Journal of Genetic Counseling, Vol. 1, No. 1, 1992
Seeing the Baby: The Impact of Ultrasound Technology Rita B e c k B l a c k 1,2
This paper reports results of a study of prenatal diagnosis patients who underwent ultrasound examinations and lost their pregnancies through miscarriage or elective terminations. The majority of the women felt that viewing the ultrasound image influenced their relationship to the fetus and their coping with the pregnancy loss. The women commented on the power of ultrasound to make their pregnancies more real as well as the painful yet sometimes beneficial consequences of seeing the fetus. Clinical implications are considered for health professionals who provide prenatal diagnostic services or counseling after pregnancy loss. KEY WORDS: ultrasound; psychological impact of prenatal diagnosis.
INTRODUCTION A limited number of research studies have examined the experiences of women undergoing ultrasound scanning. Their findings suggest that for women with normal pregnancies and low risk for complications, viewing the fetus on ultrasound generally is a most positive, reassuring, and significant event (Campbell et al., 1982; Kohn et al., 1980; Milne and Rich, 1981). Women usually are eager to see their fetus and concentrate intensely on discerning the fetal shape from the ultrasound image. Areas that show motion, such as the beating heart and extremities, get a major amount of attention and seem to provide mothers with significant reassurance about the health of their baby (Kohn et al., 1980). The ultrasound image also allays fears that may exist about the "wholeness" of the baby; although some 1Columbia University School of Social Work, New York, New York 10025. 2Correspondence should be directed to Rita Beck Black, Columbia University School of Social Work, 622 W. 113 St., New York, New York 10025. 45 1059-7700/92/0300-0045506.50/1 9 1992 National Societyof Genetic Counselors,Inc.
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women continue to express anxiety about the normality of fetal structures that are not dearly revealed by the technique (Milne and Rich, 1981). Previous studies about women's experiences during pregnancy and the development of maternal bonds to the baby have emphasized the perception of fetal movement as an important milestone (Bibring et al., 1961). As the mother feels movement, she begins the process of knowing the baby as an autonomous individual. However, until recently, the pregnant woman was unable to "see" her baby. The mental image that she formed thus arose only from her imagination (Milne and Rich, 1981). As shown in the work of Lumley (1980), prior to the availability of ultrasound and other forms of prenatal technology, the majority of women only gradually came to see the fetus as a baby. Especially striking was the first trimester when most women had only a vague mental image of the fetus' shape and few described the fetus as a baby. Even well into the second trimester, Lumley (1980) found that only 44% of women described the fetus as a baby. Potential benefits of seeing the fetal image include reduction of maternal anxiety about the development of the fetus, resolution of early ambivalence about the pregnancy, and greater maternal attention to prenatal medical recommendations and healthful changes in eating and lifestyle (Fletcher and Evans, 1983; Reading and Cox, 1982). The introduction of ultrasound techniques during pregnancy has raised important questions about whether this technology accelerates the process of parental bonding (Fletcher and Evans, 1983). Pregnant women who have undergone ultrasound report "an increased sense of knowing their babies" (Milne and Rich, 1981, p. 32) and seem to feel closer to them (Kohn et al., 1980). Seeing the baby move seems to further confirm its life and identity even if movement already has been felt prior to the ultrasound (Milne and Rich, 1981). The intensity with which women examine the ultrasound images of their fetuses seems not unlike the intensity with which women stare at their newborns in the early phases of bonding after birth (Klaus and Kennell, 1982). Ultrasound can he an important and often positive experience for many women experiencing normal pregnancies. However, available research says little about the experiences of women who undergo the ultrasound because they are at increased risk for bearing a child with a serious defect and then go on to lose the baby they have observed on the ultrasound screen. Because this technology presents such strong possibilities for hastening a woman's developing relationship to her fetus and therefore of having an impact on her coping with the loss of that fetus, this investigation examined the experience of ultrasound by prenatal diagnosis patients who lost their pregnancies.
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METHODS AND DESCRIPTION OF PARTICIPANTS Subjects were obtained from women enrolled in the National Institute of Child Health and Human Development's Collaborative Chorionic Villus Sampling (CVS) and Amniocentesis Study (Rhoads et al., 1989). Collaborative study subjects were invited to participate in the follow-up study if they experienced pregnancy losses between July 1985 and January 1988, as a result of either elective terminations after abnormal test results or spontaneous abortion. To be eligible, patients also had to have a telephone and sufficient fluency in English for the interview. Semi-structured interviews were conducted by telephone at approximately 1 and 6 months after the pregnancy losses. The overall participation rate was 60.5% yielding a total sample of 121 subjects who participated in one or both interviews. These women were similar to their counterparts in the larger, collaborative study and were mainly white (94%), married (91%), well educated (63% had completed college or a more advanced level of education), and affluent (74% had family incomes of $40,000 or more). Gestational ages at the time of the pregnancy losses ranged from 7 to 27 weeks, with most losses occurring toward the end of the first trimester or early in the second trimester (X = 13.7 weeks, SD 3.8). Seventy (57.8%) underwent elective abortions and 51 (42.1%) lost their pregnancies following spontaneous miscarriages. Data reported on in this paper comes from the 105 women who participated in the first round of interviews, conducted at approximately 1-2 months after each woman's pregnancy loss. Interviews included fixed, closed-ended questions as well as opportunities for open-ended discussion of responses to specific items or of other issues of concern to the woman. [Additional details about recruitment procedures, characteristics of the sample, and other findings not reported on in this paper can be found in Black (1989, 1991).] The women in the present study had undergone ultrasound examinations of their fetuses at 7-10 weeks gestation, the point at which they entered the national study of CVS and amniocentesis. In addition, some participants had one or more scans done prior to their entry into the project and some had additional ultrasound examinations because of concerns raised by results of the testing or at the time of amniocentesis, if that procedure was used. On average, they had seen the fetuses two times on ultrasound before they lost their pregnancies (although eight reported having had 4 ultrasounds and one woman had viewed her fetus 5 times before the loss). The time elapsed between the interview and their last ultrasound view of the fetus varied depending on the nature and timing of their losses, but all shared the relative newness of adjusting to their altered reality of no longer being pregnant.
