants, Sample Size
Jörgensen et al 1984 Sweden, University Hospital, Lund
(1985a) (64) Women who had termination after
a diagnosis of major fetal mal-
formation following routine scan
at 17 wk 10 women, 6–34 months
after the termination
Jörgensen et al 1984 Sweden, University Hospital, Lund
(1985b) (65) Women who had a fetal malfor-
mation diagnosed late in preg-
nancy at the routine 32 wk scan
14 women, 7–39 months after ba-
by’s birth; all babies were alive,
and 1/2 were judged to be healthy
at follow-up
Jørgensen (1995) 1988–89 Denmark, Sønderjylland, and
(9) catchment of Hvidovre Hospital
4553 pregnant women over 18 yr;
3667 analyzed (81%)
Julian Reynier 1990 France, Bouches-du-Rhone
et al (1994) (22) Representative sample of French-
speaking women who had normal
live-born baby
644 women approached, 514
interviewed
Kemp & Page Not later than USA (location unknown)
(1987) (93) 1986 85 women, 53 with ‘‘normal’’ and
32 with ‘‘high-risk’’ pregnancies;
all high-risk women had scan, 41/
53 of normal
Kohn et al 1978 USA, Pennsylvania hospital
(1980) (49) Women referred for obstetric
ultrasound who had never seen a
scan or x-ray image in this or any
earlier pregnancy; possible fetal
Methods
Semistructured interviews carried
out either at home or in the
department of obstetrics.
Exploring diagnosis of severe
malformation, decision to have
abortion, and feelings since.
Semistructured interviews, at
home or in department of
obstetrics, about pregnancy
after diagnosis of malformation
from ultrasound.
Self-completion questionnaires to
be completed at appointment or
returned by mail at 30 wk for
those who had accepted AFP
screening, or 16-18 wk for those
(approximately 10%) who had
declined it. Questions about
routine offer of Amniocentesis/
CVS and ultrasound.
Telephone interviews mainly
closed questions, ? in first few
days/weeks after birth, to ask
about reasons for use of ultra-
sound and what it can do.
Questionnaire study with scales
to measure attachment.
Self-completion questionnaires
before and after scan about
views of baby. Scan was seen by
the women and explained to
them with opportunity for
240
Comments and Relevance
Results to Review Questions
Discussion of difficult decision to Findings that relate to the
have a termination and reactions specific features of ultra-
felt afterwards, including fears sound are not given. It
that they had in some way caused would have been useful
the malformation. Five women (for this review) to have
had some reason to suspect a known in detail about
problem in the pregnancy, and 5 women’s experiences of the
did not. Study did not find any scan and being told about
difference in their reported reac- the malformation.
tions to the diagnosis. Review question—4
Three women were not told about This study also deals with
the malformation during preg- the type of consequences
nancy, and had suspected that that can arise from other
something was wrong. They were methods of identifying
upset at the interview about not fetal anomalies.
being told. Women reported that Review question—4
the remainder of the pregnancy
was a great strain. Some had
imagined very severe malforma-
tion and experienced some relief
after the birth.
Women who had declined AFP test Review question—other
were less favorable toward routine (should ultrasound be
offer of ultrasound for detecting available in Denmark?)
malformation. Where ultrasound
was already routine, more women
supported its routine use. Women
were more likely to say that they
themselves would accept screening
than to recommend its routine offer.
93% said that midtrimester scan Review question—1
was to see if baby was normal.
Only a small proportion (9%)
thought that one could be sure of
normal baby if no abnormalities
seen with ultrasound. They were
more likely to have a lower edu-
cation level.
Prenatal attachment was not asso- Review questions—5, PsI
ciated with anything that authors
measured, including having had a
scan.
Questionnaires are reprinted with This early study responded
numbers of responses for each to the new technology that
item. Some changes are apparent provided real-time images.
after scan, e.g., in descriptions of It recorded only immediate
the fetus as active, and perception reactions to the scan.
BIRTH 29:4 December 2002
 death was reason for exclusion
from study
discussion. Authors commented
about women’s questions during
the scan and reactions of a few
women in the longer term.
of space for the fetus. Women
were particularly interested in
seeing movement, and reported
that seeing the heart beating was
important to them. A few women
were worried in case seeing the
fetus made it more difficult if
something went wrong. Authors
reported on 3 women who they
thought showed better attach-
ment to the baby after the scan.
Although the authors were
careful in their conclu-
sions, the work has been
taken to show an impact of
scanning on attachment
more generally.
Review questions—2, 3, 5,
PsI
BIRTH 29:4 December 2002

