October 24, 2012

Choosing What We Show

Recently, I interacted with a woman around my age who had come to the clinic where I was working with the intention of terminating her pregnancy.  It's been so long I can't remember how many weeks along she was, but not far.  Women enter these difficult and emotionally wrought visits with a clinician in all styles.  Some openly weep, some list all the reasons why this is the right decision - as if convincing themselves, some are silent and refuse to make eye contact, many are curious - about the pregnancy, about their options, about what they might see or not see, how their lives may be different depending on how they choose.

I feel so lucky to live in a country, in a time, when women get to make these decisions - though saddened that their decisions were not instead the less emotionally draining one of choosing effective birth control or choosing not to have sex in the first place.  I feel even more lucky to have worked in a clinic that allowed women the space to feel, think, and process whatever they needed.

This woman, let's call her Sarah* (*obviously not her real name), knew she was pregnant but was not sure how many weeks - so we did an abdominal (on the belly) ultrasound to take measurements to date her pregnancy.  There has been a good deal research on interactions with ultrasound technicians by women considering termination and the data is surprising.  But first, because ultrasound is a tricky subject these days, let me set the facts straight: everyone who is seeking or considering a termination usually has an ultrasound to date the pregnancy, because this determines many things about the possible procedures and counseling.  In the vast majority of cases, this ultrasound is done abdominally (on the belly) and is only done transvaginally (in the vagina) if the pregnancy is too early, and therefore the uterus too low in the pelvis and too small to see through the abdomen.  There are some people trying to pass laws about ultrasound and pregnancy termination that require very different things, including transvaginal ultrasounds, narration of ultrasounds, listening to heart beats, seeing moving images, etc.  This has not been my experience.  

In research investigating how to interact with a woman considering termination when conducting an abdominal (on the belly) ultrasound, the results are surprising in that many women are interested in seeing the image, many would even like an image printed to take home.  Even more fascinating is that there does not seem to be a pattern with the choices women make (in terms of keeping the pregnancy or terminating the pregnancy).  Additionally, when ultrasonographers (the people who do the ultrasounds) and clinicians are interviewed, they largely believe that women should not see the ultrasound if they are considering or have decided to terminate a pregnancy.  There are still many questions to be answered - including if the age of gestation matters (many of these papers were only involving women who were intending to have first trimester terminations), larger sample sizes, longer term effects, correlation with other factors such as parity and reasons for termination.

Planned Parenthood has a national policy where every woman is asked, before stepping into the ultrasound room, if she would like to know if she has more than one pregnancy (twins, triplets, etc), and if she would like to see any images.  Anecdotally, I have been told that most other clinics don't ask and do not offer unless the woman asks explicitly to see a picture.  

As I have had more experience with this, and after hearing an amazing presentation on some soon to be published data on women's experiences of ultrasound before a termination, I decided that I am going to ask women if there is anything they would like to see or not see, know or not know.  And I have been fascinated by the results.  

Which brings me back - finally - to Sarah*.  Sarah was very quiet when I brought her to the ultrsound room.  I had already asked Sarah the same question I ask everyone and she had said she would like to see an image.  Again, based on experience, the teaching I have received, and the data I have seen, whenever I show anyone an image, I zoom out so that there's slightly more realistic perspective of the size of the pregnancy, and I point out the abdominal wall, the uterus, and the pregnancy, as well as any other obvious structures.  When I did this for Sarah, she started crying.  In my desire to comfort her, I quickly turned the ultrasound away from her and sat in a chair next to her.  I asked her what was going on her in head at that moment, and if there was anything I could help with.  When she shook her head No, I put my hand on her back and reminded her that the next step at our clinic is to talk in depth with a counselor.  I asked her if she wanted to see any other images, and when she said No, I walked with her to the counselor's office, where the three of us sat and talked for a long time.

To be continued in the next post, as it takes this thought in a slightly different direction.


"I pointed out that she was, by definition, pro-choice.  In its simplest form all it means is that the woman gets to decide".
-Susan Wicklund, Physician and Author of This Common Secret
(click the link to see a NYT review of her book)

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