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Interviews were tape-recorded with the consent of the participant. Initial qualitative coding of major themes was done by the author, and confirmed by a research assistant who coded a random sample of ten interviews with 94% agreement. Subsequent, more detailed analyses of the interviews were done independently by the author. Since the respondents varied considerably in the length of their open-ended comments, the themes identified in this paper are presented to suggest points of departure for future research and clinical observation. Therefore, no attempt was made for this paper to quantify the exact frequency of specific themes. RESULTS The women confirmed in their responses to fixed, closed-ended questions that ultrasound had been an important experience. Sixty-three (60%) said that seeing the ultrasound image had led them to feel closer to the fetus and 46 (44%) responded affirmatively when asked if viewing the fetus on ultrasound had made coping with the loss more difficult; only a very few (9, 9%) felt it had made coping any easier. Major themes identified in their open-ended comments are presented below.
The Reality of Seeing Seeing the image of a fetus on the ultrasound screen marked for many of the women that "moment of acceptance that you were indeed pregnant." Many had been pregnant before or seen pictures of developing fetuses in textbooks; some even had seen ultrasounds in previous pregnancies. Yet prior knowledge and experience was not the same as actually seeing that very real, moving picture of what was going on inside themselves. The women's intellectualizations often gave way at that moment of recognition. It m a d e it m o r e t h a n a concept, it m a d e it w h a t a p p e a r e d to be, a living thing; we saw it m o v e its little a r m s and legs; we saw a little face, the s h a d o w of a face . . . I had i m a g i n e d it [but] w h e n I saw the size of it and this and that, I m e a n , it's just, it's h a r d e r to say to myself it's just a miscarriage.
For one woman, the pregnancy had come as a surprise, and the sickness of early pregnancy had reinforced her ambivalence. However, the ultrasound image changed her perspective. T h e s y m p t o m s of p r e g n a n c y for m e were really p r o n o u n c e d , but they were basically u n c o m f o r t a b l e ; like terrible nausea, a lot of fatigue . . . . So on one level y o u ' r e dealing with a c h a n g e in y o u r body that s e e m s almost negative and n o t h i n g positive really h a p p e n s at that stage; you're not aware, there's no m o v e m e n t s or anything; but having s e e n it, s e e n the difference in actual m o v i n g entities, s o m e t h i n g that really had life . . . it h a d a very p r o n o u n c e d effect on my h u s b a n d and m y s e l f . . .
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we were slightly ambivalent before t h a t . . . I didn't plan on getting p r e g n a n t . . . but actually seeing that m a d e a very big difference; it was no question after t h a t . . . it's suddenly having a conception of what emerging life really is,
Some of the women had tried to distance themselves from the pregnancy because of the genetic risk. They had tried to adopt the stance of a "tentative" pregnancy (Rothman, 1986), hoping thereby to lessen the impact if a defect were found. The ultrasound image tended to remove that tentativeness. 9 . . on an intellectual level, the way I was best able to handle all of these things was to [say] in my head, I was not pregnant, until they told me that the results would be good. A n d I really was able. I said nothing to anybody. My parents did not know . . . and none of my friends 9 I just acted as if I was not . . . but seeing it, kind of emotionally . . . I guess I had to realize that I really was [pregnant].
I tried to really protect myself from the eventuality of losing this baby. Even from the minute I knew I was pregnant it was almost like O K I'm pregnant, so what. I didn't really feel m u c h 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; that all the precautions my husband and I had taken to protect our feelings just went right out the window when we saw that . . . .
When a follow-up ultrasound revealed that the fetus had died, the dramatic impact of no longer seeing movement was evident. [With ultrasound] I think you go very quickly from "this is a fetus" to "this is a baby." Seeing the heart beat is a big emotional thing; likewise not seeing the heart beat was devastating.
Additional Anguish Just as the ultrasound image made the pregnancy "real" for many women, that extra reality sometimes brought them additional anguish during and after the pregnancy loss. One woman said the ultrasound was the worst part of the testing for her. Others viewed it as an experience that heightened their general grief over the loss. One woman vividly described how she carried the ultrasound image with her into the termination. To tell you the truth, I flashed on it [the ultrasound picture], thinking about terminating it. I kept thinking about that's what it is, that's what it looks like, but - - m y baby. A n d it may have made it a little more difficult because it put it into view, into reality, that it was really there . . . because you say what is not seen is easier to accept but that really put it in front of your face, and you knew . . . .
