Current knowledge, attitudes and
practices of expectant women toward routine sonography in pregnancy at Naguru
health centre, Uganda
Aloysius Gonzaga1,&, Elsie Kiguli-Malwadde1, Businge
Francis1, Byanyima Rosemary2
1Makerere University, College of Health Sciences, Radiology Department,
2Mulago Hospital, Radiology Department
Mubuuke Aloysius Gonzaga, College
of Health Sciences, School of Medicine, Radiology Department, Makerere
University, P.O. Box 7072, Kampala-Uganda, Tel: +256772616788
There has been increased
medicalization of pregnancy globally due to advances in technology in the field
of healthcare and most especially in obstetric care .
The predominance of this perception is rooted in a number of trends extending
over a period of time. In support of these trends, policy makers cite the
reduction in maternal and perinatal morbidity and mortality as justification
for all the changes made in obstetrical care [2,3].
Routine obstetric ultrasound has been one of the most important advances in
antenatal care worldwide [2-5].
However, it has been
reported that innovative medical technologies like obstetric sonography have
the potential to raise social, ethical and economic dilemmas for both health
workers and the recipients of health services .
Uganda is a land locked country in Eastern Africa with a total land area of
236040 square kilometers. It has a total population of 28.3 million, 87.7% of
whom live in rural areas and have limited access to tertiary education .
In Uganda, health care delivery has been decentralized from the top to the
bottom with the aim of bringing services nearer to the people. From the top
downwards, there are National referral Hospitals, Regional referral Hospitals,
District Hospitals and Health Centre IV to I at County, Sub-county, Parish and
Village levels, respectively .
In most of these health care facilities including private health care
facilities, routine obstetric sonography has been fully embraced.
While obstetric sonography has proven to be beneficial in situations where it
is indicated, the role of it being routine remains contentious [8,9].
There is a wealth of literature about the psychosocial effects and therapeutic
benefits of prenatal sonography. Bashour et al and Georgsson et al reported
that the ultrasound experience will reassure the pregnant woman about fetal
well-being, encourage women to abandon practices harmful to the fetus,
facilitate early bonding and will be enjoyable and interesting [9,10].
Indeed many women have got many expectations from routine scans like knowing
the fetal sex, status of the baby and expected date of delivery [11,12].
Whynes further reports that, most women now accept the scan uncritically
because of the enormous expectations they have, but most especially viewing
their babies live on the screen and knowing the fetal sex .
Nigenda et al concurred with the aforementioned views when they reported that
pregnant women attending antenatal care in developing countries have got
several expectations when they are sent for ultrasound, most which are about
knowing the sex of the fetus, viability, expected due date and the reassurance
that the baby is fine .
Conversely, Tautz et al advise that sometimes pregnant women have got over
expectations that may not be met during scanning which creates a different
feeling for them after the scan .
This is mostly encountered with women who have some knowledge about obstetric
sonography. It has been reported that women with higher levels of formal
education are more likely to have many expectations as well as ask many
questions compared to women with low levels of formal education .
The health care providers have also contributed in a way to this obsession.
Gammeltoft and Nguyen report that health workers themselves have declared
obstetric ultrasound an indispensable part of modern antenatal care and
therefore recommend it. This has created a dramatic overuse of this technology
mainly because of its over commercialization for monetary gains in both public
and private health facilities. For example in a survey carried out in Viet Nam,
400 women had an average of 6.6 scans during their pregnancy and one-fifth had
had ten scans or more .
Gammeltoft and Nguyen conclude by suggesting the need for guidelines for the
appropriate use of obstetric ultrasound in antenatal care. Similar findings and
suggestions were reported by Bashour et al in their study with Syrian women .
It has been reported that majority of women especially in developed countries
no longer have fears regarding the safety of ultrasound, and so go for it
The paucity of literature in the Ugandan situation exploring this issue
warrants attention. By listening to women talk, health workers and policy
makers may have an enhanced and broad understanding of the knowledge, attitudes
and perceptions these women have about obstetric ultrasound. The purpose of the
present study was to explore knowledge, attitudes and perceptions of pregnant
women about obstetric scanning, whose findings are documented below.
study was conducted at Naguru Health Centre IV, Kampala district, Uganda. Naguru
Health Centre offers out-patient services, maternity, immunization, general
theatre services with a capacity of about 25 beds and 35 full time staff.
was an exploratory study in which semi-structured key-informant individual
interviews were conducted. Individual interviews help to collect insightful
descriptions from participants [17,18].
