The Commodification of Obstetric Ultrasound Scanning in Hanoi, Viet Nam

Abstract

Growing numbers of pregnant women across the world now routinely have ultrasound scans as part of antenatal care, including in low-income countries. This article presents the findings of anthropological research on the use of obstetric ultrasonography in routine antenatal care in Hanoi, Viet Nam. The findings come from observation, a survey and interviews with women seeking ultrasound scans at a main maternity hospital and interviews with doctors providing ultrasound there. We found a dramatic overuse of ultrasound scanning; the 400 women surveyed had had an average of 6.6 scans and 8.3 antenatal visits during pregnancy, while one-fifth had had ten scans or more. Doctors considered obstetric ultrasound an indispensable part of modern antenatal care. For two-thirds of the women, the main reason for frequent scans was reassurance of normal fetal development. However, the women often also said their doctor had recommended the scans. This overuse must be seen in the context of growing commercialisation in the Vietnamese health care system, where ultrasound provides an important source of revenue for both private and public providers. There is an urgent need in Viet Nam for policy and practice guidelines on the appropriate use of ultrasonography in pregnancy and how best to combine it with essential antenatal care, and information dissemination to women.

Résumé

De plus en plus de femmes enceintes se soumettent systématiquement à des échographies dans le cadre des soins prénatals, même dans les pays à faible revenu. Cet article présente les conclusions d'une recherche anthropologique sur l'utilisation des échographies pour la surveillance de la grossesse à Hanoi, Viet Nam. Il utilise des observations, une enquête, et des entretiens avec des femmes venues pour une échographie dans une grande maternité et avec des médecins réalisant les échographies dans cet hôpital. Nous avons constaté un recours excessif aux échographies ; les 400 femmes interrogées avaient subi en moyenne 6,6 échographies et 8,3 visites prénatales pendant leur grossesse, alors qu'un cinquième avaient eu dix échographies ou plus. Les médecins considéraient les échographies comme un élément indispensable e soins prénatals modernes. Pour les deux tiers des femmes, la principale raison de la fréquence des échographies était de s'assurer du développement normal du fłtus. Néanmoins, les femmes ont aussi fréquemment affirmé que leur médecin avait recommandé ces examens. Cet emploi excessif doit être placé dans le contexte de la commercialisation croissante du système de santé vietnamien, où les échographies constituent une source appréciable de revenu pour les praticiens privés et publics. Le Viet Nam doit sans tarder définir des directives pratiques sur l'utilisation correcte des échographies obstétriques et sur la meilleure manière de les associer avec des soins prénatals essentiels, et diffuser des informations aux femmes.

Resumen

A nivel mundial, cada vez más mujeres embarazadas solicitan que se les practique una ecografía rutinaria como parte de la atención antenatal, incluso en los países de bajos ingresos. En este artículo se exponen los hallazgos de investigaciones antropológicas sobre el uso de la ecografía obstétrica en la atención antenatal rutinaria en Hanoi, Viet Nam. Los hallazgos provienen de observaciones, una encuesta y entrevistas con mujeres que buscan exámenes de ecografía con médicos de un importante hospital de maternidad. Se encontró un uso excesivo de la ecografía; las 400 mujeres encuestadas habían tenido un promedio de 6.6 ecografías y 8.3 consultas antenatales durante el embarazo, mientras que una quinta parte había tenido diez o más ecografías. Los médicos consideran a la ecografía obstétrica una parte indispensable de la atención antenatal moderna. Para dos terceras partes de las mujeres, el motivo principal para tener ecografías frecuentes era que les aseguraran un desarrollo fetal normal. Sin embargo, ellas a menudo dijeron que su médico había recomendado las ecografías. Este uso excesivo debe verse en el contexto de una creciente comercialización en el sistema de salud vietnamita, donde la ecografía constituye una fuente importante de ingreso tanto para los prestadores de servicios privados comos públicos. Existe una necesidad urgente en Viet Nam de formular normas de políticas y prácticas sobre el uso adecuado de la ecografía en el embarazo y sobre la mejor forma de combinarlo con la atención antenatal esencial, y de difundir la información a las mujeres.