Some wished they had not seen the fetus and suggested that women be given the option about whether or not to observe the screen during the ultrasound examination. For example, one noted that she would not have ultrasound again because it made it all too real. Another generalized
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b e y o n d the u l t r a s o u n d to say she w o u l d w a n t less i n f o r m a t i o n in a f u t u r e pregnancy. If I ever get pregnant again, I wouldn't want as much knowledge of the baby so early. You feel so much more bonded and start planning a lot more for the future. I might not even look next time and definitely wouldn't want to know the sex. However, a n o t h e r p a r t i c i p a n t p o i n t e d o u t that the idea of t u r n i n g the u l t r a s o u n d s c r e e n away f r o m h e r line of sight was i n c o n c e i v a b l e e v e n t h o u g h it h a d a d d e d to her distress. She could n o t i m a g i n e n o t j o i n i n g in with the professionals who were watching h e r "child."
The Benefits of Confronting Reality W h e n asked w h e t h e r seeing the fetus o n u l t r a s o u n d had in any way eased coping with their p r e g n a n c y losses, the w o m e n ' s varied responses suggested that this q u e s t i o n had evoked a painful paradox. H o w could something so e m o t i o n a l l y painful carry any benefits? As indicated above, the h e i g h t e n e d reality i n d u c e d by the u l t r a s o u n d evoked painful feelings that some would have preferred to avoid. However, others talked a b o u t the b e n e fits, albeit painful, of c o n f r o n t i n g the reality of their experiences. W o m e n who e x p e r i e n c e miscarriages, especially early in gestation, m a y have limited i n f o r m a t i o n a b o u t their p r e g n a n c y a n d the r e a s o n s for it ending. A l t h o u g h they may have felt some physical s y m p t o m s of pregn a n c y , t h e r e is little to m a k e t h e b a b y itself or its d e m i s e a reality. U l t r a s o u n d seems to have filled in at least a few of those u n k n o w n s for some of the w o m e n in this study. O n e participant, who miscarried after CVS, talked a b o u t seeing " n o t h i n g " inside the u t e r u s o n a follow-up ult r a s o u n d e x a m i n a t i o n b e c a u s e the fetus had died some time before. She started h e m o r r h a g i n g right there in the hospital a n d stayed o n for a dilation a n d c u r e t t a g e ( D & C ) . H a v i n g seen the reality of her e m p t y uterus, she felt "very positive a b o u t going a n d having the D & C . " A similar experience is described below. The ultrasound, well, I don't know . . . maybe it made it black and white. You know I saw it's heart beating two weeks before when I [initially]was going to have the CVS; and then when I had the CVS . . . there was no fetal heart beat. I saw it for myself, it was like written straight out . . . because when you have a miscarriage it's like, there's so many doubts in your mind of what happened, and it's usually happened so early that you don't know what happened or didn't see any concrete things; and I think maybe it did make it easier to see it . . . I just felt different with the other miscarriage . . . because I'd never seen, I hadn't seen a picture of the baby. . . . It might have made it easier. It just seems like it's funny to make it easier but I would say easier to cope with. I hadn't thought of it in like that sense before but I think maybe it did help.
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Some seemed almost grateful that ultrasound had proven so powerful in forcing them to confront the realities of their pregnancies9 9 . . I actually lost a baby instead of a fetus, and I think that the sonogram has a
lot to do with that . . . . It made me feel as though I was losing a person instead of a pregnancy; so that maybe the impact on me was stronger emotionally, but I don't feel negative about the sonogram. I mean, I'm glad that there was some kind of visual image, you know. I think it's important to see it. I think it's important to confront it . . . . I would have been better off if I had really let myself think about it more 9 To talk about it m o r e with friends . . . . I'm glad I saw it, it m a d e it more real, you know. It wasn't just a medical procedure that was happening to me, because you can't be shielded from it. First of all, you have hormones racing through your body to begin with, and when you lose a baby it's like giving birth and you really have to deal with that. A n d I know I was trying to sort of come in through the back door, saying if I didn't think about it then the loss wouldn't be as bad as if I had thought about [it] . . . . I mean, to answer your question, I'm glad I saw it and I think w o m e n should see it so they know that there was a reason for all the things they were going through.
In the following extended excerpt, one participant describes how ultrasound served as an unexpected and poignant vehicle that enabled her to feel closer to her unborn child as it slowly died and to accept the finality of the loss. In this case, the ultrasound provided the initial diagnosis of her baby's condition, Turner Syndrome. Many fetuses with this problem develop fluid-filled cysts, as this mother describes below, and many miscarry, as did her baby. This family had hoped to continue the pregnancy, despite knowledge of the baby's problems. We went into that [first] ultrasound kind of elated at seeing the baby, and seeing it move; and I m e a n it was just wonderful watching it . . . all ! saw was the baby, I didn't see what was wrong with her cause I couldn't make out that the shadows were really cysts . . . we went the next day down to [the hospital] for the second ultrasound and that was really hard. Even though I watched the baby move and watched the whole time that they were pointing out things, but they were pointing out the problems, and that was really hard to see. A n d then the third time that I went was about two weeks after the initial [ultrasound] and the baby was barely moving at all; and that really upset me. It really was bad to know that she, I was seeing concretely that she was not well and that she was going to die . . . when the baby wasn't moving, I said something about that, and [the technician, who had been doing the scans each week] said, well, would you like me to play back the tape of the first one where she was moving? A n d I said y e s . . , it was good to see that again because I could see how my baby had gotten worse from the first ultrasound to just a few weeks later. So I was really glad that I could go back and see what t h e first o n e looked like; a n d we also have a picture, they took a photograph from the first one, so I have that too . . . . I'm glad that I did [see the ultrasounds I. I don't think anything of this has been easy. But it certainly helped me to understand better . . . I think in the steps that I'm taking towards finally accepting all of t h i s - - t h a t [the ultrasound] certainly has helped. Because I was able to see that my baby wasn't well and even as hard as it was to see them pointing out the cysts and the fluid and the lungs and around the heart and, and everything, at least I could see and understand that something was wrong.
