Investigating the Cultural Meaning of Obstetric Ultrasound in Rural Pakistan
Creators: Ibrahimi, Janat
Publisher: name: University of Alberta Library
Year: 2022

<p>Background and Rationale: Obstetric ultrasounds have become a routine practice in pregnancy management globally. Evidence, however, suggests that while obstetric scans in high-income countries is associated with positive experiences to both mother and greater society, the technology may not be having similar impact in low-and middle- income countries. Available evidence shows the detrimental impact of obstetric ultrasounds on fetal sex identification and consequent abortions of female fetuses in India. Studies from Vietnam, Tanzania and Uganda suggest women have started perceiving ultrasound scans as the entirety of antenatal care. Other studies suggest mothers are overestimating the diagnostic and therapeutic abilities of ultrasound technology to the point where they are not receiving the appropriate care. The concerning nature of the current evidence available in the literature indicates the need for a detailed, qualitative investigation that examines both women and providersâ€™ understandings and practices of obstetric ultrasound use. <br>
Objective: To explore the impact of ultrasound technology on both the biomedical, and lay, cultural management of pregnancy in Rural Pakistan. <br>
Method: Data were drawn from two qualitative research projects conducted in Pakistan between 2009 and 2015. The first study, entitled â€œAddressing disparities in maternal health care in Pakistan: gender, class and exclusionâ€ is a critical ethnography of maternal health services in a village in Chakwal, Punjab. Data were generated over the course of 10-months using 134 observations, 94 in-depth interviews, and 11 focus group discussions. The second project, â€œAre community midwives addressing the inequities in access to skilled birth attendance in Pakistan? Gender, class and social exclusionâ€, used an institutional ethnographic approach to explore whether a new cadre of midwives were improving access to skilled maternity care for poor and socially excluded women in two districts â€“ Layyah and Jhelum in Punjab. Data were collected using in-depth interviews with 83 health care providers and 139 community members, and 180 formal and informal observations of patient-provider interactions in health facilities. Transcripts were selected if they contained the term â€œultrasoundâ€. Data was organized using Quirkos software and analyzed through thematic analysis.<br>
Results: Our findings revealed that an obstetric ultrasound was a common procedure for pregnant women in rural Pakistan as part of their pregnancy management. In fact, the data suggests women perceived the scan as synonymous with antenatal care and assumed it was an integral part of their antenatal visit, irrespective of any stated medical indication. It was sometimes the only care they sought during pregnancy, with 80% reporting a scan while only 49% reported receiving a blood test, blood pressure measurement or a urinalysis. A common reason underlying these patterns of use was the mothersâ€™ strong trust in ultrasound technologyâ€™s abilities to diagnose ill-health broadly and believing it alone would ensure a healthy pregnancy and healthy baby.  So strong was this trust in the powers of ultrasound technology, that mothers expected delivery dates and fetal sex reports to be precise.  Any deviations were unacceptable. Both providers, especially those in the private sector, and patients appear to play a mutually reinforcing role in driving non-medically indicated scans. Providers were observed implementing different strategies to market their ultrasound services including prioritizing ultrasound scans during appointments, encouraging monthly scans, and offering weekly discounts. Pregnant patients are reinforcing the behaviour of providers through demanding ultrasound scans in hopes of giving birth to a son.<br>
Conclusions: Obstetric ultrasound has become the preferred method of surveillance during healthy pregnancies to the extent that its use is understood as synonymous and equivalent to antenatal care. It appears that both providers, particularly those in the profit-driven private sector, and patients have mutually reinforced the demand for un-necessary ultrasound scans during pregnancy. Given the limited role of obstetric ultrasound in pregnancy surveillance, it is important to ensure that the technology does not replace routine elements of antenatal care. Health policy makers need to address the market forces underlying the for-profit private health care sector to the limit unscrupulous use of ultrasound technology that is driving the concerning reality that women in rural Pakistan are replacing ordinary antenatal care surveillance with repeated ultrasound scans. Measures must be taken to ensure that health care provision for women during pregnancy is driven not by profit, but by medical recommendation.</p>