Social Science & Medicine 50 (2000) 689701

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Between fear and relief: how rural pregnant women experience foetal ultrasound in a Botswana district hospital
Siegrid Tautz*, Albrecht Jahn, Imelda Molokomme, Regina Go rgen
University of Heidelberg, Department of Tropical Hygiene and Public Health, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany

Abstract Ultrasound technology has achieved almost universal coverage in industrialised countries with particular importance in antenatal surveillance. Its routine use has, however, been viewed critically from medical as well as from sociological perspectives. Studies on women's perception of ultrasound underline the crucial role of client provider communication supporting the technical procedure. Ultrasound is now increasingly available in developing countries. Little is known about how clients in these settings perceive the technology. This study was concerned with women's experience of ultrasound scanning in an African district hospital setting and how their experience concurs with the health professionals' views about the new technology. The study was qualitative and used semi-structured in-depth interviews with 41 clients and structured nonparticipant observation of the examination process, as well as semistructured interviews with health sta. Most women viewed ultrasound as being benecial. Some expressed considerable fear. The quality of client provider interaction played a decisive role in how the procedure was perceived. Many statements, however, reect women's overestimation of the diagnostic power of ultrasound and prenatal therapeutic possibilities. Technology and its often expatriate providers tend to be mystied and at the same time non-technological procedures provided by local sta in the context of normal history taking and antenatal care undervalued. Health sta expressed very positive views of ultrasound. They admitted, however, that since the availability of ultrasound they were tempted to take histories and physical examinations less thoroughly than before. Irrational expectations from the clients' side and unindicated overuse of ultrasound by health professionals may in the long run interact in a way that possibly undermines the quality and rational utilisation of antenatal care and respective referral guidelines. Indications for the use of ultrasound must be clearly specied within specic societal contexts and mechanism of ensuring adherence to these criteria be established. Communication with patients and appropriate information about the benets and limitations of ultrasound are essential to alleviate fear, and to discourage irrational expectations and demand. # 2000 Elsevier Science Ltd. All rights reserved.
Keywords: Ultrasound; Perceived quality of care; Communication; Medical technology; Medicalisation; Botswana

* Corresponding author. Fax: +49-6221-1382320. E-mail address: siegrid.tautz@urz.uni-heidelberg.de (S. Tautz). 0277-9536/00/$ - see front matter # 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 2 7 7 - 9 5 3 6 ( 9 9 ) 0 0 3 2 1 - 4

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Introduction Ultrasound technology has achieved almost universal coverage in industrialised countries' hospitals and surgeries. Its particular importance has been in antenatal surveillance and obstetrics where routine screening by ultrasound has become an integral part of antenatal care provision irrespective of the risk status attributed either to the mother or foetus: `Seeing the foetus on screen is becoming a technological pregnancy milestone almost as important as the biological ones' (Sandelowski, 1994:263) The technology however has come under increased scrutiny from various angles. From a medical point of view controversy exists regarding its use as a screening tool (Ewigman et al., 1993; Neilson and Grant, 1989; Newnham et al., 1993; WHO, 1984), but also because the potential harm of scanning has according to some authors so far not been adequately assessed (Beech and Robinson, 1994; Oakley, 1994; Wagner, 1994; WHO, 1984). Moreover, the routine use of ultrasound for antenatal screening has been viewed critically from a sociological perspective (Oakley, 1980, 1984; Rosengren and Sartell, 1986; Wagner, 1994). Ultrasound is now increasingly available in developing countries' hospitals. Little is known, however, about how clients in a developing country setting perceive this kind of technology as studies about women's perception of ultrasound have so far been limited to industrialised countries. The present study's aim was therefore to nd out how pregnant women in a rural African setting experience foetal ultrasound. The paper starts with a review of the debates surrounding the use of ultrasound for foetal imaging. After an introduction to the study area and methods used it proceeds with the presentation and discussion of results. The conclusion takes up the most pertinent themes and suggests respective interventions. Review of literature Routine use for screening versus selective use of ultrasound Ultrasound screening has been advocated as a tool to diagnose foetal abnormality, multiple or ectopic pregnancies, foetal growth retardation and to conrm gestational age. Available information suggests that the selective use of ultrasound in antenatal surveillance can be valuable in specic situations in which the diagnosis remains uncertain after clinical history has been ascertained and a physical examination has been performed (Neilson and Grant, 1989). It however does not provide a basis for recommending its routine use as a screening tool. (Enkin et al., 1995; WHO, 1994).

