Technoscience in Prenatal Care
Carina Mattsson
Department of Human Work Science, Lulea University
S- 971 87 Lulea, Sweden,
tel.:+46 920 72068
fax.:+46 920 91030,
e-mail: Carina.Mattsson @ard.luth.se

Abstract

From time immemorial we have sought knowledge concerning the unborn child. Our search for
knowledge has been intensified through the use of scientific methods. Medical technology has
greatly added to our knowledge of fetal development and our capacity to  ÔseeÕ the unborn child.
The increased use of technological devices in maternity care is now and then the subject of debate. I
have examined papers and articles for analysis of the debate on the use of ultrasound scanning as a
prenatal technology. I raise the question of what these different arguments imply for research and for
the presentation of science and technology in prenatal care.

I outline the standard view on the use of ultrasound scanning in Swedish maternity care:that the
scanning procedure is harmless and is used primarily to determine the babyÕs gestational age. i also
present four other views that also can be identified in the debate. They concern womenÕs
reproductive integrity, medical and psychological benefits, medical and economic issues, and our
interest in ÔseeingÕ the fetus. I examine the types of argument used to back up these views and
discuss what consequences different types of argument have for research and for the presentation of
science and technology. What messages do we convey when we introduce a specific technique? What
effects do these  different messages have on the prevailing view of knowledge within prenatal care?
How do we work to achieve the object that all women should have access to the knowledge and
resources they need to judge the use  of a specific technique in respect of their own particular needs?

 INTRODUCTION

Medical technology has greatly added to our knowledge of fetal development and our capacity to
ÔseeÕ the unborn child. The relatively new ultrasound technology was developed within the
military-industrial complex and has been used in several areas outside medicine, like submarine
detection, industrial flaw detection, and industrial cleaning (Blume, 1992;Yoxen,1987; Moskowitz,
1993).The technology is widely used in medicine. In obstetrics and gynaecology it is used for
screening pregnant women and for examination of both pregnant and non-pregnant women due to
other indications. The anatomy of the fetus can be imaged with real-time scanning for diagnosis, and
we can obtain facts in direct contact with the fetus using technical equipment.

In Swedish maternity care ultrasound technology is used primarily to determine the gestational age of
the fetus. The technology is used as just one of many health checkups during pregnancy. Many of
these health checkups are effective and generally accepted. Among these are the checkups organised
by the Country Council in preventive maternity care. However, the increased use of technological
devices in maternity care is now and then the subject of debate, and some methods used in preventive
health care are at present being questioned. This concerns above all the routinized health
examinations in the form of so-called screenings that have been decades there has also been a
growing interest in the social consequences of prenatal screening tests for the woman and her family.
This may be related to the fact that the number of possible prenatal  screening tests has increased
rapidly(Rubin et al, 1983).Until recently there has also been a lack of research interest in innovations
of special interest for women, like technologies linked to their roles as child-bearers and child-rearers
(Berner, 1993).

In this paper I have examined papers and articles for analysis of the debate on the use of ultrasound
scanning as a prenatal technology. I do not attempt to present a developed medical sociology. My
aim is here to examine the argument s made in the debate. I raise the question of what these different
arguments imply for research and for presentation of science and technology in prenatal care. I
begin by outlining the standard view on use of ultrasound scanning in Swedish maternity care:that the
scanning procedure is harmless and is used primarily to determine the babyÕs gestational age. I also
present four other views that can be identified in the debate. They concern the following issues,and
our interest in ÔseeingÕ the fetus. I examine the types of argument used to back up these views. There
are gaps and methodological differences between the studies chosen for analysis,though these studies
have many common themes and the arguments presented. I want to point out that the diversity of
opinion reflected in the various studies should not be overlooked. The views of some women are not
necessarily shared by all women. Finally, it must be noted that the research discussed has almost all
been reported in the English,Swedish, and Norwegian languages. Not all of these studies have been
fully published, and some have remained in the form of reports or occasional papers. A number of
such unpublished studies have no doubt been missed because they have not come to my attention. I
have examined papers published up to the end of March 1995.

