The third way of dealing with bad news is to proffer it directly during the exam, which is always a traumatic situation for pregnant women and also anguishing for the professionals involved. I have rarely seen this kind of situation, but my doctor informants provided me with various accounts. Evidently the severity of the pathology played an important role in determining the degree of difficulty experienced by ultrasonographers in dealing with this kind of communication:. Silvio asks me: "Did Carla tell you about the tight spot she found herself in?
A pregnant woman came with so many people, that they couldn't all fit in the room. So they decided to do the following: they would take turns going into the room. But the problem was that right at the beginning of the exam she discovered that the fetus was anencephalus! She became so upset that she ended up interrupting the exam in the middle and came to me to ask me for advice on what to do".
The professionals' strategies could be defeated by the pregnant women's visual socialization, when they managed to decode that there was something wrong and queried the doctors directly about it. These circumstances were particularly embarrassing, for it was as if they took the doctor by 'surprise', before he had had the time to calmly decide on a way to deal with the situation. The difficult moments caused by the pregnant woman or others 'seeing' something was the theme of various conversations between doctors, a practice which I interpreted as a way of sharing experiences, possibly trying to reduce levels of tension by providing mutual support:.
Sandra says that when she sees things that are "very wrong" with the fetus, she "ends up speaking". We talk about a problematic case whose image was still on the screen; she comments that P asked "What's that dark spot?
Silvio told me about a case that had happened to him the day before:. You should have been here Then I said: 'I have some very bad news for you'".
Sensitive or worried pregnant women would stare fixedly at the doctors, trying to detect negative or positive signs about what was happening from the expressions on their faces, and the professionals were aware that they were being scrutinized. In the course of the period of observation, it became clear that there is considerable disagreement among ultrasonographers concerning the question of bad news and how to break it to pregnant women. The Brazilian Ultrasound Society does not issue guidelines regarding this matter, and so the attitudes adopted depend on the personal decisions of professionals, based on their values and beliefs.
Maternal concern about fetal health is not exactly a novelty.
The aspect that should be highlighted, and which has been radically reconfigured, derives from the fact that, until the appearance and diffusion of ultrasonography together with other prenatal diagnosis technologies , doubts about the normality of the fetus were only dispelled at birth. The myth of the 'objectivity of the technical image' and its vicissitudes. There is a relatively unexplored theme in the literature, which specialists in imaging diagnosis are quite familiar with, and professionals are directly confronted with its practical, sometimes dramatic, consequences.
All the professionals that were ethnographed were deeply aware of the weight and importance of subjectivity in their daily routines, in both the decoding of images and their direct contact with clients. When this attribution of objectivity came from patients, it was treated with a certain degree of tolerance, but when doctor colleagues were the culprits, it was greeted by my informants with considerable irritation.
An angry female doctor recounted a situation that she classified as "surreal": "Yesterday I attended a deaf-mute woman with a request for a transvaginal [ultrasound] which did not contain the suspected diagnosis, and who, on top of all this, came to do the exam unaccompanied. Incredible , don't you think? How was I supposed to know what to look for? Lack of information or, worse, the mythologization of ultrasound's diagnostic possibilities on the part of professionals of other specialties can have serious consequences for pregnant women and their fetuses:.
A pregnant woman in her 13 th week of pregnancy recounts that nearly two months ago she had to undergo a scan of her thyroid before an operation, which meant taking radioactive contrast. As the result of the exam was 'negative' she took the contrast and underwent the operation. Shortly afterwards she found out that she was pregnant; when she did the first exam the embryo was probably too small for the machine's resolution.
He reveals his preoccupation to me: "Up to now there are no visible malformations, but one can't be sure of anything. Other situations linked to the generalized belief that the image can provide all the information needed to elucidate problems border on the comic, as in the following case, that was recounted informally:. A lady phones her gynecologist's office and explains to the secretary that she has to contact him urgently because she is having a hemorrhage.
The doctor isn't there and the secretary tries to help and be pro-active, suggesting: " You'd better do an ultrasound exam to see if you've lost the baby". The patient answers: "But I'm 52 years old! Taken together, these situations furnish elements showing that the 'objectivity' of the ultrasonographic image is merely a culturally shared myth, a situation in which ultrasonographers constitute an exception, in so far as they are more fully aware of this technology's possibilities and limitations than laypeople and their colleagues.