Comprehensive controlled studies (Ewigman et al., 1993; Newnham et al., 1993) established strikingly that `screening ultrasonography did not improve perinatal outcome as compared with the selective use of ultrasonography on the basis of clinician judgement' (Ewigman et al., 1993:15, Jahn et al., 1998). Among the basic principles of screening is to screen only for conditions for which something can be done (Peters et al., 1996). These studies point to the doubtful impact of the possibly more precise and faster diagnosis on patient management. According to WHO guidelines for use of technology (1994) technology must be scientically sound, accessible, aordable and acceptable. Routine use of ultrasound as a screening tool is regarded as neither necessary nor benecial and therefore discouraged by WHO's Safe Motherhood Initiative (WHO, 1995), and ultrasound equipment does not form part of the recommended standard equipment for district hospitals (WHO, 1991, 1992a 1994). Meanwhile, practice has however far outstripped policy (Taylor, 1997). Medical technology in pregnancy: psychosocial issues From a sociological and feminist perspective the routine use of ultrasound for antenatal screening has been criticised for various reasons. First and foremost, it is argued, it has contributed to the general `medicalisation' of pregnancy and childbirth (Oakley, 1984, 1994; Riessman, 1983; Rosengren and Sartell, 1986; Wagner, 1994), medicalisation being referred to as the process by which `medical jurisdiction has expanded in recent years and now encompasses many problems which hitherto were not dened as medical issues' (Williams and Calnan, 1996:1609). Accordingly, the biomedical interpretation of pregnancy has `reconceptualized pregnancy as medically problematic rather than as experientally and organically demanding' (Barker, 1998:1067). The risk approach as such, which is the almost globally employed strategy for pregnancy surveillance, is questioned by some authors as possibly encouraging the adoption of a `sick role' (Oakley, 1994; Kenen, 1996) in that the close surveillance system it implies, may suggest to women that there is something genuinely sickening about the process of having a baby. The role of medical technology in this context is seen as exacerbating this development. Its omnipresence has been viewed as instrumental in the process of increasing dependency on medical experts and their control over women's bodies and lives, alienating them from what used to be experienced as natural processes in women's reproductive lives (Oakley, 1980). Central to the debate between proponents of `high' vs `low technology' (Rosengren and Sartell, 1986) and routine use vs selective use of technology appears the

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issue of `who controls?' While high technology was considered to strengthen the medical experts' control, low technology was seen as facilitating patient control. `While high technology was enthroning the specialist, low technology was busy demystifying the same specialist' (Rosengren and Sartell, 1986:140) a `clash of values' that not only in gynaecology and obstetrics but generally has received attention (Illich, 1975; Williams and Calnan, 1996; Gabe and Calnan, 1989). The `smothering dominance of medical technology' has been criticised for displacing persons as the focus of interest. Barger-Lux and Heaney (1986) see the `technological imperative', as a `two-edged force of potential benet and potential harm' (p.1315), benecial in that the best care that is technically feasible is given, harmful in that it has an inherent tendency of fewer care-giving personnel, less time devoted to non-technical activities, and diminished acknowledgement of the patients' need for support in terms of person-to-person care. `Machines become the denitive advisors, and the human caregiver retreats behind them. Under the unfettered reign of the technological imperative, the attention and interest of caregivers are diverted to devices and procedures.' (p.1316). The implication for social relations of medical innovations however are, according to Oakley, nowhere more important than in pregnancy, `a condition in which social and emotional factors play a profoundly important part, requiring that repertoire of traditional clinical skills that simply cannot be replaced by machines' (Oakley, 1994:196). The few studies that look into women's perception of ultrasound support this view by underlining the crucial role of communication supporting the technical procedure. A study of pregnant women's attitudes to ultrasound scanning in England for example, revealed that the majority of women interviewed were enthusiastic about the method. One important source of dissatisfaction however, was uncommunicativeness on the part of the operator in terms of failure to reveal and/ or to explain the process and the foetal image (Hyde, 1986). Vice versa, the provision of adequate feedback has been found to be an essential factor in positively experiencing ultrasound scanning (Thorpe et al., 1993; Neilson/Cochrane database, undated). However, even with supporting communication and adequate feedback the use of ultrasound as a technology of prenatal diagnosis is seen as a double-edged sword in an additional sense: contrary to the claim of prenatal diagnosis as oering expanded choices `the mere availability of the technology of prenatal diagnosis is viewed as mandating that it be chosen and the relative lack of foetal therapy undermining that choice' (Sandelowski and Jones, 1996:353). Therefore this claim is viewed as a ction and even `a mockery of the concept of choice' (Rothman, quoted in Sandelowski

and Jones, 1996:353). Even when women `choose' to undergo prenatal diagnosis, they may nd that it transforms their experiences of pregnancy and their relationship with their developing foetus. Rothman has labelled this phenomenon `tentative pregnancy' in a study on women who had undergone amniocentesis (Rothmann, 1986). However, prenatal testing has virtually become a `sine qua non of both good obstetric care and responsible parenting' (Rothmann, 1986), placing a heavy burden on women or couples in light of the limited options available and the respective ethical dilemmas, not only but particularly, in case of an adverse result (Grith and Gough, 1985; Hutson et al., 1985; Kenen, 1996; Mooney and Lange, 1993; Rodin and Collins, 1991; Sandelowski, 1996). In any case, women increasingly `face social pressures and social control, blame and sanctions for their actions (or inactions), their choices before and during pregnancy' (Gregg, 1993:69). Another aspect sharply criticised by feminist writers is related to the claim that ultrasound enhances parental bonding with the foetus and thus inuences the mother's health behaviour. According to Waldenstrom et al. (1988) for example, scanned mothers' babies have higher birthweights. The claim that `ultrasound enables obstetricians to ``introduce'' mothers to their foetuses and facilitates a new phenomenon called prenatal bonding' has been viewed as very contentious: `Mothers and babies are in a relationship with one another before they meet on the ultrasound screen' (Oakley, 1994:196; Taylor, 1997). Lastly and this is the nal consequence of pregnancies being viewed as something tentative the widespread misuse of diagnostic ultrasound for determining the foetus' sex, for example in Asia, leading to a high abortion rate of female babies, has been a focal point of criticism in public debate. (WHO, 1992b; Han, 1994). Ultrasound in developing countries aspects of technology transfer Ultrasound is now increasingly available in developing countries' hospitals and is often one of the rst pieces of equipment that expatriate medical sta organise through their own initiative. Data about ultrasound in developing country settings are very scarce. The few published experiences (Palmer, 1993) provide a fairly positive account because of its relatively low cost, mobility, easy maintenance and clinical potential: `Those who hold that ultrasound should be the rst (and often only) investigation will have that view enhanced if the setting is Africa' (The Lancet, 1990). Such assessments, however, refer primarily to its selective diagnostic use and are not specically related to antenatal and obstetric care.

