KNOWLEDGE, ATTITUDE AND PRACTICES OF PREGNANT WOMEN TOWARDS ROUTINE ULTRASONOGRAPHY IN ENUGU URBAN USING UNTH AND PARKLANE HOSPITAL
TABLE OF CONTENT
TITLE PAGE………………………………………………………………..
CERTIFICATION……………………………………………………………
DEDICATION……………………………………………………………….
ACKNOWLEDGEMENT………………………………………………….
CHAPTER ONE
INTRODUCTION…………………………………………………………
- Statement of problem……………………………………………………
1.2 Objective of study………………………………………………………..
1.3 Significance of the study………………………………………………
1.4 Scope of study………………………………………………………….
1.5 Literature review……………………………………………………….
CHAPTER TWO
THEORITCAL BACKGROUND
2.1 What is ultrasound................................................................................
2.2 Ultrasound machines……………………………………………………
2.2.1 What does the ultrasound equipment look like………………………..
2.2.2 Components of an Ultrasound Machine…………………………….
2.2.3 How Ultrasound Machines Work…………………………………
2.2.4 Different areas of the body where Ultrasound can be used to scan…………………………………………………………………………...
2.2.5 The Best Person to Perform Your Ultrasound Exam……………
2.2.6 The limitations of Ultrasound Imaging…………………………..
2.2.7 What are the benefits vs. risks?....................................................
2.3 Prenatal/pregnancy ultrasound…………………………………….
2.3.1 How to Prepare for the Test……………………………………..
2.3.2 How the test is performed……………………………………..
2.3.3 How the Test Will Feel…………………………………………
2.3.4 Common uses of the Procedure………………………………….
2.3.5 Why the Test is performed………………………………………
2.3.6 Normal Results……………………………………………………
2.3.7 What Abnormal Results Mean………………………………….
2.4 Safety of prenatal ultrasound……………………………………
2.5 The limitations of obstetric ultrasound imaging…………………..
2.5 Recommendations on ultrasound…………………………………
CHAPTER THREE
RESEARCH METHODOLOGY
3.1 Research design……………………………………………………
3.2 Area of study……………………………………………………..
3.3 Target population…………………………………………………
3.4 Determination of sample size……………………………………..
3.5 Sample technique…………………………………………………..
3.7 Method of data collection…………………………………………..
3.8 Data analysis…………………………………………………………
CHAPTER FOUR
DATA PRESENTATION AND DISCUSSION
4.1 Data presentation………………………………………………..
4.2 Discussion of data………………………………………………..
CHAPTER FIVE
SUMMARY OF FINDINGS, RECOMMENDATION AND CONCLUSION
5.1 Summary of findings……………………………………………...
5.2 Recommendation…………………………………………………
5.3 Limitation of studies………………………………………………
CONCLUSION………………………………………………………..
APPROVAL PAGEs
QUESTIONNAIRE
REFERENCES
ABSTRACT
This study aimed at finding out the knowledge, attitudes, and practices of pregnant women towards routine sonography.
A prospective cross-sectional survey method was adopted. The data was collected through self-administered among 180 respondents and 176 were returned duly completed. The data collected were analyzed using descriptive statistics.
The present study shows that most of the women who present for antenatal care have general knowledge of ultrasound scan (95.5%:4.5%) especially those with high level of education which is 35.2% compared to 9.7% of those with low level of education. There is limitation of knowledge on the reasons and benefit of ultrasound with only 1.7% knowing that it can be used to check for any sign of bleeding. There is poor knowledge on when best to undergo ultrasound scanning examination, 50% of the respondent indicating the 7th-9th month of pregnancy (3rd trimester) and Some of the women present for ultrasound scanning of their own volition without doctor’s referral. it also shows that the majority of the women (94.3%) will like to see their baby during the scan as this will help to alleviate their fears (59.7%).
This led to the conclusion that there is a need for increased awareness and education on the importance and benefit of the routine practice of Ultrasound scanning during antenatal care.
CHAPTER ONE
INTRODUCTION
BACKGROUND OF STUDY
Ultrasonography (sonography) involves the use of ultrasound to produce images of structures in the human body4. The ultrasound probe send out a short pulse of high frequency sound and detects the waves (echoes) occurring at interfaces within the organs. The direction of the pulse can then be moved across the area of interest with each pulse to build up a comp1lete image. Sound is emitted by a transducer source and when this sound interacts with tissues and organs echoes are created. The echoes can be used to identify how far away the tissue or organ is, how large it is, its shape and its internal consistency (fluid, solid or mixed), and how uniform it is.
The ultrasound transducer functions as both a loudspeaker (to create the sound) and a microphone (to record the returning echoes). When the ultrasound transducer is pressed against the skin, it directs a stream of inaudible, high-frequency sound into the body. As the sound waves echo from the body's fluids and tissues, the sensitive microphone in the transducer records the characteristics of the reflected sound. There are two major components of the ultrasound examination: a) returning sound waves are instantly measured and displayed by a computer, which in turn creates a video picture on the ultrasound monitor (real-time images); b) images frozen by the ultrasound machine and stored as representative images of the real-time findings. Both the real-time images and the frozen images of the examination can be recorded on videotape, on film, or on computer disk.
