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Pregnancy Choices and the Role of Ultrasound Viewing

York, Ashley B.; Bagwell, Laurie L.

doi: 10.1097/CNJ.0000000000000557
Feature: research/practice
Free

ABSTRACT: Limited research exists on the impact of ultrasound use in abortion or pregnancy clinic settings, to assist women in decision-making regarding their pregnancy. A retrospective chart review study was conducted at a pregnancy resource center to examine the impact of ultrasound viewing on a woman's decision to continue her pregnancy. During a 1-year period, intention to terminate pregnancy was reduced from 44 cases to 14 cases after viewing the ultrasound. Nursing implications include understanding the value of ultrasound viewing among pregnant women considering abortion.

Ashley B. York, DNP, APRN, is an assistant professor at Samford University in Homewood, Alabama. She is certified as a nurse practitioner in women's health and adult/gerontology primary care and has volunteered at a Christian pregnancy resource center.

Laurie L. Bagwell, DNP, APRN, is an associate professor at Union University in Jackson, Tennessee, and DNP advisor to Ashley York. She also is certified as a family nurse practitioner.

The authors declare no conflict of interest.

Accepted by peer-review 07/09/2018

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Nurses are devoted to providing evidence-based recommendations and care to patients in many settings. With the ongoing debate about abortion, evidence-based research is needed from multiple clinical settings to enable nurses to provide helpful information to patients. Due to the complexity of this topic, nurses who work with women facing the decision to carry or abort their pregnancy face ethically and spiritually tough issues.

Many women choose abortion to resolve an unexpected pregnancy. The Guttmacher Institute (2018) reports that in 2014, 19% of pregnancies in the United States were terminated by elective abortion. Table 1 relays abortion statistics in the United States from 2014, which were down 12% from the 1.06 million abortions reported in 2011 (Guttmacher).

TABLE 1

TABLE 1

Ultrasound has become a routine part of obstetrics and abortion care, often used to assess the gestational age of the fetus (Kimport & Weitz, 2015). The World Health Organization (2012) states that determining a fetus's gestational age is an essential factor in selecting the most appropriate abortion method. Ultrasound is one method of determination, along with a bimanual pelvic exam, abdominal exam, recognition of pregnancy symptoms, and laboratory testing.

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ULTRASOUND USE DEBATE

Ultrasound is performed using a handheld transducer placed on the skin. Ultrasound waves from the transducer travel into the body and are reflected to the transducer as the waves hit organs and tissues under the skin. During a pregnancy ultrasound, a woman can view images via a monitor, including the structures of the fetus and the fetal heartbeat, if present (National Institute of Biomedical Imaging and Bioengineering, 2016). Speculation on the persuasive use of ultrasound imaging for pregnant women considering abortion arose after research demonstrated that ultrasound viewing can have a positive effect on maternal and fetal attachment (Alhusen, 2008 ; Pretorius et al., 2006).

Gatter, Kimport, Foster, Weitz, and Upadhyay's (2014) study on ultrasound viewing as a preprocedure to abortion at an urban Planned Parenthood clinic showed that of the 42.5% of women who chose to view their ultrasound, 98.4% still terminated their pregnancy. These women were considered to have high certainty for abortion. However, 7.4% of women who had medium to low certainty for abortion decided to continue their pregnancy after viewing the ultrasound. The study authors concluded that voluntary viewing of the ultrasound might contribute to a proportion of patients changing their decision to have an elective abortion.

Another study involving 20 participants investigated the perspective of women on ultrasound viewing in the abortion care context. Researchers suggested that the current assumptions that ultrasound viewing dissuades women from having an abortion were inaccurate or incomplete (Kimport, Preskill, Cockrill, & Weitz, 2012). Abortion opponents promote ultrasound viewing, with a patient's informed consent, with the aim of prompting women who are considering abortion to continue the pregnancy, once they have seen their fetus (Kimport et al.).

Limited research exists on the impact of ultrasound use in abortion and pregnancy clinic settings. Existing research has limitations in sample size, study location, and in ethnicity and economic demographics of the samples. More research is needed to support current and proposed state-level legislation requirements for ultrasound procedures and viewing for women contemplating the termination of their pregnancy. Currently, in 28 states (National Right to Life, 2018), ultrasound, and in some cases the offer to view the ultrasound, is required by law prior to an abortion. Further research on ultrasound viewing can benefit nurses who educate and care for women facing the decision to continue or terminate a pregnancy.

