Sexual & Reproductive Healthcare 7 (2016) 8–13
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Sexual & Reproductive Healthcare
j o u r n a l h o m e p a g e : w w w. s r h c j o u r n a l . o r g
Viewing the unborn child – pregnant women’s expectations, attitudes
and experiences regarding fetal ultrasound examination
Liv Øyen a,*, Ingvild Aune b
a Post Graduate Programme on Obstetric Ultrasound for Midwives, St. Olavs University Hospital, Norwegian University of Science and Technology, Olav
Kyrres gate 17, 7006 Trondheim, Norway
b Department of Nursing Science, Midwifery Education, Faculty of Health and Social Science, Sør-Trøndelag University College, Mauritz Hansens gate 2,
7004 Trondheim, Norway
A R T I C L E
I N F O
Article history:
Received 2 June 2015
Revised 24 August 2015
Accepted 5 October 2015
Keywords:
Prenatal care
Ultrasound
Women’s view
Expectation
Experience
A B S T R A C T
Objective: To gain a deeper understanding of pregnant women’s expectations, attitudes and experiences regarding ultrasound examination during pregnancy.
Methods: In-depth interviews were conducted with eight pregnant Norwegian women prior to their 18week scan. The data were analyzed through systematic text condensation.
Results: The analysis generated three main themes: (1) I want to know if everything is fine, (2) Viewing
the unborn child, (3) Holistic care. The women had a strong wish for ultrasound scanning and medical
knowledge about their “baby” was their first priority interest. Visualizing the “baby” represented a strong
emotional dimension for the parents-to-be and initiated the bonding process and the planning of a new
life. The women wanted to be empowered and approached in a holistic way, where dialogic communication was needed.
Conclusion: The women wanted medical knowledge about the fetal health. They considered the examination a visual experience together with their partner. The scan provided a personification of and an
attachment to the fetus. This experience was the first step in the planning of a new life. The women had
ambivalent feelings related to the ultrasound examination and they highlighted the importance of holistic care, where the sharing of information happens on an individual basis.
© 2015 Elsevier B.V. All rights reserved.
Introduction
Ultrasound examination during pregnancy is a frequently debated
topic in Norway, which has led to two Consensus conferences. The
first one, in 1986, discussed what at the time was seen as “overuse”
of ultrasound scans during pregnancy, without resulting in any conclusions. In order to systemize and organize the use of it, one
ultrasound examination became available to pregnant women across
the country [1]. The second conference, held in 1995, discussed the
ethical aspects of using ultrasound. Knowledge of the conditions
in the womb could be lifesaving for some fetuses, while other conditions might lead to abortion. This conference resulted in a
continuation of ultrasound scan at 18 weeks of gestation, which still
is the only official offer available to pregnant women in Norway today
[2].
* Corresponding author. Post Graduate Programme on Obstetric Ultrasound for
Midwives, St. Olavs University Hospital, Norwegian University of Science and
Technology, Olav Kyrres gate 17, 7006 Trondheim, Norway. Tel.: +47 72574667/+47
95888068.
E-mail address: [email protected] (L. Øyen).
http://dx.doi.org/10.1016/j.srhc.2015.10.003
1877-5756/© 2015 Elsevier B.V. All rights reserved.
Prenatal care is part of the primary health services and has a long
tradition in Norway. The responsibility lies with the municipalities, while the specialist health services are responsible for care
during birth and the early postnatal period. The ultrasound examination at 18 weeks is organized as consultation number two in the
official prenatal care programme [3]. The scan takes place at the hospital and is carried out by midwives with professional competence
on ultrasound. The ultrasound scan is mainly offered for medical
reasons; fetal number, gestational age, location of the placenta and
fetal anatomy [4]. As almost every pregnant woman in Norway undergoes this scan, it becomes an important part of prenatal care.