All but 4 women said that they

enjoyed seeing the baby.
Kovacevik Not later than Croatia, Zagreb Quasi-randomized study? 146 Anxiety and stress fell after the Review question—PsI
(1993) (94) 1992 296 primigravidas referred for were high feedback, 150 were low scan, as in other studies. It is not
ultrasound feedback, giving a 4-way split by clear whether high feedback was
150 ‘‘risk’’ and 146 ‘‘no risk’’ risk status and feedback. Psy- associated with sharper falls in
chological test before and after anxiety, etc.
scan. Fathers also included.
Langer et al Not later than Austria, University of Vienna Questionnaires given before and Changes occurred in some of the Review question—PsI
(1988) (95) 1985 60 women at 12–20 wk gestation after scan to assess women’s ways that the fetus was described.
Ringler et al Scanned for first time this preg- views of fetus and pregnancy. After the scan the fetus was more
(1985) (96) nancy and before fetal movements likely to be described as active.
Fischl et al were felt
(1983) (97)
Larsen et al Not later than Denmark, Herlev University Self-completion questionnaire to Women’s knowledge of scan’s Review questions—1, 2
(2000) (21) 1999 Hospital explore women’s knowledge and purpose was generally good.
500 consecutive, unselected, views about 2nd trimester Fewer than 1% reported that scan
Danish-speaking women between ultrasound. had made them feel less secure,
16–20 wk pregnant, attending for 86% more secure, and 12% no
2nd trimester scan; 493 completed difference. Overall reactions to the
questionnaire scan by women and partners was
very positive.
Layng (1998) Not later than UK, Berkshire Postal questionnaire to ask about 42/68 women replied that they Small local study, but little
(17) 1998 96 women within (?) one general preparation for ultrasound test thought that they had not been work is available so far on
practice who had recently received and knowledge of Down syn- adequately prepared for the test. use of ultrasound for
ultrasound scan to look at nuchal drome. 24/62 rated their knowledge of Down syndrome screening.
translucency; 68 responded Down syndrome as 3 or less on a Report is brief.
scale of 1–10. Review question—1
Lydon & Not later than Nth. America probably (no place Interviews about commitment to Number of fetal body parts repor- Review questions—PsI, 5
Dunkel- 1991 specified) baby at 4 time points: 1and 2, ted by woman as having been seen
Schetter 41 women, all had amniocentesis immediately before and after at ultrasound is said to be pre-
(1994) (98) on grounds of maternal age, ultrasound and amniocentesis; 3, dictive of woman’s expressed
14–20 wk by phone 7–10 days later; 4, by commitment at first phone inter-
Amniocentesis preceded by scan; phone 2–7 days after test result. view.
no abnormalities detected
Michelacci et al Not later than Italy, Bologna Series of psychological tests Anxiety fell after each scan. The Review question—PsI
(1988) (99) 1988 20 ‘‘low-risk’’ pregnant women had before and after each scan. pre-scan anxiety was rather
3 scans, 1 in each trimester, same similar for each trimester.
obstetrician
241
Table 4. Continued
242