Key Words:

• ultrasonography
• antenatal care
• commodification of health care
• Viet Nam

The world over, a rapid diffusion of new technology for the management of reproduction is taking place, and technologies which were initially developed in affluent parts of the world are now proliferating in developing countries. While many critical social scientists have investigated women's use of modern contraception and abortion in the global South,^1–3 little is known about the social processes through which technologies for use in pregnancy, such as ultrasonography or amniocentesis, have been taken up by women and health care providers in the developing world. Only the application of ultrasonography to determine fetal sex in countries with a strong son preference has been consistently studied.⁴

Ultrasonography is both affordable and accessible; hence, it has considerable potential for further spread in low-income societies.⁵⁶ Since growing numbers of pregnant women across the world are now routinely exposed to ultrasound scanning, the application of this technology is of major public health significance, especially in health care settings where maternity care is not closely regulated or monitored. There is no epidemiological evidence at present that ultrasound scanning during pregnancy is harmful, but in the context of greatly increased use, caveats have been raised. A recent Cochrane review, for instance, emphasises that “no firm conclusion [regarding safety] has been reached from available data.”⁷

Over the past two decades, the use of obstetric ultrasonography has undergone substantial expansion in affluent countries, and is now an integral part of antenatal care in the global North. In addition to the initial 2D scans, 3D and 4D scans are also now available: 3D scans provide three dimensional images which facilitate detection of certain fetal anomalies and produce appealing photos of the face of the child-to-be, while 4D scans, also known as “live”, dynamic, or motion 3Ds, add a time dimension, thereby providing a “movie” of the fetus.

The expansion of obstetric ultrasonography has taken place under the influence of commercial interests; the interests of medical practitioners, who find it useful for a variety of purposes; and pregnant women's desire to see the child-to-be prior to birth.^8–10 In middle- and low-income countries, a rapid proliferation of this technology also seems to be occurring. A recent study in Syria found that pregnant women obtained up to 20 scans per pregnancy.⁶ Ultrasound equipment is often one of the first new technologies that expatriate staff purchase when working in a developing country setting.⁵

While it is well established that ultrasound is beneficial where a woman is at high risk of complications during pregnancy and labour, its advantages in low-risk pregnancies are contested, and economic studies have questioned whether routine ultrasound scanning is a cost-effective use of limited public health care funding.¹¹ A Cochrane meta-analysis of research on the value of obstetric ultrasound confirms that the benefits of ultrasound screening in early pregnancy include better assessment of gestational age, early detection of multiple pregnancy, identification of placental position, diagnosis of non-viable pregnancies and detection of fetal malformations. The review also notes, however, that these advantages do not translate into substantial improvements in pregnancy outcome, such as decreased perinatal mortality.¹² In late pregnancy, another Cochrane review concludes, routine ultrasonography does not confer benefit to mother or baby. That review also emphasises the lack of studies on maternal psychological implications of ultrasound or on consequences for long-term neurological development in children exposed in late pregnancy.⁷

In the US, professional guidelines recommend ultrasonography in pregnancy only when clinically indicated, yet antenatal ultrasound has become routine.⁸ The US Preventive Services Task Force observes: “Despite the lack of evidence on its positive impact on health outcomes and the 1996 USPSTF recommendation against its routine use, ultrasonography in pregnancy is widely pervasive and has become the standard of care in hospitals in the US.”¹³ Similarly, the American College of Radiology states: “Fetal ultrasound should be performed only when there is a valid medical reason, and the lowest possible ultrasonic exposure settings should be used to gain the necessary diagnostic information.”¹⁴ In Canada, the Guidelines Advisory Committee under the Ministry of Health recommends one ultrasound scan in each pregnancy, stating that there is “fair evidence to recommend a single ultrasound screen in the second trimester for healthy women with low-risk pregnancies [even though] such screening has no statistically significant effect on live births or on Apgar scores”, but “poor evidence to recommend serial ultrasound screens in the second or third trimester, for healthy women with low-risk pregnancies”.¹⁵ In most European countries it is national policy at present to carry out either one or two scans during pregnancy.^9,16

In this article, we present the findings of anthropological research on the use of obstetric ultrasonography in routine antenatal care in urban northern Viet Nam. The research was conducted from the end of 2003 to early 2006. It examines women's and health care providers' motivations for using this new technology and the reasons for its overuse.

