Thursday
Jan072010
Are Canadians joyriding the ultrasound machine?
Thursday, January 7, 2010 
In the Canadian Maternity Experiences Survey released in 2009, 99.8 percent of Canadian women reported that they had at least one prenatal ultrasound and the average number was three (3) per pregnancy. A study released this week in the Canadian Medical Association Journal, which looked at data from the health care system, confirmed those findings and reported that in Ontario, the average number of ultrasounds in a singleton pregnancy in 2006 was 3.3 (a significant increase from an average of two in 1996).There seems to be some confusion about what the guidelines say. In the CMAJ study, they say that "guidelines generally recommend that two ultrasound examinations be performed in a pregnancy without complications - one in the first trimester, for measurement of nuchal translucency to screen for aneuploidy, and one in the second trimester to screen for fetal anomalies." In a CBC article on the Canadian Maternity Experiences Survey, the author wrote: "For a normal pregnancy, guidelines in Canada support a single ultrasound to be offered at 18 to 19 weeks in conjunction with a discussion of its benefits." The article also mentions that the World Health Organization recommends ultrasound on indication only or one at about 18 weeks. So Canadian women in a pregnancy without complications should be getting one or two ultrasounds, depending on who you talk to, but they are getting more than three on average.
Why the increase?
One hypothesis is that the average age of pregnant women is increasing in Canada and that this means there would be more high risk pregnancies. However, the CMAJ study found that:
In our study, rising utilization could not be explained soley by increases in maternal age, changes in maternal risk profiles or increases in uptake of first-trimester scanning for nuchal translucency. Hence it would appear that nonclinical factors may largely explain the increases in prenatal ultrasonography that we observed. These factors may include the practice of defensive medicine, the desire to reassure a patient that her pregnancy is progressing normally, patient demand and even the "entertainment" value of seeing one's fetus.
Unfortunately, the data set did not include information on the reasons why the ultrasounds were performed and, as a result, the researchers were not able to explore this hypothesis further.
Should we be concerned?
The obvious downside to more ultrasounds is the cost to our healthcare system. The CMAJ study found that the total dollar value of the additional ultrasounds conducted between 1996 and 2006 in Ontario was around $30 million. But if those tests are truly benefiting women, then it would be money well spent. But is it? The CMAJ study noted that while the benefits of ultrasounds in high risk pregnancies are fairly clear, the value and safety of additional ultrasounds in low risk pregnancies is not as clear. The authors noted:
Prenatal ultrasonography is widely regarded as safe.However, some studies have suggested that frequent prenatal ultrasonography may be associated with intrauterine growth restriction, delayed speech and non–righthandedness. Moreover, when a prenatal ultrasound examination is performed in a low-risk pregnancy, unintended harmful consequences may outweigh any potential benefits. For example, incidental benign findings — which are becoming increasingly prevalent with advances in technology — can cause anxiety and can lead to additional investigations, some of which may be invasive, such as amniocentesis.
So perhaps in the absence of any true reason for additional ultrasounds, less really is more.
My situation, your situation
Personally, I had three ultrasounds in each of my pregnancies. I had the two standard ultrasounds mentioned above in each pregnancy. I had an additional early ultrasound in my first pregnancy due to a concern that it could be an ectopic pregnancy. My baby was turned around during our 18 week ultrasound and never gave any indication of his gender, so we had to wait until the birth to find out his gender. I had an additional second trimester ultrasound in my second pregnancy when I went to Emergency after experiencing a gush of fluid. So I had more than the usual number required, but still less than the average and both for medical reasons.
What about you? If you had a low risk pregnancy, did you have additional ultrasounds? Did you opt not to have any ultrasounds? I'm curious where my readers fit into the data presented here.
