Attitude of Expectant Mothers on the Use of Ultrasound in Pregnancy in a Tertiary Institution in South East of Nigeria
- *Corresponding Author:
- Dr. Ikeako LC
Department of Obstetrics and Gynecology, Anambra State University Teaching Hospital, Amaka, Awka, Nigeria.
Citation: Ikeako LC, Ezegwui HU, Onwudiwe E, Enwereji JO. Attitude of expectant mothers on the use of ultrasound in pregnancy in a tertiary institution in south east of Nigeria. Ann Med Health Sci Res 2014;4:949-53.
Background: With the worldâÂÂwide availability of ultrasound services even in the developing countries, routine ultrasonography in pregnancy remains a controversial issue. However, in this era of reproductive health right and evidenceâÂÂbased medicine, the views of women need to be ascertained. Aims: The aim is to assess the attitude of antenatal women toward sonography in pregnancy. Subjects and Methods: A descriptive selfâÂÂadministered questionnaireâÂÂbased crossâÂÂsectional study using 208 women that booked for antenatal care from January 1, 2009 to June 30, 2009 at the University of Nigeria Teaching Hospital, Enugu. Results: The number of respondents who had ultrasonography in their previous pregnancies was 58.7% (122/208). Although many reasons were given for personal ultrasound requests, 19.7% (24/122) of the women who had obstetric scan in their previous pregnancies thought it was a normal booking test done for every pregnant woman. When compared with other booking investigations, 60.1% (125/208), mainly civil servants .expressed the views that ultrasound in pregnancy is costly, while 24.4% (59/208) felt it is cheap, 9.1% (19/208) said it is very costly, while the remaining 2.4% (5/208) thought it is not affordable. Apart from visualizing the images of their babies, 17.8% (37/208) of the cases wanted to know the sexes of their babies while 15.4% (32/208) was for determination of fetal position. Out of 110, 52.9% (110/208) were of the opinion that women can decide when to request for sonography. Conclusion: The attitude of Nigerian women to sonography is good. Majority of them request ultrasound for fetal observation and gender determination.
Attitude, Expectant, Mothers, Nigeria, Pregnancy, Ultrasound
The introduction of ultrasound in obstetrics by Prof. Donald in 1958 revolutionized the process of fetal monitoring and diagnosis in prenatal care. Prenatal ultrasound is unique because of the direct access, it gives parents to images of the fetus. At present, ultrasound has become an indispensable part of modern antenatal care (ANC) in both developing and industrialized countries. Ultrasound is safe, portable, less expensive than other imaging modalities, noninvasive, and has a real‑time imaging capability that is essential in obstetrics. The recent advances in methods of prenatal diagnosis, particularly prenatal ultrasound has resulted in a better understanding of certain congenital anomalies and consequently, the improvement in surgical and medical procedures to treat birth defects earlier with improved outcomes.
The benefits of diagnostic ultrasound in both developed and poor resource settings are well‑known and undisputed. In South Africa, a community‑based ultrasound service significantly reduced referral to a regional center for fetal surveillance.
With increased awareness about the benefits of ultrasound, there are increased requests for examinations by both the clinicians and patients. In some situation, women want sonograms for reasons that may not be of immediate value to the clinician in the decision‑making process. The result is a waste of scarce resources especially in developing countries where high cost of services often acts as a disincentive to utilization of maternity services. Harris and Marks observed that the use of ultrasound in pregnancy could be cost effective if sonograms are employed for high‑risk group or specific indications.
During sonograms, women in developing countries request for determination of the sex of the baby, expected date of delivery, the position of the baby, and the reassurance that the baby is in good health. Often, the expectations from these examinations are high without appropriate regards to the technological limitations[11‑14] due to poor counseling
Many studies and reviews have been carried out locally and internationally on the routine use of ultrasound in pregnancy. However, most of these studies centered on fetal and maternal outcome vis‑à‑vis the routine use of ultrasonography and its cost effectiveness in pregnancy. None of these studies in our area considered the views of the pregnant women on the antenatal use of ultrasound.
This descriptive cross‑sectional survey assessed the attitude of antenatal women toward sonogram.