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DISCUSSION Ultrasound technology allows the woman and her partner to "see" inside the womb. In that act of seeing, the fetus becomes a baby. The parents take away from the ultrasound a mental image built both from their memory of the machine-generated picture and from their imagination; one that they continue to respond to over time (Milne and Rich, 1981). These are simple, perhaps not surprising statements, yet their implications can be profound. For the woman with a low risk pregnancy, who sees an apparently healthy baby, ultrasound offers an often exhilarating experience that accelerates the pleasures of getting acquainted with her new offspring. The common anxieties of even the "low risk" mother about the normality of her unborn baby seem quieted after seeing that the baby is "whole" and moving. The implications of seeing are very different, however, for the woman who learns later that the baby carries a serious defect or who suddenly sees an ultrasound image of an unmoving or less than whole baby. In this study, the women spoke about the various meanings that this "seeing" had for them and the different mental images that they carried with them in their grief. Although they generally seemed to agree that the ultrasound made their pregnancy and the baby "more real," the heightened reality that seemed a gift for some, was an unwanted, added burden for others. Some felt that seeing their baby was a painful yet ultimately helpful experience in moving them through their grief. Seeing the baby made things more difficult in the short run because it strengthened the bond that was to be severed. Yet, these women seemed to be saying that they needed to feel the pain of loss in order to move beyond it. Other women in this study echoed the countervailing sentiment in our culture which says that painful feelings are best avoided, put aside, and forgotten. They found that having a vivid mental image of the baby made it harder to deny the reality that they had lost a baby rather than just a pregnancy. They felt little gratitude for a technology that seemed to increase their distress. The current study does not answer the question of which coping style "works best" or under what conditions. Future research efforts should be directed toward increasing our understanding of the many subtle factors that contribute to a woman's ability to move forward after losing a pregnancy, particularly in the context of the high technology world of prenatal diagnosis. Most of the women in this study did seem to move forward and cope adequately with their losses (Black, 1989). Their comments suggest that although it is unlikely that the ultrasound experience alone was crucial
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to either successful or unsuccessful coping, it nevertheless entered into the dynamics of their coping. The clinical importance of ultrasound for the pregnant woman thus derives from its power to evoke strong emotions toward the baby; emotions that embellish the ultrasound picture with deep personal meaning for the woman. For health professionals who perform this procedure, these findings underscore the importance of helping to prepare women for the strong emotions and possible anxiety that can accompany this test. Clinicians who have contact with a woman who terminates a pregnancy because of a serious defect in the fetus or one who miscarries should be mindful of any ultrasound experiences that may have taken place. The process of letting go, which is such a crucial part of the bereavement process, calls for a painful revival followed by a painful lessening of memories that tie one to the person who is deceased (Osterweis et al., 1984). For many women, their mental image of the fetus viewed on ultrasound becomes one of those ties that bind them to their baby. Some women will prefer not to review these memories. However, others are likely to value professionals who understand the importance of this experience and are willing to listen as they speak of the meaning it held for them. Whether the mother speaks about the size and shape of the baby, its movement or tack of movement, or the personality characteristics that she read into the fuzzy image on the screen, these all are part of her appropriate process of grieving and of gradually letting go.
ACKNOWLEDGMENTS The author gratefully acknowledges the following colleagues for the assistance they provided on this project: Janet Lerner, Maurice J. Mahoney, Miriam Schoenfeld DiMaio, Lora Baum, Karen Copeland, Beth Fine, Nancy Lockwood, Barbara Rosinsky, Jane Schuette, Linda Sealy, Alison Stein, Leslie Vought, and Darcy Strouse. This study was aided by a subcontract to Yale University Grant HD 19872, National Institute of Child Health and Human Development.
REFERENCES
Bibring G, Dwyer TF, Huntington DS, Valenstein AF (1961) A study of the psychological process in pregnancyand of the earliest mother-child relationship.Psychoanal Study Child 16:6-72. Black RB (1989) A one and six-month follow-up of prenatal diagnosis patients who lost pregnancies. Prenat Diagn 9:795-804. Black RB (1991) Women's voices after pregnancy loss: Couples, patterns of communication and support. Soc Work Health Care 16 (in press).
