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Receipt of information and womenÕs attitudes towards

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 ORIGINAL PAPER
7
Ultrasound Obstet Gynecol 2002; 19
: 7Ð12
Blackwell Science Ltd
Receipt of information and womenÕs attitudes towards ultrasound scanning during pregnancy
D. K. WHYNES* for the Nottingham Pregnancy Diary Research Group
*
School of Economics, University of Nottingham, Nottingham, UK
KEYWORDS
:
Information, Pregnancy, Satisfaction, Ultrasound
ABSTRACT
Objective
To audit womenÕs receipt of information during
routine antenatal ultrasound investigations; and to investi-
gate womenÕs perceptions of, and attitudes towards, routine
screening.
Design
Analysis of the records of 384 women from in and
around Nottingham, UK, who maintained a diary through-
out the course of their pregnancies.
Results
The mean number of ultrasound scans received by
each women during her pregnancy was 2.6, with more than
96% of women receiving at least one scan. Women initially
scanned earlier received more scans in total. Women appeared
aware of the specific reasons for each scan being undertaken,
and only a minority were dissatisfied by the information they
had received. The preponderance of information received
during the scans related to results and arrangements for
subsequent visits, with only 10% of women reporting receiv-
ing information about the procedure itself. Most women
reported positive feelings towards scanning, and few gave
indications that they would prefer changes in the conduct of
the procedure.
Conclusions
The great majority of the women in our study
were satisfied with their experiences of routine ultrasound
scanning, accepting the procedure uncritically.
INTRODUCTION
Since the 1970s, ultrasound scanning has become a routine
element of antenatal care, both in Europe
1
and in the USA
2
.
As a diagnostic test, it facilitates an accurate estimate of
gestational age and enables checks to be made for abnor-
malities and the presence of multiple fetuses
3
. Although the
cost-effectiveness case for routine scanning remains far from
proven
4
, there are grounds for believing that it might be cost-
saving to the healthcare system
5
.
Over and above its diagnostic capabilities, routine ultra-
sound scanning has important psychological consequences.
It can reduce anxiety in subjects
6,7
, stimulate a parental bond
with the fetus
8
and contribute to positive health behavior
9
.
A subject preference for routine, rather than selective, ultra-
sound is indicated by trial evidence
10,11
, as indeed is a psy-
chological benefit for receiving ultrasound at the first antenatal
visit
12
.
Average psychological consequences for a trial cohort,
however, will almost certainly be hiding interindividual vari-
ations. Although scanning in cases where test results are neg-
ative typically does offer reassurance and decreases anxiety,
imparting the results of scanning which reveals fetal anoma-
lies significantly increases the subjectsÕ anxiety levels
13,14
.
Moreover, and in spite of this never having been the clinical
purpose of the investigation, many prospective parents see
the ultrasound scan as a means of learning about their future
childÕs gender
15,16
. Evidence suggests that women who learn
they are carrying a fetus of the ÔwrongÕ gender, according to
prior aspirations, are more depressed and experience more
labor problems
17
.
Continuing the theme, the level of reassurance benefit or
anxiety reduction resulting from the use of ultrasound is likely
to be a function both of the quality of the information flowing
to the prospective parents from the care professionals
18,19
and
the parentsÕ specific psychological dispositions or Ôcoping
styleÕ
20
. Scanning as reassurance depends not on the ultra-
sound image per se
but on the expectation created and the
interpretation put onto it. On presenting for ultrasound, the
majority of women appear uninformed as to both the pur-
pose and the safety of the investigation
21
. One panel of women
faced with an experimental information leaflet, for example,
was ÔshockedÕ when informed that the technique actually had
a non-zero false-positive rate
22
. Subjects often display a mis-
understanding of ultrasoundÕs capability, typically expecting
more information than the technique is capable of delivering
23
.