Year Carried Country, Setting, Comments and Relevance

Study Out Participants, Sample Size Methods Results to Review Questions

Milne & Rich Not later than USA, NE region, large university Aim of scan was dating. Study Detailed and illuminating data An early study (probably
(1981) (37) 1981 hospital used observation and interview. about how scans were done and carried out before 1981).
20 women, 20–35 wk pregnant; first Women were accompanied by how women reacted. Women were Review questions—2, 3, 4
experience of real-time scanning researcher, from the period concerned that this novel proce-
before scan, during, and after. dure could harm their baby, and
16/20 were interviewed might be painful. Women’s
afterwards. pleasure at recognition of baby’s
shape or movement is described.
Mitchell & Not later than Canada (location not specified) Observation of scans, ‘‘conversa- Results of this qualitative study are This chapter also compares
Georges 1993 49 pregnant women expecting first tions’’ with caregivers, and difficult to summarize, but touch Mitchell’s findings with
(1998) (50) baby and labeled as ‘‘low risk’’ interviews with 49 women (and on views of sonographers about those of Georges (see entry
some of their partners). women from different ethnic in this table).
backgrounds. There are descrip- Review questions—3, 5
tions of the way the scan is
‘‘interpreted’’ for parents, and the
way staff could be said to use the
scan to put across messages about
appropriate behavior.
Oakley (1997) 1994–95 New Zealand, Dunedin Semistructured interviews Most thought they had received a Some verbatim accounts
(30) 41 women, volunteer sample, performed mainly at home,after scan because it was routine. and detailed comments in
pregnant (15–42 wk); all had a scan. Information given during scan this thesis are very useful.
received a scan, but main purpose varied greatly. Confusion over Review questions—1, 2, 3, 4
unclear post-scan ‘‘results’’ for some
women. Impact of uncertain or
‘‘worrying’’ scan results, and
‘‘false positives.’’
Puddifoot & Not later than England, NE England and West Study of male partners of women Men reported levels of grief com- The reports suggest that
Johnson (1999) 1998 Midlands who had miscarried, using parable with those in studies of seeing scan images may
Johnson & Men referred through health ser- self-completion questionnaires women. Paper 1: Reports higher affect the way that the
Puddifoot vices; all were partners of women and psychological scales, within grief scores in men who had seen fetus is imagined and may
(1998) (78,79) who had miscarried before 25 wk 8 wk of the miscarriage. Two the fetus at a scan. Paper 2: influence grief after loss.
of pregnancy reports from the same study. Reports that vividness of men’s On the other hand, men’s
Paper 1, 323 men reported imagery about the fetus predisposition toward the
Paper 2, 158 men was positively associated with baby may affect both the
whether they had seen a scan, and choice to go to a scan and
to a lesser extent, whether they the grief. Tentative con-
had planned to see a scan. Those clusions because of effect
who had neither seen one nor of collecting data retro-
planned to had lowest scores. spectively.
Review question—5
Reading et al Not later than UK, King’s College Hospital 67 women randomly allocated to The high-feedback group was more The longitudinal element of
(1981, 1982a,b, 1981 129 ‘‘obstetrically normal’’ first- ‘‘high feedback’’ (seeing the positive about the scan immedi- this study has also been
1984, 1988) time mothers, 10–14 wk pregnant screen and having the image ately afterwards. No differential used to look at change
Reading & Cox at entry to the study explained) and 62 to ‘‘low-feed- impact on anxiety and no longer over time regardless of
(1982) Reading back’’ groups. Anxiety and other term effects were found, except allocated group.
(1983) Camp- measures were tested before and that women in the high-feedback Review questions—3, PsI
bell et al after scan, then with further group were most likely to rate
(1982) (46, 77, scans at 16 wk, 32 wk, just after that first scan as the most
BIRTH 29:4 December 2002

100–105) birth, and 3 months after birth. important for them.