Appropriations, fusions and reconfigurations. Although the proposal of the research was to make a qualitative analysis, the sessions observed 33 revealed a question of a quantitative order: despite the considerable medicalization of pregnancy, most ultrasound exams revealed 'normal' pregnancies 34 , which undoubtedly contributes markedly to the constitution of obstetrical ultrasound as a spectacle, form of leisure and an object of consumption. This transformation in the meaning of the exam plays an important role in the simultaneous reconfiguration of social perceptions of pregnancy and of the fetus, and articulates itself with other issues that transcend the field of obstetrical medicine.
The creativity with which pregnant women and those accompanying them appropriated and interpreted 'objective' medical information produced by the apparatus and interpreted by the professionals constitutes a clear example of how the production of medicalizing truths about pregnancy and the fetus is established and consolidated.
The image of the fetus is taken as equivalent to its presence 'in person', 'live' and in real time, like when the clients and doctors start 'giving him orders': "Don't do that , little baby! Without ceasing to be a diagnostic technology, the production of countless non-medical 'truths' about pregnancy and the fetus also makes fetal ultrasound an object of consumption and a form of entertainment.
This shift constitutes what Martin-Barbero, discussing popular culture and the process of communication through the prism of reception, calls 'resistances' Martin-Barbero, , p. First of all it should be emphasized that this medicalization is not an authoritarian process produced 'machiavelically' by doctors, but is much more a complex articulation, in which a 'need' to monitor and supervise the health of the woman and the fetus is constructed.
This need is informed, modeled and instigated by the contemporary culture of risk, in which a pregnancy "without surprises" is expected Arney, , p. In addition, it is important to highlight that all the actors involved are part of a cultural configuration in which visuality and spectacularity are predominant, thus contributing to the creation of a situation in which the visualization of the image of the fetus is equated by those present with its existence outside the uterus, producing a kind of 'virtual birth' before the baby in fact sees the light of day.
The production of the 'pleasure of seeing' the fetal images is one of the most significant results of all this articulation, which, in turn, levers a situation in which pregnant women actively demand to be submitted to the exam, generating a feedback cycle. Thus a dynamic that is constitutive of the field is constructed: the in a sense playful appropriation of the exam, as well as the attribution of unusual meanings based on the fetal images and even on the medical 'truths' themselves, instigate the consumption of ultrasound exams, and consequently reinforce the medicalization that is implicit in the use of ultrasonography during pregnancy.
Fiocruz, The absence of a Brazilian study of the subject led me to carry out an ethnography in Rio de Janeiro. Henrique, in B, Dr.
Lucia and in C, Dr. Between exams, I used to stay in the doctors' room and interact with them, and this experience also provided me with very interesting elements for the research. The field was very rich in situations of this kind, a discussion that is per se very interesting and complex, but which is beyond the scope of this study.
Accordingly, the ultrasound image can be seen as the interface through which the actors of the universe observed have been reconfiguring various aspects of the social construction of pregnancy. However, although they were merely approximated figures, they were read by the lay actors as actual concrete measurements. At the beginning of the fieldwork I often found it extremely difficult to look away from the monitor, and I was forced to discipline my gaze so as not to be 'co-opted' by the native culture, and manage to pay attention to the discourses, interactions and negotiations that took place unceasingly.
I reserved the term 'visualization' for the direct situation that occurred during the exams: for example, everyone 'visualized' the images on the monitor screen. In the citations the parts emphasized by the actors are underlined. My emphases are in italyc type. I use G to designate the pregnant women and P for their partners.
I use brackets to indicate actions or complement data, and omission points to show where the material has been edited. In the second case, some precautions have to be taken such as the use of aspirin by the pregnant woman and the strict monitoring of maternal and fetal circulatory conditions, and fetal growth, through ultrasound exams. That is, they are boys and girls solely from an emic point of view.
The same can be said about the use of the words 'mum' and 'dad', which anticipate mother- and fatherhood as if the baby had already been born. On this subject, see Chazan ; , p. As it is an illegal practice, there are various methodological difficulties involved in epidemiological research into abortion in Brazil. Some studies estimate a national average of one abortion per 3.
Reproductive Politics in Twentieth-Century France and Britain
There is only a relative consensus that ultrasonographers should not indicate complementary exams to dispel certain doubts about diagnoses, so as not to run the risk of perpetrating ethical offences in relation to the obstetricians responsible. Power and the profession of obstetrics. Chicago: The University of Chicago Press. Minneapolis: University of Minnesota Press. Trabalho apresentado na 5.