By Jean Robinson
One of our constant concerns is the publication of simplistic "surveys" of women's views carried out by doctors and published in medical journals, when they would be unlikely to rate publication in a social science journal or psychology journal. They often seem designed to find out what doctors want to prove. Here is a recent example.
A radiologist from Seoul in Korea and a team from San Diego in California including a psychologist devised a questionnaire to see if three-dimensional scans helped bonding more than two dimensional scans. It was not a randomised study. One hundred mothers were telephoned between a month and two years after they had given birth. Half had had 2-D ultrasound only, and half had also had 3-D scans, as well, each scan lasting half an hour. The women had been classified as high risk, but all were found to be carrying normal babies. All were given a copy of the scans.
Not surprisingly, the mothers with 3-D pictures were more likely to have shown them to others. Mothers were asked if they had had a mental image of what their baby would be like before the scan and more than half in both groups said 'no' (Some were done as early as 12 weeks - some as late as 36 weeks). After the scan, 32% of 2-D scanned mothers had a mental image of the baby, and 82% of the 3-D mothers had. Mothers were asked "Did you feel that you already 'knew' your baby right after he/she was born because of the ultrasound experience?" 56% of 2-D and 70% of 3-D mothers said they did (Over 80% in both groups had said that looking at the pictures had created a closer relationship with the child). Although in comments, most mothers had been favourable, there were more exclamatory comments from 3- D mothers (amazed, wonderful, fabulous).
However a few mothers in both groups had been disappointed at the quality of images. Even with 3D, the fetus might not be in a position to show the face, which was particularly important to the mother.
A previous editorial on scanning for parental pleasure has said that bonding should be considered as part of the obstetric ultrasound examination. The authors comment: "There is great controversy as to whether patients should have the option to undergo these studies for pleasure for a potential benefit from increased maternal-fetal bonding and strengthening the support system for families. Therefore, it would be helpful to have scientific data to determine whether there is any positive benefit for the patient."
One could drive a coach and horses through the quality of the study. It shows - surprise, surprise - that more detailed pictures rather than fuzzy images give mothers a better picture of the baby, and they are more likely to show them around. They do not mention what happened to mothers, or the babies, in this high-risk clinic whose scans showed abnormalities. How useful to be able to justify use of the technology with "proof" that mothers want it, and it helps bonding. Whether it does or not, would mothers have agreed if they had known the exposure, and thus any potential harm, was likely to be greater? Pretty pictures may come at a higher price than they realise.
A much better study of women's views comes from Toronto in Canada, and it is the first paper on a hitherto neglected subject: how women want to be treated if the scan gives bad news. The survey was designed by a multi-disciplinary team, which included patients, as well as social worker, a political scientist, nurses, obstetricians and patients, and one of the authors of the paper was a patient advocate.
Over 100 women who had been given news of damaged babies after a scan, were telephoned between one and six months later, and if they agreed they were sent a questionnaire about what was most important to them in how women should be treated if given bad news.
More than two-thirds had had babies with severe anomalies, and a third had had "soft" markers or obstetric complications. On a scale of 1 (unimportant) to 9 (very important), they rated how important various aspects were to them. The quality of information they were given rated top. It should be clear and understandable, (top rating of 8.9), there should be enough time for them to ask questions, and all the options should be clearly explained. Being given information about follow-up care was almost as important, with information in writing as well as spoken getting a high, but slightly lower rating. Those with lower levels of education were more likely to value written information.
The speed with which women got information was also important, and man y of them preferred to get informat ion from th e sonographer immediately , but that clashed with their need to have comprehensive information from their obstetrician. Women gave a very high rating (8.3) to the importance of the person telling them bad news being sympathetic. They valued being offered help to get home, for example, not necessarily because they needed the help, but because it showed that the person speaking to them cared.
Having a support person with them was also rated as high on the importance scale, and a large number wanted to arrange to have a supporter (family or friend) with them when they were given such information.
A particularly interesting question was whether women preferred the term "fetus" or "baby" to be used. Women were clearly split on this, the larger number preferring baby (especially those who had less education), but a significant number preferring 'fetus'. However a number considered this issue unimportant.
Privacy was highly important to women being given bad information, even more important than being given information quickly, with a rating of 8.2. Being fully dressed at the time, sitting not lying down, and other people being seated if they were sitting were not as important, but still rated as fairly high at 6 or over. The lighting in the room was far less important.
Women were also asked for their views on how they had been treated. Although most were satisfied, the researchers expressed concern that a significant minority had criticisms. Nearly a third were dissatisfied with information giving, and 20% dissatisfied with privacy at the time.
Their views were not affected by the severity of their baby's condition, or their age. Only education levels had an effect on some of the questions. The authors suggest that a prospective study should be done, with longer term follow up.
Complaints about how women are treated when being given information after scans crop up from time to time in our calls, and we know how much they value a warm, empathetic approach at such a time rather than the cool professional one. This study is a useful beginning on a very important topic, which will be helpful to professionals. However, we hope the "ask if they need help getting home" data is not used as a quick substitute for the real thing ("tick the box"), in the way that "give women the dead baby to hold after a stillbirth to help bereavement" wrongly became an automatic part of the pattern, and became a source of complaints. Offering transport help in this study symbolised empathy to the women, but it was the empathy and not the offer of transport that was important. Although women were given an opportunity to add comments on any other issues, we don't have an analysis of these. Presumably by the time women compiled answers, many will have had terminations, and we wonder if that had any effect on responses (eg uses of term baby or fetus).
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