Reading & Platt Not later than USA, Los Angeles Women randomly allocated to
(1985) (106) 1984 Women at ‘‘high-risk’’ in 3rd one of four groups: 11 to high-
trimester feedback ultrasound; 8 to low-
feedback ultrasound; 11 to fetal
heart rate monitoring; 7 in con-
trol group shown a video of an
ultrasound that they knew was
not their own. Psychological
assessment was done before and
after procedure.
Rice & 1994–95 Australia, Melbourne Qualitative interviews, in Thai, in
The very small numbers, and lack Review question—PsI
of detail about trial procedures
and comparability, make it diffi-
cult to know what to make of this
study. Anxiety fell for all women
after the test, but appeared to fall
more sharply for women in the
high-feedback ultrasound group.
Women showed general acceptance The only study that we
BIRTH 29:4 December 2002

Naksook 30 Thai women living in Mel-
(1999) (38) bourne; 17 had given birth in
Australia only, 9 in both Thailand
and Australia, and 4 in Thailand
only
Roberts 1983–94 UK
(1986a, b) 142 readers of New Generation, the
(55,56) magazine of National Childbirth
Trust; volunteer sample
Sandelowski 1987–93 USA (location unknown)
(1994a, b) 62 childbearing couples, 42 of
(39,40) whom had been infertile, and all
had received at least one ultra-
sound scan
Santalahti et al 1993–94 Finland, Turku, Jyvaskyla &
(1998) (23) Kuopio
Survey 1. Ultrasound survey (Tur-
ku) 497 pregnant women (most
15–22 wk pregnant) were offered
questionnaire, 424 returned
Survey 2. Serum screening survey
(Jyvaskyla and Kuopio): 1035
pregnant women (all but 5 had
received a scan) were offered
questionnaire, 909 returned
Skov (1991) (10) 1988 Denmark, Kolding Hospital
220 pregnant women
woman’s home. This paper
reports results on women’s
views of ultrasound and other
types of prenatal screening, and
is part of a wider study.
Women wrote in response to a
short questionnaire published in
magazine asking basic questions
about their experience of ultra-
sound
Interviews at several points dur-
ing pregnancy. The study was
designed to look at transition to
parenthood, with a focus on
infertility.
Self-completion questionnaire
about knowledge and views of
prenatal screening, including
ultrasound, were handed out at
antenatal clinic visits. Two sep-
arate surveys.
A survey about whether
ultrasound should be available
routinely in Denmark.
of ultrasound, with some expres-
sing pleasure and excitement at the
image of the fetus. Some women
who had more than one scan wor-
ried about possible harmful effects
on the baby. Women discussed
links between screening and their
religious/cultural views on
acceptance of what life brings.
Importance of how, when, and by
whom results were discussed. Also
described discomfort and lack of
reassurance during scan.
Contrasting reactions to ultrasound
and amniocentesis (experienced by
a subset). Described men’s views
about ultrasound and women’s
views about their partner’s reac-
tions. Photos and videos. Ultra-
sound as a ‘‘first meeting with the
baby.’’
Findings cover knowledge of tests
and views about what they can
detect. Education level was linked
to knowledge. Women were less
aware of potential for ultrasound
to detect abnormalities.
93% of respondents supported the
routine offer of ultrasound to all
pregnant women (from author’s
abstract).
found that examines views
of women who migrated
into a health system where
ultrasound was routine.
Review questions—2, 4
Review question—3
Data about use of ultra-
sound not gathered delib-
erately.
Review questions—2, 5
This study showed how
ultrasound was seen more
positively than other preg-
nancy screening tech-
niques, even when used to
detect anomalies.
Review question—1
Review question—other
(Should ultrasound be
available in Denmark?)
243
Table 4. Continued
244