The psychological impact of scanning, in terms of satisfac-
tion with the experience, thus depends in large part upon
how subjects perceive the procedure. Perception itself is a
Correspondence: Prof. DK Whynes, School of Economics, University of Nottingham, Nottingham NG7 2RD, UK (e-mail: david.whynes@nottingham.ac.uk)
Accepted 13-6-01
UOG_517.fm Page 7 Thursday, December 27, 2001 2:51 PM
WomenÕs attitudes towards ultrasound scanning Whynes
8
Ultrasound in Obstetrics and Gynecology
function of understanding and information received, the latter
not necessarily being equivalent to that which professionals
believe they have imparted during the procedure. We pre-
sent the results of a study of routine antenatal ultrasound,
undertaken in Nottingham, UK, during 1997Ð98, concerned
to understand womenÕs attitudes to the procedure, in the light
of the information which they believe they have received.
METHODS
The data used were a subset of those collected during the
Nottingham Pregnancy Diary project. This project was designed
to generate subject-initiated data on a great many different
aspects of maternity care, covering the entire period between
the confirmation of pregnancy and several weeks beyond
birth. Women were invited to record both objective events
(e.g. each contact with a care professional for antenatal,
maternity and postnatal care) and subjective responses (such
as feelings, fears, anxieties and satisfaction with care at all
stages). Of necessity, the diary was a substantial document,
running to some 150 pages in A5 format. The content was
semistructured, incorporating both open- and closed-ended
questions, with blank pages available for further, written
comments. The project received full ethical approval, and a
detailed description of the diaryÕs construction and content
has been published previously
24
. Aggregate analysis of the
diary results has suggested that there are no substantial grounds
for believing that those completing a diary were unrepres-
entative of either local or national populations
25
.
In total, 706 subjects were invited to participate in the
diary project (all women whose pregnancies were confirmed
and booked in one particular calendar month). No specific
exclusion criteria were imposed. With respect to antenatal
ultrasound, respondents recorded the date and location of
each scan received. They expressed their feelings towards
each scan on a five-point Likert-type scale, ranging from Ôvery
negativeÕ to Ôvery positiveÕ and were invited to add any written
comments which they felt were appropriate. For each scan,
they recorded what they understood to be the reason for the
scan, based on any information that had been provided to
them or for which they had asked. A checklist of nine spe-
cific categories of reason was presented to them, including
Ôno reason givenÕ and Ôother (please specify)Õ. They also
recorded the content of any feedback of information from a
healthcare professional, and commented on anything they
would have liked to have been different about the scanning
procedure.
All scans were conducted within the National Health Ser-
vice (at no cost to the subject), at either the City Hospital
(66.2% of subjects) or the University Hospital (33.8%). Both
hospitals encourage partner and family attendance for ultra-
sound. Scanning was conducted according to the regular
protocols of each of these hospitals, although, for all of the
following analysis, the screening site emerged as an insigni-
ficant factor in explaining the results.
RESULTS
Diaries were returned by 397 women (56.2% of those to
whom diaries had been issued). Of these, 384 provided records
for ultrasound procedures, and the analysis is based on this
sample. The median (SD) age was 28 (5.5) years (mean 27.7;
range 15Ð43 years). The majority of subjects (92.9%) clas-
sified themselves as Ôwhite CaucasianÕ, followed by ÔIndian/
PakistaniÕ (3.1%) and ÔWest IndianÕ (1.6%). Nearly one-half
(44.8%) of the women had no previous children, 37.3% had
one and the remainder (17.9%) had two or more. Seventeen
women had previously experienced one or more terminations
and 31 had experienced one or more miscarriages (five had
experienced both).
Number of scans
The 384 women recorded a total of 989 scans, implying a
crude mean of 2.6 scans per woman. The modal number of
scans was two per woman, and the maximum received by any
one person was nine. The median date for all those receiv-
ing their first scan was 15 weeks of gestation (interquartile
range 12Ð17, mean 14.3, SD 4.0), for all those receiving their
second scan, 19 weeks (interquartile range 18Ð20, mean
19.2, SD 5.7) and the median date for all third scans was
24 weeks (interquartile range 19Ð34, mean 25.9, SD 8.5).