The Standard View

This view is that the scanning procedure is harmless and is used primarily to determine the babyÕs
gestational age. Ultrasound scanning is almost a routine procedure in maternity care in Sweden
today. This technique has caught the public imagination in a manner untypical of medical
procedures. It has been  found to be generally acceptable and is positively demanded by many
women and those close to them. The general acceptability of the procedure to mothers and their
positive demands for it has become part of the justification of its use. The supporters of what  I call
the standard view all helped to justify the routine use of ultrasound scanning. However, scanning
praxis has to a great extent been formulated by the physicians. It has been defined as a question of
medicine. The technology is certainly a question of medicine, but its consequences are also
existential, psychological, juridical, and social. Public acceptance of the technology has probably
been facilitated by the high level of confidence in the authorities involved in health care in Sweden.
There are exceedingly few people who inform themselves about the pros and cons of medical
examinations (Waldenstrom,1994).

The implementation of routine ultrasound scanning during pregnancy in Sweden started in the late
seventies. Since the screening procedure became everyday routine in maternity care, the number of
examinations per pregnancy has increased and several examinations are performed during longer
periods of time. The common view in health care is that ultrasound examination during pregnancy is
harmless to the fetus. All pregnant women are offered an ultrasound examination around the
seventeenth gestational week. 99.5 per cent of the women choose to participate (Jorgensen,
Agerg,1993).

When the health authorities offer women an ultrasound examination, their information varies a lot.
The women are informed verbally and in writing that the purpose of the examination is to:


(1) determine the babyÕs gestational age;
(2) detect multiple pregnancies;
(3) detect any possible serious abnormalities of early pregnancy.

The written information presented to the women at the prenatal clinic is taken from the publication
ÒExpecting a childÓ[in Swedish:Vsnta barnÓ](1994), issued by the Swedish Medical Research
Council.

ÒMost prenatal clinics offer routine ultrasound examinations. The technique is used to measure the
size of the fetus and thus estimated its gestational week and the time when the child will be fully
developed. It is possible to discover twins and locate the placenta. The examination is painless and is
considered absolutely harmless. The ultrasound scan is not compulsory, and one is free to refuse an
invitation to be examined. It is a good method for determining the length of your pregnancy, though
you often know yourself when you became pregnant and how many weeks the fetus is.Ó (From
ÒExpecting a childÓ)

In addition to this the midwife can give verbal information. There is great variation concerning how
detailed this information is (Lindmark, Ottosson, 1993).

Alternative Views 

The alternative views I presented should not be considered as mutually exclusive. This presentation
should be regarded as a way of structuring  information for discussion of the issues presented. In
practice many studies represent a mix of views and sometimes it is difficult to categorise the studies.

 WomenÕs reproductive integrity

Reproductive technology has involved enormous changes to the reproductive integrity of women. A
great number of women worry about the risk of giving birth to a seriously ill or injured child. They
can regard the techniques as positive since they can offer them control of the fetus. Other women
regard the technology as a threat to their reproductive integrity. Their self-determination feels
reduced and they can more or less feel forced to submit to the technique. Those who adopt this view
are mainly feminists. The proponents are concerned about the widespread increased  reliance on
technology and that Ôonly high-tech care is of real valueÕ. They fear that detailed information on
fetal development provided by medical technology can supersede maternal reports about their own
pregnancies, such as information  about the conception date, fetal position, fetal movement and the
like. Rather than relying on pregnant womenÕs accounts of how they experience their pregnancies, or
even physical examination of womenÕs bodies,doctors now can rely on the ÒobjectiveÓ, measurable
data generated by machines (Wajcman, 1991). New technologies help to create a situation where
gynaecologists and obstetricians Ôknow moreÕ about pregnancy and about womenÕs bodies than
women do themselves (Stanworth, 1987). Oakley draws attention to a risk associated with the reliance
on technology. When doctors choose to trust technologically produced data in place of womenÕs
observations about their own bodies and fetuses, it becomes Òpossible to ignore the status of pregnant
women as humans beings;Ó and, when machine-generated data are deemed more reliable than
womenÕs self-knowledge, Òthen the woman does not need not to be asked anymore(Oakley,1987).Ó
Proponents of this view are afraid that pregnant women can experience a diminished sense of
competence in the face of sophisticated medical procedures; and that they sometimes will lose
confidence in their own instincts and knowledge about their pregnancy and fetus.They may seek
reassurance by relying on the information produced by technology, such as the external fetal images
generated by ultrasound technique, rather than their own bodily sensations (Petchesky 1987).