Doppler ultrasonography is the application of diagnostic ultrasound to detect moving blood cells and measure their direction and speed of movement.
The real-time element of ultrasound allows for the detection of movement i.e. foetal movements, heart valve function, and blood vessel pulsation. This component is an integral part of the examination and the technologist and the radiologist must be very familiar with what normal real-time functions of various organs and tissues as to complete a thorough assessment of each patient. Conventional ultrasound displays the images as thin sections (like looking at single slices of bread in a loaf). 3-D ultrasound is the result of modern computer technology that can reformat data into three-dimensional images (like looking at the entire loaf of bread in various projections). 4-D ultrasound is 3-D ultrasound in motion. As far as is known, there are no adverse effects from the use of ultrasound used at diagnostic energies.
Ultrasound was originally developed in early days to detect enemy submarine during warfare. After the war in 1955, surgeon in Glasgow named Ian Donald began to experiment with it for medical uses. Using beef steaks as “control” subjects, he scanned the abdominal tumours he had removed from his patients and found that different tissues gave different patterns of sound wave echo. He quickly realized the potential of ultrasound for examining a growing baby in uterus and this brought about prenatal sonography.
Prenatal sonography is the use of ultrasound in the management of pregnancy. Since its introduction in the 1950’s, ultrasonography has become a very useful diagnostic tool in obstetrics. It has dramatically changed the practice of obstetrics by enabling visualisation of the fetus and intrauterine environment4.
Prenatal ultrasound is very beneficial to the referring clinician in obstetric management of patients. Many unsuspected foetal and maternal problems can be detected and appropriate interventional measures initiated well on time.
Pregnant women can see their first ultrasound as a tool that enables them to reach different goals during their pregnancy. Many of goals concern meeting and connecting with the baby, suggesting that pregnant women consider the examination an important step towards parenthood.
The knowledge, attitude, perception, psychological reaction and practices of pregnant women and women of child bearing age towards obstetric intervention are becoming important areas of concern noted by some group of scientist in the early 80’s . The reaction varies from little or no knowledge of the investigating modalities, its usefulness, harmfulness if any, to some even suspecting it could harm their unborn baby, cause cancer, while others leave all concerns to the referring obstetrician and radiologist who must know what they are doing. It has been observed that interactions among patients can instil fears and can also alleviate fear in most women9.
This realization has resulted in several studies carried out in the in the western world to determine how patients in general and in particular antenatal care, perceive and react to ultrasonography. Some interesting findings include the women’s dissatisfaction of non-communication with the person carrying out the examination, over expectation of what ultrasonography is able to do, leaving the women frustrated when these expectations are not met. It is the desire of healthcare providers to attend to patients in such a way that their burdens are significantly alleviated before leaving the hospital10.
The purpose of the present study is to explore the knowledge, attitude and practices of pregnant women about routine sonography in Enugu urban.
1.1 STATEMENT OF PROBLEM
- The knowledge, attitude and practices of routine ultrasonography among pregnant women have not been documented in our locality examination.
- It has been observed that some women who present for ultrasound do not have full knowledge of the reasons for ultrasound examination.
- It has been observed that some women present for ultrasound examination without physician referral.
- The knowledge of safety and benefit of routine sonography in pregnancy from the patient perspective has not been assessed in our locality.
1.2 OBJECTIVE OF STUDY
- To assess the level of information women presenting for ultrasonography have about the examination.
- To assess the attitude of these women towards routine prenatal ultrasound examination
- To ascertain the perception of the women towards routine ultrasonography examination.
- To ascertain if the women suspect any risks attached to routine ultrasound examination.
1.3 SIGNIFICANCE OF THE STUDY
- The study will to define the level of knowledge of pregnant women towards routine sonography.
- It will reveal if there were perceived risks by the women who present for ultrasonography and to clarify such.
- This study will create a guide on how to address the women that come for routine sonography.
- It will help the sonologist/sonographer to know the kind of information to pass to the woman during and after examination.
1.4 SCOPE OF STUDY
The research work is to be carried out at antenatal clinics in Government hospitals within Enugu urban using UNTH and PARKLANE hospital as a case study.
1.5 LITERATURE REVIEW
Lowdermelk et al in their work noted that antenatal care is care provided to a woman from conception through labour and is designed to monitor the progress of pregnancy in order to support maternal health and normal foetal development. They concluded that Obstetric ultrasonography, unarguably, is an important aspect of antenatal care1.
McDuffie et al in their work found out that antenatal care forms the foundation of all health care. The medical circumstances predict not only immediate neonatal outcome but also long-term outcome, including intelligence quotient and school performance. They concluded in their Observational studies that antenatal care improves pregnancy outcome2.
Nsemukile et al in their study which showed higher antenatal coverage in urban and rural areas concluded that good quality antenatal cares can reduce many risks of 3death, sickness, and disability for both mothers and infants3.
Woo in his work observed, that since introduction of ultrasound in the 1950’s; ultrasonography has become a very useful diagnostic tool in obstetrics. He noted that the use of ultrasonography has dramatically changed the practice of obstetrics by enabling visualisation of the fetus and intrauterine environment4.
