Ultrasound ambivalence

Like most things about pregnancy, and life in general, I’m prone to ask questions about things typically deemed as normal or “a given”,  partly because I like to be prepared, partly because I’m an idealist (do I dare admit it?) and partly because I don’t trust the status quo.  Hospital birth? Eek. Circumcision? Hmm. Prenatal testing? No spanks. But ultrasounds weren’t on the list. We’ve all seen the movies: the squirt of the transmission gel on a big, round belly, the painstaking movements of the ultrasound tech wielding the sensor, staring up starry-eyed at the ultrasound screen as you gaze upon the strange being living inside of you. Ultrasounds are part and parcel to the pregnancy experience. They’re nostalgic; after all, ultrasound technology has been in use for nearly 50 years. But over the years, the use of obstetric ultrasounds has increased exponentially, occurring early and early in pregnancy.

When I started spotting very early on in my first trimester,  the first thing the doctor did was give me an ultrasound. Before 12 weeks or so, these ultrasounds are transvaginal, definitely more invasive than the abdominal kind. Most OB offices won’t do ultrasounds before 12 weeks for a few reasons. In those first few weeks, barely anything is visible – just an empty-looking gestational sac. And babies grow at varying rates during this time. I had hoped that an early ultrasound would put my mind at ease (“No, you’re not miscarrying because I see an egg sac…”) but instead, they became one of the main sources of my early pregnancy anxiety. After continuing to spot for some time, and after the 3rd ultrasound without seeing much, the doctor had me do blood work to measure HCG levels. As my previous post stated, mine didn’t rise “properly” (though there are several studies showing that many healthy pregnancies don’t fall into this doubling pattern – my mother-in-law experienced this with both her pregnancies), and this combined with the ultrasound had the doctor calling me after hours saying “Things don’t look good.”

When I went in for my 4th ultrasound to confirm that, indeed, things did not look good, I saw an egg sac and a fetal pole – good signs that the pregnancy was progressing normal. “This is why we try not to do early ultrasounds,” said the doc. “Babies just grow at different rates.” Well then, did I have an ultrasound-happy obstetrician? Should I have refused the first few ultrasounds? Shouldn’t she have told me that spotting in early pregnancy is normal and we won’t find any results on the ultrasound for another week or so?

On average, a woman with a low-risk pregnancy will have 2-3 ultrasounds total her entire pregnancy. By the time I was 13 weeks, I had already had 6, not counting the basic anomaly scan at 18 weeks. Did all of these ultrasounds put me at ease? Yes and no. Yes, seeing my little babe’s heart flutter on the screen helped me rest assured. But those random and uneventful weeks when ultrasounds weren’t necessary (usually, the midwifes will just check the fetal heart rate with a monitor), I found myself worrying that they were missing something. Because my pregnancy was so closely (and literally) watched in those first few weeks, I get uneasy when so much time passes without peering inside my womb.

My mother and women in her generation went almost their entire pregnancies without the use of ultrasound technology, with only one or two scans. Before this century, the first time parents saw their children was outside of the womb. Nowadays, ultrasounds are used to determine any number of fetal or placental anomalies way before due date, as well as identifying the sex of the child. Most would argue that these are positive advancements. And I would argue that, certainly, being prepared for your child and all its possible needs sure beats being shocked. But I can only wonder if ultrasound technology (not to mention prenatal testing in the form of blood work and amniocentesis), is contributing to the Too Much Information epidemic of which most modern pregnant women are suffering.

A close friend from mine went in for a routine ultrasound during her pregnancy, which ended up being a rather traumatic experience. The ultrasound showed a soft marker for Down Syndrome  (heart calcification), which meant that their child had a 1 in 400 chance of having an extra 21st chromosome. Most of the time, the calcification clears up and has zero effect on the child. But instead of being reassured with the statistics, my friend and her partner were ushered into a room to meet with a genetic counselor, though they had previously mentioned that no such counseling was necessary (as abortion was not an option). Several months later, they welcomed a healthy, ‘normal’ child into the world, though they spent the last few months of pregnancy wondering with some trepidation about the fate of their child.