Although opinions differ on ultrasound viewing, research is lacking on whether ultrasound influences the decision a woman makes. If ultrasound does not impact decision-making, use of this technology to help women decide about abortion is a poor allocation of resources. This study is not addressing use of ultrasound as a procedure in abortion care, but rather exploring the role ultrasound may have in affecting a woman's decision to terminate or continue her pregnancy. The study used a setting not used in prior research—a pregnancy resource center, adding to the body of knowledge on the topic.

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INVESTIGATING ULTRASOUND VIEWING

A study was conducted to explore the influence of ultrasound viewing among women considering elective abortion. The clinical setting used for the study was a Christian pregnancy resource center (PRC) in western Tennessee. The center operates under a medical advisory board, with a nurse manager and other registered nurses, and is affiliated with Care Net and the National Institute of Family and Life Advocates (NIFLA). The center provides education, ultrasounds, and pregnancy tests. All tests are voluntary and free.

Patients complete a pregnancy intention form upon intake at the PRC. The form asks women, “If you are pregnant, what is your intention?” Answer choices are: 1) abort, 2) intend to carry to term, or 3) undecided. Patients complete the same form upon completion of an ultrasound.

A retrospective chart review of responses on the PRC's pregnancy intention form was conducted using a convenience sample of patients who visited the center from January 1 through December 31, 2015. Institutional Review Board approval for the study was obtained from Union University. Patients who were between the ages 18 and 45, pregnant, and received an ultrasound at the PRC were eligible for inclusion in the study. Exclusion criteria included a negative pregnancy test and missing data on the preultrasound and postultrasound pregnancy intention form. If multiple ultrasounds for a single pregnancy were present in the data sample, the last result for that pregnancy was taken; if the patient had multiple separate pregnancies, these ultrasounds counted as a separate observation.

For study inclusion, patients also had to meet the PRC's criteria for receiving an ultrasound. Per clinic regulations, exclusion criteria for an ultrasound included a previous ultrasound for that pregnancy, experiencing bleeding equal to or greater than a menstrual cycle, being previously seen by a provider for prenatal care, and a history of tubal pregnancy. If a patient answered yes to a previous tubal pregnancy, she was referred to obstetric services due to the need for a higher-level ultrasound. If both PRC and study criteria were met for an ultrasound, the patient's record was included in this study.

Data were collected using electronic health records from the PRC. All data were deidentified by the PRC before the researcher obtained study information. A total of 585 patient encounters initially meeting study criteria were merged and transferred to a spreadsheet. After exclusion criteria were applied, 328 patient records (N = 328) were included in the study and analyzed.

The goal of data analysis was to look for correlation and association of viewing the ultrasound with a change in reported pregnancy intention. Descriptive statistics and measures of association were obtained using Statistical Package for the Social Sciences (SPSS) Version 23.

Analysis revealed the patients' mean age was 25.89 years. The majority were African American (59%), in their first reported pregnancy (67.4%), and single (61.9%) (Table 2). Of the 328 women in the study, 34 reported whether or not they had had a previous abortion. Of these 34, 21 had not had a previous abortion, 11 reported one previous abortion, and 2 had three previous abortions.

TABLE 2

TABLE 2

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BEFORE AND AFTER ULTRASOUND RESULTS

Table 3 shows patient responses to the question of whether to abort, carry, or if they were undecided about their pregnancy, as reported on the pregnancy intention form. The association between the carry, abort, or undecided values before the ultrasound and after the ultrasound was analyzed using Cramér's V test. The Cramér's V statistic ∅c provides a result of 0, indicating no association, to 1 indicating complete association between nominal-level variables. Cramér's V in this study was ∅c = 0.628, indicating an association between the women's choices before and after ultrasound viewing. The Contingency Coefficient of 0.736 (maximum value of 1 indicates perfect correlation) supports a positive correlation between the women's choices before and after viewing the ultrasound and their decision to change their choice. Data reveal that the intention of planning to abort before ultrasound was reduced from 44 cases to 14 cases after viewing of the ultrasound. These results support that ultrasound viewing influenced the women who were planning on abortion to continue, rather than terminate, their pregnancy.