The importance of informing the woman and her partner specifically about the purpose of the ultrasound examination, its
possibilities and limitations has been emphasized [5,6]. The choice
of prenatal screening should be conditioned by the access to correct,
comprehensible and sufficient information and it is important that
women are encouraged to choose according to their own values and
wishes. The possibility of making a choice is affected by economic, political and ethical considerations. Apart from these factors,
knowledge, combined with a reflective attitude, is the foundation
of all informed choices [7]. Ebert et al. [8] claim that socially disadvantaged women do not feel confident to engage in discussions
relating to choice. Situations such as inadequate contextualized
L. Øyen, I. Aune/Sexual & Reproductive Healthcare 7 (2016) 8–13
information, perceived risks in not obeying routine procedures, as
well as the actions and reactions of midwives may result in silent
compliance. It may be interpreted as a way for the women to take
responsibility for their baby’s well-being by delegating health care
decision-making to professionals. According to Nicol [9], an informed choice related to ultrasound examination may be impossible
to achieve because of the established routines in maternity care.
Women also experience social pressure to undergo the examination in order to get a photo of the baby as part of a maternity
package. They perceive the ultrasound scan as part of the antenatal care, and thus decide that receiving the offer is “the correct course
of action”.
Studies show that women feel anxious that something might be
wrong with the fetus prior to the ultrasound scan [6,10]. However,
normal developments during the ultrasound examination tend to
reduce anxiety among pregnant women [10,11]. In her study, DiPietro
[12] highlights that viewing a fetus on ultrasound involves a shortterm maternal psychological benefit, including reduction in anxiety
following a reassuring scanning process.
Several studies show that the ultrasound examination is highly
desired by women, because it confirms a new life and a new family.
Being able to see “the baby” on the screen creates overwhelming
emotions and an attachment to the fetus [6,13,14]. Molander et al.
[14] emphasize that pregnant women consider their first ultrasound scan as a way of approaching different goals during pregnancy.
The goals are about meeting and connecting with the “baby”, and
represent an important step toward parenthood.
Objective
The aim of this study is to gain knowledge and a deeper understanding of pregnant women’s expectations, attitudes and
experiences regarding ultrasound examination during pregnancy.
Methods
Data collection
A qualitative approach was chosen for data collection, and the
data presented are from in-depth interviews prior to the ultrasound examination at 18 weeks of gestation. The informants were
picked from a random sample taken from the hospital’s scanning
list. The informants were healthy women with normal pregnancies of different ages and social statuses, and included both
primiparous and multiparous women. They had to master the Norwegian language. 12 women were contacted by telephone and
invited to participate in the study. Eight Norwegian women, with
different backgrounds, aged 20–37, volunteered to participate. The
educational level of the participants ranged from primary school
to university education. Four women were primiparous and four
were multiparous. The participants received written and oral information about the aim of the study, and were given assurances
that all data would be treated confidentially. The informants provided a written informed consent to participate in the study. The
project was approved by the Regional Research Ethics Committee
(Ref. No. 2011/2046). All interviews were conducted at the hospital and lasted 45–60 minutes. Two of the eight interviews were
9
conducted on the same day as the ultrasound scanning while the
others took place two to three days before the scan. An interview
guide was prepared in advance. The questions were derived from
a literature review on the topic as well as from professional knowledge and experience. The interview guide was based on four main
topics:
(1)
(2)
(3)
(4)
Informed choice
Aim of the ultrasound scan
Emotional state of mind
Visualization
The data collected were rich in content as all informants talked
freely about the topics and offered thorough descriptions of their
experiences. After 8 interviews, data saturation was achieved.
Data analysis
The interviews were tape-recorded and transcribed verbatim. The
transcribed interviews were carefully analyzed through systematic text condensation. This method, developed by Malterud [15], is
a modified version of Giorgi’s [16] phenomenological analysis. The
purpose of the phenomenological analysis is to gain knowledge about
the informants’ experiences within a particular field. The researcher tries to identify the essence or the themes emerging from
the data. The method of analysis followed a four-step process [17].
First, all the interviews were read in order to obtain an overall impression; the broad picture being more important than the details.
The researchers looked for themes that reflected the women’s
thoughts about ultrasound scanning and an effort was made to
bracket hypotheses, preconceptions and the theoretical framework of reference. In the second step, meaning units representing
the different aspects of the ultrasound scan were identified and
coded. In the third step, the content of each of the coded groups
was condensed, abstracted and summarized. The last step of the
analysis involved re-contextualization. The women’s expectations, attitudes and experiences regarding ultrasound scanning were
summarized in re-contextualized versions that provided the basis
for new descriptions or concepts. Table 1 shows one example of the
analyzing process.