Research setting and methods

The data were collected within a larger anthropological study investigating the use of new technologies for prenatal screening in Viet Nam. The study was conducted in Hanoi by a research team of one Danish and ten Vietnamese researchers. The main aim of the research was to explore how pregnant women decided whether to continue or terminate a pregnancy if ultrasonography detected a fetal anomaly.* The research was carried out at Hanoi's Obstetrics and Gynaecology Hospital, a major maternity hospital which, in 2004, had 15,098 births, 23,672 antenatal care users, and conducted 83,313 ultrasound scans.

As an element in this larger research project, we also studied the routine use of ultrasound in pregnancies without complications; this article derives from this component of the research. Data collection included: 1) participant observation and interviews with women seeking ultrasound scans at the hospital, 2) interviews with doctors providing ultrasound there, 3) interviews with senior doctors and Ministry of Health officials involved in the introduction of obstetric ultrasound in Viet Nam and 4) a media study.

Initially, we conducted 100 semi-structured interviews with pregnant women obtaining 3D scans at the maternity hospital. These interviews were conducted in the 3D scanning room while the women awaited their turn, and focused mainly on their use of sonography during pregnancy and their motives for seeking scans. As these interviews revealed an excessive use of sonograms, we conducted a survey among 400 women giving birth at the hospital, using a short questionnaire to assess the number of scans (2D or 3D) each woman had during pregnancy. This survey was carried out in December 2004. Next, we conducted 16 ethnographic interviews with women obtaining 2D and 3D scans on their experiences of pregnancy and birth, with particular attention to their use of ultrasound scans during pregnancy. These interviews were carried out in the women's homes a few months after they had given birth. Many women in Viet Nam feel physically and psychologically vulnerable during pregnancy and the post-partum period. This sometimes made it difficult to explore more sensitive issues in depth, such as their fears of something being wrong with the baby.

We also carried out daily observations of patient–provider interactions in the 3D scanning room over a period of four months and conducted semi-structured interviews with 14 doctors working with ultrasound at the hospital, to learn about their perspectives on the advantages and disadvantages of obstetric scans. Several of these doctors also ran private practices to supplement their income.

We also interviewed two Ministry of Health officials and seven senior doctors working in other settings who were considered by their colleagues to be among the pioneers in the introduction of obstetric ultrasound scanning in northern Viet Nam. Finally, we reviewed ten popular journals and magazines from December 2004 to April 2005, collecting articles on ultrasound scanning and other new technologies used in pregnancy.

The proliferation of ultrasonography in Hanoi

In urban areas of Viet Nam in 2001–02, 90% of pregnant women had at least one antenatal care visit, while 73% of women had the three visits recommended by the Ministry of Health.²⁰ In Hanoi, obstetric ultrasonography has recently become a key technology in routine pregnancy care. Ten years ago, pregnant women in Hanoi would obtain an ultrasound scan only on indication, and five years ago the technology was still used only sporadically. Ultrasound scans are now easily available, being offered by hospitals and clinics within the public health care system as well as by a host of private providers. With prices ranging from 20,000 Vietnamese dong (US$1.30) for a 2D scan to 300,000 Vietnamese dong for a 4D scan, sonograms are affordable for most urban women.

Since 2003, sex-selective abortions have been prohibited in Viet Nam, and health care providers performing ultrasound scans are not allowed to inform pregnant women of fetal sex. However, increasingly skewed sex ratios in Viet Nam suggest that sex-selective abortions may still be taking place,²¹ implying that women do find someone who will inform them of the sex of the fetus.

The proliferation of ultrasound scanning in Viet Nam coincides with the introduction of market economic reforms which were initiated in the late 1980s, replacing the socialist planned economy. The developing consumer economy has also brought commercialisation of childbearing and family life. With national economic growth rates at around 9% per year, the market for pregnancy and baby care goods is steadily expanding. Commodities such as toys, prams, disposable nappies and formula milk, which were unavailable in Viet Nam a few years back, are now standard elements of urban family life. In this context, antenatal care and its accessories can be seen as commodities on offer. Particularly popular goods provided within the antenatal care setting are print-outs of 3D scans and keepsake 4D DVDs of the fetus sold by private obstetricians.