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Little is known about how clients in a developing country setting perceive this kind of technology. Ultrasound is not just an isolated piece of equipment but related to a foreign, that is, western concept of health and medicine. Western cultures are imbued with `technical rationality' (Elliott in Barger-Lux and Heaney, 1986:1314) implying that `essentially all problems are seen as manageable with technical solutions, and rationality reasonableness, plausibility, proof can be established only through scientic means using scientic criteria' (Barger-Lux and Heaney, 1986:1314). Arguments and criteria based on other than objectively veriable measurements according to Barger-Lux and Heaney are relegated in this world view to a distinct and sometimes distant second place. Little thought is given to how this paradigm ts into non-western contexts. Too often transfer and use of medical technologies in developing countries are based on the simplistic assumption that the advantages of western technology are self-evident and universal. Consideration has mainly been given to the techniques' eectiveness or infrastructural aspects logistics, facilities, maintenance and management (Perry and Marx, 1992). Only in case of maladoption has research been carried out, as has been the case with regards to family planning programmes. However, it is argued, `transfer of foreign medical technology to developing countries means not only transfer of drugs and equipment, but also the transfer of a foreign cultural perception of disease, the so-called western medical paradigm' (Bonair et al., 1989:769). This underlines the importance of an analysis of the cultural, social, economic and institutional context in which the technology is to be used (Banta, 1983; MacCormack, 1989).

Study area and methods The study was carried out in May/June 1995 in Maun, the capital of Ngamiland, a health sub-district of the vast and sparsely populated North West-District of Botswana. Maun General Hospital is the referral centre for the whole North-West District with a population of 98,000 served by one primary hospital and 13 clinics, each of which supervises up to four health posts, the latter being staed with enrolled nurses mostly not trained in midwifery. Ngami sub-district, the main catchment area, has a population of 60,000.1 82% of the population live within 15 km of a xed health facility, 78% within 8 km and 60% within 8 km from maternity services. Botswana has, due to the infrastructural investment in the economically prosper1

ous period of the 1980s, a comparatively well-equipped multi-tiered health system with district hospitals being the main link between clinics, primary hospitals and the two referral hospitals. The country's demographic and health indicators range among the most favourable in sub-Saharan Africa with infant mortality at 60/ 1000, under-ve-mortality at 58/1000, maternal mortality at 100249/100,000 and a life expectancy of 61 years (WHO, 1995b). Given the comparatively high GNP per capita of USD 2790 (WHO, 1995), these indicators are still surprisingly high. The study area's indicators (North West District Council, 1994) with regards to infants and children are slightly better (IMR:45/1000); maternal mortality gures however range at the upper end (250/100,000) and are still considered to be unreliable (North West District Council, 1994, 1995). Antenatal care coverage dened as at least two visits is at 80%, ranging from more than 90% around Maun to less than 40% in remote rural areas. Similarly, in urban areas (greater Maun) 80% of deliveries take place in the district hospital while in remote areas in the West almost 100% of the women deliver at home. Antenatal care follows the risk approach with basic screening being done at primary facilities, i.e. health posts, clinics and the hospitals' antenatal care units, and referral to the district hospital in case of problems identied. The present study was a component of a wider study with the aim of assessing the appropriateness of an ultrasound service at district hospital level in terms of the diagnostic value, cost eectiveness and the clients' acceptance, the emphasis being on the clinical study component (Bussmann et al., 1996). Enrolment of clients for the clinical study was limited to a symptomoriented indication list that, as far as pregnancy-related problems that could be investigated with a real time scanner are concerned, included: inconsistent fundal height, bleeding, pain, no foetal heart heard, premature rupture of membranes, preeclampsia, postmaturity, premature labour, uncertain lie, suspected multiple pregnancy and uncertain dates. Referral of women for ultrasound examination by the doctor in charge at the outpatients' department (OPD) or the maternity ward was expected to follow these indications. Ultrasound examination as a general screening strategy in pregnancy was not practised in Maun. Methodology In order to study women's views of an area that little is known about, a qualitative research approach was chosen including semi-structured individual indepth interviews with women and systematic observation of doctor-client interaction in 18 cases. Open unstructured observation during the rst days served as a basis for the formulation of a structured

1995, projected from the 1991 census.

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observation guide and for the adaptation of the interview guideline. Nineteen interviewees were interviewed in their homesteads around Maun. They had undergone ultrasound examination within a recall period of 3 months. Another 22 interviews were held straight after the ultrasound examination in the hospital, either in a vacant tea-room or another quiet place. This allowed comparison of the spontaneous reaction to the fresh scanning experience in the hospital with a more reected response of those interviewed after a respective recall period. There was no noticeable dierence in the degree of detail and accuracy in the accounts of both groups of clients. The hospital-based interviews further provided a chance to relate some of the questions directly to the situation observed before. Interviews were held in SeTswana with assistance of an interpreter familiar with the area and with previous experience in qualitative interviewing techniques. Questions were posed in an open conversational manner and encouraged women to narrate their scanning experience, perceived benets and potential risks. The clients' background characteristics were as follows: Age: 1520 years, nine women; 2130 years, 18 women; 3140 years, 13 women; above 40, 1 woman. Education: no schooling, 8 women; 78 years, 12 women; 910 years, 16 women; 1112 years, 3 women. Two women had an academical degree. Employment: no formal employment, 25 women; unskilled labour, 12 women; and skilled employment, 4 women. To complement and compare certain aspects of client experience with the views of health professionals directly or indirectly in touch with the new technology, ten interviews were held with hospital sta. These included ve doctors with a referring function (outpatients' department and maternity), nurse/midwives from the maternity ward and the ultrasound-operating doctor. Results and discussion The examination setting and procedure, and communication with clients The ultrasound room was tiny and very crowded. Most pregnant women came unaccompanied for examination. The windows were closed with thick black curtains and during scanning the light was switched o so that it was completely dark. When the client came in, she took a seat while the doctor had a look at her antenatal record and the ultrasound enrolment sheet, lled in by the referring doctor at the outpatients department (OPD). The patient was then asked to lie on the bed, the light switched o and the scanning performed. In some cases the screen was shown and brief