Hadlock et al in their work argued that, even with sophisticated equipment the diagnostic accuracy of ultrasound is observer dependent and requires good knowledge of anatomy, pathology, medicine, surgery and related subjects. He observed that 60-70 per cent of pregnant women in United States had ultrasound at some point during pregnancy; he noted that out of that number, only 40-60 per cent of the pregnancies are being properly evaluated with ultrasound5.
Dogra in his work found out that, ultrasound was initially crude and render only basic information about the foetus, but with the current technology it offers possibility of complete assessment of the foetus with high resolution images, sophisticated measurement, computation and analysis of foetal haemodynamics6.
Kongnyuy et al in their work reasoned that, there has been increased medicalization of pregnancy globally due to advances in ultrasound technology and most especially in obstetric care. However, they noted that this advances has resulted in the reduction of maternal, perinatal morbidity and mortality as justification for all the changes made in obstetrical care7.
Williams et al in their work observed that innovative medical technologies like obstetric sonography have the potential to raise social, ethical and economical dilemmas for both health workers and the recipient of health services. They reported that routine obstetric ultrasound has been one of the most important advances in antenatal care worldwide8.
Kleiman et al in their work observed that the knowledge, attitude, perception, psychological reaction and practices of pregnant women and women of child bearing age towards obstetric ultrasound are becoming important areas of concern. They noted that the reaction varies from little or no knowledge of the investigating modalities, its usefulness, harmfulness if any, to some even suspecting it could harm their unborn baby or cause cancer, while others leave all concerns to the referring obstetrician and radiologist who must know what they are doing9.
Tautz’s et al in their work observed that most women normally have over expectation of what ultrasonography is able to do, leaving them frustrated when these expectations are not met and this creates a different feeling for them after the scan. They also concluded that it should be the desire and work of healthcare providers to attend to patients in such a way that their burdens are significantly alleviated before leaving the hospital10.
Vangeenderhuysen in his work found out that, routine obstetric ultrasound has been one of the most important advances in antenatal care worldwide. He also noted that, in most of the health care facilities, routine obstetric sonography has been fully embraced. As a result of this most women willingly go for obstetric scan sometimes even without doctor’s advice11.
Gammeltoft et al in their research found out that health workers themselves have declared obstetric ultrasound an indispensable part of modern antenatal care and therefore recommend it. They also reasoned that this has created a dramatic overuse of this technology mainly because of its over commercialization for monetary gains in both public and private health facilities. For example in their survey of Viet Nam women, found out that, 400 women had an average of 6.6 scans during their pregnancy while one-fifth had ten scans or more. They concluded by suggesting the need for guidelines for the appropriate use of obstetric ultrasound in antenatal care12.
Goldberg in his work observed that routine ultrasound examination and its use has become a standard during pregnancy, though in low-risk pregnancy ultrasound has not been proven to be advantageous in terms of perinatal mortality and morbidity. He also found out that diagnoses resulting from prenatal ultrasonography include multiple gestation, congenital fetal abnormalities, fetal growth problems and amniotic fluid volume determination and placental abnormalities such as placenta previa13.
Boyd et al In their Study of ultrasound as a perinatal diagnostic tool which focused on whether ultrasound improves perinatal outcomes and the psychological effect of such an examination on women, found out that women’s experience of prenatal ultrasound is influenced by physical and environmental factors and the behaviour of the ultrasound examiner14.
Freeman et al in their work on perception of pregnant women and their knowledge of ultrasound, found out that behaviours of the examiner contribute to a woman’s labelling of the ultrasound experience as positive or negative. These women identify being objectified by the examination when they experience poor communication pattern during fetal ultrasound diagnosis15.
Eurenius et al in their work on “the experiences of staff who perform ultrasound examinations” found out that during ultrasound, women sense information and react psychologically to it. They noted that women sense information through verbal and nonverbal communication cues in the room and length of time taken for the ultrasound i.e women were very alert to verbal and non-verbal expressions from health care professionals about what was seen on the screen and attempt to understand the professional conversation. They discovered that nonverbal aspect of the ultrasound experience caused women to sense information and suspect problem during and after the ultrasound exam16.
Neilson in his work reasoned that while obstetric sonography has proven to be beneficial in situation where it is indicated, the role of it being routine remains contentious17.
Bricker et al in their review of the Cochrane database 2002 on routine ultrasound in late pregnancy observed a lack of research on women's experience of this type of procedure. They however noted that routine ultrasound scanning does not improve the outcome of pregnancy in terms of an increased number of live births or reduced perinatal morbidity18.
Anderson in his work on “specific aspects of breaking bad news in perinatal situations and the consequence of such an action” found out that women are psychologically affected on bad news transmission concerning foetal development19.
Alkazaleh et al. in his work surveyed 117 women with pregnancy complications detected sonographically. He observed that Sixty-seven women responded to their survey of broad characteristics of bad news transmission. They recommend further research into the area of bad news transmission using other research designs20.
Detraux et al. in their work tabulated retrospective quantitative data from prenatal ultrasound diagnosis of fetal abnormality using a developmental psychology perspective. They observed that consideration should be taken when telling women the sex of their baby and on announcing the fetal abnormality. They concluded that this knowledge affect a woman’s emotion and relationship with her unborn child before and later on in life21.