Ultrasound scans provide an important source of revenue for private as well as public health care providers. In 1989, comprehensive health sector reforms were implemented in Viet Nam, including the introduction of user fees for health services, legalisation of private medical practice and de-regulation of the pharmaceutical sector. The present underfunding of the health sector creates strong incentives for public as well as private practitioners to earn additional income through revenue-generating services. This tends to foster over-use of e.g. medication and diagnostic tests. The UN has recently warned that high-tech equipment, laboratory services and pharmaceuticals will be inappropriately used within the Vietnamese health care system, as mechanisms of supervision and regulation are weak, professional self-regulation does not exist, providers are poorly paid and personal payments are by far the most significant source of health care financing.²²

In this context, the introduction of ultrasonography in antenatal care is occurring in an ad hoc and haphazard manner, driven by market forces rather than health policy. Although the overuse of obstetric ultrasound has drawn some attention in the media, the Ministry of Health has not yet issued any standards or guidelines for its use. The National Standards and Guidelines for Reproductive Health Care mention ultrasonography only in relation to complications of pregnancy.²³ Scanning equipment is purchased through local health care budgets and by private health care providers, and national-level data on its use do not exist. Since regulation is limited, private obstetricians may, in principle, purchase and operate ultrasound equipment without prior training. Obstetricians working within the public sector usually undergo a basic training course in ultrasonography and obtain a certificate before operating the equipment.

In the media, ultrasound scanning and other medical technologies are generally described as heralding a new era. Only one of the six feature articles on ultrasound scanning identified in the media study focused on the problem of overuse, however. The rest described the technology in largely positive terms, presenting it as one among many new and fascinating consumer goods that the market economy offers. For instance:

“Her feelings when she first saw the pictures of her beloved 28-week-old child can hardly be described. A pretty face, hands waving, and even a pretty little mouth… yawn! With the 4D scanning machine Voluson 730 PRO, the only one of its kind in Viet Nam, parents- and grandparents-to-be can for the first time watch real, live ‘films’ of their child.” ²⁴

Women's assessment of the value of antenatal ultrasound

We found a dramatic overuse of ultrasonography among pregnant women at Hanoi Obstetrics and Gynaecology hospital. The 400 women who answered the survey had had 1–21 scans during pregnancy, with an average of 6.6 scans each. One fifth of the women (n=78) had had ten or more scans and two-thirds (n=268) had had 4–9 scans. During our ethnographic interviews we encountered women who had had even more scans, including one who had had over 30. At the time of the interviews, 38% of the 100 women we interviewed in the 3D scanning room had had ultrasound scans from both public and private health care providers.

Many women explained that they had been encouraged by doctors to have a minimum of one scan per month, and they had assumed this was the medically recommended frequency. Often, doctors in public as well as private facilities had recommended having a scan with each antenatal visit. Twenty-nine year old Thu, for instance, mostly obtained antenatal care from private providers:

“I think it is best to have one scan each month. If I did not, the doctor told me I should. Every time I came for antenatal care, the doctor told me I should have a scan. So for me, antenatal care was primarily scanning, I did not have many other examinations.”

Some women also sought additional scans on their own initiative. They described ultrasound as “modern”, “scientific” and “progressive”, and found it useful for getting to know the sex of the fetus and its position, and seeing it develop from month to month. Undoubtedly, though, the main motivation driving women to obtain repeated scans was for reassurance regarding fetal normality. Only by seeing the fetus, they felt, could they be sure that it had all its limbs and was developing “normally”.

“During my pregnancy I was very careful. I felt quite worried, so I had to have many scans. I went for 3D scans each time. Some months I went twice. Sometimes I would come home from work feeling very tired, and even if the week before I had just had a scan, if I felt it was not moving much, I went again. In all I had more than 20 scans, but I felt it was OK, because with my first child I had many scans too. I do not think it does any harm, so I just go to feel reassured. It is like having an antenatal check-up.” (Hu’o’ng, age 28)

Ky Anh, Viet Nam

Many women were also eager to learn the sex of the fetus. Yet since this information can be provided through one or perhaps two scans, the desire to ascertain fetal sex cannot explain women's extensive use of ultrasonography. When we asked women coming for a 3D ultrasound scan to give the main reason why they wanted to have a scan, only 4% mentioned fetal sex, while 33% wanted to see how the fetus was developing, 20% wanted to make sure the fetus was healthy and 16% wanted reassurance that the fetus had no disability.