Subjects and Methods
Pretested structured questionnaires were administered to 208 consecutive antenatal attendees from January 1, to June 30, 2009. The questionnaires were administered by two resident doctors who also interpreted the English language to vernacular for those who do not understand English.
The data collection was divided into two sections. Section A contains questions on demographic data. Section B contains questions on history of prenatal ultrasound in their previous pregnancies, reasons for personal request and whether ultrasound should be added to the booking investigations irrespective of the cost.
This was done using descriptive statistics with the aid of Statistical Package for Social Science (SPSS) for windows version 12.0. 1, SPSS version 17 (Chicago IL, USA). Chi‑squared test was used to examine the significant association between variables. Statistical significance was set at level ≤ 0.05.
Permission was obtained from the ethical committee of the University Teaching Hospital, Enugu. Consent was also obtained from each study participant. They were assured of confidentiality and their right to decline participation without any form of danger, malice, or prejudice.
The questionnaires were administered to 208 consecutive antenatal attendees. The age distribution ranged from 16 to 43 years. The mean age (standard deviation) was 22.4 (3.2) years.
Table 1 shows that 30.3% (63/208) were civil servants, 68.8% (143/208) had tertiary education, 45.2% (94/208) were multiparous, and 53.3% (111/208) were in the second trimester of gestation.
|Above 40||14 (6.8)|
|Gestational age (index pregnancy (weeks))|
|Hairdresser hair stylist||2(1.0)|
Table 1: Socio‑demographic characteristics
Out of the 208 patients who participated in the study, 58% (122/208) had ultrasonography in their previous pregnancies. The reasons for ultrasonography in their previous pregnancies were determination of the fetal position 30.3% (37/208), fetal well‑being 16.4% (20/208), gender determination 14.8% (18/208) and 19.7% (37/208) thought it was normal test for every patient.
In the current pregnancy, 73.1% (152/208) of the patients believed that the ultrasound should be done for every pregnant woman like other booking investigations while 26.9% (56/208) felt that it should not be included in the booking investigations. Among the primigravidae 73.7% (46/63) agreed that it should be included. Others include 74% (32/43) among the primiparous, 78% (73/94) among para 2 to para 5, while 75% (6/8) was recorded among those > para 5. Parity did not significantly influence the request for personal sonography (P = 0.855).
Apart from observing their babies, 17.8% (37/208) said their reason for ultrasound request is to know the sex of their baby, while 15.4% (32/208) said it is to know the position of their babies [Table 2].
|Reasons for ultrasound request||Frequency (%)|
|Fetal observation||56 (26.9)|
|Sex determination||37 (17.8)|
|Presentation of fetus||32 (15.4)|
|Gestational age||17 (8.17)|
|Placental location||13 (6.25)|
|Fetal well‑being||10 (4.80)|
|Estimated birth weight||10 (4.80)|
|Fetal abnormality||9 (4.35)|
|Maternal well‑being||9 (4.35)|
|number of babies||6 (2.88)|
|To know the date delivery||4 (1.92)|
|To confirm pregnancy||3 (1.44)|
|Fetal blood group||1 (0.48)|
|For self‑satisfaction||1 (0.48)|
Table 2: Indications for personal ultrasound request
Compared with other booking investigations as shown in Table 3, 60.1% thought that ultrasonography in pregnancy is costly, 28.4% (59/208) felt that the obstetric scan is cheap while 9.1% (19/208) and 2.4% (5/208), respectively, considered obstetric scan very costly and not affordable. Sixty percent of those who thought it was not affordable were civil servants while 40% (were traders).
|Cost of scan||Frequency (%)|
Table 3: Their views on the cost of obstetric scan when compared with other booking investigations
One hundred and ten (52.9%) patients expressed the view that women should have the right to request for sonography anytime while 47.1% (98/208) were of the contrary opinion. Of the women who believed it is their right to request for sonography, 79% (87/110) were degree holders, 19.1% (21/110) attended secondary school while the remaining 1.8% (2/110) had first school leaving certificate [Table 4]. The level of education significantly influenced the decision for personal ultrasound requests (P = 0.001).
|Educational level||Should women request forpersonal ultrasound|
|First school leaving certificate||2||5||7|
Table 4: Contingency table showing their educational attainment and their response on personal request for ultrasound
This study revealed that most of the respondents were civil servants and degree holders. This is most likely due to the status of Enugu being a state capital. Majority of the respondents 53.3% (111/208) booked in the second trimester. In Tanzania, no interviewees attended for the first ANC visit before 12 weeks. Other studies have also shown a characteristic pattern of late booking for ANC in developing countries[16,17] which precludes accurate determination of gestational age.