Open-ended questions were used and responses tape-recorded. Each interview
began with obtaining consent from the participant, explanation of the study
followed by a discussion of any concerns. Participants were assured of the
confidentiality of their opinions. The tape-recorded interview followed the
completion of the aforementioned tasks. Demographic information for each
participant was also collected. All the participants of this study had had an
ultrasound in their pregnancy. There were no restrictions to maternal age and
gestational week of the pregnancy. Primigravida and multiparous women were all
included to obtain feelings and attitudes of both groups. There were, however
restrictions to women having any complication(s) as the pregnancy experience
may be extremely different for them. In order to ensure validity, all the
researchers participated in data collection to ensure triangulation by having a
team research approach. At the same time triangulation was done by comparing
data to already existing literature, and transcripts were always kept and
referred to during the research period and the participants were requested to
verify the recorded interview on the tape; all to ensure validity.
women were considered for the study through convenience sampling. This sample
size provided enough data saturation whereby the responses had become
repetitive and redundant at the 30th woman and no new ideas were coming up. At
the same time, the responses got provided enough depth which is key in focused
ethnography exploratory qualitative studies like this study rather than
dwelling on the breadth of the sample size that provide similar responses even
after data saturation .
content analysis, a valued method for analyzing qualitative data was used .
This involved content analysis to extract the meanings of the informants, and
also transcription. Raw data was proof-read against audio-taped interviews and
coded into categories of similar meaning. This technique is one Wilson
collectively refers to as analytic description .
Categories were established, resulting into content themes, consistent with the
value of thematic content analysis in qualitative methods .
These themes summarized the meaning of the data which addressed the purpose of
the study. Bivariate, multivariate and logistic regression model were the
methods used to analyse the quantitative part of the data using SPSS. A
Chi-square was used to test statistical significance and a p-value of 0.05 was
adopted for this study.
was obtained from the Radiology department of Makerere University and also from
Naguru Health Centre. Consent was also obtained from each study participant.
Confidentiality, autonomy, respects and dignity of all the participants was
strictly observed throughout the study. Additionally participants
were assured of their rights to decline participating in the study and also not
to answer questions they felt uncomfortable with. The participants were also
assured that there will be no harm, prejudice, malice or any form of danger
should they wish not to participate in the study. This study strictly adhered
to the principles of the Declaration of Helsinki.
women participated in this study with age range of 19 to 42 years, and
an average age of 28.3 years. 66.7% (n=20) were Christians and 33.3% (n=10)
were Muslims. 43.3% (n=13) were primigravida and 56.7% (n=17) had been pregnant
before. All were pregnant at the time of their interview. Of the 30
women interviewed, 16.7% (n=5) were in the 10th gestation week, 13.3%
(n=4) were in the 17th gestation week, 10% (n=3) were in the 23rd
gestation week, 6.7% (n=2) were in the 28th gestation week, 10%
(n=3) were in the 32nd gestation week, 10% (n=3) were in the 33rd
gestation week and the remaining 33.3% (n=10) were above the 33rd
week of gestation. 16.7% (n=5) were undergoing scan for the first time, 66.6%
(n=20) were doing scan for the second time while the remaining 16.7% (n=5) were
doing it for the third time. All had partners at the time of the
interview. 26.7% (n=8) of the women had no formal education, 33.3% (n=10) had
attained primary level education, 23.3% (n=7) had secondary education and 16.7%
(n=5) had tertiary level education. 26.7% (n=8) were not employed, 33.3% (n=10)
were market vendors, 23.3% (n=7) were retail shopkeepers, 6.6% (n=2) were
nurses, 6.6% (n=2) were primary school teachers and 3.5% (n=1) was a secondary
key themes were identified: knowledge, attitude and practices.
women reported having some knowledge about obstetric sonography no matter the
level of education, parity or type of occupation. However, knowledge levels
varied depending on the level of education. For example the 2 nurses in this
study cited the uses of obstetric sonography which included determining fetal
presentation and lie, expected date of delivery, location of placenta, checking
whether the cord was around the neck and assessing the fetal parts. On the
contrary, the 8 women without formal education knew the existence of obstetric
scan for showing that the baby is alive as one lady explicitly put it in a
local language because she could not speak English: “Ka T.V kakeebera
ob`omwana mulamu kyoka, ebirara tekasobola kubiraba”, literally meaning
that ultrasound simply checks for fetal viability. Pressed further, they could
not give any more reasons. The women with primary education cited other reasons
like assessing fetal movements and number of fetuses. The secondary school
teacher went ahead to cite reasons like checking any abnormalities of the
mother’s organs and uterus in addition to checking the baby’s viability.
source of knowledge again varied according to level of education. The nurses,
primary and secondary school teachers cited sources like radio and T.V
programmes, newspapers, health promotion activities and peers, while the market
vendors cited talks given by mid-wives when they go antenatal check-ups and
their peers only. However, all the 30 women in this study expressed that they
know ultrasound may lead to cancer, regardless of their level of education.