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Campbell S, Reading AE, Cox DN, Sledmere CM, Mooney R, Chudleigh P, Beedle J, Ruddick H (1982) Ultrasound scanning in pregnancy: The short-term psychological effects of early real-time scans. J Psychosom Obstet Gynaecol 1:57-61. Fletcher JC, Evans MI (1983) Maternal bonding in early fetal ultrasound examinations. N Engl J Med 308:392-393. Klaus MH, Kennell JH (1982) Parent-blfant Bonding (2nd Ed). St. Louis, Missouri: C.V. Mosby. Kohn CL, Nelson A, Weiner S (1980) Gravidas' responses to realtime ultrasound fetal image. JOGN Nurs 9:77-80. Lumley J (1980) The image of the fetus in the first trimester. Birth Family J 7:5-14. Milne LS, Rich OJ (1981) Cognitive and affective aspects of the responses of pregnant women to sonography. Matern ChiM Nurs J 10.'15-39. Osterweis M, Solomon F, Green M (eds) (1984) Bereavement: Reactions, Consequences, and Care. Washington, D.C.: National Academy Press. Reading AE, Cox DN (1982) The effects of ultrasound examination on maternal anxiety levels. J Behav Med 5:237-247. Rhoads GG, Jackson L, Schlesselman S, delaCruz FF, Desnick RJ, Golbus MS, Ledbetter DH, Lubs HA, Mahoney MJ, Pergament E, Simpson JL, Carpenter RJ, Elias S, Ginsberg NA, Goldberg JD, Hobbins JC, Lynch L, Shiono PH, Wapner RJ, Zachary JM (1989) Safety and efficacy of transcervical chorionic villus sampling. Initial results from the U.S. collaborative study. N Engl J Med 320:609-617. Rothman BK (1986) The Tentative Pregnancy. New York: Penguin Books.
Seeing the Baby: The Impact of Ultrasound Technology Rita B e c k B l a c k 1,2
This paper reports results of a study of prenatal diagnosis patients who underwent ultrasound examinations and lost their pregnancies through miscarriage or elective terminations. The majority of the women felt that viewing the ultrasound image influenced their relationship to the fetus and their coping with the pregnancy loss. The women commented on the power of ultrasound to make their pregnancies more real as well as the painful yet sometimes beneficial consequences of seeing the fetus. Clinical implications are considered for health professionals who provide prenatal diagnostic services or counseling after pregnancy loss. KEY WORDS: ultrasound; psychological impact of prenatal diagnosis.
INTRODUCTION A limited number of research studies have examined the experiences of women undergoing ultrasound scanning. Their findings suggest that for women with normal pregnancies and low risk for complications, viewing the fetus on ultrasound generally is a most positive, reassuring, and significant event (Campbell et al., 1982; Kohn et al., 1980; Milne and Rich, 1981). Women usually are eager to see their fetus and concentrate intensely on discerning the fetal shape from the ultrasound image. Areas that show motion, such as the beating heart and extremities, get a major amount of attention and seem to provide mothers with significant reassurance about the health of their baby (Kohn et al., 1980). The ultrasound image also allays fears that may exist about the "wholeness" of the baby; although some 1Columbia University School of Social Work, New York, New York 10025. 2Correspondence should be directed to Rita Beck Black, Columbia University School of Social Work, 622 W. 113 St., New York, New York 10025. 45 1059-7700/92/0300-0045506.50/1 9 1992 National Societyof Genetic Counselors,Inc.
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Black
women continue to express anxiety about the normality of fetal structures that are not dearly revealed by the technique (Milne and Rich, 1981). Previous studies about women's experiences during pregnancy and the development of maternal bonds to the baby have emphasized the perception of fetal movement as an important milestone (Bibring et al., 1961). As the mother feels movement, she begins the process of knowing the baby as an autonomous individual. However, until recently, the pregnant woman was unable to "see" her baby. The mental image that she formed thus arose only from her imagination (Milne and Rich, 1981). As shown in the work of Lumley (1980), prior to the availability of ultrasound and other forms of prenatal technology, the majority of women only gradually came to see the fetus as a baby. Especially striking was the first trimester when most women had only a vague mental image of the fetus' shape and few described the fetus as a baby. Even well into the second trimester, Lumley (1980) found that only 44% of women described the fetus as a baby. Potential benefits of seeing the fetal image include reduction of maternal anxiety about the development of the fetus, resolution of early ambivalence about the pregnancy, and greater maternal attention to prenatal medical recommendations and healthful changes in eating and lifestyle (Fletcher and Evans, 1983; Reading and Cox, 1982). The introduction of ultrasound techniques during pregnancy has raised important questions about whether this technology accelerates the process of parental bonding (Fletcher and Evans, 1983). Pregnant women who have undergone ultrasound report "an increased sense of knowing their babies" (Milne and Rich, 1981, p. 32) and seem to feel closer to them (Kohn et al., 1980). Seeing the baby move seems to further confirm its life and identity even if movement already has been felt prior to the ultrasound (Milne and Rich, 1981). The intensity with which women examine the ultrasound images of their fetuses seems not unlike the intensity with which women stare at their newborns in the early phases of bonding after birth (Klaus and Kennell, 1982). Ultrasound can he an important and often positive experience for many women experiencing normal pregnancies. However, available research says little about the experiences of women who undergo the ultrasound because they are at increased risk for bearing a child with a serious defect and then go on to lose the baby they have observed on the ultrasound screen. Because this technology presents such strong possibilities for hastening a woman's developing relationship to her fetus and therefore of having an impact on her coping with the loss of that fetus, this investigation examined the experience of ultrasound by prenatal diagnosis patients who lost their pregnancies.