Image credit: -julianol- on flickr
Reader Comments (82)
I had 1 at 19wks in my first pregancy and 1 at 20wks in my second pregnancy. I actually waived quite a few of the tests during both pregnancies and I suppose I could have waived the u/s too but I kind of wanted to see the baby...it really is a magical experience. Plus, it's always good to have any nebulous fears of random health problems laid to rest by an uneventful u/s. I'd probably do it again if I had a third baby but in general I'm more than happy to limit u/s to just 1. There's a part of me that would like to actually not have any but I don't think I have the willpower. :P
Wow - that seems like a lot of "standard" ultrasounds to me, but take that with the caveat that I had one (under the care of an OB) before switching to midwife-assisted care at a birth center. I am also very anti-intervention unless it's absolutely necessary, but I didn't learn that u/s may have negative consequences until after I'd had the one.
If we get pg again, I would have to do more research before getting an u/s. I will be 35 this year, so I've already been told by the medical establishment that more things could "go wrong" in a subsequent pg. (sigh) I just don't know.
I had an ultrasound at 8 weeks, 11 weeks for a first trimester screening, and at 18 weeks. At 18 weeks, they coudln't get a good picture of the heart, so I ended up going back twice for a grand total of 5 ultrasounds this pregnancy. I was so tired of missing work and going for ultrasounds that I was prepared to tell them I'd take my chances on the heart anatomy if they couldn't see it during my third ultrasound that week (everything turned out to be fine, as I expected).
There have been ultrasound boutiques opened up in my state of Connecticut, run by technicians who will perform an ultrasound for a fee and make a DVD of it. The state's attorney general shut them down a few months ago, since they're not medical and therefore not regulated. I think most people didn't understand that there are risks associated with ultrasounds, so they would go just for the heck of it.
I am in Canada.
Pregnancy 1
4 ultrasounds
#1 - dating purposes. I was sure about dates but my doctor thought I felt further along. I wasn't, so she realized that's just how I grow babies.
#2 - with an amnio due to "advanced maternal age"
#3 - standard 18-20 week
#4 - My measurements / growth slowed significantly at 35 weeks so I was sent for the NST. Once again, that's just how I grow babies.
Pregnancy 2
2 ultrasounds
#1 - nuchal (again due to advanced maternal age)
#2 - standard 18-20 week
I had almost the exact same pregnancy both times for growth so my doctor did not order the additional u/s's.
I live in Edinburgh, and round here, it is common to only offer one ultrasound around the 12 week mark - to check that there is indeed a baby, establish the number of babies, and confirm dates. Growth is then usually monitored using uterus height. Additional scans are only done if medically necessary - I had three for my first-born, two for my second-born, both because of a cervical fibroid that made vaginal delivery impossible. I also had one or two other fibroids that had to be monitored to ensure they weren't restricting the baby's growth or too close to the placenta.
My experience: Was 30 and in Canada with first pregnancy, considered low risk, and had 2 ultrasounds. Was 36 with second pregnancy and missed my first ultrasound due to international move from Canada to Australia, then had one standard ultrasound as a low risk patient upon entering the Australian medical system, then near end of pregnancy I became considered high risk and given another ultrasound. So 2 each time.
My thoughts: I don't get the impression that we're joyriding the utrasound system. For instance, my girlfriend was only given the stardard ultrasounds even though she desperately wanted to know the gender of baby, but doc denied her request because it was not a medical necessity. I suppose like most issues, it all depends on who your care provider is.
I live in Canada, in BC. I had five ultrasounds: 1) at 7 weeks at the fertility centre where we received help to conceive, which they routinely do to establish number of fetuses (fetii?) and also because I had experienced some bleeding in the 6th week. 2) We paid out of pocket for a nuchal translucency test at 13 weeks due to my (ahem) advanced maternal age and because we wanted to avoid an amnio if there was no indication we needed one. 3) Because there was something (I knew then, can't remember now) in my bloodwork that indicated a potential for high blood pressure issues at 16 weeks. 4) The usual 20 week ultrasound, and 5) a follow up for the third one at 24 weeks.
I had some risks associated with my pregnancy: advanced maternal age, high blood pressure, and gestational diabetes. Seeing The Imp squirming around in there was most reassuring - necessary? Maybe not - he's a healthy little boy. But all but the routine 20 week ultrasound were medically indicated and I feel grateful to live in a part of the world where I don't have to fight insurance companies for payment. But I do wish nuchal ultrasounds were covered in BC.
