Keywords
ultrasonography - prenatal care - obstetrics - attitude - demography - Iran
Introduction
Ultrasound examinations are usually requested with medical indications, such as prenatal
screening. Mothers may undergo sonography to assess prenatal complications with valid
reasons or evaluate fetal development due to adverse outcomes of some drugs or interventions.
However, the mothers may request to have sonography without indication or out of routine
screenings.[1]
[2]
[3] Also, maternal perspective should be manipulated and improved to manage health expenditures
effectively.[4]
[5]
[6] Furthermore, sociodemographic characteristics, obstetric history, and mothers' attitude
can affect mothers' motivation toward ultrasound scans.[7]
[8] Most of the ultrasound assessments are not according to the medical indications;
examples are watching the baby and gender determination. This implies the necessity
of research on pregnant women's attitudes toward ultrasound examinations.[9]
[10]
A previous study showed that several sociodemographic, obstetrics, and attitudinal
factors affect mothers' requests for sonographies.[7] Moreover, Garcia et al mentioned that besides mother and their partners, all staff
should be well informed about ultrasound scans and their indications during pregnancy.[11] Nevertheless, other studies have demonstrated that nonmedical reasons such as reassurance
of normal fetal development, gender determination, and watching the baby on screen
constitute the majority of ultrasound examinations.[7]
[12]
[13] For example, in a cross-sectional study, authors found that 23.2% of pregnant women
in the United Kingdom had four or more ultrasound exams during their antenatal care
in 1995. Interestingly, this figure had almost doubled by the year 2014. Moreover,
ultrasounds with medical indications, such as dating and anomaly scans, also had increased
from 31.1 and 68.7% to 95.1 and 99.1% in the span of 19 years, respectively.[12] This means that irrespective of the scan reason, pregnant women in the United Kingdom
are becoming more inclined to have more ultrasound exams during their antenatal care.
However, as a health care provider perspective, scans with nonmedical indications
are not cost effective and are a financial burden on the health care system.
Although most of the related studies on this matter have been conducted in other parts
of the world, there is little amount of evidence regarding this issue in Iran. As
mother's attitude toward perinatal sonography may be affected by several social, economic,
and cultural factors; therefore, this study aimed to investigate sociodemographic,
obstetric, and attitudinal factors that might affect preferences for prenatal ultrasound
scan by assessing the number of requests and mothers' motivation for the prenatal
ultrasound assessment in Mashhad, Iran.
Materials and Methods
Study Population and Sample Size
We conducted a cross-sectional study in six hospitals of Mashhad of Medical Sciences
from March to June 2018. The study's sample size was calculated to be 360 volunteers,
based on the Enakpene's study, using Cochrane method.[14] A simple nonrandom sampling method according to the number of admissions for delivery
was used to collect data. Women who had delivered recently (postpartum period, 6 weeks
after delivery) or were expecting to have an upcoming delivery (been in the third
trimester) were included in the study and those who did not want to participate in
the study or refused to continue were excluded. The mothers could have a normal vaginal
delivery or a cesarean section.
Data Collection
A questionnaire was designed in a panel discussion of gynecologists and social medicine
experts to collect data on the study. The questionnaires were filled out by the cooperation
of participants and doctors as an interviewer. It had three parts, including sociodemographic
data (mothers' age, mothers' age at the marriage time, mothers' level of education,
mothers' career, family income, and having insurance), obstetric history (miscarriage
age and number of miscarriage), and some information about prenatal ultrasound in
current pregnancy (including the number of ultrasound examination, child sex and attitude
of mothers toward possible ultrasound's risk factors).
Ethics
All the participants were provided with written informed consent and were allowed
to discontinue the study. The patient's privacy and confidentiality of collected data
were also considered. Moreover, the study protocol was approved by the Ethics Committee
of Mashhad University of Medical sciences.
Data Analysis
Data were analyzed by using SPSS version 16. Mann–Whitney, Kruskal–Wallis, and Pearson's
Chi-squared tests were used to compare the mean number of sonographies between different
variables. Moreover, to assess the correlation between number of ultrasonographies
and different study data, Spearman's Rho test was used. Statistical significance was
considered p <0.05.