Results
Three themes emerged during the review of the material: “I want
to know if everything is fine”, “Viewing the unborn child” and “Holistic care”. Quotations from the informants are used to support the
findings.
I want to know if everything is fine
This theme describes the women’s satisfaction with receiving
an offer of ultrasound examination during prenatal care. They identified this scan as the most important form of consultation they
received during pregnancy. Together with their partner, they looked
forward to getting information about the pregnancy and their new
baby. The women preferred to get this as early as possible during
pregnancy in order to avoid the possibility of receiving bad news
Table 1
One example of the analyzing process.
Theme
Sub-theme
From code to meaning
Code
Quotation
Viewing the unborn child
Parenthood and attachment
The visual experience
strengthened the relationship
and connection to the baby
Experience
“Experiencing another human
living inside you, and
simultaneously being able to
see it – that is impressive!”
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at the time of birth. The women knew that it is impossible to discover everything; nothing is guaranteed. Their feelings switched
between joy and anxiety, while hoping that everything would be
fine.
Knowledge about fetal health
The women wanted all available information in order to find out
if their baby seemed healthy, or discover things that could have an
impact on its life. First and foremost, the informants experienced
that ultrasound examination was based on medical considerations. The women expressed themselves in this way:
The aim must be to detect physical damage, that is the medical…/
…/You have so many thoughts, and then you wonder if it’s all
imagination. We are really lucky to have the possibility to find
out about our baby’s health. (E)
All the women in the study expressed their main motivation for
taking the ultrasound scan in the same way: “I want to know if everything is fine”. The women also expressed:
It’s important for me to know if there is life inside; if everything looks fine. (D)
They can see if the baby is healthy and calm things down if something is wrong; maybe help me get to know what can be done.
(C)
The women sought dialog with the person responsible for the
scan, and wanted the midwife to understand how important it was
for the pregnant woman and her partner to receive information about
their specific baby:
The waiting time for the ultrasound scan was experienced differently for women with children compared to those without
children. The women who were primiparous found the ultrasound scan at 18 weeks of gestation to be too long a wait:
You experience a sense of unreality before you get the ultrasound scan. I yearn for the scan and I’m counting the days. (E)
Being able to see reassures and calms you down. You need it
when you are struggling a bit emotionally. (G)
The women also found there was too little time for midwifery
care during the first part of pregnancy.
Then you feel alone and you know nothing about what’s inside.
(D)
Then you are just waiting for a sign that all is well. (A)
The women who had children found that time flew by. They did
not focus as much on pregnancy as the first time.
Shocking how fast time flies! Have been busy, so it’s from now
on I begin to have contact with the baby in the womb. (E)
Viewing the unborn child
This main theme describes the first visual meeting between the
parents-to-be and their baby. This meeting caused a strong emotional experience which marked the beginning of parenthood,
attachment to the baby, and the planning of a new life.
Last time I heard what they said. But if it could be possible to
share some of our own thoughts and concerns, it would be
another type of examination. (E)
Parenthood and attachment
The women highlighted that the ultrasound examination is a
common experience for the mother and father-to-be. They also
pointed out that this type of examination in pregnancy involves live
images of their baby, enabling a visual experience and a strengthening of the relationship and connection to the baby.
Emotional ambivalence
The women experienced an ambivalent feeling of pleasure and
anxiety when considering the ultrasound examination. The fear that
something could be wrong was always there, but they tried not to
focus on this in the present. Ultrasound examination generates strong
emotions, and the women wished the midwife to take this into
consideration.
The most important is to create a bond between the father,
mother and baby. Imagine seeing the head, four limbs and a
beating heart, and at the same time realizing that this is ours!
– And then it can be our secret for a little while. – It’s so good
to experience such wonderful feelings. (E)
It’s too long to wait for something you are looking forward to,
but then you don’t know if it’s something to look forward to
either. (C)
The visual images confirms life, you just know that it’s real. (E)
But one should not take sorrow in advance. (D)
The women knew that the ultrasound examination might reveal
abnormal developments or disease affecting the fetus, but leading
up to the examination the women tried to keep their hopes alive,
and did not want to spend time on negative thinking. They neither
saw the importance of having a lot of information in advance about
possible anomalies that may be detected, as they would not be able
to deal with it at that point anyway.