When asked about the source of this knowledge, it was a common thread that they
had got it from their friends.
friend told me that over-getting exposed to the scan may shorten my life
through acquisition of cancer for me and my baby”, one secondary school
further exploration, all the women expressed willingness to learn more about
routine obstetric scan and whether it has any effects to their lives and that
of their babies. They also expressed deficit in knowledge about what ultrasound
can and cannot do.
the women reported a positive attitude towards obstetric sonography with 66.7%
(n=20) of them saying that the scan could help them plan better for their
pregnancies. 83.3% (n=25) had a positive feeling about scanning and accepted it
uncritically when their doctor requested for it.
even asked my doctor to request for me a scan just to see my baby
jumping on the T.V”, one lady asserted. “It feels good to know
the sex of the baby in advance and I start preparing for him or her. This makes
me enjoy my pregnancy more”, another lady said.
all the women expressed their feelings about the safety of their lives and the
lives of their babies due to overexposure to ultrasound.
I get worried that I may get cancer due to this scan because my friends have
told me so”, one lady said.
fear of getting cancer due to exposure to the scan was a common perception in all
the responses. Additionally, all women expressed their dissatisfaction with
the person doing the scan due to lack of proper communication with them. Many
of them had questions, but were not either responded to or they were responded
to rudely as one lady put it,
the doctor shouted at me for asking many questions, I lost all the excitement I
had of seeing my baby on the T.V”.
women reported that they duly accepted to go for the scan in their pregnancy.
Some even reported requesting for it themselves. The commonest reasons cited
for them to willingly go the scan were to know the fetal sex (100%), expected
date of delivery (100%) and viability (81.2%). One lady, pregnant
for the second time, described her need for the scan:
wanted it to be routine and that's why I asked the doctor to order for me one
even if I was feeling fine”.
(n=22) women wanted a scan for “reassurance” that the baby
was fine. All the 30 women said that they would actually go for a scan even if
their doctor did not request for it just to look at the baby.
women expressed dissatisfaction however, about the false information got in
their previous scans as one of them explicitly put it:
was told when I went to the scan that I had a baby boy. I did all my shopping
buying only blue things, only to give birth to a girl. I no longer have trust
in those scan things and I may not go for it again”.
knowing fetal viability, factors like age, occupation and education level
significantly influenced the decision to seek for the scan on bivariate analysis
(p=0.004), but all were not significant on multivariate analysis (p=0.094).
knowing fetal sex as a driving force to seek for the scan; age, religion,
occupation and gravidity were significant on bivariate analysis (p=0.002),
however only gravidity and level of education remained the significant independent
variables on logistic regression model (p=0.003). Primigravida women were about
four times more likely to request for the sex of the baby than multi-parous
women, (OR 3.78, 95% CI 1.51-9.43). Women with some formal education were seven
times more likely than the uneducated ones to request for the sex of the fetus,
(OR 6.9, 95% CI 1.46-333.21). The impendiment to do routine obstetric scans
expressed by all women was the fear for its effects to their lives and their babies;
most especially the fear to get cancer from exposure to ultrasound was
expressed by all women.
study involved women with a range of biosocial variables. Regarding their
knowledge about the use of obstetric sonography, all women expressed some level
of knowledge about obstetric sonography. This is partly due to the wide use of
ultrasound in health care today as part of routine antenatal care as well as
the unlimited access to information. However, the kind of knowledge these women
have again varies mainly due to their level of education.
The level of education tends to influence the methods in which these women
acquire and synthesize information about ultrasound. Women with lower levels of
formal education tend to be limited to only peers and when they go for
antenatal checkups which expose them to limited information about obstetric
sonography. This is why it noted that such women think that the scan is to only
check whether the baby is alive or not. On the contrary, women with higher
levels of formal education had diverse information sources like newspapers,
radio programmes. This is partly because they can read, listen and comprehend
this information, being literate. Therefore these women could cite very many
other pertinent indications for obstetric scan. This therefore shows the
significance of some level of formal education in society as it equips people
with skills to access reliable information.
