16 NUMBER 6 November/December 2003
Letter from Glasgow
Ultrasound scanning in pregnancy: The hope and the
I don’t want to go blowing trumpets here but I’m afraid I really
must. You’ll understand that I’m not blowing any brass instruments
on my own behalf but that of Glasgow (renowned for its hospitable and friendly
natives who are called Glaswegians) and a certain Professor Ian Donald who
worked in Glasgow.
Ultrasound scanning in pregnancy was pioneered here in Glasgow in the 1950s
(the decade before my parents moved to Glasgow from India) and Professor Ian
Donald was the person who did the pioneering work (www.ob-ultrasound.net).
Appointed to the Regius Chair of Midwifery at the University of Glasgow, Ian
Donald spotted the potential of sonar for medical purposes. This was aided
considerably by a famous industrial company in Scotland, Babcock and Wilcox,
based just outside Glasgow in the town of Renfrew. Babcock and Wilcox allowed
him to use an ultrasonic metal flaw detector on excised fibroids and ovarian
cysts. Following those early investigations, it was towards the end of the
1950s that the knowledge Ian Donald gained was applied to the field of obstetrics.
Consequently, a great tool was developed to help obstetricians and midwives
provide information on the foetus and the mother to help provide safer and
better care for both.
There are two reasons for writing about ultrasound in pregnancy—the first
is that ultrasound scanning is an area that NHS Quality Improvement Scotland
(NHS QIS), for whom I work, are currently looking at, and the second is the
abuse of ultrasound scanning by some in India.
NHS QIS are undertaking a health technology assessment (HTA) on routine ultrasound
scanning in the first 24 weeks of pregnancy. As I explained in my previous
Letter, an HTA considers clinical effectiveness (including a systematic review
and meta-analyses, if necessary), cost-effectiveness (including economic modelling),
patients’ and carers’ needs and preferences, and organizational
issues (including training, quality assurance and medicolegal issues) when
assessing any health technology (intervention) under review.1 The objective
of this HTA is to answer the question: ‘What is the most clinically and
cost-effective routine ultrasound scanning policy which can be offered to pregnant
women in Scotland before 24 weeks of pregnancy: a first trimester scan only,
a second trimester scan only; or a first plus a second trimester scan?’ The
intention is to produce recommendations for the NHS in Scotland that will ensure
that all pregnant women get the same access to routine scanning in a normal
pregnancy—the issues of scanning in problem pregnancies are not dealt
with in this HTA.
The final report will be a 200+ page document and is scheduled for publication
in February 2004. Contained within the report will be all the work undertaken,
the assumptions made, and the final recommendations so that the public, clinicians,
statisticians, health economists and policy-makers can scrutinize all that
NHS QIS has done. For those interested in the progress of this HTA, further
information is available on our website www.nhshealthquality.org. Currently,
the last document we produced was the Consultation Report2 of the HTA, which
is also available on our website. This highlighted the use of ultrasound in
the first 24 weeks of pregnancy in assessing foetal viability, measuring gestational
age, diagnosing multiple pregnancies, making a qualitative assessment of amniotic
fluid, and identifying foetal structural abnormalities. The draft recommendations
(and I emphasize the word draft as these may change as comments and other evidence
presented during the consultation period are considered) include the following:
that all pregnant women are offered two routine ultrasound scans; a first trimester
nuchal translucency scan at 11–13 weeks which also involves maternal
serum screening for Down syndrome; and a second trimester anomaly scan at 18–20
weeks of gestation.
In many respects, it is not the details of the recommendations which will emerge
from the HTA that are important. What is much more important is the concept
that this HTA is being undertaken to assist the NHS to provide a consistent
and high quality service of routine ultrasound scanning throughout Scotland.
That is, it aims to improve healthcare provision to pregnant women (and hence
their babies) using all the existing evidence that we have to provide the best
possible care within the resources available to us. That is the hope.
The shame is what I read about the abuse of ultrasound scanning during pregnancy
in India. We know from the 2001 Census in India that the female:male ratio
has worsened from 10 years previously and that the overall ratio for India
is now 933:1000.3 It is also clear from my own knowledge on the issue that
private obstetric clinics have been using, and continue to use, ultrasound
scanning (as well as other antenatal diagnostic techniques) to selectively
identify and abort female foetuses. My shame is two-fold. The first is that
my professional peers are abusing medical knowledge and skills to knowingly
flout the Pre-conception and Pre-natal Diagnostic Techniques (Prohibition of
Sex Selection) Act in India. Furthermore, these doctors are also breaking their
Hippocratic oath to do the best for their patient. The second shame is wider
and asks what sort of society are we perpetuating in India that uses medical
knowledge and technology not to help women and girls but seeks to subjugate
them further in a medieval mind-set that aborts foetuses for the simple reason
that they have XX chromosomes.
I am proud of much that India has achieved but remain to be convinced about
its achievements on the rights of women. The National Human Development Report3
makes it clear that there has been some slight improvement in gender equality
in the past two decades in India. However, it notes that ‘on average
the attainments of women on human development indicators are only two-thirds
of those of men’. We also know that some states in India are much further
developed with regard to gender equality, with women in southern India generally
faring better than those in northern India. Moving towards gender equality
requires increasing female literacy and the empowerment of women. This then
begins to challenge the existing gender power relationships and social/cultural
But as female foeticide highlights, female literacy and education by themselves
are not enough to change attitudes to female foeticide.3 In some respects educated
individuals behave in exactly the same manner as those who are illiterate,
emphasizing the need for a multi-level and multi-pronged approach to gender
As a public health physician I know that, demographically, having a favourable
female:male ratio in India will have a profound impact on India’s capability
of progressing to the advanced industrial, technological and IT-literate society
it seeks to, and can, become. Hand-in-hand with those steps need to be social
and cultural advances that tackle the issues of female foeticide, and protect
and promote the rights of girls and women.
From the shame of abusing ultrasound scanning in pregnancy there may be hope.
I am aware of the actions that health professionals and others such as B.S.
Dahiya, the Director-General of Health Services in Haryana,4 are taking to
challenge the abuse of ultrasound scanning in pregnancy in India. I applaud
and support any initiative that seeks to protect female foetuses, girls and
women so that they can play their role in India’s future.
- Kohli HS. Letter from Glasgow. Natl Med J India 2003;16:275–6.
- NHS Quality Improvement Scotland. Routine ultrasound
scanning before 24 weeks of pregnancy. HTA Consultation
Assessment Report. Glasgow: NHS QIS; 2003.
- Planning Commission. National Human Development
Report 2001. New Delhi: Planning Commission, Government
of India; 2002.
- Vasudev S. Female foeticide. India Today (UK
edition) 2003 Nov 10; pp. 10–16