Sub-consciousness works and prepares you. Last night I had such
a horrible dream that reality can only be better./…/I should have
a predictability that is not there, but I must believe that all is
well. It’s a small chance that it would not be so. We take it as it
comes./…/I want to know now rather than at birth because preparation is important. (A)
I do not think it’s possible to prepare for something that may
go wrong, but you must deal with it. (B)
It’s just the way things go. If only the baby will be healthy, I think.
(H)
Experiencing another human living inside you, and simultaneously being able to see it – that is impressive! (A)
The women felt that the ultrasound examination enabled the
pregnancy and the baby to become more real for the partner, who
is not able to experience this in the same way as the woman does
through her body. The women claimed that they, during the ultrasound examination, took their partner for a journey full of visual
images of their baby. They highlighted that this half hour was full
of impressions with strong mental and emotional dimensions.
When I think of ultrasound I see a small intimate, cosy room
where I hold my husband’s hand and together we get to see our
baby, a small human being with a beating heart. (E)
Planning a new life
The women and their partners used the ultrasound examination in planning the pregnancy process leading toward birth and a
new life with the baby. They emphasized that the scan would leave
unique memories that would benefit the phase before birth as well
as the future.
Knowing who is in there will help the preparation, as it makes
it possible to plan how to take the pregnancy process forward.
(E)
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It’s very special to see the one who will be with us in a while. I
feel happiness about what is coming. (C)
The women wanted concise, understandable and user-friendly
information.
The women also considered the baby’s gender as a preparation
for parenthood, even if this was not the most important thing.
Much of the information is written in such a poor language that
it’s useless. (E)
It’s not for my own sake I want to know, but it’s a person living
in my belly. The relationship becomes more personal if you know
whether it’s a boy or girl and you can give it a name. (G)
Others felt guilty about reflecting on the baby’s gender.
One day I became excited when thinking of whether it was a boy
or girl. The next moment I thought that it’s not allowed to think
so. I have always heard that it doesn’t matter, what matters is
that the baby is healthy. (C)
The women were concerned about the great responsibility that
comes with pregnancy, childbirth and the postnatal period. They
highlighted that they had to make sure to take care of themselves
during pregnancy; doing exercise, eating healthy food, not drinking alcohol, enabling the baby to feel well in the mother’s womb.
It’s a great gift and a huge responsibility. It turns your life upside
down. You have to realize that there is another person to care
for. (B)
Individual needs during pregnancy
The women would have wanted several ultrasound scans during
pregnancy, if this had been possible. They perceived the offer of one
ultrasound scan as an official recommendation and that this recommendation was based on safety considerations concerning the
fetus. The women were uncertain about the risks associated with
ultrasound technology and whether the risk would increase with
several examinations.
I might have wished several ultrasound scans, but don’t want
to expose my baby more than is recommended. (E)
I hear the rumours … I don’t know if they are justified … that
it can be harmful to take more than one scan. At the same time,
you can pay for an ultrasound scan whenever you want. (C)
He thinks more of practical things when the kid is born, and is
eager to look for equipment. (H)
The informants also commented on the social pressure related
to ultrasound scans during pregnancy. There were great expectations from family and friends that they would accept the offer. Those
who had been informed about the “big news” shared the joy with
the couple and the pregnant woman was often asked: “Have you
had an ultrasound scan?” or “when are you going to have an ultrasound scan?”, as it was taken for granted that she would have
one.
He has already started talking about taking the kid out for fishing.
(F)
I feel some pressure from the environment. My girlfriends were
surprised that I hadn’t demanded a 12-week scan. (A)
According to the women, the partner’s preparation and planning were different:
Holistic care
This main theme describes how pregnant women experience receiving information about ultrasound scanning and their need for
individualized care.
Information about the ultrasound scan
All women in this study wanted the ultrasound scan strongly.