Seeing the Baby: The Impact of Ultrasound Technology
47
METHODS AND DESCRIPTION OF PARTICIPANTS Subjects were obtained from women enrolled in the National Institute of Child Health and Human Development's Collaborative Chorionic Villus Sampling (CVS) and Amniocentesis Study (Rhoads et al., 1989). Collaborative study subjects were invited to participate in the follow-up study if they experienced pregnancy losses between July 1985 and January 1988, as a result of either elective terminations after abnormal test results or spontaneous abortion. To be eligible, patients also had to have a telephone and sufficient fluency in English for the interview. Semi-structured interviews were conducted by telephone at approximately 1 and 6 months after the pregnancy losses. The overall participation rate was 60.5% yielding a total sample of 121 subjects who participated in one or both interviews. These women were similar to their counterparts in the larger, collaborative study and were mainly white (94%), married (91%), well educated (63% had completed college or a more advanced level of education), and affluent (74% had family incomes of $40,000 or more). Gestational ages at the time of the pregnancy losses ranged from 7 to 27 weeks, with most losses occurring toward the end of the first trimester or early in the second trimester (X = 13.7 weeks, SD 3.8). Seventy (57.8%) underwent elective abortions and 51 (42.1%) lost their pregnancies following spontaneous miscarriages. Data reported on in this paper comes from the 105 women who participated in the first round of interviews, conducted at approximately 1-2 months after each woman's pregnancy loss. Interviews included fixed, closed-ended questions as well as opportunities for open-ended discussion of responses to specific items or of other issues of concern to the woman. [Additional details about recruitment procedures, characteristics of the sample, and other findings not reported on in this paper can be found in Black (1989, 1991).] The women in the present study had undergone ultrasound examinations of their fetuses at 7-10 weeks gestation, the point at which they entered the national study of CVS and amniocentesis. In addition, some participants had one or more scans done prior to their entry into the project and some had additional ultrasound examinations because of concerns raised by results of the testing or at the time of amniocentesis, if that procedure was used. On average, they had seen the fetuses two times on ultrasound before they lost their pregnancies (although eight reported having had 4 ultrasounds and one woman had viewed her fetus 5 times before the loss). The time elapsed between the interview and their last ultrasound view of the fetus varied depending on the nature and timing of their losses, but all shared the relative newness of adjusting to their altered reality of no longer being pregnant.
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Interviews were tape-recorded with the consent of the participant. Initial qualitative coding of major themes was done by the author, and confirmed by a research assistant who coded a random sample of ten interviews with 94% agreement. Subsequent, more detailed analyses of the interviews were done independently by the author. Since the respondents varied considerably in the length of their open-ended comments, the themes identified in this paper are presented to suggest points of departure for future research and clinical observation. Therefore, no attempt was made for this paper to quantify the exact frequency of specific themes. RESULTS The women confirmed in their responses to fixed, closed-ended questions that ultrasound had been an important experience. Sixty-three (60%) said that seeing the ultrasound image had led them to feel closer to the fetus and 46 (44%) responded affirmatively when asked if viewing the fetus on ultrasound had made coping with the loss more difficult; only a very few (9, 9%) felt it had made coping any easier. Major themes identified in their open-ended comments are presented below.
The Reality of Seeing Seeing the image of a fetus on the ultrasound screen marked for many of the women that "moment of acceptance that you were indeed pregnant." Many had been pregnant before or seen pictures of developing fetuses in textbooks; some even had seen ultrasounds in previous pregnancies. Yet prior knowledge and experience was not the same as actually seeing that very real, moving picture of what was going on inside themselves. The women's intellectualizations often gave way at that moment of recognition. It m a d e it m o r e t h a n a concept, it m a d e it w h a t a p p e a r e d to be, a living thing; we saw it m o v e its little a r m s and legs; we saw a little face, the s h a d o w of a face . . . I had i m a g i n e d it [but] w h e n I saw the size of it and this and that, I m e a n , it's just, it's h a r d e r to say to myself it's just a miscarriage.
For one woman, the pregnancy had come as a surprise, and the sickness of early pregnancy had reinforced her ambivalence. However, the ultrasound image changed her perspective. T h e s y m p t o m s of p r e g n a n c y for m e were really p r o n o u n c e d , but they were basically u n c o m f o r t a b l e ; like terrible nausea, a lot of fatigue . . . . So on one level y o u ' r e dealing with a c h a n g e in y o u r body that s e e m s almost negative and n o t h i n g positive really h a p p e n s at that stage; you're not aware, there's no m o v e m e n t s or anything; but having s e e n it, s e e n the difference in actual m o v i n g entities, s o m e t h i n g that really had life . . . it h a d a very p r o n o u n c e d effect on my h u s b a n d and m y s e l f . . .
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we were slightly ambivalent before t h a t . . . I didn't plan on getting p r e g n a n t . . . but actually seeing that m a d e a very big difference; it was no question after t h a t . . . it's suddenly having a conception of what emerging life really is,
Some of the women had tried to distance themselves from the pregnancy because of the genetic risk. They had tried to adopt the stance of a "tentative" pregnancy (Rothman, 1986), hoping thereby to lessen the impact if a defect were found. The ultrasound image tended to remove that tentativeness. 9 . . on an intellectual level, the way I was best able to handle all of these things was to [say] in my head, I was not pregnant, until they told me that the results would be good. A n d I really was able. I said nothing to anybody. My parents did not know . . . and none of my friends 9 I just acted as if I was not . . . but seeing it, kind of emotionally . . . I guess I had to realize that I really was [pregnant].
I tried to really protect myself from the eventuality of losing this baby. Even from the minute I knew I was pregnant it was almost like O K I'm pregnant, so what. I didn't really feel m u c h 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; that all the precautions my husband and I had taken to protect our feelings just went right out the window when we saw that . . . .