The technique can also be regarded as an anxiety-creating technique. The very existence of screening
programmes creates anxiety in women and further ÔmedicalizesÕ pregnancy. Rothman (1986)
describes how the very existence of prenatal diagnosis puts the women into a horrifying dilemma. If
she undergoes amniocentesis she must risk damaging a normal fetus, and then decide, if something is
ÔwrongÕ, whether to abort a wanted child. Throughout the long wait for the fetus move (Birke et al
1992). This medicalization of the pregnant woman is supposed to pose a threat to the reproductive
integrity of women.

Connected with this threat to womenÕs reproductive integrity is the social pressure women can
experience. The social pressure to commit oneself to a screening programme is great. Women can,
for example, internalise social pressures, ÒchoosingÓ to use technologies in the absence of perceived
alternatives (Rothman 1986;Gregg 1993). Even when doctors do not recommended procedures or
tests specially, women face other pressures Ð from family members, friends, co-workers, and media Ð
to use particular technologies has the potential to increase the pressures women experience, by
influencing public opinion and public polices regarding human procreation. The ensuing attitudes
and policies may make womenÕs procreative and prenatal choices increasingly difficult. The choices
pregnant women face can leave them with a growing sense of insecurity or inadequacy. Women can
experience the weight of an exaggerated burden of personal,individual responsibility. There is a
freedom in making prenatal choices, but these choices are often accompanied by social and internal
pressures, and feelings of ambivalence and guilt.


Medical and psychological benefits 

The emphasis of this part of my presentation is the psychological benefits to be derived from
ultrasound screening. Proponents of this view emphasise that the examination can provide the women
with great pleasure and benefits both the mother and child. Ultrasound is considered potentially
harmless biologically to the unborn child. Ultrasound enables  the mother and father to see their
child in the uterus, and a common views is that the method also is psychologically beneficial to the
pregnant mother and her baby. Proponents of this  view stress above all Ôthe bonding argumentÕ: that
ultrasound is reported to promote the bonding of the parents with the fetus (Fletcher and
Evans,1983). A randomized control study Waldenstrom et al (1988) found that babies of mothers
scanned had higher birth  weights than those of mothers who did not have an ultrasound
examination. The bonding effect as here hypothesised is mediated by the experience of ultrasound.

Being  able to see her unborn child on an ultrasound monitor could also have a beneficial emotional
effect for a mother who has ambivalent feeling about her pregnancy or is particularly worried,
anxious,or depressed about the prospect of having a baby. Findings of Milne and Rich (1981)
conclude that increased maternal awareness of the pregnancy arising from having viewed the
ultrasound foetal image, aids ÒbondingÓ between the mother and baby; and that maternal anxiety
often is reduced following scanning.

Women are reported to be very positively disposed to the examination. There is a common view that
the scan is nothing more than an easily performed medical procedure, according to positive
experience of the examination should continue as a routine in the maternity care controls, and feel on
the whole reassured concerning the examination. Within the majority of women who from the
beginning have a positive attitude to their sense of contact with the expected child grows
(Nathorst-Boos, 1986). Thorpe et al (1993) found an immediate satisfaction obtained from the
feedback provided by ultrasound but also an underlying uncertainty about its safety.

Regarding the medical benefits it should be mentioned that artificially started deliveries have
decreased, and there is a lower risk of complications and emergency Caesarean operations. Fewer
births occur after the full term of pregnancy (Sandberg, 1994).

Medical and economic uncertainties 

Experimental evidence of the benefits of ultrasound screening is still debated in the literature, and
there is an even balance between those who conclude that the technique is beneficial and those who
conclude that it is not.There are critics who emphasise that the technology in not proved safe
(Waldenstrom, 1994; Verny, 1987). They argue that the application of ultrasound in prenatal care
does not have a history of sufficient duration to enable an assessment of the long-term consequences
of its use. Experience of ultrasound screening has shown it to be an effective diagnostic tool when
used with high-risk populations, but provided little support to date for its routine use with low-risk
populations (Hansson,1994;Hogberg, Axelsson, 1993; Jorgensen and Aberg, 1993)

Another criticism of the method is that the benefits are unproportional to the cost. The main problem
is that ultrasound examinations bind up resources that could be used for other purposes. A report
from  WHO shows that there are countries which spend more money on ultrasound examinations than
on maternity care on the whole (Waldenstrom, 1994). On two occasions, in 1984 and 1993, WHO
even advised its member countries to cease providing routine ultrasound screening during pregnancy.
The organization does not question ultrasound examinations performed when fetal deformities are
suspected, or to obtain information when complications are feared at childbirth. Critics also call
attention to possible, serious adverse psychological effects of wrong diagnosis (both positive and
negative) following screening.