All women in this study said they know that ultrasound can lead to cancer. This
is misleading information got from friends and peers which is not justified.
This is a critical point this study has brought out. Women in the developed
world uncritically go for obstetric scan without any of the fears expressed in
this study .
However, this is a different issue in Uganda and probably in the rest of the
developing world. Health care providers need to come out and address the issues
raised so as to cover the knowledge gap of the public about the safety of
women reported having a positive attitude towards obstetric sonography. This is
partly due to the excitement these women have in anticipation of seeing their
babies on the scan. Probably seeing their babies playing around, knowing the
fetal sex, knowing the expected date of delivery and just knowing that their
baby was fine are very important factors that influence the women’s perception
of obstetric sonography. It allows them to see the progress of their babies
which creates an early fetal-maternal bonding even before birth. So this makes
obstetric sonography popular and highly regarded by pregnant women.
Indeed, many pregnant women are bound to make self-requests for ultrasound even
when it is not indicated by the doctor just to see their babies or to know the
sex of the baby. Healthcare providers need to be aware of this. The fear of
cancer again has influenced women’s perception of ultrasound, and a number of
them are worried about this. This is a serious issue that needs to be addressed
by healthcare providers. An important issue of health workers not responding to
patients during the scan is of great concern. This has influenced the way
patients perceive these health workers. This is due to poor interpersonal
skills demonstrated by the people doing the scan and this trickles down to
their training which must change, so that health workers communicate with
patients effectively. The introduction of Problem Based Learning/Community
Based Education and Service at the College of Health Sciences, Makerere
University was aimed at producing graduates with good interpersonal to address
this issue .
The importance of communication with patients during the scan was also
highlighted by Whynes .
women reported accepting doing a scan as requested by the health workers. The
compliance of women to do the scan may be explained by the perceived benefits
these women expect to get from the scan, some of which include knowing fetal
sex, expected due date and fetal viability. Knowing that the scan can give
information on all these is possibly the major reason as to why women readily
go for it even when their doctor has not requested for it. However, the urge to
do an obstetric scan is probably influenced by other biosocial factors as this
study has shown. For example, primigravid women were more likely to go for a
scan simply to know the sex of the baby as opposed to multi-parous women. This
may be due to excitement of being a mother for the first time and preparing for
the baby in advance, an experience that raises high hopes in women of first
time pregnancies. This finding is similar to what Enakpene et al reported .
However, careful consideration should be taken when telling women the sex of
their babies. This raises numerous ethical, legal and social dilemmas, in
addition to how this knowledge of fetal sex affects a woman’s emotions and relationship
with her unborn child before and later on in life. It should be remembered that
there are always false positives and false negatives with fetal sex which may
have numerous implications like selective abortions of unwanted fetal genders.
Williams et al also warn about the ethical implications of telling pregnant
women the fetal gender .
Bashour et al also caution about the excessive misuse of obstetric sonography
even when it is not justified due to its commercialization for monetary gains
by health workers .
Some pregnant women are even making self-requests for the scan without any
valid indication for it from a health worker just because they can pay for it.
This study also uniquely brings out an important issue; women think that
ultrasound can actually lead to cancer and affect them as well as their babies,
and this perception runs through from the illiterate to the literate ones. This
is a perception women have and which needs to be urgently addressed in Uganda
and probably globally. The sample size used in this study is a major
limitation; however, the findings herein are useful to all health workers and
policy makers and open a way for further research in this area.
Obstetric sonography has
been embraced as being a vital part of pre-natal care. Most women want it and
duly go for it. However, guidelines are needed for the appropriate use of
ultrasound in pregnancy and how best to combine it in the antenatal health care
package and not just over-commercializing it. The perception of women that
sonography can lead to cancer needs to be addressed and health care providers
and mothers should know the purpose of sonography in pregnancy and what it can
and cannot achieve
We declare that
we have no any conflict of interest.
All Authors contributed generously
and worked as a team right from the conception of the idea to the final
production of this piece of work. All Authors were in touch throughout the
We would like
to acknowledge the participants of this study, Makerere University Radiology
department and Naguru Health Centre staffs.