When a follow-up ultrasound revealed that the fetus had died, the dramatic impact of no longer seeing movement was evident. [With ultrasound] I think you go very quickly from "this is a fetus" to "this is a baby." Seeing the heart beat is a big emotional thing; likewise not seeing the heart beat was devastating.
Additional Anguish Just as the ultrasound image made the pregnancy "real" for many women, that extra reality sometimes brought them additional anguish during and after the pregnancy loss. One woman said the ultrasound was the worst part of the testing for her. Others viewed it as an experience that heightened their general grief over the loss. One woman vividly described how she carried the ultrasound image with her into the termination. To tell you the truth, I flashed on it [the ultrasound picture], thinking about terminating it. I kept thinking about that's what it is, that's what it looks like, but - - m y baby. A n d it may have made it a little more difficult because it put it into view, into reality, that it was really there . . . because you say what is not seen is easier to accept but that really put it in front of your face, and you knew . . . .
Some wished they had not seen the fetus and suggested that women be given the option about whether or not to observe the screen during the ultrasound examination. For example, one noted that she would not have ultrasound again because it made it all too real. Another generalized
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b e y o n d the u l t r a s o u n d to say she w o u l d w a n t less i n f o r m a t i o n in a f u t u r e pregnancy. If I ever get pregnant again, I wouldn't want as much knowledge of the baby so early. You feel so much more bonded and start planning a lot more for the future. I might not even look next time and definitely wouldn't want to know the sex. However, a n o t h e r p a r t i c i p a n t p o i n t e d o u t that the idea of t u r n i n g the u l t r a s o u n d s c r e e n away f r o m h e r line of sight was i n c o n c e i v a b l e e v e n t h o u g h it h a d a d d e d to her distress. She could n o t i m a g i n e n o t j o i n i n g in with the professionals who were watching h e r "child."
The Benefits of Confronting Reality W h e n asked w h e t h e r seeing the fetus o n u l t r a s o u n d had in any way eased coping with their p r e g n a n c y losses, the w o m e n ' s varied responses suggested that this q u e s t i o n had evoked a painful paradox. H o w could something so e m o t i o n a l l y painful carry any benefits? As indicated above, the h e i g h t e n e d reality i n d u c e d by the u l t r a s o u n d evoked painful feelings that some would have preferred to avoid. However, others talked a b o u t the b e n e fits, albeit painful, of c o n f r o n t i n g the reality of their experiences. W o m e n who e x p e r i e n c e miscarriages, especially early in gestation, m a y have limited i n f o r m a t i o n a b o u t their p r e g n a n c y a n d the r e a s o n s for it ending. A l t h o u g h they may have felt some physical s y m p t o m s of pregn a n c y , t h e r e is little to m a k e t h e b a b y itself or its d e m i s e a reality. U l t r a s o u n d seems to have filled in at least a few of those u n k n o w n s for some of the w o m e n in this study. O n e participant, who miscarried after CVS, talked a b o u t seeing " n o t h i n g " inside the u t e r u s o n a follow-up ult r a s o u n d e x a m i n a t i o n b e c a u s e the fetus had died some time before. She started h e m o r r h a g i n g right there in the hospital a n d stayed o n for a dilation a n d c u r e t t a g e ( D & C ) . H a v i n g seen the reality of her e m p t y uterus, she felt "very positive a b o u t going a n d having the D & C . " A similar experience is described below. The ultrasound, well, I don't know . . . maybe it made it black and white. You know I saw it's heart beating two weeks before when I [initially]was going to have the CVS; and then when I had the CVS . . . there was no fetal heart beat. I saw it for myself, it was like written straight out . . . because when you have a miscarriage it's like, there's so many doubts in your mind of what happened, and it's usually happened so early that you don't know what happened or didn't see any concrete things; and I think maybe it did make it easier to see it . . . I just felt different with the other miscarriage . . . because I'd never seen, I hadn't seen a picture of the baby. . . . It might have made it easier. It just seems like it's funny to make it easier but I would say easier to cope with. I hadn't thought of it in like that sense before but I think maybe it did help.
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Some seemed almost grateful that ultrasound had proven so powerful in forcing them to confront the realities of their pregnancies9 9 . . I actually lost a baby instead of a fetus, and I think that the sonogram has a
lot to do with that . . . . It made me feel as though I was losing a person instead of a pregnancy; so that maybe the impact on me was stronger emotionally, but I don't feel negative about the sonogram. I mean, I'm glad that there was some kind of visual image, you know. I think it's important to see it. I think it's important to confront it . . . . I would have been better off if I had really let myself think about it more 9 To talk about it m o r e with friends . . . . I'm glad I saw it, it m a d e it more real, you know. It wasn't just a medical procedure that was happening to me, because you can't be shielded from it. First of all, you have hormones racing through your body to begin with, and when you lose a baby it's like giving birth and you really have to deal with that. A n d I know I was trying to sort of come in through the back door, saying if I didn't think about it then the loss wouldn't be as bad as if I had thought about [it] . . . . I mean, to answer your question, I'm glad I saw it and I think w o m e n should see it so they know that there was a reason for all the things they were going through.