comments and/or a result given. After scanning the patient sat for quite some time while the doctor entered the result into the maternity card. In addition, as the ultrasound service was a study project, patient data were entered into the computer. Finally the patient was dismissed and asked to return to OPD as the hospital procedure required that examination results were communicated through the doctor in charge at OPD. As they took turns from morning to afternoon, a client could well have passed through three doctors at Maun Hospital only, in some instances for minor indications such as conrmation of gestational age. Verbal communication between doctor and clients was very restricted. Almost 100% of doctors in the government health system are expatriates. Very few patients speak English and the expatriate doctor spoke only a few words SeTswana, so that the presence of an interpreter was essential. The `interpreter', though a very cheerful person, was a hospital orderly whose English too was very basic, so that most instructions given to patients sounded more like one-word commands. Similarly, questions and comments by patients after scanning and conversations between them and the interpreter were often not retranslated to the doctor or merely in brief statements, even when they were a response to a question asked by the doctor. As a result, communication was very impaired and reduced to a basic level, supported by non-verbal gestures (`lie down', `pull your dress up', etc.). Procedures were not explained to the clients and if feedback was given it was brief. A quarter of the women observed were shown the screen including brief comments. The average time spent was 15 min, of which: 30% were spent on the actual scanning; 15% on patient records; 30% on entering data into the computer for the purpose of the clinical study; 10% for various activities (such as answering the phone); and 15% on communicating with the patient. Communication here refers to brief questions such as name, residence, when the pain or bleeding started, last menstruation, in other words, part of the anamnestic process. On the whole, the doctor's attention tended to be more focused on the screen rather than on the physical client. How clients experienced the scanning process In order to nd out to which extent women remembered the ultrasound examination and whether there were any outstanding issues in their narrative they were asked to recall in all detail what happened after they had entered the room for ultrasound examination. Surprisingly, those women recalling the event in a period of up to three months were in no respect less detailed in their description than those interviewed

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within a day after examination. Even in their emotional involvement there was no apparent dierence. From being or not being greeted up to being referred back to the outpatients' department the majority of the women recalled this experience in great detail. Assuming that frequency of naming a particular component of a more comprehensive procedure does say something about the impression it left behind and hence its importance, it can be concluded that the most impressive elements of the examination were: the switching o of the light (32 out of 41 women); the substance/medication being put on the stomach (30); and the moving of an object (`torch, radio, computer, machine') on the stomach (30). Darkness was associated with death and danger or at least perceived as something very unusual as normally an examination room is `brightly lit'. The striking issue here is that the sta was completely unaware of this perception and that these miserable feelings could possibly have been avoided by a brief introductory explanation of the procedure and its requirements.2 The moving of the sensor and application of the gel, though mentioned by the majority of interviewees otherwise didn't seem to have left a negative impression. To those who were very scared, the sensor may have added to the general anxiety. A few women attributed the power to visualise the womb's inside on the screen to the gel, making it more tangible and possibly consistent with their own experience of powerful medicine. Explanation of the procedure Interviewees were asked whether the screen was shown and what was explained during and/or after scanning. Almost half of the women responded that they were not shown the screen. Explanations received from the doctor can be roughly grouped into three categories: no explanation (12); basic information (25); and more elaborate explanation (4). Clients who had received more elaborate explanations were Englishspeaking. Women of the `no explanation'-group for example said: ``Up to now no one explained anything to me, neither the doctor at ultrasound nor the doctor who I was told to go back to'' (10).3 ``Nothing, just that I could go home, so I went'' (3). One illiterate woman resumed: ``She didn't explain anything because I don't know anything'' (4). Women having received some basic information gave statements like: ``That the baby was okay''. ``That the baby would come earlier than I was told at the clinic'' (36). An example of a more detailed interaction was por2 3