On average, the 400 women we interviewed had 8.3 antenatal care visits each – far more than recommended by the Ministry of Health – the highest number being 21. One in ten women (n=37) had less than four visits, two-thirds (n=269) had 4–9 visits, and a fifth (n=88) had ten or more visits. Most women thus had scans as part of more comprehensive antenatal care. Yet in some cases, there was a worrying tendency for women to replace antenatal care with ultrasound scanning, and one woman had no other antenatal care than scans. As it is common to go “shopping” for antenatal care at different service delivery points, public and private, there is not necessarily any continuity in the care provided, and women often purchased ultrasounds separately from other antenatal care services. The woman who had more than 30 scans said:

“I did not have antenatal care, only ultrasound. The doctor also did not tell me to have antenatal care, I just asked for an ultrasound scanning to see how the fetus was developing. Comparing ultrasound and antenatal care, I think ultrasound is better. During pregnancy everyone is worried for their child, but through ultrasound scanning one can see that it is developing normally.”

Most of the women we interviewed emphasised the necessity of both antenatal care and ultrasound scanning, but the majority found ultrasound scanning to be superior to all other forms of antenatal care, due to its perceived precision and the varied information it provides:

“Ultrasound scanning for sure is better. You can see the amniotic fluid and see if the fetus is developing normally or not”, “Ordinary antenatal care only includes listening to the heart beat of the fetus and the doctor measures your blood pressure. But with ultrasound scanning you can see everything”, “It tells you the date of birth and if the fetus has any disease”, “It tells you everything. Does the fetus develop normally, are arms and legs normal, does the brain develop well, whether it has any disabilities.”

Some women thought antenatal care as they had experienced it gave them very little additional information, and therefore felt they did not need it.

Doctors' perceptions of obstetric ultrasonography

The doctors we interviewed all praised obstetric ultrasound, finding it difficult to imagine how antenatal care could be provided without it. Many framed the high number of scans as a step forward out of the poverty that the country has struggled with for decades and as a positive sign of women's increasing consciousness of the need for good pregnancy care.

“My first impression of ultrasound scanning was that it was a revolution for examinations in obstetrics and gynaecology. It was like a dream come true. Before we had ultrasound it was very difficult to diagnose, so when we got it I said, ‘This is incredibly good for women and for patients.’ I still think so today, I think it is great.” (Senior sonographer)

“This is scientific progress. It is convenient for patients, painless, a reasonable price, you can detect a lot of things, and there are many advantages that both patients and providers appreciate.” (Obstetrician)

“As a doctor, you want to give your patient the best possible care. Today we have ultrasound scans because now the country has more money. In the past we could not provide this kind of care. But today, our lives have improved, social conditions have improved, and so people care more about their health. They also have more knowledge, culturally we have advanced. Also medicine must progress, and in that process, equipment is very important.” (Senior obstetrician)

While some doctors said they recommended three scans during pregnancy, others saw one scan a month as the optimal number. The majority found no problem in encouraging pregnant women to have repeated scans.

“It has been thoroughly researched and it is proven that it is not harmful, so we do not have to be concerned about that.” (Sonographer)

However, some did bring up concerns about the current overuse of the technology among women in Hanoi.

“I think ultrasound scanning is very beneficial. But it should not be overused. They say scanning waves are not harmful at all for the child, or at least science has not found any problems yet. But I still believe we should use scanning only to a reasonable extent… You should also not use scans if they are not necessary.” (Obstetrician)

Even though scans provide an important source of revenue for providers and hospitals, this was very rarely acknowledged by the doctors except in informal, joking remarks. Those doctors who did acknowledge overuse of ultrasound most often blamed women's desire to see the baby prior to birth.

“They are not at all afraid of spending money on antenatal care or ultrasound scanning. I often tell them that a scan is not necessary: ‘I am afraid it is too expensive for you, let me just examine you, we do not need the scan’, I tell them. But they like to see the child on the screen, that's what young women are like today.” (Obstetrician)

All the doctors emphasised that ultrasound scanning could never replace essential antenatal care, but should be combined with it. Some pointed out that ultrasonography might not always enhance the overall quality of antenatal care. Thus, the popularity of ultrasound had increased the patient load at the maternity hospital considerably which, according to many of them, rendered it difficult to provide an appropriate quality of care.