Kowalcek et al in their work observed that when prenatal ultrasound assessment is undertaken for obstetrical indications, a much higher percentage of abnormal findings is expected with associated maternal anxiety especially when the ultrasound result are unexpected22.
Filly in his research indicate that women undergoing prenatal ultrasound examination, regardless of whether they perceive the ultrasound result as positive or negative, are acutely sensitive to the surrounding environment. They exhibit acute recall of their physical and emotional sensations during the ultrasound procedure. The women identified lack of attention to their physical comfort and lack of interaction with the examiner as contributing to feeling objectified to the point of anger and frustration23.
Garcia et al. observed that women in the study valued the presence of a personnel support worker during prenatal ultrasound examination. They also observed that these women tried to be relationally attuned to the examiner and that these women normally do not expect a diagnosis immediately but they did want an indication that the ultrasound image required clarification by a physician24.
Zechmeister has noted that the introduction of US technology during pregnancy can push the history of the 'child' into the antenatal period. He found out that all of the unexpected ultrasound images were reacted to with shock and surprise irrespective of the diagnosis and yet no ultrasound diagnosis was questioned, even when a wrong fetal diagnosis is made. He also suggested further research to discern whether women with unexpected prenatal ultrasound images interpreted to them are emotionally and psychologically able to question the interpretations at that time25.
Rempel et al in their work explored the pregnancy decision-making processes of parents following an antenatal diagnosis of fetal congenital heart disease using a qualitative design, describing parents post diagnosis relationship and interaction patterns with health care professionals. They found out that although the majority of women who undergo prenatal ultrasound have normal findings and are reassured about the health of their baby, some women have been found to suffer stress and high anxiety levels. They also found that prospective parents involved in decisions after a prenatal ultrasound diagnosis of congenital heart disease consider this to be their 'first parenting decisions'26.
Bashour et al in their study with Syrian women has reported that majority of women especially in developed countries no longer have fears regarding the safety of ultrasound, and so go for it uncritically. They also noted that the ultrasound experience will reassure the pregnant woman about fetal well-being, encourage women to abandon practices harmful to the fetus, facilitate early bonding and will be enjoyable and interesting27.
Lalor et al in their work reported that, many women have got many expectations from routine scans like knowing the fetal sex, status of the baby and expected date of delivery. They further reasoned that, most women now accept the scan uncritically because of the enormous expectations they have, but most especially viewing their baby live on the screen and knowing the fetal sex28.
Nigenda et al in their work concurred with the aforementioned views when they reported that pregnant women attending antenatal care in developing countries have got several expectations when they are sent for ultrasound, most of which includes; knowing the sex of the fetus, fetal viability, expected due date, fetal heart rate and the reassurance that the baby is fine29.
Enakpene et al in their work observed that women who have some knowledge about obstetric sonography and women with higher levels of formal education are more likely to have many expectations as well as ask many questions compared to women with low levels of formal education. They concluded that this can result to psychosocial effects or therapeutic benefits of prenatal sonography and the health care providers can also contributed in a way to this obsession30.
World Health organization in their work observed that the high rate of maternal mortality in Nigeria is an increasing concern. It is recorded as 800 deaths per100, 000 live births. They concluded that direct causes of maternal death are related to obstetric complications of pregnancy, labour and childbirth and some of these complications can be detected by ultrasonography31.
Ngoma et al in their work observed that access to medical services is an important component of healthy policy in developing countries. Access to medicine is considered a basic human right by activist working in the health sector in developing countries. They concluded that higher emphasis on curative than preventive health care has also been one of the causes of increase in maternal mortality32.
Ugwu et al in their work to investigate patients access to obstetric ultrasonography in some rural area observed virtually no population based study assessing the predicaments in access to obstetric ultrasound services in a less developed areas and rural setting. They observed that previous studies have been satisfaction and perception based. In their result they found out that only 30% of women out of a total of 300 had previous access to obstetric ultrasonography and over 80% were willing to go for the exam. They concluded that access to obstetric ultrasonography in the suburbs of Enugu state is poor and there is need for improvement33.
Levi in his work found that ultrasound has become an integral part of modern obstetrics. He observed that ultrasonography in the first trimester enables the establishment of viability, determination of chronicity and measure nuchal translucency in order to evaluate the risk of chromosomal abnormalities like Down's syndrome while the second trimester scan is used primarily to detect structural abnormalities. They concluded that obstetric ultrasound is beneficial in mother and child care34.
Routine second trimester analysis in their work found out that although the cost effectiveness of routine ultrasonography examination has been questioned by some, they observed that there is evidence to support that it might be cost effective to the health care system35.
Fletcher et al in their work observed that to some parents ultrasound is done only to determine the gender of the fetus and they point out that there is always false positive and false negative with fetal sex which may have numerous implications like selective abortion of unwanted fetal gender, therefore care should be taken in announcing of fetal sex to women. They observed that this knowledge affects a woman’s emotion. They concluded that ultrasound apart from providing diagnostic benefit, has been seen to improve maternal bonding36.