I don’t live in Canada, but I’ll share anyway. I honestly lost count of how many ultrasounds I had during my pregnancy with my son. I had a miscarriage two months before I got pregnant with him and was extremely anxious throughout my pregnancy. Let me see if I can list them out:
• I had some spotting before my official first visit so they did an ultrasound to check things out. I was 5 weeks, 6 days and got to see the heartbeat.
• I went back shortly after that for my real first visit and had another ultrasound. I told my doctor how scared I was because the previous pregnancy had ended shortly before the 8th week, but I hadn’t known it until I came in at 10 weeks. She scheduled me for an appointment two weeks later to take another look. So that makes three.
• My mother had previously worked with the doctors at the practice I went to, so they knew her, and she went with me to my 16 week appointment. When she asked if we could take a peek, they indulged her. So that makes four.
• I had my “big” ultrasound at 20 weeks. That makes five.
• I had a couple of additional ones after that, accompanied by non stress tests, because my blood pressure was running a little high and they wanted to check his growth. Turns out he was a big fella, and I had my final ultrasound at 38 weeks when they determined he was already 9 pounds and scheduled my c-section for the following week.
All told, I guess I had around 7 ultrasounds. I loved getting to see him and be reassured that everything was ok, as I was kind of a nervous wreck after having lost the first baby.
Pregnancy #1 I had two ultrasounds - the one they did at the beginning to confirm a normal pregnancy, and the ~20 weeks one where I found out the gender.
Pregnancy #2 started out the same way, but then I had a third at ~33-34 weeks due to measuring behind dates. That's the only one I've ever had where they sent me to an ultrasound tech rather than just using the machine in the OB's office. Frustrating part was by my next visit the OB didn't have the results. My regular OB was out on vacation for a couple weeks at the time and I was being passed around the office as a patient. Visit after that the next OB decided to check on me and see if he could see why I was still measuring small, as he couldn't find the results either, and sent me in for an urgent C-section due to low amniotic fluid and breech presentation.
Pregnancy #3, the regular two ultrasounds I had with every other pregnancy, then one at 39.5 weeks when the OB wanted to be absolutely certain that the baby was breech again before asking me to do a C-section rather than VBAC. Frustrating! She sent me home with exercises to try to flip the baby, and orders to report to the hospital at 5:30. She did another right before the C-section at the hospital, trying to give me every chance to have my VBAC but unwilling to do a breech delivery.
So I guess I'm not too far off that 3 ultrasound average level.
I'm a Canadian (for what it's worth in your survey). My female doctor is against any kind of unnecessary testing when the situation/case doesn't warrant it, so perhaps I was offered fewer appointments than other "typical" patients. I also think maternal age plays a role in how many ultrasounds one is assigned.
First child (34 yrs maternal age): 1 ultrasound at 11 weeks b/c of spotting. 1 ultrasound at 20 weeks.
Second child (36 years maternal age): 1 ultrasound at 20 weeks.
Third child (37 years maternal age): 1 ultrasound at 7 weeks for dating (unexpected pregnancy), 1 ultrasound at 12 weeks for nuchal translucency (I had to pay), 1 ultrasound at 21 weeks where genetic anomaly discovered, 5 more ultrasounds from 21-24 weeks until we lost the baby. (If I had carried to term, I would have been required to have weekly ultrasounds.)
A friend of mine, who is very petite, was told her son was 9.5-10lbs, so they scheduled a c-section 2 weeks before her due date. He was born just over 6lbs.