trayed by a schoolteacher's response: ``I was asked whether I wanted to see the baby; if I wanted to I could look at the video; then I looked at it and she was explaining as she was moving. She was trying to show me each and every part which is there: the limbs, the head and the body. Then she was asking me if I wanted a boy or a girl and I said I wanted a girl. She said though she couldn't see the sex very clearly, it's likely that it would be a girl'' (21). Usually the baby's sex is not disclosed, even on request, as it is feared to stimulate irrational demand and potential misuse. This incident shows however, that a more educated and eloquent client has better means of negotiating the procedure and respective interaction. In some narratives it became apparent that explanation was elicited by the clients' interest: ``She didn't explain. She didn't instruct me to look at the video. I'm the one who looked at it. So she showed me the dierent parts of the baby: the heart, the head, feet, the spine; then it was over'' (35). This may be seen as an indication that more intense doctorpatient interaction often requires a certain degree of condence on the clients' side. What women had seen on the screen and how they felt about seeing the image Of the women who were shown the screen, most reported that they had seen some specic parts of the baby's body: the head, the spine, the heart, the legs, hands extended, even face, nose, eyes, or generally `an outline of what looks like a baby's body' or `the baby playing'. Probed whether they had actually been able to identify what the doctor had pointed at they maintained that they had clearly seen the individual parts mentioned: ``I saw it, I really saw it!'' (32). Only one modied: ``I saw the head of the child and the back, but I couldn't really see, just black stu, but I believe, it's okay'', which indicates that the fact alone that one is supposedly able to see the baby may have a reassuring eect. The interviewees' statements on how they felt about the procedure fall into roughly three categories: those who felt to various degrees reassured, those who felt indierent, and those who uttered negative feelings of doubt, anxiety or disappointment. Positive feelings were attributed to various reasons: ``I was happy because at times one is not sure. You can think the baby plays but he does not and they may tell you that the pregnancy has aborted. With this you can go and see for yourself that the baby is there'' (23). ``I was happy since I didn't know the sex of my child and the way my stomach was and I was relieved to see the baby moving'' (13). ``I felt very reassured because at times you just carry water; there's no baby in it'' (6).

This was introduced after this study's completion. Numbers in brackets refer to numbers given to individual interviews.

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The statements that sounded more indierent, supported by respective body language, were like: ``I felt quite okay and I didn't feel anything'' (3). ``I didn't feel much about it because that's what I feel even without seeing it because I had felt the movements earlier on'' (14). Five of the 16 women expressing negative feelings did so because they were unhappy or even desolate about the results: one pregnancy conrmed, one not conrmed, two abortions and one stillbirth. The woman who experienced the stillbirth expressed great dissatisfaction with the way she was handled, not only at ultrasound but at maternity too: ``From ultrasound I was taken to maternity. There I was examined again and they took me back to ultrasound. I was very fearful. No one ever bothered to explain to me and to tell me the truth. I could feel the baby wasn't alive any more. I just knew it from the way they acted'' (2).4 A great deal of anxiety was related to the equipment as such and the environment it is used in. ``The rst time I thought I was going to be killed. I didn't know it was something like a computer, but something electrical, that would strike and kill me.5 When they said I would be going for ultrasound, the word made me feel scared and I just had to force myself because I was very sick. But later I enjoyed it when I better understood what the machine was able to do'' (15). ``At rst, when the light was switched o, I was very scared. I thought, now the baby was really dead. But now I am so happy and relieved because I've seen it's alive. I'm very happy'' (17). Five more women mentioned that switching o the light had caused a lot of anxiety, which explains the high recall of the component `lights switched o' in their description of the examination process. This fear appeared to have been exacerbated by lack of communication: ``When the light was switched o F F F I was sure that now the baby had died and nothing was explained to me. And I couldn't look at the mirror to see for myself. So when I left I was still scared, though the doctor said at the end that the baby was okay. But it's only now that the baby is here and is healthy that I'm not worried any more'' (9). Disappointment was expressed when despite subjective ailments and pains no problem was detected by the scan. That appeared to make things worse for the patient: ``I'm not happy at all, because she didn't see the thing that has been inside my tummy since 1991. It's biting me and causing pain. Even now, apart from the baby there's something in there moving around all over the tummy. I had hoped that this doctor could
4 According to the records the foetus was still alive at US scanning, but postmaturity suspected. 5 In the local culture there is a fear of devices that are used on the body as possibly electrocuting or lightening.

have seen it with this machine'' (7). Similar events were reported by the ultrasound-operating doctor, other key informants and witnessed during observations: ``So it means if this machine can not detect the problem, I'm going to die''. In cases of failure to come up with a tangible diagnosis evil spirits were feared to be so strong that they manage to overpower or dodge even a powerful machine. Prenatal diagnosis from a cultural point of view `Culture is something dierent' Traditionally, pregnant women are not supposed to preoccupy themselves too concretely with their womb: ``Normally in BoTswana we don't want to know what is going on in our body, particularly when there are babies in our stomach. They say it's not our culture to look inside. Only God should know what is going on in there, but I now think it's good to have the possibility of looking inside'' (15). Some, in particular the younger women, did not perceive a problem. Others vigorously commented that this view was outdated: ``Ah, those were the olden days. Things change. That was long back when these things were not yet available. But today, when you are sick you should go and have everything possible done, and you can't believe in culture. Culture is something dierent. I don't see anything wrong with seeing inside'' (20). Seven women expressed this in one way or the other. Of these women none were illiterate, only two were unemployed and two had academic training. One woman, a teacher, explicitly referred to this aspect: `` F F F but since I went through my studies I accepted that these are the things that happen in life and one has to accept them'' (21). The reference to `God' in the above statement raises the question in how far the term `culture' as used by the interviewees reects indigenous views. Whether it is already blended with Christian views by the missions' inuence cannot be ascertained, as this was not an indepth anthropological eld study. The authors' experience in dierent African settings suggests however, that the majority of people in this study's main age groups are not able to identify precisely which proscriptions originate in `traditional' or Christian-inuenced realms, respectively. Women did make the distinction as to who would be breaking the taboo as illustrated in the following statement: `` F F F yes, it's my culture and I believe in that. (But you said you were happy about seeing the baby?) laughing yes that's dierent. When the doctor does it it's okay. But if a friend or relative from my culture would have told me to go and have that examination done I would refuse. Then it's not right'' (18). And similarly: ``I don't feel scared about seeing my inside and the baby though our culture usually doesn't