Larsen et al in their work observed that issues of health workers not responding to patients during scan are of great concern to women and this has influenced the way women perceive these health workers and this is due to inter personal skills demonstrated by the people doing the scan. They concluded that this affects the reaction of women towards prenatal sonography37.
Beech in his works found out that routine ultrasound in 27,024 late pregnancies in low-risk or unselected populations do not confer benefit on mother or baby. He concluded that routine scan does not seem to be associated with reductions in adverse outcomes for babies38.
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KNOWLEDGE, ATTITUDE AND PRACTICES OF PREGNANT WOMEN TOWARDS ROUTINE ULTRASONOGRAPHY IN ENUGU URBAN USING UNTH AND PARKLANE HOSPITAL
TABLE OF CONTENT
TITLE PAGE………………………………………………………………..
CERTIFICATION……………………………………………………………
DEDICATION……………………………………………………………….
ACKNOWLEDGEMENT………………………………………………….
CHAPTER ONE
INTRODUCTION…………………………………………………………
1.2 Objective of study………………………………………………………..
1.3 Significance of the study………………………………………………
1.4 Scope of study………………………………………………………….
1.5 Literature review……………………………………………………….
CHAPTER TWO
THEORITCAL BACKGROUND
2.1 What is ultrasound................................................................................
2.2 Ultrasound machines……………………………………………………
2.2.1 What does the ultrasound equipment look like………………………..
2.2.2 Components of an Ultrasound Machine…………………………….
2.2.3 How Ultrasound Machines Work…………………………………
2.2.4 Different areas of the body where Ultrasound can be used to scan…………………………………………………………………………...
2.2.5 The Best Person to Perform Your Ultrasound Exam……………
2.2.6 The limitations of Ultrasound Imaging…………………………..
2.2.7 What are the benefits vs. risks?....................................................
2.3 Prenatal/pregnancy ultrasound…………………………………….
2.3.1 How to Prepare for the Test……………………………………..
2.3.2 How the test is performed……………………………………..
2.3.3 How the Test Will Feel…………………………………………
2.3.4 Common uses of the Procedure………………………………….
2.3.5 Why the Test is performed………………………………………
2.3.6 Normal Results……………………………………………………
2.3.7 What Abnormal Results Mean………………………………….
2.4 Safety of prenatal ultrasound……………………………………
2.5 The limitations of obstetric ultrasound imaging…………………..
2.5 Recommendations on ultrasound…………………………………
CHAPTER THREE
RESEARCH METHODOLOGY
3.1 Research design……………………………………………………
3.2 Area of study……………………………………………………..
3.3 Target population…………………………………………………
3.4 Determination of sample size……………………………………..
3.5 Sample technique…………………………………………………..
3.7 Method of data collection…………………………………………..
3.8 Data analysis…………………………………………………………
CHAPTER FOUR
DATA PRESENTATION AND DISCUSSION
4.1 Data presentation………………………………………………..
4.2 Discussion of data………………………………………………..
CHAPTER FIVE
SUMMARY OF FINDINGS, RECOMMENDATION AND CONCLUSION
5.1 Summary of findings……………………………………………...
5.2 Recommendation…………………………………………………
5.3 Limitation of studies………………………………………………
CONCLUSION………………………………………………………..
APPROVAL PAGEs
QUESTIONNAIRE
REFERENCES
ABSTRACT
This study aimed at finding out the knowledge, attitudes, and practices of pregnant women towards routine sonography.
A prospective cross-sectional survey method was adopted. The data was collected through self-administered among 180 respondents and 176 were returned duly completed. The data collected were analyzed using descriptive statistics.
The present study shows that most of the women who present for antenatal care have general knowledge of ultrasound scan (95.5%:4.5%) especially those with high level of education which is 35.2% compared to 9.7% of those with low level of education. There is limitation of knowledge on the reasons and benefit of ultrasound with only 1.7% knowing that it can be used to check for any sign of bleeding. There is poor knowledge on when best to undergo ultrasound scanning examination, 50% of the respondent indicating the 7th-9th month of pregnancy (3rd trimester) and Some of the women present for ultrasound scanning of their own volition without doctor’s referral. it also shows that the majority of the women (94.3%) will like to see their baby during the scan as this will help to alleviate their fears (59.7%).
This led to the conclusion that there is a need for increased awareness and education on the importance and benefit of the routine practice of Ultrasound scanning during antenatal care.
CHAPTER ONE
INTRODUCTION
BACKGROUND OF STUDY
Ultrasonography (sonography) involves the use of ultrasound to produce images of structures in the human body4. The ultrasound probe send out a short pulse of high frequency sound and detects the waves (echoes) occurring at interfaces within the organs. The direction of the pulse can then be moved across the area of interest with each pulse to build up a comp1lete image. Sound is emitted by a transducer source and when this sound interacts with tissues and organs echoes are created. The echoes can be used to identify how far away the tissue or organ is, how large it is, its shape and its internal consistency (fluid, solid or mixed), and how uniform it is.