For both of my pregnancies I had 2 u/s. The confirmation one at the beginning and then the sex determination. We also with #2 paid for a 3/D one. We'd been told it was a girl which would be a miracle in DH's family and reallllly didn't believe them so wanted a real 3D girl bits shot. :)
We had 3 covered by MSP: 2 standard ultrasounds and 1 during an emergency visit. We were hoping to find out the gender in the 2nd standard visit but couldn't book an appointment with places that would reveal the gender for that time period. Sadly, I think we know of people in low risk pregnancies who have requested for additional visits to see and hear their baby again. We tried to get an appointment at the same place actually and they were all booked but heard they got in for their 3rd visit. We were a bit annoyed because we really wanted to find out the gender but because of the timing and different clinic, we couldn't. That is why we ended up paying for a 3D/4D ultrasound, mainly to find out the gender.
I really wan't big on getting ultrasounds during my pregnancy -- just doesn't seem all the necessary unless they are worried or there's a problem.
Had standard one around 20 weeks to determine sex & to check progress, but that was that :)
Two healthy and normal pregnancies and three ultrasounds. I had the 12 week u/s with my first essentially to make the pregnancy seem real. I wanted to see the baby and the heartbeat even though I was not interested in any of the additional screening. I then had the 18 - 20 week u/s to check for abnormalities. With my second, I skipped the first, u/s altogether and just had the second.
I had two ultrasounds with both pregnancies. The first, each time, was at the end of the first trimester to confirm fetal viability so that I knew I hadn't had a missed miscarriage (not a nuchal scan - all I wanted to know with that one was whether the fetus was alive). The second was the 18 - 20 week ultrasound, to look for major anomalies. I didn't want to go ultrasound-happy, because of the concerns about it; but I did want to a) make sure that I actually had a viable pregnancy before breaking the news to people, and b) be forewarned if there was anything so badly wrong that the baby would actually end up being stillborn or a vegetable or anything on that level.
(But I'm not in Canada, and no doubt the statistics are very different in the NHS!)
I live in Saskatchewan, was low-risk and under 35, and had three ultrasounds at 14, 20 and 39(?) weeks. I had expected the first two but thought the third one seemed unnecessary. We had opted out of identifying the sex but the doctor got a great 3D photo of our baby's face. I had been telling everyone for months that I was sure we were having a girl but the face in the picture definitely looked boyish. After seeing it, my family became convinced that I was having a boy. They were right.
@Sarah V.: Can't you determine whether the fetus is alive by listening for the heart beat? (I can't remember how early in pregnancy they started doing that, but I remember that being the standard way to check each appointment that the baby was still alive).
Very much luck of the draw whether you can hear a heartbeat that early in pregnancy. The first time round, now you come to mention it, the GP did manage to hear the fetal heartbeat at my first appointment, so I suppose I could have skipped that ultrasound, but I don't think I quite dared to believe everything was OK until I'd seen it with my own eyes. ;-) Besides, the dates I'd worked out suggested it really should have been too early for anyone to hear it, so just the fact that she heard it meant that my dates were thrown into question and so I wanted the ultrasound to check what was going on. The second time, the midwife just couldn't get the heartbeat at the first appointment, which was a shame because by then I'd moved to an area of the UK that didn't pay for 12-week scans and I knew I was going to have to pay for a private scan if I wanted one at that time. I even arranged with the midwife to go back for another try a week later, but she still couldn't get it no matter how hard she tried, and so I had to go ahead and pay for the scan. I wasn't announcing my pregnancy to anyone until I'd confirmed that it was viable.
By the way, what you say reminds me that the usual gadget for listening to the fetal heartbeat also uses ultrasound, although I'm assuming it's a lower dose. I asked the midwives to use the ear trumpet instead at some of my appointments to minimise ultrasound exposure.
@Sarah V.: That is interesting about the heartbeat gadget also having ultrasound, especially since there is a "home" one that people can buy here. I wonder if it does too?
I had 3 ultrasounds for my first pregnancy. I had some bleeding right after I found out I was pregnant around 7 weeks and then again two weeks later for more bleeding. Everyone kept assuming I was miscarrying so the ultrasound was to rule it out. Later I had my standard ultrasound at 19 weeks. For my second pregnancy I only had the one standard one. I didn't want to learn the sex of either of my babies so it was for fetal abnormalities.