Results
Study Participants
Although it was estimated to have 360 mothers in our study, data of around 60 cases
were missed, as they refused to continue the study and finally samples of 300 women
were enrolled in the study. Participants had a mean age of 25.95 ± 4.77 years and
an age range of 15 to 37 years. The average number of ultrasound scans was 3.50 ± 1.35,
with a maximum of nine sonographies in three women (1%). The data gathered from the
women showed 6.6% of them had screening only in one trimester, 42.2% had a screening
in two trimesters, and 51.1% had a screening in all three trimesters ([Table 1]).
Table 1
Age of the participants, the average number of ultrasound scans, and the distribution
of scans through trimesters
|
Variable
|
Total
(n = 300)
|
|
Age
|
25.95 ± 4.77
|
|
Ultrasound scans
|
3.50 ± 1.35
|
|
Scans during trimesters
|
First trimester
|
6.6%
|
|
Second trimester
|
42.2%
|
|
Third trimester
|
51.1%
|
Note: Data are presented as mean ± standard deviation or n (%).
The Motivation of Women for Prenatal Ultrasound
As can be seen in [Fig. 1], the most crucial reason for requesting prenatal ultrasound is gender determination
followed by fetus vitality and fetus age.
Fig. 1 Reasons of mothers to request prenatal ultrasonography by percent.
Sociodemographic
Our correlation test results showed that mothers with a higher education level requested
more ultrasound scans (r = 0.23; p < 0.001). Moreover, mothers whose jobs were clerks and students had more requests
than others (p = 0.003). Furthermore, those mothers with a higher family income had more requests
for sonographies (p = 0.010). Mothers who had insurance also asked for more sonographies than those with
no insurance (p = 0.010). At last, there was no significant association between ultrasound scan with
maternal age and marriage age (p > 0.05; [Table 2]).
Table 2
Comparing the mean number of sonographies between different sociodemographic, obstetric,
and attitudinal statuses and the results of correlation test
|
Feature
|
Number of ultrasound scans
(mean ± SD)
|
n
(%)
|
p-Value
|
|
Maternal age[a]
|
≤20
|
3.17 ± 1.21
|
42
(14.0)
|
0.64
|
|
20–25
|
3.58 ± 1.13
|
97
(32.3)
|
|
25–30
|
3.56 ± 1.84
|
102
(34.0)
|
|
30≤
|
3.19 ± 2.02
|
59
(19.6)
|
|
Level of education[a]
|
Illiterate or elementary
|
2.97 ± 2.04
|
58
(19.3)
|
<0.001
|
|
Diploma
|
3.48 ± 2.09
|
153
(51.0)
|
|
Associate D[b]
|
3.33 ± 2.22
|
24
(8.0)
|
|
Bachelor's D[b]
|
3.80 ± 1.98
|
65
(21.7)
|
|
Mothers' career[d]
|
House wife
|
3.40 ± 1.68
|
268
(89.3)
|
0.0003
|
|
Clerk
|
3.73 ± 1.58
|
2
(0.7)
|
|
Worker and farmer
|
2.00 ± 1.45
|
4
(1.3)
|
|
Student
|
4.50 ± 1.25
|
22
(7.3)
|
|
Self-employee
|
4.00 ± 1.75
|
4
(1.3)
|
|
Family income[d]
|
Low
|
3.30 ± 1.64
|
105
(35.0)
|
0.01
|
|
Moderate
|
3.41 ± 1.33
|
143
(47.7)
|
|
High
|
3.80 ± 1.54
|
50
(16.7)
|
|
Insurance[b]
|
Yes
|
3.47 ± 1.25
|
273
(91.0)
|
0.01
|
|
No
|
3.11 ± 1.34
|
27
(9.0)
|
|
Marriage age[a]
|
<20
|
3.42 ± 1.28
|
122 (40.7)
|
0.055
|
|
86
(28.7)
|
|
20≤
|
3.48 ± 1.05
|
92
(30.7)
|
|
Number of recent miscarriage[c]
|
0
|
3.42 ± 1.08
|
255
(85.0)
|
0.55
|
|
1
|
3.92 ± 1.09
|
24
(8.0)
|
|
2
|
3.14 ± 1.14
|
21
(7.0)
|
|
Child sex[b]
|
Male
|
3.60 ± 1.65
|
153
(51.0)
|
0.02
|
|
Female
|
3.20 ± 1.24
|
55
(18.3)
|
|
Attitude toward sonography risk[c]
|
It has no risk
|
3.67 ± 1.27
|
84
(28.0)
|
0.02
|
|
Have no idea about the risk
|
3.35 ± 1.40
|
210
(70.0)
|
Abbreviation: SD, standard deviation.