The ultrasound transducer functions as both a loudspeaker (to create the sound) and a microphone (to record the returning echoes). When the ultrasound transducer is pressed against the skin, it directs a stream of inaudible, high-frequency sound into the body. As the sound waves echo from the body's fluids and tissues, the sensitive microphone in the transducer records the characteristics of the reflected sound. There are two major components of the ultrasound examination: a) returning sound waves are instantly measured and displayed by a computer, which in turn creates a video picture on the ultrasound monitor (real-time images); b) images frozen by the ultrasound machine and stored as representative images of the real-time findings. Both the real-time images and the frozen images of the examination can be recorded on videotape, on film, or on computer disk.
Doppler ultrasonography is the application of diagnostic ultrasound to detect moving blood cells and measure their direction and speed of movement.
The real-time element of ultrasound allows for the detection of movement i.e. foetal movements, heart valve function, and blood vessel pulsation. This component is an integral part of the examination and the technologist and the radiologist must be very familiar with what normal real-time functions of various organs and tissues as to complete a thorough assessment of each patient. Conventional ultrasound displays the images as thin sections (like looking at single slices of bread in a loaf). 3-D ultrasound is the result of modern computer technology that can reformat data into three-dimensional images (like looking at the entire loaf of bread in various projections). 4-D ultrasound is 3-D ultrasound in motion. As far as is known, there are no adverse effects from the use of ultrasound used at diagnostic energies.
Ultrasound was originally developed in early days to detect enemy submarine during warfare. After the war in 1955, surgeon in Glasgow named Ian Donald began to experiment with it for medical uses. Using beef steaks as “control” subjects, he scanned the abdominal tumours he had removed from his patients and found that different tissues gave different patterns of sound wave echo. He quickly realized the potential of ultrasound for examining a growing baby in uterus and this brought about prenatal sonography.
Prenatal sonography is the use of ultrasound in the management of pregnancy. Since its introduction in the 1950’s, ultrasonography has become a very useful diagnostic tool in obstetrics. It has dramatically changed the practice of obstetrics by enabling visualisation of the fetus and intrauterine environment4.
Prenatal ultrasound is very beneficial to the referring clinician in obstetric management of patients. Many unsuspected foetal and maternal problems can be detected and appropriate interventional measures initiated well on time.
Pregnant women can see their first ultrasound as a tool that enables them to reach different goals during their pregnancy. Many of goals concern meeting and connecting with the baby, suggesting that pregnant women consider the examination an important step towards parenthood.
The knowledge, attitude, perception, psychological reaction and practices of pregnant women and women of child bearing age towards obstetric intervention are becoming important areas of concern noted by some group of scientist in the early 80’s . The reaction varies from little or no knowledge of the investigating modalities, its usefulness, harmfulness if any, to some even suspecting it could harm their unborn baby, cause cancer, while others leave all concerns to the referring obstetrician and radiologist who must know what they are doing. It has been observed that interactions among patients can instil fears and can also alleviate fear in most women9.
This realization has resulted in several studies carried out in the in the western world to determine how patients in general and in particular antenatal care, perceive and react to ultrasonography. Some interesting findings include the women’s dissatisfaction of non-communication with the person carrying out the examination, over expectation of what ultrasonography is able to do, leaving the women frustrated when these expectations are not met. It is the desire of healthcare providers to attend to patients in such a way that their burdens are significantly alleviated before leaving the hospital10.
The purpose of the present study is to explore the knowledge, attitude and practices of pregnant women about routine sonography in Enugu urban.
1.1 STATEMENT OF PROBLEM
1.2 OBJECTIVE OF STUDY
1.3 SIGNIFICANCE OF THE STUDY
1.4 SCOPE OF STUDY
The research work is to be carried out at antenatal clinics in Government hospitals within Enugu urban using UNTH and PARKLANE hospital as a case study.
1.5 LITERATURE REVIEW
Lowdermelk et al in their work noted that antenatal care is care provided to a woman from conception through labour and is designed to monitor the progress of pregnancy in order to support maternal health and normal foetal development. They concluded that Obstetric ultrasonography, unarguably, is an important aspect of antenatal care1.
McDuffie et al in their work found out that antenatal care forms the foundation of all health care. The medical circumstances predict not only immediate neonatal outcome but also long-term outcome, including intelligence quotient and school performance. They concluded in their Observational studies that antenatal care improves pregnancy outcome2.
Nsemukile et al in their study which showed higher antenatal coverage in urban and rural areas concluded that good quality antenatal cares can reduce many risks of 3death, sickness, and disability for both mothers and infants3.
Woo in his work observed, that since introduction of ultrasound in the 1950’s; ultrasonography has become a very useful diagnostic tool in obstetrics. He noted that the use of ultrasonography has dramatically changed the practice of obstetrics by enabling visualisation of the fetus and intrauterine environment4.
Hadlock et al in their work argued that, even with sophisticated equipment the diagnostic accuracy of ultrasound is observer dependent and requires good knowledge of anatomy, pathology, medicine, surgery and related subjects. He observed that 60-70 per cent of pregnant women in United States had ultrasound at some point during pregnancy; he noted that out of that number, only 40-60 per cent of the pregnancies are being properly evaluated with ultrasound5.