Table 1 categorizes the sample by total number of scans
received by each woman and the date of her first scan. There
was a significant statistical association between the date of
the first scan and the number of scans which women received
throughout the course of the pregnancy, i.e. the earlier the
first scan then the more scans experienced in total (one-way
analysis of variance, F
= 31.7, P
< 0.01). We were unable to
identify any statistically significant sociodemographic deter-
minants of the total number of scans received by women (e.g.
by age, social class, housing type, ethnicity and educational
level). Women with previous experience of miscarriage or
termination appear to have been followed more closely. They
Table 1 Number and timing of scans received throughout the pregnancy
Week at first scan
Total number of scans received Number of subjects Proportion of sample (%) Mean SD
1 75 19.5 18.0 3.1
2 144 37.5 14.6 2.9
3 88 22.9 13.1 3.8
4 61 15.9 12.0 3.9
5 and above 16 4.2 11.4 5.1
Total 384 100.0 14.3 4.0
UOG_517.fm Page 8 Thursday, December 27, 2001 2:51 PM
Ultrasound in Obstetrics and Gynecology
9
WomenÕs attitudes towards ultrasound scanning Whynes
received a higher mean number of scans than those without
such experience (2.9 vs. 2.4; MannÐWhitney Z
= 2.6, P
= 0.01),
although the week of their first scan was not significantly earlier
(MannÐWhitney Z
= Ð1.6, P
= 0.11).
Reasons for ultrasound scanning
For the sample of scans as a whole, 62.9% of women claimed
that they were provided with one or two reasons for their
scan, whilst 22.0% noted four reasons or more, up to a
maximum of eight. These reported reasons for scanning are
classified in Table 2, according to the checklist provided
to subjects. As is evident, the widest variety of reasons was
offered in the earlier rounds. The determination of likely birth
data, imaging of the fetus and checking for multiple fetuses
were relatively more important in the first and second scanning
rounds, whereas checking for fetal growth and allied clinical
progress continued throughout the ultrasound regimen.
Women destined to have a larger rather than smaller num-
ber of scans during their pregnancy recorded a significantly
smaller number of reasons per scan (chi-squared = 96.5,
P
< 0.01). By implication, each of these scans could be inter-
preted as being more functionally specific. The date of first
scan was significantly earlier for women offering ÔotherÕ reasons
(9.7 vs. 14.7 weeks, t
= 7.2, P
< 0.01), checking for a viable
pregnancy and bleeding being the most frequent other reasons
specified.
Positive and negative feelings
Table 3 presents satisfaction or subjective feelings scores,
for the full sample of scans and by scanning round. Overall,
feelings were overwhelmingly positive, with approximately
three-fifths of all scans receiving the highest possible satisfac-
tion score and only 6.4% engendering any sort of negative
feelings. Within the broad trend, however, the distribution of
feelings scores moved significantly away from the positive
end as the screening round increased (chi-squared = 8.9,
P
= 0.03).
Information provided at the time of scanning
For 89.9% of the total sample of 989 scans, women recorded
written comments about the information they were given at
the time of each scan. The diary entry began: ÔThe informa-
tion I was given at the scan wasÕ, and women were requested
to complete the statement in their own words. We reviewed
the entire set of comments and concluded that the data were
amenable to classification under three headings, namely,
descriptions of information content, assessment of information
value and assessment of information quality. In a number of
cases, women made comments classifiable under more than
one heading, giving rise to 1081 responses classified within
the framework.
Descriptions of information content constituted 43.2% of
all responses. Of these, four out of every five (79.9%) indi-
cated that the information provided was specifically about
the baby (e.g. age, sex, size, position, weight) or the placenta.
Only 10.3% of comments indicated that information about
the nature of the procedure itself was communicated. The
remaining responses pertaining to content described advice
and date for the next scan. Statements assessing the quality
of the information comprised 40.1% of all responses and,
of these, 99.3% felt the information had been reassuring.
Only three women assessed the information provided as
worrying. Further examination of their diaries indicated
that there were problems with the pregnancies, suggesting
that their worries were about outcomes rather than the pro-
cedure itself.
Finally, 16.7% of responses related to information quality.
Of this group, 78.3% indicated that the information had been
comprehensive, 19.4% indicated vagueness or information
being too simple or basic and 2.2% admitted to not having
understood the information.