Our interest in seeing the fetus

The arguments presented here focus on the reproductive integrity of the woman, and in my opinion
this approach is of interest as the  Òpublic imageÓ of the fetus is a concept that has recently been
appearing in the debate with increasing frequency. There is today a strong emphasis on visual
information in comparison with other kinds of information, such as enteroceptive or tactile
information. This development became particularly evident through the popularity of the
photographer Lennart NilssonÕs (1976) book, ÒA child is bornÓ[in Swedish: ÒEtt barn blir till]. The
book has been spread all over the world in extremely large editions.

Petchesky(1987) has examined our impulse to ÒseeÓ inside the womb, and asks why it has come to
dominate our ways of knowing about pregnancy. Petchesky affirms that ultrasound tends to discredit
women  felt  experience of pregnancy in favour of objective data. Duden(1993) has studied our view
of pregnancy changes when it is no longer the woman herself who experiences and defines it, but
male doctors who use a method that originated in the manufacturing industry.

Comments

The social pressure of participating in a screening programme is great. One ought to be wary of the
pressure that women are subjected to, the dilemmas that they are confronted with, and the anxiety that
they can feel. Expectant women often receive well meant guidance and advice from members of their
social environment. Besides these influences, decision-making is dependent on the individual
structure of personality with the correlated abilities to tolerate fear and to cope with real danger.
Self-confidence and self-esteem are important to enable expectant
Women to make self-responsible decisions. However, external and internal pressure on pregnant
women have probably always existed, through particular social  conventions and cultural mores
concerning ÒappropriateÓ behaviour for pregnant women and mother. The related social sanctions
may vary from place to place and from one time period to another. But an inappropriate burden of
individual maternal responsibility can be the result, especially in the absence of adequate social
supports for mothering, for people with disabilities, for prenatal care, and health care in general.

The freedom enjoyed by women to choose a prenatal technology carries with it the ÒfreedomÓ to be
blamed,  censured or sanctioned for making choices deemed inappropriate or dangerous. The further
development and use of procreative technologies can make Òwomen-blamingÓ more likely. As
prenatal tests and other medical interventions become more and more  routine, medical and social
expectations concerning pregnant womenÕs behaviour probably will increase and become more 
institutionalised. Women increasingly may face social pressures and social control, blame, and
sanctions for their actions (or inaction), their choices before and during pregnancy, in the name of
fetal health or protection. New developments in prenatal diagnostic techniques will lead to even more
choices, for individuals and society, but these choices might also lead to new avenues for the social
control of pregnant women.

With regard to the medical and psychological advantages of ultrasound examination, there is a lack of
unequivocal proof of the positive psychological effects in the literature on the subject. I am 
convinced that  there are positive psychological effects. perhaps the questions worth posing concern
rather which situations such effects arise in, which individuals experience such effects, etc.


The present study indicates that the financial aspects are not sufficiently illuminated in relation to the
advantages resulting from this method of examination. Another factor of uncertainty concerns the
problem of preventing and handling wrong diagnoses.


What is it in our society that supports our interest in seeing/confirming?  Before the woman
exclusively experienced here pregnancy from within here own body. Today, the experience of the
pregnancy is partially externalised. the photographing  of the unborn child most probably changes
the experience of pregnancy and the Òpublic imageÓ of the fetus shapes the emotional and bodily
perception of the pregnant women.In response, some women now are asking themselves how they can
protect their own experience of pregnancy from the  intrusion of these Òpublic fetusesÓ. There is
obviously an  element of doubt concerning the real significance of bringing home an ultrasound
picture of the fetus. Some people think that this is good and that the whole process becomes real for
the mother through her being able to see a picture of the fetus. others consider pregnancy to be
exclusively an inner process, and think that one ought to use oneÕs imagination and bodily sensations
to create an image of the child (Jarnefors, 1989).