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allow going round searching what is happening inside. But the whites are the ones who come with the new technology, so it's okay to do these new things'' (30). The possibility of someone having a look into their stomach by means of diagnostic ultrasound (mirror) confronts the women with a dierent view. In industrialised countries, the use of ultrasound has contributed much to the personication of foetuses. In many societies this personication is not common, particularly in the rst few months, where the unborn is seen more as an amorphous mass rather than a concrete person (Morgan, 1997). This underlines the recognition that transferring technology is more than moving a piece of equipment from one country to another. With it is transferred the underlying western paradigm (Bonair et al., 1989), requiring a complex process of adaptation and reception some of whose dimensions are addressed here. One woman stated as a potential psychological risk: ``If someone is too much on the culture she might be aected and panic and at the end of the day this may even aect the baby'' (21). How the new concept is being accommodated in the traditional paradigm appears to be related to the women's educational background. Respondents with a higher educational level (10 and more years of schooling) simply rejected the traditional proscription of preoccupying oneself with, let alone looking within the stomach, and distanced themselves from `the old days'. Women of a lower educational status found a way of integrating the new technology into `traditional' views without replacing existing notions, a pattern referred to as `medical pluralism' (Leslie, 1980). The concept of medical pluralism implies that western and indigenous medicine are not necessarily seen as competing or contradictory systems but, as has been described by Janzen (1990a,b), Caldwell (1993) and others, as complementary in that they address dierent levels of investigation. While western medicine addresses the `hows' of disease, indigenous medicine is expected to answer the question of `why' the disease aects an individual at this point in time. A study on aspects of medical pluralism in Botswana found that `both integration (``openness''), as well as rejection (``closedness'') occur when Tswana medicine meets biomedicine' (Haram, 1991:167). The study concludes that Tswana medicine allows external elements to be assimilated and new concepts to be `tted into already existing categories of thought', or new knowledge `is regarded as valuable for only particular sorts of ailments F F F not replacing existing notions of ``truth'' and ``reality'''. The use of diagnostic technology in pregnancy by foreigners appears to facilitate the conictless use of a diagnostic technique that traditionally wouldn't be acceptable as it is `brought in' and used by the whites, thus foreigners. This, however, is likely to be a period of transition and change as for the very young, even illiterate

women from remote areas, this traditional view did not seem to be an issue any more. Perceived benets of ultrasound A few women related the benets of ultrasound scanning to their professional needs for planning ahead, for example: ``If your menstrual periods were not regular, for example after stopping the pill, and you don't actually know when you became pregnant, where do you start counting? How do you then know what to ll into your maternity leave forms? So, going for a scan is very useful!'' (21). A business woman put it similarly: ``The good thing is, that it allows you to plan. Without exact dates no planning is possible'' (29). These are new requirements in a society where the number of women in formal employment is still low but is likely to increase with time, and with it the need for precise timing and planning and thus the popularity of technologies such as ultrasound. Three quarters (28) of all respondents clearly said that according to them no risk or disadvantage in a physical or medical sense was involved in ultrasound scanning. None of the remaining women thought of any risk in a medical sense. Three quarters of the study's respondents judged ultrasound scanning as benecial including some of those who expressed dissatisfaction about the interaction and/or disappointment about the results: ``Though I'm not happy about the pregnancy it's good to know and face it as soon as possible'' (31), or: ``Though I'm worried about having to care for two more, at least now I know and I'm able to plan for them'' (5). A few women mentioned that a potential benet of scanning was to know the baby's sex, though at Maun hospital it is usually not disclosed. The majority of statements can be summarised under a heading like `knowing what's going on or what's wrong in your body'. Many women's statements portray an overestimation of the diagnostic power of ultrasound and prenatal therapeutic measures. It appears to be seen as a magic device that can see everything: ``It's good because by the time you deliver you know that everything is alright inside and there's no problem'' (25). ``If someone is expecting an abnormal baby something medical could be done in time or the pregnancy be terminated'' (14). ``You can see problems before it's too late. You can see when it's big-headed and if the child is crippled. Then they will help you in time'' (20). One woman with a missed abortion was hoping that the ultrasound was able to detect what was ``wrong with her womb and whether it is dirty from all the diseases that we get from our men'' (39). Elaborate explanations would be required to enlighten patients about the potential as well as the limitations of ultrasound as