We proceeded to generate a further three-way typology for
the information data, consisting of:
Table 2 Stated reasons for scanning, by scanning round (% of women stating they were given that reason)
Reason 1st 2nd 3rd 4th 5th and above
To determine the date of birth 65.9 18.8 8.5 3.9 4.9
To see the baby 41.4 26.5 15.2 14.3 12.2
To search for abnormalities 47.4 61.5 47.3 36.4 39.0
To check for growth 34.9 62.5 58.2 53.2 58.5
To check for twins 32.6 6.5 1.2 1.3 2.4
To examine the placenta 21.6 25.9 29.1 27.3 41.5
To obtain a picture/image 26.3 17.8 8.5 2.6 4.9
Other reason 8.1 13.6 17.0 16.9 22.0
No reason given 8.6 4.2 2.4 3.9 0.0
n 384 309 165 77 41
Table 3 Feelings, by scanning round (%)
Feelings 1st 2nd 3rd > 3rd Full sample
Very negative 3.2 1.0 2.5 6.6 2.7
Negative 2.6 5.0 3.7 3.8 3.7
OK 10.3 10.9 17.2 17.0 12.4
Positive 21.2 20.5 18.4 22.6 20.6
Very positive 62.7 62.7 58.3 50.0 60.5
n 378 303 163 106 950*
*39 missing.
UOG_517.fm Page 9 Thursday, December 27, 2001 2:51 PM
WomenÕs attitudes towards ultrasound scanning Whynes
10
Ultrasound in Obstetrics and Gynecology
(i) Factual information, defined as a scan description which
mentioned only content;
(ii) Positive information, interpreted as a scan description
which included the comment either that the information was
comprehensive or that it was reassuring, or both;
(iii) Negative information, where the response indicated
finding the scan worrying and/or the information vague or
hard to understand.
Feelings about scans where positive information was deemed
to have been imparted were significantly more positive than
either those where factual or negative information were imparted
(chi-squared = 74.44, P
< 0.01).
What would women want to change about their scans?
Here the diary entry began: ÔThe thing I would most like to
change about having the scan isÕ, and women were requested
to complete the statement in their own words. The wording
of the statement enabled us to interpret no response as no
desire for change. Of the sample, 66.6% left the field blank,
although a further 11.8% explicitly entered ÔnothingÕ. There-
after, 68 women (6.9% of the sample) expressed a wish to
change the procedure, 28 of them explicitly mentioning a
desire for longer or more thorough consultations. Twelve
explicitly mentioned the discomfort of having a full bladder.
Sixty-five women (6.6%) cited information flow as the area
for improvement, with 40 wanting more detail on interpreta-
tion of the screen image and 20 wanting fuller inclusion in
discussions, especially with respect to those accompanying
the subject. Fifty-three women (5.4%) indicated that, on
reflection, they would have wished different people to have
been present at the scan, either family or professionals. Finally,
27 women cited the timing of the appointment as the problem,
with 23 requesting shorter waiting times.
The preferences for change were examined for consistency
across scanning rounds. We were unable to establish any
relationship between the round and comments relating to
changes in informational content or changing the procedure
itself. Understandably, women who failed to indicate a pre-
ferred change or entered ÔnothingÕ recorded more positive
feelings about their scans than those who made explicit state-
ments about wanting to effect changes (chi-squared = 18.16,
P
< 0.01).
Textual analysis
Although we have, thus far, analyzed the open-ended diary
records on the basis of inference as to content, the precise
forms of words used convey meaning. From the regularity
with which it was noted, discovering the gender of the fetus
was clearly both important and a source of pleasure. The senti-
ment was typically expressed very simply: Our baby is a girl,
yippee! or: ItÕs a boy! all well. On occasions, more lengthy
comments appeared:
We really wanted to determine the sex of our baby, but
the midwife was not keen on finding out, and told us she
couldnÕt tell. The scan was the highlight of the pregnancy
so far. [Scan at 33 weeks]: At this stage I really would have
liked to have another scan. I requested this but was told
this was not routine unless major concerns. We both really
want to know if it is a boy or girl.