In the following extended excerpt, one participant describes how ultrasound served as an unexpected and poignant vehicle that enabled her to feel closer to her unborn child as it slowly died and to accept the finality of the loss. In this case, the ultrasound provided the initial diagnosis of her baby's condition, Turner Syndrome. Many fetuses with this problem develop fluid-filled cysts, as this mother describes below, and many miscarry, as did her baby. This family had hoped to continue the pregnancy, despite knowledge of the baby's problems. We went into that [first] ultrasound kind of elated at seeing the baby, and seeing it move; and I m e a n it was just wonderful watching it . . . all ! saw was the baby, I didn't see what was wrong with her cause I couldn't make out that the shadows were really cysts . . . we went the next day down to [the hospital] for the second ultrasound and that was really hard. Even though I watched the baby move and watched the whole time that they were pointing out things, but they were pointing out the problems, and that was really hard to see. A n d then the third time that I went was about two weeks after the initial [ultrasound] and the baby was barely moving at all; and that really upset me. It really was bad to know that she, I was seeing concretely that she was not well and that she was going to die . . . when the baby wasn't moving, I said something about that, and [the technician, who had been doing the scans each week] said, well, would you like me to play back the tape of the first one where she was moving? A n d I said y e s . . , it was good to see that again because I could see how my baby had gotten worse from the first ultrasound to just a few weeks later. So I was really glad that I could go back and see what t h e first o n e looked like; a n d we also have a picture, they took a photograph from the first one, so I have that too . . . . I'm glad that I did [see the ultrasounds I. I don't think anything of this has been easy. But it certainly helped me to understand better . . . I think in the steps that I'm taking towards finally accepting all of t h i s - - t h a t [the ultrasound] certainly has helped. Because I was able to see that my baby wasn't well and even as hard as it was to see them pointing out the cysts and the fluid and the lungs and around the heart and, and everything, at least I could see and understand that something was wrong.
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DISCUSSION Ultrasound technology allows the woman and her partner to "see" inside the womb. In that act of seeing, the fetus becomes a baby. The parents take away from the ultrasound a mental image built both from their memory of the machine-generated picture and from their imagination; one that they continue to respond to over time (Milne and Rich, 1981). These are simple, perhaps not surprising statements, yet their implications can be profound. For the woman with a low risk pregnancy, who sees an apparently healthy baby, ultrasound offers an often exhilarating experience that accelerates the pleasures of getting acquainted with her new offspring. The common anxieties of even the "low risk" mother about the normality of her unborn baby seem quieted after seeing that the baby is "whole" and moving. The implications of seeing are very different, however, for the woman who learns later that the baby carries a serious defect or who suddenly sees an ultrasound image of an unmoving or less than whole baby. In this study, the women spoke about the various meanings that this "seeing" had for them and the different mental images that they carried with them in their grief. Although they generally seemed to agree that the ultrasound made their pregnancy and the baby "more real," the heightened reality that seemed a gift for some, was an unwanted, added burden for others. Some felt that seeing their baby was a painful yet ultimately helpful experience in moving them through their grief. Seeing the baby made things more difficult in the short run because it strengthened the bond that was to be severed. Yet, these women seemed to be saying that they needed to feel the pain of loss in order to move beyond it. Other women in this study echoed the countervailing sentiment in our culture which says that painful feelings are best avoided, put aside, and forgotten. They found that having a vivid mental image of the baby made it harder to deny the reality that they had lost a baby rather than just a pregnancy. They felt little gratitude for a technology that seemed to increase their distress. The current study does not answer the question of which coping style "works best" or under what conditions. Future research efforts should be directed toward increasing our understanding of the many subtle factors that contribute to a woman's ability to move forward after losing a pregnancy, particularly in the context of the high technology world of prenatal diagnosis. Most of the women in this study did seem to move forward and cope adequately with their losses (Black, 1989). Their comments suggest that although it is unlikely that the ultrasound experience alone was crucial
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to either successful or unsuccessful coping, it nevertheless entered into the dynamics of their coping. The clinical importance of ultrasound for the pregnant woman thus derives from its power to evoke strong emotions toward the baby; emotions that embellish the ultrasound picture with deep personal meaning for the woman. For health professionals who perform this procedure, these findings underscore the importance of helping to prepare women for the strong emotions and possible anxiety that can accompany this test. Clinicians who have contact with a woman who terminates a pregnancy because of a serious defect in the fetus or one who miscarries should be mindful of any ultrasound experiences that may have taken place. The process of letting go, which is such a crucial part of the bereavement process, calls for a painful revival followed by a painful lessening of memories that tie one to the person who is deceased (Osterweis et al., 1984). For many women, their mental image of the fetus viewed on ultrasound becomes one of those ties that bind them to their baby. Some women will prefer not to review these memories. However, others are likely to value professionals who understand the importance of this experience and are willing to listen as they speak of the meaning it held for them. Whether the mother speaks about the size and shape of the baby, its movement or tack of movement, or the personality characteristics that she read into the fuzzy image on the screen, these all are part of her appropriate process of grieving and of gradually letting go.
ACKNOWLEDGMENTS The author gratefully acknowledges the following colleagues for the assistance they provided on this project: Janet Lerner, Maurice J. Mahoney, Miriam Schoenfeld DiMaio, Lora Baum, Karen Copeland, Beth Fine, Nancy Lockwood, Barbara Rosinsky, Jane Schuette, Linda Sealy, Alison Stein, Leslie Vought, and Darcy Strouse. This study was aided by a subcontract to Yale University Grant HD 19872, National Institute of Child Health and Human Development.
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