Year Carried Country, Setting, Comments and Relevance

Study Out Participants, Sample Size Methods Results to Review Questions

Smith & Not later than UK, 6 hospitals Observation study of routine ante- Information about serum screening An important part of the
Marteau (1995) 1994 215 women, 28 midwives, and 9 natal visits to look at how serum was given more often than about picture of women’s know-
(24) obstetricians screening and fetal anomaly fetal anomaly scanning. Purpose ledge and choices.
Women were seeing a midwife at scanning are mentioned/explained of anomaly scanning was less likely Review question—1
booking (10–12 wk) or an to women. to be mentioned. Information
obstetrician at 16 wk about meaning of results and
possible errors was given very
rarely.
Sommerseth 1990 Norway Questionnaire survey about infor- Just over one-half of respondents Review question—1
(1993) (107) 891 pregnant women in national mation given to women in rela- said that they were given no
representative sample tion to routine scan at around 17 information about the scan; a
wk of pregnancy. substantial number
thought that the scan was com-
pulsory. The author argues for
better information for women
(from author’s abstract).
Sparling et al Not later than USA, North Carolina Women were approached when Differences between 3 ‘‘risk’’ Review question—PsI
(1988) (108) 1988 108 pregnant women referred for attending for ultrasound between groups were not detected in scores
ultrasound (? ‘‘high risk’’) 20–32 wk and completed. psy- on anxiety, depression, and
Final sample ¼ 80 in 3 risk strata chological and other question- hostility (but numbers are very
on basis of first ultrasound naires. Ultrasound session was small). No differences in mother/
(impaired ¼ 16, question- observed. Further contacts with child interaction detected.
able ¼ 31, normal ¼ 33) women in later pregnancy, just
after birth, and at 3 months after.
Interviews and observation of
parent/child interaction carried
out.
Stephens et al Not later than USA, San Diego, California, Questionnaire study of pregnant 98% wanted a scan; 37% would be Review questions—1, 2
(2000) (32) 1999 Naval Medical Center women at entry to maternity care prepared to pay for it if not pre-
137/150 low-risk women ap- to assess reasons for wanting, or scribed. Reasons for wanting a
proached not wanting, an ultrasound scan. scan included: to determine gender
of fetus, to determine health and
growth of fetus; for reassurance,
etc.
Tautz et al 1995 Botswana, Maum A qualitative study using inter- Selected points of interest from this This is the only study found
(2000) (41) 41 pregnant and newly delivered views with patients and staff and detailed qualitative study included: that looks at care in a poor
women who were referred for observation of scans in a mater- women were poorly informed country. It is also one of
ultrasound for clinical indica- nity hospital. about purpose and potential of the the few that includes
tions in a setting where ultra- scan and about how it would be observation of scans
sound was not routine done. They rarely shared a lan- alongside interview.
Observation of 18 women’s guage with staff who carried it out, Review questions—1, 2, 3
ultrasound scans and interviews so they lacked information as scan
with 10 doctors and midwives was being done. Some were afraid
of the process. Some overestimated
what the scan could detect. There
was a tendency to see the equipment
as novel, a thing devised by
‘‘whites,’’ and to think that it
BIRTH 29:4 December 2002
 should be used if a doctor re-
commended it. Women commen-
ted about the lack of explanation,
and also discussed ways in which
the technique might be at odds
with their culture’s approach to
pregnancy.
Teichman Not later than Israel The intervention appears to have Anxiety (for all 197 women) was Review question—PsI
et al 1990 197 primigravid ‘‘low-risk’’ involved giving or withholding infor- higher after the scan than before,
(1991) (109) women with no pevious ultra- mation on gender of fetus. It is not and higher still just after the birth.
sound (25–27 wk) clear how randomization worked
BIRTH 29:4 December 2002