None of the subjects recorded disappointment at discovering
fetal gender, although we suspect that any woman experien-
cing such sentiments would be unlikely to commit them to
paper. This having been said, the gender issue was some-
times handled unsympathetically from the subjectÕs point
of view:
I feel that the midwife jumped in too quick when I asked
about the sex of the baby. She didnÕt say Ôare you sureÕ or
even consult my partner, she just went straight down, we
also had to sign a form acknowledging the fact that if
the babyÕs sex turned out opposite to prediction, that we
wouldnÕt sue themÑit was quite formal.
As noted earlier, ultrasound can be a double-edged sword
with respect to womenÕs anxieties, depending upon outcome.
Contrasting perceptions emerge clearly from the following
diary records from two different subjects:
[Scan at 13 weeks]: I was really frightened prior to my scan
because of bleeding and previous miscarriage. But we had
a lovely midwife who put us at ease and made the scan
lovely. [Scan at 21 weeks]: Although I was anxious that
they might find a problem with the baby it was nice to see
our child. The detail was good and the explanations to my
husband and myself were excellent. Even the untrained
eye could make out some detail such as the spine and the
hands and feet. Even its stomach and heart were obvious.
Brilliant!
[Scan at 15 weeks]: Upsetting and disheartening ... The
hospital scan showed two cysts on the brain. I was on my
own and was too shocked to ask many questions ... The
information I wanted would have been given to me, it was
just such a shock you donÕt know what to ask there and
then ... After my visit, my midwife spoke to my doctor
because I was worried. DrÑ phoned me that evening to
reassure me, my midwife also phoned on two occasions
afterwards before I went back to hospital to see if it was
alright.
Multiple scanning beyond four rounds was rare in the sample,
and uncertainty relating to a repeated investigation was
expressed only in one (evidently resolved) case:
[Third scan at 20 weeks]: I would have liked more informa-
tion about the scan, i.e. size of baby, what they were looking
for and if everything was OK. [Scan at 26 weeks]: I am not
sure all these scans are necessary. Are they sure they are
safe? [Scan at 30 weeks]: I have accepted that this is normal
procedure now and stopped worrying.
As judged by a lack of textual evidence to the contrary, an
acceptance of the routinization of scanning was clearly evi-
dent (even for this multiple scan subject). Only two women
UOG_517.fm Page 10 Thursday, December 27, 2001 2:51 PM
Ultrasound in Obstetrics and Gynecology
11
WomenÕs attitudes towards ultrasound scanning Whynes
provided evidence of exerting a degree of control over their
own management:
[Visit to GP at week 6]: I found the visit very reassuring,
and was able to dispel some of my anxieties. I was also
helped to decide that careful monitoring wasnÕt necessary
for me. IÕm not the sort of person to be able to stop my life
over something that might or might not happen. Also I
reached the decision that an early scan would not be a good
idea as it would make the baby very real, and therefore, if
I lost it later, it would be harder to deal with.
[Scan at 22 weeks]: I did consider not having a scan this
pregnancy, but eventually decided that I would have it
later. In both of my previous pregnancies I have had a scan
at 18 weeks and have been asked to return as things did not
appear normal (minor difficulties). However, when I returned
everything was fine, in the meantime I had unnecessary
worry. I managed to avoid this this time. I am confident of
my due date and a termination would not be something
I would consider, so therefore there is no reason to have
the scan at 18 weeks. My GP gave me full support in this
decision.
DISCUSSION
Survey evidence indicates that over 80% of departments in
the UK undertake detailed anomaly screening at 18Ð20 weeks
of gestation. Many also offer a ÔbookingÕ or dating scan, to
facilitate the planning of any surveillance strategy or further
examinations which might be deemed necessary
3
. Ultrasound
use in Nottingham evidently conforms closely to this pattern.