My sister experienced something similar during one of her routine ultrasounds. The tech found choriod plexus cysts in the fluid around the baby’s brain – pretty non-threatening in and of themselves, but a soft indicator of genetic abnormalities like Edwards syndrome. Most of the time, these cysts will clear up by 24 weeks, and the midwife reassured my sister that she likely had nothing to worry about. Nonetheless, the waiting time is always stressful, even if you feel called to welcome all life into the world. Of course, at 24 weeks, another ultrasound showed that the cysts had cleared up.

There are plenty other stories like this, with expecting parents encounter disconcerting news through an ultrasound that later turns out to be a non-issue. Before the advent of ultrasound technology, how many healthy babies were born who, while in-utero, also had heart calcification and or plexus cysts?  How would we ever know? Are ultrasounds giving pregnant women too much information to stress over during an already stressful season of life?

Plenty  of women use ultrasound technology to determine the sex of their child. And though this seems pretty benign (and often is – again, who doesn’t want to be prepared?), there is one sinister effect: sex-selective abortion. Yesterday, I was listening to a Freakonomics podcast called “Misadventures in Babymaking,” about the the one-child policy in China. According to the podcast, the natural sex ratio at birth in all human populations is 105 boys to 100 girls, because baby boys are fragile and die more often in infancy. In China, however, the ratio is more like 121 boys to 100 girls. This is known as the “Missing Women Problem,” which dates back to an observation Amartya Sen made in 1990. He compared the total number of women in all of Asia (not just China) with what should have been the natural sex ratio, and found that a hundred million women were missing, i.e., 100,000,000 baby girls were never born.  Some estimate that that number is now 160 million missing women. The son preference spans many different countries, including China, India, Vietnam, South Korea, Taiwan, Armenia, Albania, Azerbaijan – places with very different political, economic, religious and cultural perspectives. Yet the one thing that ties these countries together is the ultrasound. In the words of Stephen Dubner, “One piece of technology. 160 million missing women.” Dubner also points out that the ultrasound machine didn’t create this kind of problem, but it does enable it: “‘Son preference’ already existed, but along came a new birth technology that let mothers do something about it. Technology has consequences – often unintended ones.”

Sex-selective abortion, like the 90% abortion rate of fetuses with Down Syndrome, is disturbing on a number of levels. But what’s especially chilling is that ultrasounds are not 100 percent accurate. I know several women who were told they were having a girl that turned out to be a boy (or vice versa). I’ve also heard countless stories of women pressured to abort their “severely disabled fetus” that turned out to be perfectly healthy (or a perfectly wonderful disabled child). Ultrasounds, though useful in moderation, have become like gods dispensing knowledge that determines the future of our children. We should all find this worrisome.

But I also know that ultrasound technology has enabled women with poor fetal diagnoses to connect with their in-utero children who will almost inevitably die after birth. My friends Dayna and Eric learned that their child had a fatal birth defect, anencephaly, at their 20 week ultrasound. They also learned that their child was a boy, and so they named him Ethan and spent the next 5 months bonding with him and preparing for his birth and his death. Their story is heartbreaking and lifegiving, and if it weren’t for that fateful ultrasound, they would never had known how little time they had with their son.

So, all that to be said, I feel ambivalent about ultrasounds, as I do with most medical technology surrounding birth.  I know some women refuse ultrasounds for their entire pregnancy, perhaps in protest of the above, perhaps because a few studies show ultrasounds may have a negative effect on fetal outcome, or perhaps because they find not knowing more comforting than knowing too much. Whatever the reason, I admire these women. So brave! So at peace! So old-school! Yet, I can’t help but continue to cling to the reassurance the ultrasound gives me, and rejoice in the brief glimpse of the little stranger growing inside of me. I’m still amazed by the grainy black-and-white picture on my fridge that shows 2 tiny feet and 10 tiny, fully-formed toes.

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