Fifty‑eight percent (122/208) had sonography in their previous pregnancies. This could be, as a result of increased awareness, wide availability of ultrasound facilities, and the personnel to deliver the services. The figure 58% (122/208) recorded in this study was comparable to the number of women that had sonography in their previous pregnancies in a similar study by Enakpene et al. in Ibadan, South West of Nigeria. The previous ultrasound scans were mainly to determine the position of the baby. The women were probably apprehensive about the consequences of malpresentation at delivery. Interestingly, a large number of these women 73.1% (152/208) in this study felt it was a routine test done for every pregnant woman. This agrees with the findings which showed that most women received little information from health professionals about the indications, capabilities, and limitations of the scan and had expectations that exceeded the purpose and ability of the examination.[15,20]
In the study, 17.8% had ultrasonography to determine the gender of their babies even though the limitations of such gender determination have been established. The figure recorded in this study was a little less than that observed by Enakpene et al. in Ibadan. This shows that there is still much emphasis placed on the sex of the child in our environment. However, this contrasts with a report from Sokoto in Northern Nigeria where women were indifferent about gender of their babies, preferring to be “satisfied with anyone that comes”. The desire to know the gender of the fetus before delivery has been cited as one of the drawbacks of ultrasound as this has resulted in sex selective abortions especially in a society with strong male preference.[15,22]
There is a need for caution when telling women the sex of their babies since there are always false positives and false negatives. Chigbu et al. noted that women who received an incorrect determination of fetal sex by ultrasound experienced marital conflicts, domestic violence, negative perceptions of ultrasound, and difficulty with the upbringing of the newborn.
The most common reason for requesting for ultrasonography by the patients were fetal observation 56 (26.9%). In Tanzania and Australia, the emotional reassurance of seeing the baby and confirming viability were common reasons for desiring scans.[15,25]
Out of 125, 60.1% (125/208) patients in this study expressed the views that ultrasonography is expensive. This was not surprising as 30.3% of the patients were civil servants and 25.5% were either students or unemployed. This was, however, contrary to the findings in Borno, Northern Nigeria, where 72.7% of the respondents expressed the view that ultrasonography was not expensive due to the fact that they were largely dependent on their spouses or government for payment for the services.
The level of education and occupation influenced their views on their right to request for an ultrasound. Seventy‑nine percent of the women that felt it is their right to request for an ultrasound any time they want attended tertiary institutions and were mainly professionals. This is not surprising as the level of education determines one’s occupation and also the awareness of reproductive health right. In addition, Mubuuke et al. observed that the level of education tends to influence the methods in which women obtain and analyze information about ultrasound.
The study examined the attitude of expectant mothers who could access antenatal services at the tertiary institution and, therefore, cannot be generalized. In addition, cross‑study comparisons may be misleading due to the absence of a standardized questionnaire for this type of study.
The study shows that the attitude of Nigerian women to sonography is good. The notion that ultrasonography is expensive could be dispelled by adequate explanations of the benefits in modern obstetric care.
- Donald I, Macvicar J, Brown TG. Investigation of abdominal masses by pulsed ultrasound. Lancet 1958;1:1188‑95.
- Georgsson Ohman S, Waldenström U. Second‑trimester routine ultrasound screening: Expectations and experiences in a nationwide Swedish sample. Ultrasound Obstet Gynecol 2008;32:15‑22.
- Gammeltoft T, Nguyen HT. The commodification of obstetric ultrasound scanning in Hanoi, Viet Nam. Reprod Health Matters 2007;15:163‑71.
- Kirk Shung K. Diagnostic ultrasound: Past, present, and future. J Med Biol Eng 2011;31:371‑4.