Conclusions

What are the implications of these different arguments for research and for the presentation of
science and technology in prenatal care? To begin with I would like to emphasise that I do not see
technology as inherently good or bad. It has to some extent the potential of being used for good and
bad purposes. The integration of technology in systems and routines of use may lead to very
different consequences for different groups of people that encounter the technology in question.
Ultrasound is a grand achievement in the field of science which can be of advantage for the health of
the mother and, above all, for the health of the child. The problems connected with the method may
have resulted from the fact that the technology has developed quickly from being a research
instrument to becoming a method of examining, all healthy pregnant women. one should, of course ,
be able to prove beyond all reasonable doubt that the advantages of a method of examination
outweigh the disadvantages, with regard to medical, psychological and financial aspects. An analysis
of the different arguments studied indicates that this is not always the case.

What messages do we convey when we introduce a specific technology, and how is the technology
presented in different contexts ? What purposes are fulfilled by these messages  for different
categories of people, in different situations, in our society, in our part of the world? The messages are 
assumed to fulfil different purposes  for different categories of individuals, in different situations, for
our society, and in our part of the  word, etc. We can envisage that the  ultrasound scan might be
carried out for the following purposes: to gain insight into what is actually happening inside the
womanÕs body; to obtain a photo; to perform a kind of quality control; to acquire a consciousness of
the reality of the pregnancy that first comes with the photographing, and to create  enhanced
awareness and increased emotional attachment.

My analysis of the studies examined here shows that the presentation of the technology varies. In
general one can say that the pregnant woman should obtain basic information concerning the
implications of an ultrasound examination, so that she can make a proper choice as to whether she
wishes to participate or not. Also of importance is how the information is presented. the ultrasound
screening is very seldom preceded by detailed individual information and advice. The woman has
extremely limited possibilities of forming an opinion in advance one the consequences, advantages
and disadvantages of the different possible results of the examination. if one systematically provides
ultrasound scanning to search for fetal deformities, it is not sufficient to provide general information
concerning the possibility of finding certain ÒdeviationsÓ in the fetus (Lindmark and
Ottosson,1993). Moreover, if pregnant women are not actively offered fetal diagnosis, some women
will probably refrain from an examination who today have difficulties in saying no(Jarnefors,1989).
There is a  debate taking place in Sweden today concerning the guidelines that are to be followed in
connection with ultrasound screening.

What effects do these  different messages have on the prevailing view of knowledge within prenatal
care? Reproductive technologies have a potential to challenge established social and cultural norms
and values. We still do not know what the implications for society will be if genetic screening
becomes truly  widespread over the world and how it will affect the view of knowledge within prenatal
care. The view of knowledge can also be changed through new forms of perception, images, concepts,
and attitudes that are the result of the creation and application of a particular technique. What does
this new technique mean to different groups of people, clients, medical staff, and those women who
decline to make use of it? These are question to be answered.

The present study indicates that  there is variation concerning the presentation of ultrasound
technology, these  messages  that are communicate, and how the information on the technology
influences the view of knowledge. There is thus need of additional studies that illustrate these
questions.

How do we then work to achieve the objective that all women should have access to the knowledge 
and resources the need to judge the use of a specific technology in respect of their own particular
needs?  The variation in our view of ultrasound technology is, in my opinion, proof of the fact that
there is an important need for more empirical studies in this area. Moreover, it is important that
prenatal diagnosis should be discussed in society and that the ethically difficult questions should be
illuminated. The pregnant couple can then, even before their visit to the prenatal clinic, acquire good
insight and find it easier to choose. In addition, it is, of course, extremely important to avoid wrong
diagnoses and preserve the womanÕs integrity and self-determination. There is also a risk that the
openness that prevails with regard to reproduction is an openness that can be exploited by politicians,
medical staff, experts and industries in technological instrumentation. In certain countries ultrasound
is used to diagnose the sex of the unborn child, so that parents can then decide whether or not to
abort female fetuses. Global experience of developments in this direction are frightening. Moreover
today there is a demand  for sex diagnostics in our increasingly multicultural society. We must decide
how we wish to utilise the technology and where development is leading us. Even now we can use the
technologies differently, integrating them  into a more holistic clinical dialogue between  womenÓs
felt knowledge and the technical information ÒdiscoveredÓ on the screen.

Acknowledgements

The following people have given valuable help in discussing this questions, but are in no way
responsible for the paper: Elisabeth Gulbrandsen, Annika Forssen, and Christina Mortberg at Gender
and Technology, Lulea University.

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