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a diagnostic technique, the prerequisite being adequate time and a common means of communication. For these women, ultrasound scanning, it appears, had a more clinical character than it is reported to be the case in western countries where foetal imaging is largely conceived to be a ritual of conrming that everything is ne rather than nding out something wrong (Green, 1994; Sandelowski and Jones, 1996). Women in western countries have described the experience more as a fun event than a clinical test (Georges, 1996; Sandelowski, 1994). This may to some extent be attributed to the fact that half the interviewees consisted of clients referred for a specic indication. How much relief was expressed about knowing that `there's life in the baby' was surprising. Some of the women were in an advanced stage of an uneventful pregnancy and not pregnant for the rst time. What made them emphasise the reassuring aspect to that extent when they must have felt the baby's movements earlier on? There appeared to be a tendency of `devaluing the own experience in favour of a publicly observable image' (Whitbeck, 1988:56). Only one woman had mentioned in this respect that she `didn't feel much about it as that is what I can feel for myself without seeing the screen'. This certain loss of self-reliance (`It's them out there who know') reects a `diminished sense of competence in the face of sophisticated medical procedures' (Gregg, 1993:56) that may gradually lead to increasing dependency on medical experts and medicalisation. Reassurance is sought by relying on the information produced by technology such as ultrasound, rather than women's own bodily sensations. Georges has described this privileged role of foetal imaging in the production of authoritative knowledge around pregnancy for both doctors and women in rural Greece (1996). Mystication of the providers of technology A conspicuous issue that comes out in a number of statements is the way people relate this technology to the experts or to `the whites': ``I wondered what those things were and where my baby was but then I told myself just not to think about it. It's them who know. (probed: who?) The doctors, the whites'' (10). ``And I was so surprised how white people can do such things and how they can see the baby inside. I think it's that substance they put on the stomach that helps them see inside and get the picture on the video. Anyway, it's them out there to understand and use technology to our benet'' (20). ``I asked myself how these people do these things and I wanted to know how they made it that this can happen, and I asked the doctor at OPD. I was very excited about this new technology done by whites that can do that'' (12). These statements reect a mystication of not only

technology but also of the `whites' `who bring in those new things'. The equally modern health service oered by local sta (African nurses or doctors) is hereby devalued: `what our people'/`those people at OPD do is just rubbish', though it may have been, in terms of rational health service organisation, the most appropriate kind of care to be rendered. This observation coincides with Jordan's distinction of the `use value' vs `symbolic value' of technology, the latter fuelling its rapid diusion and acceptance: `Sometimes high technology is adopted because it is equated with progressive medicine and, especially in developing countries, with being modern rather than backward' (Jordan, 1987:317). How the quality of communication inuences women's assessment of ultrasound Some of the women who were apprehensive about spelling out benets related their feelings to lack of explanations: ``Maybe to some people it's benecial. But to me it's useless because I do not know what these things on TV were, and whether this was something inside me and where my baby was'' (10). ``It's only benecial if you can see and you are explained what's happening to your baby'' (8). Three others related the disadvantages to poor communication: ``There are no disadvantages or risks as such but they should explain fully about the machine and teach us about the purpose of it. There should be someone there to help you translate fully any questions you have'' (12). This claim was made by an exceptionally condent illiterate woman. The women's statements give striking evidence of their desperate need for personal attention and communication. It appears to be a key factor in determining women's perception of the procedure, and in that respect African women are little dierent from their European counterparts (Hyde, 1986; Thorpe et al., 1993). The quality of communication in terms of explaining the procedure and its result as well as showing the screen made a marked dierence in the way the whole event was perceived and interpreted. Those who received explanations understood the purpose of the examination better and were more positive even enthusiastic than those who did not receive an explanation. Those who were apprehensive established a strong link between the lack of communication and questionable benet. This supports previous research about women's perception of ultrasound. The provision of feedback has been found to be integral for a positive experience (Thorpe et al., 1993). On the other hand, failure to explain the process and the result adequately has been reported to be a major source of dissatisfaction (Hyde, 1986). Similarly, a study on community satisfaction with primary health

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care services in Morogoro/Tanzania established that the communities' perceptions of technical skills were coloured by their judgement of interpersonal skills (Gilson et al., 1994). As above ndings illustrate, communication in the majority of cases was reduced to most basic instructions and if at all explanations. Apart from the language barrier, which is not so exceptional in an African hospital setting, the doctor's main preoccupation was with the technical equipment and the recording of results. In terms of direct interaction without technological medium the patient received only marginal attention, a feature criticised as `the smothering dominance of technology F F F that tends to displace persons as the focus of interest' (Barger-Lux and Heaney et al., 1986:1313), or more generally the `technological imperative' (Tymstra, 1989). The health professionals' views To compare women's experiences of ultrasound technology with those sta members' views who were directly or indirectly in touch with the new technology, health professionals were asked to what extent easy access to ultrasound had changed their work. Here, only aspects related to how the presence of technology potentially transforms the clinical work are presented, as they aect the clients' experience. All doctors and maternity sta interviewed expressed that the introduction of ultrasound service had a very positive impact on their day-to-day work, emphasising aspects of greater diagnostic accuracy and faster diagnosis, particularly with regards to antenatal clients. Situations requiring a scan most often referred to, were suspected placenta praevia, incomplete abortion, ectopic pregnancy, bleeding, and suspected multiple pregnancy. One important positive aspect mentioned repeatedly was the decrease in referrals to the next referral hospital (500 km distance), which, apart from the time-saving aspect, was considered more cost-eective. One potential disadvantage pointed out by all doctors was the negative eect of easy access to ultrasound scanning on thoroughness of history taking and physical examination: ``At times you just don't bother to critically examine patients. There's a tendency of sending them for ultrasound''. ``There could be a temptation that one examines a patient less thoroughly than expected. It depends on the individual. But the form that you have to ll for ultrasound would discourage you from being lazy. You have to indicate what you think the problem may be. You can't just refer. But the risk is there to say: why should I exhaust myself? (laughing ) F F F the human factor.'' The same doctor, supported by others, emphasised however, that when the patients come back from ultrasound to the