All received a scan since it appears that for the 3 groups,

100 were told fetal gender, 41 not
given this information, and 56, who
said in advance they would not want
it. Anxiety and depression were
assessed 10–14 days before scan, just
after scan, and after birth.
Thornton et al 1991–94 UK, Leeds and Bradford A randomized controlled trial asses- The intervention did not affect the Review questions—1, 2
(1995) (27) 1691 women booking for sing impact of extra information uptake of ultrasound or serum
antenatal care before 15 wk about prenatal tests on uptake of screening for Down syndrome. It
tests, and on anxiety, satisfaction, lowered the uptake of screening
and understanding. 3 groups: (1) for cystic fibrosis. Anxiety was
control, (2) extra information given lower in the group offered indi-
individually, (3) extra information vidual information (at 20 and 34
given in a class. Postal questionnaires wk). 99% of women accepted
at 16–18 wk, 20 wk, 34 wk of offer of ultrasound.
pregnancy, and 6 wk post birth.
Thorpe et al Not later than UK (assume Bristol) Qualitative interview study exploring Many women voiced concern Review question—2
(1993) (42) 1993 42 mothers approached for women’s reactions to pregnancy about the safety of cerebral
consent to do a cerebral ul- ultrasound and to cerebral ultra- ultrasound for their new baby.
trasound scan on their new sound for their newborn. Pregnancy ultrasound was categ-
baby (not because of any risk orized by some women as being
factor or indication) about reassurance and the confir-
30/42 agreed to scan of baby; mation of normality. Women’s
all but 3 mothers had preg- comments also highlighted
nancy ultrasound emotional appeal of pregnancy
ultrasound.
Tourette & Not later than France (location not given) Questionnaire administered by? It Women were generally well Review questions—1, 3,5
Bouhard 1985 85 women at different gesta- covers experience of ultrasound, informed about purposes of
(1986) (68) tions, 25 before ultrasound, 60 knowledge of purpose, reactions to ultrasound. Some aspects of scan,
after 3 locations: hospital, pri- scan, information, presence of part- and communication with staff,
vate clinic of woman’s obste- ner, etc. caused concern.
trician, at a radiologist’s clinic
Tsoi & Hunter Not later than UK, King’s College Hospital, Interview before and after scan to AFP group were more anxious 1/3 of women dropped out
(1987) Hunter 1985 London study anxiety and attitude to preg- before scan. Anxiety fell for both between post-scan and
et al (1987) 30 pregnant women with raised nancy. Postal questionnaire sent 4 wk groups after scan (no differences follow-up assessments, so
Tsoi et al AFP for ultrasound after scan. then, or at follow-up). Women in this may undermine
(1987) 30 control pregnant women for both groups reacted very posi- reported finding of a rise in
(44,110,111) routine ultrasound tively to scan. Some wanted more anxiety in both groups at
information during and after scan. follow-up.
Review question—2, 3, PsI
245
Table 4. Continued
246

