title: Increasing possibilities - Increasing dilemmas: A qualitative study of Swedish midwives' experiences of ultrasound use in pregnancy.
abstract: OBJECTIVE
  to explore Swedish midwives' experiences and views of the use of obstetric ultrasound in clinical management of pregnancy, and in situations where maternal and fetal health interests conflict.
  
  
  METHODS
  an exploratory qualitative study based on focus group discussions (FGDs) was undertaken in 2013 as part of the CROss Country Ultrasound Study (CROCUS). Data were analysed using qualitative content analysis.
  
  
  METHODS
  midwives (N=25) were recruited from four public hospitals located in the northern and central parts of Sweden.
  
  
  RESULTS
  the analysis resulted in three categories. The first 'Acknowledging ultrasound as optimising care but also as creating worry and ethical dilemmas' reflects midwives' experiences of two different aspects of ultrasound use, one being recognition of ultrasound as an important tool to optimise care and pregnancy outcomes, the other being the dilemmas that arise for maternity care in situations of uncertain or unwanted findings. The second category 'Dealing with insufficient informed consent processes and differing expectations of ultrasound' describes routine ultrasound as an unquestioned norm that means its full purpose and use is not always well communicated to, or understood by, expectant parents, resulting in differing expectations of ultrasound outcomes between caregivers and expectant parents. Midwives also experienced expectant parents as having great trust in ultrasound, with perceptions of 'all clear' scan as a 'guarantee' for a healthy baby. The third category 'Balancing maternal and fetal health interests in a context of medico-technical development' included experiences of the fetus being given greater importance in maternity care as diagnostic and fetal treatment possibilities increase; that new methods are often introduced without appropriate ethical discussion; and also that ethical challenges will increase in line with increasing demand for 'quality assurance' in pregnancy.
  
  
  CONCLUSIONS
  midwives described ultrasound as a vital tool in pregnancy surveillance and management, facilitating conditions to be optimised for the woman and her baby during pregnancy, birth and the postpartum period. However, the increasing possibility of obtaining detailed information about the fetus was also experienced as increasing ethical dilemmas in maternity care. This study indicates that there is a need to improve informed consent processes regarding the use of ultrasound for prenatal screening and diagnostic purposes. The ambivalence midwives expressed in relation to management of ultrasound findings furthermore indicates a need for ongoing training for maternity care professionals to increase confidence in counselling women and to promote consistency in management. Finally, it is important to monitor any increasing focus on the fetus by care providers for potential impacts on women's autonomy to make their own decisions about pregnancy and birth.
authors: Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden; Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia. Electronic address: kristina.edvardsson@umu.se.
authors: Kristina
authors: K
authors: Edvardsson
authors: Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden. Electronic address: ann.lalos@umu.se.
authors: Ann
authors: A
authors: Lalos
authors: Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden. Electronic address: annika.ahman@umu.se.
authors: Annika
authors: A
authors: Åhman
authors: Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia. Electronic address: r.small@latrobe.edu.au.
authors: Rhonda
authors: R
authors: Small
authors: Department of Women's and Childrens Health, Karolinska Institute, Stockholm, Sweden; Department of Medicine, Centre for Pharmacoepidemiology, Karolinska Institute, Stockholm, Sweden. Electronic address: sofie.graner@karolinska.se.
authors: Sophie
authors: S
authors: Graner Md PhD
authors: Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden. Electronic address: ingrid.mogren@umu.se.
authors: Ingrid
authors: I
authors: Mogren
mesh_terms: D001291:Attitude of Health Personnel; D005260:Female; D017144:Focus Groups; D006801:Humans; D007258:Informed Consent / Q000941:ethics; D008880:Midwifery / Q000941:ethics / Q000379:methods*; D011247:Pregnancy; D011248:Pregnancy Complications / Q000517:prevention & control; D011295:Prenatal Care / Q000379:methods*; D036301:Qualitative Research; D011787:Quality of Health Care; D013548:Sweden; D016216:Ultrasonography, Prenatal / Q000706:statistics & numerical data*
keywords: Ethics; Midwives; Obstetric ultrasound; Pregnant women; Prenatal diagnosis; Sweden