outpatients' department (a stipulated procedure), they still try to correlate their clinical ndings to the ultrasound diagnosis. Taking into account however, that doctors take turns at OPD from morning to afternoon, and patients may well have passed through three dierent doctors, this feedback-mechanism may have its limits. The ultrasound-operating doctor assessed the quality of the tentative diagnosis based on prior history taking, as deteriorating and often too supercial. This was conrmed by the statements of more than half of the referral sta: ``We somehow became dependent on the ultrasound. There are certain things that we managed to do without ultrasound, but this time we just send them for ultrasound. At the moment, I would say, it's somehow being overused.'' There are two pertinent issues arising from the doctors' statements. Firstly, the tendency of taking histories less thoroughly than before the introduction of the ultrasound service, is of particular concern in a developing country setting that often lacks sustainability, and requires health professionals to be able to resort to their ve senses at any time. Taking into account human nature as evidenced by the doctors' statements the thorough employment of clinical skills may wear o over time in a situation of easy access to technology. The second concern is related to the loss of communicative opportunities that is implied in replacing traditional history-taking by a technical procedure, which in itself was criticised by clients for the lack of accompanying explanation. This supports the stance of those criticising the inherent tendency of technology to supersede non-technological procedures, implying less time being devoted to non-technical activities. Not only in terms of diminished acknowledgement of the patients' need for support in terms of person-to-person care, but even in terms of quality and appropriateness of care, this development earlier on referred to as `technological imperative' obviously has its setbacks. Conclusions Major issues raised in the introductory literature review included the controversial assessment of the use of ultrasound as a screening tool and, related to that, its contribution to what has been labelled `technological imperative'. Moreover, the role of communication with clients as a prerequisite for positively experiencing the examination was highlighted. The assessment of the usefulness and benets of ultrasound in Maun General Hospital shows no evidence of a `clash of values' (Rosengren and Sartell, 1986) between service providers and users as has been suggested for industrialised countries. However, where there appears to be a clash of values, it lies in the communication process

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that accompanies the examination. Many clients are not satised with the quality of communication. Where they do not express this explicitly, in some instances the way they describe the whole context indicates that lack of explanation contributed considerably to their dissatisfaction. While impaired communication has been described previously as a shortcoming in modern, highly technological medicine, the problem may be aggravated in a setting like Maun by not only a language barrier but presumably cultural and educational barriers too, which is not so exceptional in an African district hospital setting. The most conspicuous issue, however, is that clients not only miss better communication as an aspect supporting the clinical procedure but more comprehensively, the judgement of the whole procedure including the technical quality of care is inuenced by the quality of explanation and interaction. Besides not being given appropriate attention in the specic examination situation, the general trend of relying on the highest technological diagnostic procedures available contributes to the patients' increasing alienation. In the setting of Maun General Hospital, routine screening by ultrasound in antenatal care is not used as a strategy. However, health professionals' temptation of handling the list of recommended indications for ultrasound examination generously and referring clients at the expense of thorough history-taking, may lead to a tendency of overusing ultrasound. Supported by increasing patient demand there is the danger of a gradual introduction of ultrasound scanning as a nearroutine procedure for women attending the hospital outpatients' department and even the antenatal unit. These include women referred for various reasons from primary or intermediate level, women from the urban vicinity using the hospital as a primary level of care, and those having the courage of demanding a scan, the latter being mainly urban and more educated women. Two issues are at stake: Firstly, from an equity point of view, this tendency implies a skewed resource allocation towards the urban and better-o segments of the population. Secondly, the `technological imperative' implies that even in this setting, the mere availability of technology mandates that it be chosen irrespective of its proven evidence and the availability of simpler, cheaper and clinically equally eective procedures. Even though the number of scanned women in Maun is still very low in relation to the reference population this pattern is starting to take shape. It is based on a complex interaction of professionals' and clients' expectations. Client expectations, however, are hardly based on precise information but to a considerable extent on the mystication of technical equipment, procedures and their providers in this specic case the only European doctor at the hospital at the expense of condence

in the appropriateness of simple procedures and their providers. Technology is not assessed by its `use value' only but at least equally so by its `symbolic value' (Jordan, 1987). This trend may in the long run undermine the quality and rational utilisation of antenatal care and respective referral guidelines. How then can a balance be maintained between the benets of medical technology with possibly detrimental repercussions in a given social context and how can the use of ultrasound be made more rational? In order to prevent near-routine use of ultrasound that is not evidence-based, specic indications for referral of patients for an ultrasound scan must be dened and a mechanism of ensuring adherence to these selective criteria be developed. This may be dicult to implement given the occurrence of borderline cases and the very attractiveness of advanced technology. Intense orientation of sta members on the potential and limitations of ultrasound is required. At the same time the importance of adhering to thorough classical history-taking as a prerequisite for an informed and appropriate diagnostic decision must be emphasised. Besides technical training and orientation there is a dire need for training of sta in social and communication skills. Not only is communication essential to alleviate fear of the unknown procedure, but even illiterate women's statements demonstrate their expectation of being informed, being shown the screen and explained the image and the examination. Though explanations may not be fully understood in the given and comparable socio-cultural environments, they have a symbolic value of taking clients more seriously as whole human beings rather than reducing them to virtual wombs on the screen. Even classical clinical literature suggests that `during ultrasound examination at any time in pregnancy, mothers should see the monitor screen, have their baby's image pointed out, and receive as much information as they desire' (Enkin et al., 1995). This interaction is a learning process that has the potential of stimulating and strengthening patient awareness. And lastly, appropriate information about the potential and limitations of ultrasound are a prerequisite for discouraging irrational expectations and demand. Acknowledgements The present study was a component of a study project funded by the Commission of the European Union. We wish to thank the overall co-ordinator Dr. H. Bussmann and Dr. E. Koen-Emge, Heidelberg University Children Hospital, as well as the Maun General Hospital sta for their assistance and collaboration. Our sincere thanks also go to Friedeger

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