a Level of education, maternal age, marriage age and level of education were analyzed
with Spearman Rho.
b Child sex and having insurance were analyzed with Mann–Whitney.
c A number of recent miscarriages and mother's attitude about ultrasound risks were
analyzed with Kruskal–Wallis test.
d Maternal career and family income was analyzed with Pearson's Chi-square test.
Obstetrics and Attitude
Interestingly, mothers whose babies were boys had more requests for sonography than
those with girls (p-value = 0.020). There was a significant association between ultrasound scans and
the number of recent miscarriages (r = 0.140; p = 0.01). Moreover, the Kruskal–Wallis test showed mothers who believed that ultrasound
scan is not harmful had more requests than others (p = 0.020; [Table 2]).
Discussion
This study proved that mothers with a high level of education had more requests for
ultrasound scans, which may be due to the fact that their awareness about pregnancy
complications are greater than mothers with low education levels. Furthermore, families
with high socioeconomic status had better access to sonography and do not mind financial
factors, as previous studies also supported this finding.[7]
[15] Mothers who experienced miscarriage were more cautious about the fetus's vital signs
and thus had a higher number of sonographies. Gudex et al concluded that experiencing
recent miscarriages caused more demands for an antenatal ultrasound scan.[7] Our analysis showed mothers' views about possible risk factors of ultrasonography
influence their desire for this modality. However, some studies demonstrated that
ultrasound examination and its repetition were safe in any ages.[16]
[17]
[18] Surprisingly, we found that child sex and maternal career were associated with the
number of ultrasound viewing, which was novel. May be, cultural factors may affect
the families to be more cautious about male fetuses, as having a male child is preferred
traditionally in rural areas of Mashhad due to religious reasons. Also, maternal career
may affect the family income that may eliminate financial factors; however, this should
be further investigated in future studies.
Notably, maternal age did not have any significant relation with number of requests,
although one study observed that mothers with younger marriage age had more motivation
for ultrasonography; thus, demographic variants such as average marriage age could
differ between two populations.[15] Moreover, our study pointed out that having insurance resulted in more ultrasound
scans, supported by a previous study. Studies also pointed out that patients with
private insurance requested more ultrasound scans.[19] This should be considered by the authorities as requesting sonography without indication
poses a further economic burden on the system. Finally, our study estimated distinct
motivations for ultrasonography that gender determination was the most dominant, which
contrasts with other studies; psychiatric factors such as women's attitudes and religion
might differ in societies.[20]
Our studies, just like other studies, had some strong points and some shortcomings.
On the one hand, doctors filled out questionnaires by interviewing participants as
it was opposed to previous studies that participants filled questionnaires by themselves,
which caused heavier bias. Contrary to most previous studies, we assessed the association
of obstetric factors such as child sex and miscarriages. However, major limitation
of this study was recall bias of the participants due to the study design. Another
limitation of our study was that we did not assess other factors such as the level
of partner's education, mother's characters (including the level of anxiety), and
the prescriber's conflict of interest. In addition, the sample size of our study was
no adequate to evaluate factors such as two recent miscarriages. Finally, the lack
of randomization in choosing hospitals could result in sampling bias. With this regard,
several future studies should be conducted to overcome these limitations.
Conclusion
In conclusion, this investigation showed that maternal motivation for ultrasound examination
is influenced by some sociodemographic, obstetric, and attitudinal factors. Moreover,
the findings of this research provide insights into the economic burden of nonindicated
prenatal sonographies. As our study showed, mothers who had insurance requested more
sonographies, which poses more pressure on the insurance system. However, the role
of medical staff and doctors should be further investigated in this regard. Maybe,
restriction in nonindicated sonographies further helps system improvement and even
fetus health.