Dogra in his work found out that, ultrasound was initially crude and render only basic information about the foetus, but with the current technology it offers possibility of complete assessment of the foetus with high resolution images, sophisticated measurement, computation and analysis of foetal haemodynamics6.
Kongnyuy et al in their work reasoned that, there has been increased medicalization of pregnancy globally due to advances in ultrasound technology and most especially in obstetric care. However, they noted that this advances has resulted in the reduction of maternal, perinatal morbidity and mortality as justification for all the changes made in obstetrical care7.
Williams et al in their work observed that innovative medical technologies like obstetric sonography have the potential to raise social, ethical and economical dilemmas for both health workers and the recipient of health services. They reported that routine obstetric ultrasound has been one of the most important advances in antenatal care worldwide8.
Kleiman et al in their work observed that the knowledge, attitude, perception, psychological reaction and practices of pregnant women and women of child bearing age towards obstetric ultrasound are becoming important areas of concern. They noted that the reaction varies from little or no knowledge of the investigating modalities, its usefulness, harmfulness if any, to some even suspecting it could harm their unborn baby or cause cancer, while others leave all concerns to the referring obstetrician and radiologist who must know what they are doing9.
Tautz’s et al in their work observed that most women normally have over expectation of what ultrasonography is able to do, leaving them frustrated when these expectations are not met and this creates a different feeling for them after the scan. They also concluded that it should be the desire and work of healthcare providers to attend to patients in such a way that their burdens are significantly alleviated before leaving the hospital10.
Vangeenderhuysen in his work found out that, routine obstetric ultrasound has been one of the most important advances in antenatal care worldwide. He also noted that, in most of the health care facilities, routine obstetric sonography has been fully embraced. As a result of this most women willingly go for obstetric scan sometimes even without doctor’s advice11.
Gammeltoft et al in their research found out that health workers themselves have declared obstetric ultrasound an indispensable part of modern antenatal care and therefore recommend it. They also reasoned that this has created a dramatic overuse of this technology mainly because of its over commercialization for monetary gains in both public and private health facilities. For example in their survey of Viet Nam women, found out that, 400 women had an average of 6.6 scans during their pregnancy while one-fifth had ten scans or more. They concluded by suggesting the need for guidelines for the appropriate use of obstetric ultrasound in antenatal care12.
Goldberg in his work observed that routine ultrasound examination and its use has become a standard during pregnancy, though in low-risk pregnancy ultrasound has not been proven to be advantageous in terms of perinatal mortality and morbidity. He also found out that diagnoses resulting from prenatal ultrasonography include multiple gestation, congenital fetal abnormalities, fetal growth problems and amniotic fluid volume determination and placental abnormalities such as placenta previa13.
Boyd et al In their Study of ultrasound as a perinatal diagnostic tool which focused on whether ultrasound improves perinatal outcomes and the psychological effect of such an examination on women, found out that women’s experience of prenatal ultrasound is influenced by physical and environmental factors and the behaviour of the ultrasound examiner14.
Freeman et al in their work on perception of pregnant women and their knowledge of ultrasound, found out that behaviours of the examiner contribute to a woman’s labelling of the ultrasound experience as positive or negative. These women identify being objectified by the examination when they experience poor communication pattern during fetal ultrasound diagnosis15.
Eurenius et al in their work on “the experiences of staff who perform ultrasound examinations” found out that during ultrasound, women sense information and react psychologically to it. They noted that women sense information through verbal and nonverbal communication cues in the room and length of time taken for the ultrasound i.e women were very alert to verbal and non-verbal expressions from health care professionals about what was seen on the screen and attempt to understand the professional conversation. They discovered that nonverbal aspect of the ultrasound experience caused women to sense information and suspect problem during and after the ultrasound exam16.
Neilson in his work reasoned that while obstetric sonography has proven to be beneficial in situation where it is indicated, the role of it being routine remains contentious17.
Bricker et al in their review of the Cochrane database 2002 on routine ultrasound in late pregnancy observed a lack of research on women's experience of this type of procedure. They however noted that routine ultrasound scanning does not improve the outcome of pregnancy in terms of an increased number of live births or reduced perinatal morbidity18.
Anderson in his work on “specific aspects of breaking bad news in perinatal situations and the consequence of such an action” found out that women are psychologically affected on bad news transmission concerning foetal development19.
Alkazaleh et al. in his work surveyed 117 women with pregnancy complications detected sonographically. He observed that Sixty-seven women responded to their survey of broad characteristics of bad news transmission. They recommend further research into the area of bad news transmission using other research designs20.
Detraux et al. in their work tabulated retrospective quantitative data from prenatal ultrasound diagnosis of fetal abnormality using a developmental psychology perspective. They observed that consideration should be taken when telling women the sex of their baby and on announcing the fetal abnormality. They concluded that this knowledge affect a woman’s emotion and relationship with her unborn child before and later on in life21.
Kowalcek et al in their work observed that when prenatal ultrasound assessment is undertaken for obstetrical indications, a much higher percentage of abnormal findings is expected with associated maternal anxiety especially when the ultrasound result are unexpected22.
