The Maternal Perspective on Prenatal Ultrasound

Journal of Family Practice, July, 2000 by Mark B. Stephens, Ruby Montefalcon, David A. Lane

* BACKGROUND Most women in the United States will have a routine sonogram during pregnancy. The medical necessity of this is debatable. The goal of our study was to examine maternal beliefs about prenatal sonography.

* METHODS We surveyed 150 prenatal patients at their point of entry to maternity care at a large military medical center. The main outcome measures were the patient's desire for a prenatal sonogram, the reasons for wanting a sonogram, the number of sonograms wanted, and the patient's willingness to pay for the examination.

* RESULTS Of the 150 eligible subjects, 137 (91%) participated and 135 (98%) wanted a prenatal sonogram. Fifty-one (37%) of the respondents were willing to pay for the sonogram if it was not ordered by their provider. The reasons for wanting a sonogram (to determine the sex of the fetus, to ensure that the fetus was healthy, general maternal reassurance, and to ensure adequate fetal growth) were similar across age, race, and income (military rank).

* CONCLUSIONS Our study indicates that most women want a sonogram during pregnancy, and many are willing to pay for the examination. Women appear to want sonograms for reasons that may not assist their provider with immediate clinical decision making. This is a potentially important disagreement between cost-saving and patient satisfaction that maternity care providers must consider when deciding whether to perform prenatal sonography for women with low-risk pregnancies.

* KEY WORDS Ultrasonography, prenatal; prenatal care; patient expectations [non-MESH]. (J Fam Pract 2000; 49:601-604)

Between 60% and 70% of pregnant women in the United States will have a sonogram at some point during pregnancy,[1] at a cost of more than $1 billion to the health care system. The utility of routine antenatal sonograms is debatable. Some sources feel that screening sonography is cost-effective during pregnancy,[2,3] and argue for its routine use.[4] Others suggest that it increases the cost of prenatal care,[5] does not improve perinatal outcome,[6,7] and offers little benefit in low-risk patients.[8] The United States Preventive Services Task Force has recommended against routine third-trimester sonography and states that there is insufficient evidence to recommend for or against routine second-trimester sonography in otherwise low-risk patients.[9]

Much of the discussion about screening sonography for women with low-risk pregnancies, however, has focused on medical measures or birth outcomes. Less is known about how women feel about sonography within the context of their pregnancies. It has been reported that if appropriate positive feedback is given to the patient during the examination, a sonogram is generally reassuring to her.[10,11] With the increased availability of ultrasound technology, many women now expect and some "positively demand" sonography during pregnancy.[12] Prenatal sonography could represent an important area of conflict between patient autonomy and the clinical decision-making process.[13]

Our study was designed to address several questions pertaining to maternal perceptions of prenatal sonography: (1) What percentage of women wants to have a sonogram as part of prenatal management? (2) Why do women want prenatal sonography? (3) How many sonograms do women want during a pregnancy? (4) Are women willing to pay for the sonograms if they are not offered as part of routine prenatal care?

METHODS

Sample Recruitment

We conducted our study at the Naval Medical Center San Diego, a large tertiary referral center with 300 to 400 deliveries per month. All subjects were eligible for care in the military health care delivery system, a program that provides free care without deductibles or copayments to eligible patients. Following institutional approval, 150 consecutive low-risk prenatal patients were asked to participate at their point of entry to the maternity care system. Exclusion criteria included first trimester vaginal bleeding, suspected ectopic pregnancy, uncertain clinical dates, history of previous congenital anomaly, late entry to prenatal care, intrauterine device in place at time of conception, infertility patients, maternal medical complications, advanced maternal age, and suspected uterine abnormality.

Survey Administration

A 12-item survey was administered to participating patients that included questions about their age, race, number of previous pregnancies, and number of living children. Patients were then asked whether they wanted a sonogram during the current pregnancy, and if yes, how many. They were given the opportunity to describe the reasons for wanting (or not wanting) a prenatal sonogram. Patients were also asked whether they would be willing to pay for a sonogram if their clinician did not order one during the pregnancy and how much they would pay.

Data Analysis

Descriptive statistics were used for categorical variables. Nonparametric statistical analyses (chi-square analysis, Fisher exact test) were used to determine differences between groups and to calculate correlation coefficients (Pearson's and Spearman-rho).