They wanted to be followed up by the public services during pregnancy, but claimed that information about the public prenatal care,
as well as the choices and rights of pregnant women, was difficult
to get hold of. The women highlighted that the information leaflet
from The Directorate for Health and Social Affairs contains information they should have had already at their first consultation during
prenatal care involving their general practitioner (GP) or midwife.
The women also sought information about the ultrasound scan at
the hospital. They responded negatively to the information leaflet,
which they received in connection with the appointment for scanning. They felt that the information only focused on the person
performing the scan, who was not to be disturbed. The important
dialog during the scan was not given any emphasis.
We have the right to get information from the public health
services, but this information is so “machine-like”, it doesn’t
address the whole process. It lacks the emotional and human
dimensions. (G)
The women claimed that the Internet is the most important
source of information today. They experienced various degrees of
professionalism, and said that they had to be critical to the information. Friends and family were also cited as important sources of
information. The women felt that there is too much information
during pregnancy. Apparently, the women want information adapted
to their own context. They found it hard to read large amounts of
information before they finally discover what they are looking for.
The women believed that visualization of the fetus is not emphasized in the official medical examination. This is despite the fact
that the women emphasized the importance of “seeing their baby”.
The public health services mostly focus on the physical examination of the baby, in order to see if it’s healthy. The emotional
experience and the individualized care that we need are not emphasized. But body and mind cannot be separated. (E)
Discussion
The pregnant women in this study had a sincere desire to undergo
the ultrasound examination at 18 weeks of gestation because they
wanted medical knowledge about the fetal condition. They wanted
to know if the fetus was viable and whether it had developed as it
should. The ultrasound scan was considered the most important examination during pregnancy. Several other studies highlight that
the ultrasound examination provides valuable information about
the condition of the fetus, which in turn brings reassurance and relief
to the parents-to-be [10–12,18].
When women show up for the ultrasound examination, the
midwife expects that they have received information about the examination’s purpose and content, as this is specified both in Guidelines
for the use of ultrasound in pregnancy [4] and Guidelines for prenatal care [3]. The informed consent of the women should be ensured
before the examination. The informants in the present study considered the information given prior to the examination to be
insufficient. Several other studies support this finding [9,18–20].
Ekeland [21] argues that the problem in today’s health services is
not too little information but too poor communication. Martin et al.
[22] highlight that the focus on giving information may prevent midwives from establishing a real dialog on a daily basis during the
antenatal counseling. The study by Martin et al. [23] provides insight
into the midwives’ perception of their own prenatal counseling performance. The midwives found the client–advisor relation and the
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health education aspects of counseling during the prenatal phase
to work well, whereas decision-making support was insufficient.
The authors conclude that midwives should focus more on decisionmaking support to optimize the counseling in connection with
prenatal screening. On the other hand, in a midwifery model of care,
Dixon and Burton [24] found that midwives provide adequate information and promote informed choice in relation to prenatal
screening, with high levels of client knowledge and satisfaction. In
this model of care, the principle of informed choice is central and
the time spent on counseling long enough to enable in-depth discussions. Farrell et al. [25] highlight the need to ensure that
professionals have both the knowledge and communication skills
to effectively support pregnant women’s informed decisionmaking regarding the use of prenatal tests. Nicol [9] points out that
leaflets are often used instead of verbal communication; the women
choose to read what they want and they interpret written information about ultrasound scanning in a way that fits their coping
strategies.
None of the women in this study were given written information about the ultrasound examination at 18 weeks, and only one
of the eight women was asked whether she wanted to accept the
offer. It seems that midwives and general practitioners during prenatal care take it for granted that women want an ultrasound scan,
and therefore fail to ask the women about it. The women instead
received the following statement from the GP: “I will send a referral for ultrasound scanning to the hospital”. For pregnant women who
want a different choice, such statements may be perceived as a pressure. Several studies show that the ultrasound examination is
perceived as a part of the prenatal care and necessary for a successful pregnancy [9,26,27]. Heyman et al. [27] consider this view
to be based on an inclination to trust the health service providers
and an idea that health care services offered ought to be accepted.
Nicol [9] claims that when pregnant women find themselves in a
stressful situation, they respond by complying with what they believe
is the recommendations of the health professionals. Social pressure is also clearly evident in several other studies [28–30]. Health
professionals who work with prenatal care should encourage informed choice by parents with regard to routine ultrasound
examination [11].