Year Carried Country, Setting, Comments and Relevance

Study Out Participants, Sample Size Methods Results to Review Questions

Tymstra et al Not later than Netherlands, University Hospi- Women were offered 4 scenarios in a Women were most positive about Review question—other
(1991) (11) 1990 tal Groningen postal questionnaire that covered: use of ultrasound for detecting (Should ultrasound be
185 women ‘‘a few months’’ amniocentesis and CVS; ultrasound treatable abnormalities but even used for the detection of
after delivery; first baby for all for treatable abnormalities; ultra- for CVS/amniocentesis, 36% said abnormalities?)
women sound for untreatable abnormalities; they would definitely wish to use
127 returned questionnaires serum AFP. They were asked whether it during their next pregnancy, if
screening options should be offered to offered.
all women in Netherlands, and whe-
ther they themselves would accept
such offer.
Valbo & Blaas 1989 Norway (location unspecified) Alternate allocation trial of extra The results are difficult to interpret Review questions—1, 2
(1991) (112) 655 pregnant women information about routine ultra- because some women were
sound. Women completed a ques- excluded from the analysis.
tionnaire after the scan. Women who received extra writ-
ten information seemed to be
more satisfied with information
than those who did not. Women
were very positive about the scan,
and about the information they
received during it.
Villeneuve et al Not later than Canada, Montreal Direct observation (not reported here). Some problems with seeing the Review questions—
(1988) (43) 1987 Women and partners attending Interviews with pregnant women and image clearly were reported. 2, 3, 5
for antenatal care partners. Some seen more than once. Women said what they liked best
Questionnaires returned by Questionnaire distributed to women about seeing image of baby.
154/207 women and 64/90 and men in clinic on selected days Fathers were as positive as moth-
men over a 3 wk period and returned by ers about scan.
mail.
Whynes (2002) 1997–98 UK, Nottingham Analysis of diary entries from a sample Women’s reported reasons for the Review questions—1, 2, 3
(113) 706 unselected women booking of pregnant women taking part in a scan (against a checklist) were
for maternity care in a wider study about maternity care. mainly realistic. Their feelings
particular month invited to about scans were mainly very
join diary project positive, with only around 6%
397 returned diaries; 384 had negative feelings. For second and
entries relevant to ultrasound subsequent scans proportion of
positive feelings fell somewhat.
When invited to say what they
would change about the scan, 7%
made some comment, most com-
monly to suggest improvements in
information giving.
Wu & Eichmann Not later than USA (presumed, no location Questionnaires at 18 and 37 wk. Self- Attachment scores were lower (but Review question—PsI
(1988) (114) 1988 given) completion, attachment scales. Also? what counts as low?) in parents
57 couples, recruited at 18 wk a phone interview around same time who knew fetal gender, compared
ultrasound scan, then 34 wk (37 wk). with those who did not. But their
scan where those who asked scores were already lower before
were told fetal gender they were told fetal gender.
BIRTH 29:4 December 2002
BIRTH 29:4 December 2002 247

The review process also raised some issues about the

reporting of research. Conclusions from earlier studies
Review question—PsI

were sometimes repeated in later work by other

authors without checking if they were supported by
the evidence in those papers. In many cases studies
lacked key information about time, place, and type of
ultrasound scan being done. Social and psychological
studies of ultrasound are highly context-specific. The
way in which the technology is used has changed over
time, and varies between and within countries. Many
clusions about the effect of
both areas were less anxi-

were excluded after rand-

randomization and likeli-
Authors conclude that the

affect anxiety. Women in

ous after the scan. Con-

studies do not give much contextual information; thus,

hood that some women
feedback are limited by
lack of information on
feedback level did not

for example, it is not always possible to work out when

the research was done. We need to be extremely
cautious about putting together the results of studies in
omization.

a review such as this, and also be aware that review

findings may not be relevant in all settings or over time.
Implications of the findings of this review for
clinical practice are that parents need good informa-
tion about the purpose of the scan and its limitations.
it is not clear if the missing
(n ¼ ?) group. 182/211 were
reported in the results, but

29 were allocated or not.

They are likely to have strong positive expectations of

chological questionnaire,
and then were randomly
Women completed a psy-

(n ¼ ?) or low- feedback
assigned to either high-

a scan, and may not have up-to-date knowledge of

what the scan is designed to do. Parents need to know
what to expect so that they can make informed
decisions about care and so that they are well prepared
for adverse findings. Providing parents with this sort of
information is time consuming, and requires that all
staff are well informed. In this respect, changes in the
technology and in policies for its use can make it
211 pregnant women (4–41

difficult to provide good care to pregnant women.

Israel, Shaare Zedek

Acknowledgments
Medical Centre

The study was funded by the National Health Service

Health Technology Assessment programme, with
additional funding for the first author coming from
wk)

the Department of Health. We also give thanks to

Rachel Rowe, Sally Marchant, Catherine Baillie, Jo
Green, Sue Hall, colleagues at the National Perinatal
Epidemiology Unit and the Social Science Research
CVS ¼ chorion villus sampling; AFP ¼ alpha-fetoprotein.

Unit, London University Institute of Education, and

Not later than 1994

anonymous referees.

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