- Saadai P, Runyon T, Farmer DL. Fetal neurosurgery: Current state of the art. Future Neurol 2011;6:165‑71.
- Kongnyuy EJ, van den Broek N. The use of ultrasonography in obstetrics in developing countries. Trop Doct 2007;37:70‑2.
- Geerts L, Theron AM, Grove D, Theron GB, Odendaal HJ. A community‑based obstetric ultrasound service. Int J Gynaecol Obstet 2004;84:23‑31.
- Stephens MB, Montefalcon R, Lane DA. The maternal perspective on prenatal ultrasound. J Fam Pract 2000;49:601‑4.
- Omo‑Aghoja LO, Aisien OA, Akuse JT, Bergstrom S, Okonofua FE. Maternal mortality and emergency obstetric care in Benin City, South‑South Nigeria. J. Clin Med Res 2010;2:055‑60.
- Harris RD, Marks WM. Compact ultrasound for improving maternal and perinatal care in low‑resource settings: Review of the potential benefits, implementation challenges, and public health issues. J Ultrasound Med 2009;28:1067‑76.
- Tautz S, Jahn A, Molokomme I, Görgen R. Between fear and relief: How rural pregnant women experience foetal ultrasound in a Botswana district hospital. Soc Sci Med 2000;50:689‑701.
- Lalor JG, Devane D. Information, knowledge and expectations of the routine ultrasound scan. Midwifery 2007;23:13‑22.
- Cohen SA. The safe motherhood conference. Int Farm Plann Pers 1987;13:68‑70.
- Stanton K, Mwanri L. Global maternal and child health outcomes: The role of obstetrics ultrasound in low resource setting. J Prev Med 2013;1:22‑9.
- Firth ER, Mlay P, Walker R, Sill PR. Pregnant women’s beliefs, expectations and experiences of antenatal ultrasound in Northern Tanzania. Afr J Reprod Health 2011;15:91‑107.
- Ifenne DI, Utoo BT. Gestational age at booking for antenatal care in a tertiary health facility in north‑central, Nigeria. Niger Med J 2012;53:236‑9.
- Gharoro EP, Igbafe AA. Antenatal care: Some characteristics of the booking visit in a major teaching hospital in the developing world. J Obstet Gynaecol 2006;26:195‑7.
- Kalish RB, Thaler HT, Chasen ST, Gupta M, Berman SJ, Rosenwaks Z, et al. First‑ and second‑trimester ultrasound assessment of gestational age. Am J Obstet Gynecol 2004;191:975‑8.
- Enakpene CA, Morhason‑Bello IO, Marinho AO, Adedokun BO, Kalejaiye AO, Sogo K, et al. Clients’ reasons for prenatal ultrasonography in Ibadan, South West of Nigeria. BMC Womens Health 2009;9:12.
- Mgbor SO, Onah HE. Sonographic gender determination experience in two private health care centres in Enugu, South Eastern Nigeria. J Coll Med 2006;11:65‑6.
- Maaji SM, Ekele BA, Bello SO, Morhason‑Bello IO. Do women want disclosure of fetal gender during prenatal ultrasound scan? Ann Afr Med 2010;9:11‑4.
- Garg S, Nath A. Female feticide in India: Issues and concerns.J Postgrad Med 2008;54:276‑9.
- Gonzaga MA, Kiguli‑Malwadde E, Francis B, Rosemary B. Current knowledge, attitudes and practices of expectant women toward routine sonography in pregnancy at Naguru health centre, Uganda. Pan Afr Med J 2009;3:18.
- Chigbu CO, Odugu B, Okezie O. Implications of incorrect determination of fetal sex by ultrasound. Int J Gynaecol Obstet 2008;100:287‑90.
- Harris G, Connor L, Bisits A, Higginbotham N. “Seeing the baby”: Pleasures and dilemmas of ultrasound technologies for primiparous Australian women. Med Anthropol Q 2004;18:23‑47.
- Ugwu A, Osungbade E, Erondu F. Maternal perspectives of prenatal sonogram in a north‑eastern population in Nigeria. Libyan J Med 2009;4:140‑2.