The women in this study wanted information during the examination in order to understand the ultrasound images and the
purpose of the examinations. They welcomed dialog with the
midwife, including the opportunity to express their own thoughts,
concerns or questions. The women wanted the midwife to understand the significance of the examination for the parents-to-be.
Garcia et al. [5] and Lalor and Devane [6], who emphasize the necessity of specific information about the ultrasound examination,
support this finding. The experience of the ultrasound scan depends
on the treatment and information the woman and her partner receive
[31]. During the examination, the midwife, the pregnant woman
and her partner will enter a relationship. The relationship with the
midwife builds bridges through the sharing of information, enabling the pregnant woman to make sense of the communication.
This represents what Ekeland [21] understands as “helping communication”. A successful ultrasound examination depends on how
the helper relates to those seeking help, and whether the person
receiving help feels acknowledged. For women who accept the offer
of ultrasound examination, trust and good communication skills from
the midwife are essential for the ultrasound scan to be meaningful. Communication is at the heart of the entire ultrasound
examination, as information from the images on the screen is conveyed to the parents-to-be.
When accepting the offer of ultrasound examination the women
put their trust in the hospital as a system. The midwife herself
depends on being trusted by the couple in order to be able to provide
individualized care [32]. The examination starts when the midwife
puts the ultrasound probe on the woman’s abdomen. This is a very
vulnerable situation for the woman because she leaves her pregnant body in the midwife’s hands, and expects to be cared for. The
women in this study described an alternating sense of pleasure and
anxiety prior to the ultrasound scan. For some women there is a
growing tension before the examination, with physical and emotional discomfort [18]. Brudal [33] points out that our emotions are
guided by increased vulnerability when moving from one phase of
life to another. Women’s vulnerability during pregnancy means that
memorized coping strategies are often not useful. Usually, the way
we think follows rational logic, which is characterized by common
sense. During pregnancy, a new kind of logic arises – the emotional logic. Such emotions dominate the mind, and Brudal’s theories
may help us understand how this logic influences the woman’s experience of the scan. Ekelin et al. [11] and Aune and Möller [18] stress
that women are mentally affected by the ultrasound scan. They emphasize the advantage that all caregivers who are involved in the
ultrasound examination are aware of this fact, both in relation to
the information given before the offer is accepted and in connection with the scan itself. Midwives should provide useful information
and understand the factors that influence women’s concerns [34,35].
The women in this study considered the examination to be a
visual experience, involving personification and attachment to “their
baby”. The visual images resulted in a strong emotional experience, which was the starting point for planning a new life with a
baby. According to Aune and Möller [18], the ultrasound examination enables visualization and personification of the fetus, and the
women develop a stronger connection and different relationship to
it. Several studies indicate that the ultrasound scan confirms a new
family, and the ability to see the fetus causes overwhelming emotions and attachment [6,13,14,18]. The women in the present study
also wanted to prepare themselves in case something wrong was
detected during the scan. According to Aune and Möller [18], preparedness was considered an important factor. This also implied that
health professionals during the examination get to know about the
condition of the fetus, which better prepares them to take care of
the baby after the birth.
Limitations
In this study, the thoughts and experiences of a small group of
pregnant women in Norway were examined. We do not suggest that
these women are representative of all other pregnant women.
However, the small sample size does not mean that the findings are
irrelevant. The women gave comprehensive descriptions of their expectations, needs and attitudes using their own words. This study
enables us to understand some key factors that influence pregnant women’s experience of ultrasound scanning during pregnancy.
Conclusions
The women had an independent, sincere desire for ultrasound
examination at 18 weeks of gestation, as they wanted information about the fetal health. At the same time, they considered the
examination a visual, shared experience with their partner, including a personification of and attachment to “their baby”. The
visualization led to a strong emotional experience, which marked
the beginning of a new life with the baby. The women experienced both happiness and anxiety about the ultrasound examination.
They emphasized holistic care, where individually adapted information is an important factor.
Acknowledgements
We would like to thank the eight pregnant women who participated in this study.
L. Øyen, I. Aune/Sexual & Reproductive Healthcare 7 (2016) 8–13
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