TABLE 3

TABLE 3

A limitation of this retrospective chart review study is that conversations between patients and PRC staff members were not known. Patient conversations could have influenced patients' pregnancy intentions, in addition to the ultrasounds. Another limitation is that the information provided to patients via handouts from Care Net and NIFLA was not known and could have influenced pregnancy intentions. The fact that the PRC is a pro-life center could have influenced the women's decision-making. However, each patient receives information related to abortion and adoption. The PRC offers information on all possible options to a patient before the ultrasound, unless the patient refuses the information.

It should be noted that the emotional state of the pregnant women was not measured. Men involved in the pregnancy were not accounted for in the facility paperwork, and thus their presence and influence also was not considered. In addition, no comparison was made between reported pregnancy intentions and final pregnancy outcomes. Information about pregnancy outcomes is obtained via a postvisit follow-up phone call by the PRC client advocates and recorded in patient's records. However, much of the data about final pregnancy outcomes for the patients in this study were missing.

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IMPLICATIONS FOR PRACTICE

This research provides information about how ultrasound viewing may influence decision-making among pregnant women. The results support that viewing an ultrasound has the potential to impact the decision to continue a pregnancy for a woman who is considering abortion, especially in the context of a PRC. The study provides more research into the use of ultrasound as a tool to help women make educated and informed decisions about their healthcare needs. Nurses need to disseminate all pertinent information that allows a woman to make what she believes is the best decision about her pregnancy. This information also may benefit lawmakers as legislation is considered regarding the use of ultrasound viewing for pregnant women.

For Christian nurses, the biblical framework of God's pattern for human creation and his value of each person is helpful. Genesis 1:27 explains, “So God created man in his own image, in the image of God he created him; male and female he created them” (ESV). Humans reflect God, bearing his image. A person's value is inestimable. Jeremiah 1:5 makes clear that we are known by God before birth: “Before I formed you in the womb I knew you, and before you were born I consecrated you” (ESV). Nurses can be empowered by these verses, as well as God's promise to give wisdom, “If any of you lacks wisdom, let him ask God, who gives generously to all without reproach, and it will be given him” (James 1:5, ESV).

It is imperative for nurses who care for women facing difficult decisions about their pregnancy to have evidence-based research to knowledgably inform their patients in various settings, such as the emergency room, a clinic, or in the community. Incorporating understanding that each person is created by God in his image, and by employing godly wisdom, Christian nurses can share information about ultrasound use that offers women more facts about their pregnancy.

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Web Resources

Alhusen J. L. (2008). A literature update on maternal-fetal attachment. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 37(3), 315–328. doi:10.1111/j.1552-6909.2008.00241.x
Gatter M., Kimport K., Foster D. G., Weitz T. A., Upadhyay U. D. (2014). Relationship between ultrasound viewing and proceeding to abortion. Obstetrics & Gynecology, 123(1), 81–87. doi:10.1097/AOG.0000000000000053
Guttmacher Institute. (2018). Fact sheet: Induced abortion in the United States. Retrieved from https://www.guttmacher.org/sites/default/files/factsheet/fb_induced_abortion.pdf
Kimport K., Preskill F., Cockrill K., Weitz T. A. (2012). Women's perspectives on ultrasound viewing in the abortion care context. Women's Health Issues, 22(6), e513–e517. doi:10.1016/j.whi.2012.09.001
Kimport K., Weitz T. A. (2015). Constructing the meaning of ultrasound viewing in abortion care. Sociology of Health & Illness, 37(6), 856–869. doi:10.1111/1467-9566.12237
National Institute of Biomedical Imaging and Bioengineering. (2016). Ultrasound. Retrieved from https://www.nibib.nih.gov/science-education/science-topics/ultrasound
National Right to Life. (2018). Window into the womb: A guide to state laws on ultrasound. Retrieved from https://www.nrlc.org/uploads/stateleg/UltrasoundFactsheet.pdf
Pretorius D. H., Gattu S., Ji E. K., Hollenbach K., Newton R., Hull A., ..., Nelson T. R. (2006). Preexamination and postexamination assessment of parental-fetal bonding in patients undergoing 3-/4-dimensional obstetric ultrasonography. Journal of Ultrasound in Medicine, 25(11), 1411–1421. doi:abs/10.7863/jum.2006.25.11.1411
World Health Organization. (2012). Clinical care for women undergoing abortion. Safe abortion: Technical and safety guide for health systems (2nd ed., pp. 30–52). Geneva, Switzerland: Author. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK138188/
Keywords:

abortion; nursing care; pregnancy; pregnancy resource center; ultrasound; women's health

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