Filly in his research indicate that women undergoing prenatal ultrasound examination, regardless of whether they perceive the ultrasound result as positive or negative, are acutely sensitive to the surrounding environment. They exhibit acute recall of their physical and emotional sensations during the ultrasound procedure. The women identified lack of attention to their physical comfort and lack of interaction with the examiner as contributing to feeling objectified to the point of anger and frustration23.
Garcia et al. observed that women in the study valued the presence of a personnel support worker during prenatal ultrasound examination. They also observed that these women tried to be relationally attuned to the examiner and that these women normally do not expect a diagnosis immediately but they did want an indication that the ultrasound image required clarification by a physician24.
Zechmeister has noted that the introduction of US technology during pregnancy can push the history of the 'child' into the antenatal period. He found out that all of the unexpected ultrasound images were reacted to with shock and surprise irrespective of the diagnosis and yet no ultrasound diagnosis was questioned, even when a wrong fetal diagnosis is made. He also suggested further research to discern whether women with unexpected prenatal ultrasound images interpreted to them are emotionally and psychologically able to question the interpretations at that time25.
Rempel et al in their work explored the pregnancy decision-making processes of parents following an antenatal diagnosis of fetal congenital heart disease using a qualitative design, describing parents post diagnosis relationship and interaction patterns with health care professionals. They found out that although the majority of women who undergo prenatal ultrasound have normal findings and are reassured about the health of their baby, some women have been found to suffer stress and high anxiety levels. They also found that prospective parents involved in decisions after a prenatal ultrasound diagnosis of congenital heart disease consider this to be their 'first parenting decisions'26.
Bashour et al in their study with Syrian women has reported that majority of women especially in developed countries no longer have fears regarding the safety of ultrasound, and so go for it uncritically. They also noted that the ultrasound experience will reassure the pregnant woman about fetal well-being, encourage women to abandon practices harmful to the fetus, facilitate early bonding and will be enjoyable and interesting27.
Lalor et al in their work reported that, many women have got many expectations from routine scans like knowing the fetal sex, status of the baby and expected date of delivery. They further reasoned that, most women now accept the scan uncritically because of the enormous expectations they have, but most especially viewing their baby live on the screen and knowing the fetal sex28.
Nigenda et al in their work concurred with the aforementioned views when they reported that pregnant women attending antenatal care in developing countries have got several expectations when they are sent for ultrasound, most of which includes; knowing the sex of the fetus, fetal viability, expected due date, fetal heart rate and the reassurance that the baby is fine29.
Enakpene et al in their work observed that women who have some knowledge about obstetric sonography and women with higher levels of formal education are more likely to have many expectations as well as ask many questions compared to women with low levels of formal education. They concluded that this can result to psychosocial effects or therapeutic benefits of prenatal sonography and the health care providers can also contributed in a way to this obsession30.
World Health organization in their work observed that the high rate of maternal mortality in Nigeria is an increasing concern. It is recorded as 800 deaths per100, 000 live births. They concluded that direct causes of maternal death are related to obstetric complications of pregnancy, labour and childbirth and some of these complications can be detected by ultrasonography31.
Ngoma et al in their work observed that access to medical services is an important component of healthy policy in developing countries. Access to medicine is considered a basic human right by activist working in the health sector in developing countries. They concluded that higher emphasis on curative than preventive health care has also been one of the causes of increase in maternal mortality32.
Ugwu et al in their work to investigate patients access to obstetric ultrasonography in some rural area observed virtually no population based study assessing the predicaments in access to obstetric ultrasound services in a less developed areas and rural setting. They observed that previous studies have been satisfaction and perception based. In their result they found out that only 30% of women out of a total of 300 had previous access to obstetric ultrasonography and over 80% were willing to go for the exam. They concluded that access to obstetric ultrasonography in the suburbs of Enugu state is poor and there is need for improvement33.
Levi in his work found that ultrasound has become an integral part of modern obstetrics. He observed that ultrasonography in the first trimester enables the establishment of viability, determination of chronicity and measure nuchal translucency in order to evaluate the risk of chromosomal abnormalities like Down's syndrome while the second trimester scan is used primarily to detect structural abnormalities. They concluded that obstetric ultrasound is beneficial in mother and child care34.
Routine second trimester analysis in their work found out that although the cost effectiveness of routine ultrasonography examination has been questioned by some, they observed that there is evidence to support that it might be cost effective to the health care system35.
Fletcher et al in their work observed that to some parents ultrasound is done only to determine the gender of the fetus and they point out that there is always false positive and false negative with fetal sex which may have numerous implications like selective abortion of unwanted fetal gender, therefore care should be taken in announcing of fetal sex to women. They observed that this knowledge affects a woman’s emotion. They concluded that ultrasound apart from providing diagnostic benefit, has been seen to improve maternal bonding36.
Larsen et al in their work observed that issues of health workers not responding to patients during scan are of great concern to women and this has influenced the way women perceive these health workers and this is due to inter personal skills demonstrated by the people doing the scan. They concluded that this affects the reaction of women towards prenatal sonography37.
Beech in his works found out that routine ultrasound in 27,024 late pregnancies in low-risk or unselected populations do not confer benefit on mother or baby. He concluded that routine scan does not seem to be associated with reductions in adverse outcomes for babies38.
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