According to their protocols, each of the two hospitals rou-
tinely offers two ultrasound scans throughout the course of
the pregnancy, an early dating scan at 10Ð14 weeks of gesta-
tion and a detailed scan at 18Ð20 weeks. Further scans are
then suggested for specific clinical indications. The initial
dating scan, as reported by the women in our study, was typic-
ally at, or slightly beyond, the limit of that which might be
expected according to the protocols. This could be explained
by the recent changes in maternity care brought about by the
local implementation of Changing Childbirth
26
. Midwives
have assumed increased responsibility for maternity care in
a community setting, moving the locus of control away from
the hospital. Our evidence suggests that, in the case of the
minority of women destined to have more frequent scans
throughout their pregnancy, the date of the first scan will
tend to be earlier and relatively fewer reasons will be offered
for each scan occurring. This pattern is consistent with earlier
anticipation of a specific clinical problem and more intensive
monitoring to manage it.
In comparison with those of other European countries, the
Nottingham ultrasound regimen does appear more intensive.
In Denmark and Holland, for example, somewhat fewer women
appear to receive routine scans and, of those that do, the
average number received is lower
27,28
. This probably arises
more from clinical practice than from client preference. In one
Swedish study, women were offered an informed choice between
early, late or no ultrasound, and not one subject amongst
approximately 2500 in the trial refused the investigation
29
.
Most women in our sample reported at least one reason for
each ultrasound having been provided. Initial scans were
typically perceived of as being dating scans, with second and
later scans being understood as checks for abnormalities and
fetal growth. As would be expected, positive feelings resulted
from the vast majority of scans and, when asked, relatively
few women wanted procedural changes to be made. These
results were independent of sociodemographic factors, such
as age, social class and ethnicity, implying no perceived prob-
lems specific to any population subgroup. Positive feelings
arose not only from the reassurance which most women
would have achieved as a result of receiving Ôall clearÕ results,
but also, in many cases, from the knowledge of fetal gender
and the opportunity to visualize and obtain a fetal image.
Anxiety or worry was inevitably created amongst the small
minority who were in receipt of bad news. Such a trade-off,
between a large number of reassured, negatively tested, sub-
jects against the small number of distressed, positively tested
subjects, is endemic to all screening programs, and not only
scanning during pregnancy.
The use of ultrasound screening has become routinized, at
least in Europe, essentially on the grounds of improving the
effectiveness of the clinical management of pregnancies, and
routinization of use appears to have given rise to routiniza-
tion of subject acceptance. Our study suggests that very few
women consciously opt out of screening, not least because, as
our data have indicated, the experience itself is expected to be
psychologically rewarding for the majority. In a similar vein,
a UK trial evaluating different formats of delivering informa-
tion about testing found that the ultrasound take-up rate
amongst women always exceeded 98%
30
. In the USA, where
ultrasound use is less routinized, evidence suggests that the
subjectsÕ desire for sonography, for the purposes of maternal
reassurance and gender determination, is equally high
11
.
Recently, the focus on the purely technical side of screening
has given way to the issue of the rights of, and obligations
towards, potential screening subjects
31
. Informed consent to
participate in screening entails guaranteeing the autonomy
of subjects to refuse screening, if they so wish, coupled to the
receipt of information necessary to make the participation
decision. Interestingly enough, only one-in-10 of our women
reported that they were informed about the procedure itself,
although nearly all of them found the information reassuring.
Hardly any of the women explicitly reported that they had
questioned the safety of ultrasound. Possible explanations
would be either that they were reassured by the professionals
(without recording the fact) or they were unaware of any
safety debate (augmented by the fact that the procedure itself
was not commonly discussed). We suspect that the commonly
held view amongst women would be that clinical procedures
offered as a matter of routine must, of necessity, be safe.
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APPENDIX
The Nottingham Pregnancy Diary Research Group is an
interdisciplinary collaboration based at the University of
Nottingham. The University members comprise Veronica James
and Claire Jenkinson (School of Nursing), David Whynes
(School of Economics), Rachel Illingworth, Zo Philips and
Avril Pitman (Trent Institute for Health Services Research),
Isobel Bowler and Kate Featherstone (Division of General
Practice), Clair Chilvers and Sherie Holroyd (Division of Public
Health and Epidemiology). Nottingham Health Authority
members comprise Vicky Bailey and Lucy Keane.
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