The NMJI

Letter

VOLUME 16 NUMBER 6 November/December 2003

Letter from Glasgow

Ultrasound scanning in pregnancy: The hope and the shame
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 norms.

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 equality.

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.

References

  1. Kohli HS. Letter from Glasgow. Natl Med J India 2003;16:275–6.
  2. NHS Quality Improvement Scotland. Routine ultrasound scanning before 24 weeks of pregnancy. HTA Consultation Assessment Report. Glasgow: NHS QIS; 2003.
  3. Planning Commission. National Human Development Report 2001. New Delhi: Planning Commission, Government of India; 2002.
  4. Vasudev S. Female foeticide. India Today (UK edition) 2003 Nov 10; pp. 10–16

 

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