- Zechmeister I.Foetal images: the power of visual technology in antenatal care and the implications for women´s reproductive freedom. Health Care Anal.2001;9(4):387-400. This article on PubMed
- Vangeenderhuysen C, Abdellahi MB, Isselmou S.Training midwives in developing countries in obstetric ultrasonography: goals and application.J Gynecol Obstet Biol Reprod (Paris). 2002 Feb;31(1):100-6. This article on PubMed
- Kongnyuy EJ, Van den Brock N.The use of ultrasonography in obstetrics in developing countries.Trop Doct. 2007 Apr;37(2):70-2. This article on PubMed
- Williams C, Sandall J, Lewando-Hundt G, Heymann B, Spencer K, Grellier R.Women as moral pioneers? Experiences of first trimester antenatal screening.Social Science and Medicine.2005; 61(9): 1983-92 . This article on PubMed
- Gammeltoft T, Nguyen HT.The commodification of obstetric ultrasound scanning in Hanoi, Viet Nam.Reproductive Health Matters.2007; 15(29): 163-71. This article on PubMed
- State of Uganda Population report 2007: available (online): State of Uganda Population report 2007 (Accessed 20 December 2008)
- Mubuuke AG, Kiguli-Malwadde E, Byanyima R, Businge F.Evaluation of community based education and service courses for undergraduate radiography students at Makerere University, Uganda.Rural and Remote Health.2008; 8(4):976. This article on PubMed
- Tautz S, Jahn A, Molokommel I, Gorgen R.Between fear and relief: how rural pregnant women experience foetal ultrasound in a Botswana district hospital.Social Science and Medicine.2000; 50(5): 689-701. This article on PubMed
- Bashour H, Hafez R, Abdulsalam A.Syrian women´s perceptions and experiences of ultrasound screening in pregnancy: implications for antenatal policy.Reproductive Health Matters.2005; 13(25): 147-54. This article on PubMed
- Georgsson Ohman S, Waldenstrom U.Second trimester routine ultrasound screening: expectations and experiences in a nation wide Swedish sample.Ultrasound Obstet Gynecol. 2008 Jul;32(1):15-22. This article on PubMed
- Lalor JG, Devane D.Information, knowledge and expectations of the routine ultrasound scan.Midwifery.2007; 23(1): 13-22. This article on PubMed
- Eurenius K, Axelsson O, Gallstedt-Fransson I, Sjoden PO.Perception of information, expectations and experiences among women and their partners attending a second trimester routine ultrasound scan.Ultrasound Obstet Gynecol. 1997 Feb;9(2):86-90. This article on PubMed
- Whynes DK.Receipt of information and women´s attitudes towards ultrasound scanning during pregnancy.Ultrasound Obstet Gynecol. 2002 Jan;19(1):7-12. This article on PubMed
- Nigenda G, Langer A, Kuchaisit C, Romero M, Rojas G, Al-Osimy M, Villar J, Garcia J, Al-Mazrou Y, Ba´aqeel H, Carroli G, Farnot U, Lumbiganon P, Belizán J, Bergsjo P, Bakketeig L, Lindmark G. Women´s opinions on antenatal care in developing countries: results of a study in Cuba, Thailand, Saud Arabia and Argentina.BMC Public Health. 2003 May 20;3:17. This article on PubMed
- Enakpene CA, Morhason-Bello IO, Marinho AO, Adedokun BO, Kalejaiye AO, Sogo K, Gbadamosi SA, Awoyinka BS, Enabor OO.Clients´reasons for prenatal ultrasonography in Ibadan, South West Nigeria.BMC Women´s Health.2009; 9(9):12. This article on PubMed
- Garcia J, Bricker L, Henderson J, Martin MA, Mugford M, Nielson J, Roberts J.Women´s views of pregnancy ultrasound: a systematic review.Birth.2002; 29(4): 225-50. This article on PubMed
- Bailey PH.Finding your way around qualitative methods in nursing research.Journal of Advanced Nursing.1997; 25: 18-22. This article on PubMed
- Fetterman D.Ethnography step by step.Newbury Park: Sage.1989
- Polit DF, Beck CT.Essentials of Nursing Research: Methods, Appraisal & Utilization (6th Ed).Lippincott Williams and Wilkins, Philadelphia, 2006.
- Polit DF, Hungler BP.Nursing research: Principles and methods (5th ed.), Philadelphia: Lippincott.1995
- Research in Nursing (2nd ed.), Redmond City: Addison-Wesley.1989.
- Sandelowski M.The use of quotes in qualitative research.Research in Nursing and Health.1994; 17: 479-482. This article on PubMed
- Kiguli-Malwadde E, Kijjambu S, Kiguli S, Galukande M, Sewankambo N, Luboga S, et al.Problem based learning, Curriculum Development and change process at Faculty of Medicine, Makerere University, Uganda.African Health Sciences.2006; 6(2): 127-130. This article on PubMed