Yes. It's an argument against making them widely available for people to buy, and many doctors aren't keen on them for that reason (also, the fact that they can offer false reassurance if a woman mistakes the sound of blood through the placenta or her own heartbeat for the baby's).
I'm not Canadian, either. But I had no ultrasounds with my two (so far) pregnancies. The first I lost around 10 weeks. The second resulted in my son. I kind of felt like bucking the system, and (a) we didn't have a medical reason to have one (I guess in retrospect an ultrasound during the first would have told me the pregnancy was not viable, but I actually am fine with having it happen the way it did) and (b) we didn't want to find out the sex or any potential birth defects ahead of time. So we just didn't, both because of the fact that they can't guarantee there are no effects (well, actually, there are effects, and they can't guarantee that they're entirely benign), and because I kind of felt superior telling people I didn't have one. So, there you have it. ;) All our families were pressuring us to find out the sex, and it was kind of fun to annoy them. This is truth here! My stance is that ultrasounds are a great medical diagnostic tool but not meant for entertainment purposes, which is how most US women I know tend to treat them (picture of the baby, shot at the genitalia, for the most part). I would absolutely get one if I needed one medically.
I had one ultrasound with my first two pregnancies (I was 31 years and 33 years), both at about 18 weeks. I am now pregnant with my third and a little older (will be 36 when babe is born), had a rough go the first tri so may have to do more than one though I will avoid it if at all possible. I live in Alberta, I was surprised to read that two ultrasounds are standard practice. If you're healthy and baby is healthy, one should suffice.
I only had the one standard ultrasound at 18-20 weeks for my first (but I paid extra to get the 3D option). With my second I ended up having 2. The first was because it was a surprise pregnancy so we needed to determine the due date. The 2nd was the standard one at about 19weeks and I also paid extra to get the 3D option.
I think the increase has a lot to do with the novelty of 3D/4D ultrasounds. Many women get them just for the images, not for any real medical need. But since you do have to pay for that extra option, I don't see the issue. Our medical services isn't paying for that.
Very interesting... I'm not sure what exactly to make of this.
Thank you for posting!
I had 2 ultrasounds for each pregnancy - one in the first trimester and one between 18-20 weeks. I'm not convinced that they were necessary, but I also didn't have enough "evidence" to feel strongly about opting out of them.
[...] another food for thought goodie from PhD in Parenting, questioning the use or abuse of Ultrasounds. Now this is a blog that will no dubt have an opinion about any if all of your parentung [...]
With my 1st, I had 5
First was at 14.5 weeks b/c my blood work was showing that inconsistencies. Then again due to pelvic pain, then again when I was diagnosed with pre eclampsia then again when my measurements gave the impression Baby wasn't growing (it just later confirmed Baby settled into birthing position very early) and finally in labour to confirm a detached placenta.
My 2nd pregnancy, I had two ultrasounds, one to date the pregnancy b/c my blood work showed I was newly pregnant when according to LMP, I was 7.5 weeks (I was 3.5 weeks) and then the regular 18 week ultrasound.
For our third pregnancy, three ultrasounds. The first two were the same as above and my third ultrasound was due to water breaking at 34 weeks.
For my pregnancy, every visit is an ultrasound session. After the 1st trimester, the gynae gave me shots of how my baby look like. Its priceless. I still have them after 10 years.
[...] Are Canadians joyriding the ultrasound machine? (PostRank 7.4) [...]
I live in Alberta. With my first two babies, I had two ultrasounds. The first at 8 weeks or so and the second at 15 weeks. I'm currently pregnant with number 3 and I had my 10th ultrasound today at 32 weeks. I am considered high risk and had issues at the beginning of my pregnancy. I'm not sure why this last one was ordered but it could have been because they were concerned that the cord was wrapped around the baby. The cord was wrapped around my second child which ended up with an emergency c-section. I also noticed that a number of women who are due the same time as me were being given ultrasounds so perhaps this is becoming the norm. I've also been told that my baby is transverse by doctors and nurses only to find out he's actually in the birthing position and is just big so it seems like he's transverse.