“Both in the ultrasound scanning room and in the antenatal care room, time is too limited. There is not enough time for the patient to tell the doctor about her worries or about things she does not understand, because we have far too many patients. There is no time, or only minimal time, to talk.” (Obstetrician)

A doctor can do around 80 2D scans a day, or 40–50 of the more time consuming and complex 3D scans. We observed that these services were provided in considerable haste at the hospital, and that doctor–patient contact was limited. Many of the women confirmed that “the doctors only move the machine and read the result. They do not say or explain anything”.

Some doctors raised concerns that other antenatal care examinations were being conducted less thoroughly than before ultrasound scanning achieved such a central position in pregnancy care. One of the Ministry of Health officials we interviewed had also noticed a turn in attention from essential antenatal care to ultrasound scanning:

“Once a young pregnant woman came to my house at midnight. She suffered from severe oedema and it turned out that she had eclampsia – but this had not been detected by anyone because she had not had antenatal care. She had obtained 15 ultrasound scans, but no other antenatal care services.”

Discussion

In Viet Nam, national guidelines for reproductive health care do not recommend routine use of ultrasound in pregnancy. The current proliferation of obstetric ultrasound scanning, we contend, must be seen in the context of the on-going commercialisation in many spheres of society, including the Vietnamese health care system. Our research shows that many women are obtaining an excessive number of scans during pregnancy, often at their doctor's recommendation. The main motivation driving women to purchase repeated ultrasound scans is reassurance that the child they are expecting does not suffer from any abnormality. Doctors too like the new technology, and believe it provides information that no other antenatal care services can provide.

Our research also found, however, that other aspects of antenatal care may be being neglected. A similar situation was described in research from Syria.⁶ In Botswana, it was found that health staff tended to take histories and perform physical examinations less carefully than before the advent of ultrasound.⁵

The overuse of obstetric ultrasound could easily be interpreted as exemplifying the over-medicalisation of pregnancy and childbirth that feminist researchers have criticised for decades.²⁵ Despite the importance of this critique, however, it risks overlooking women's own, varied experiences of technology and the ways in which women are attracted to and use technology. As Rayna Rapp points out: “It is an enduring irony of contemporary feminist thought that ‘we’ who are most likely to benefit from the technologies of modernity often count ourselves among their strongest critics”.²⁶ Rather than providing one-sided critiques, it may be more important to seek greater insight into the motivations underlying women's attraction to a technology like this, and the forces determining the proliferation of technology in pregnancy globally.

The commodification of antenatal care, of which the overuse of ultrasound is an example both in Viet Nam and elsewhere, must be considered in the context of health care policy and financing more broadly. In commercialised health care systems, where market mechanisms rather than policy guidelines may determine how health care services are offered and taken up, there is considerable risk that medicines, tests and other technology will be overused. This is especially the case for a technique that offers a fascinating experience for both providers and expectant parents, and that is also relatively low-cost, easy to provide and purchase, and safe for use in pregnancy.¹⁶²⁷

As regards safety, however, existing research on the safety of obstetric ultrasound has been conducted among women who have had up to five scans in pregnancy, not 10, 20 or 30.²⁸²⁹

For developing countries, the new antenatal care model developed by the World Health Organization recommends the use of ultrasonography only for special conditions, such as twin or higher order pregnancies, and emphasises that only examinations “that serve an immediate purpose and that have been proven to be beneficial” should be performed.³⁰ A WHO Reproductive Health Library commentary on the Cochrane review on ultrasound scanning in early pregnancy states: “Clear benefits of the routine use of ultrasound scanning have not been established. On the basis of the findings of this review, routine use of ultrasound scanning in early pregnancy would not be warranted in developing countries.”³¹

In Viet Nam and similar settings, there is an urgent need for rational policy and practice guidelines on the appropriate use of ultrasonography in pregnancy and how best to combine it with essential antenatal care in ways that contribute to women's health and safe pregnancy, rather than serving professional or commercial interests. The impact of such guidelines may, however, be limited in countries where the private sector is largely unregulated, as in Viet Nam, and where public health care financing relies heavily on out-of-pocket payments. It is important, therefore, that there is also community-based information dissemination on the limits as well as the benefits of obstetric ultrasound, so that pregnant women are able to make informed decisions about its use.

Notes

* Three papers with preliminary results have been published in Vietnamese academic journals.^17–19