THE UNIVERSITY OF HULL 3D Ultrasound in Pregnancy: Discourses, Women’s Experiences and Psychological Understanding being a Thesis submitted for the Degree of Doctor of Philosophy in the University of Hull by Franziska Wadephul MSc (Sustainable Agriculture), University of London BSc (Development Studies), University of East Anglia December 2013 i Contents Page Abstract viii Acknowledgements x List of Tables xi List of Figures xii Publications xiii Chapter 1 Introduction 1 1.1 Ultrasound in pregnancy 1 1.1.1 The use of ultrasound in pregnancy 1 1.1.2 Three- and four-dimensional ultrasound 1 scans 1.1.3 Why do research into 3D and 4D scans? 2 1.1.4 This study 3 1.2 Organisation of the thesis 4 Chapter 2 Ultrasound scans: historical and contemporary context 6 2.1 Introduction 6 2.2 Historical context 6 2.2.1 The medicalisation of pregnancy 6 2.2.2 The changing image of the fetus 14 2.2.3 Development of ultrasound 16 2.3 Emerging themes 18 2.3.1 Medicalisation 18 2.3.2 Fetal representations 23 2.3.3 Commercialisation 26 2.4 Ultrasound in context 29 2.4.1 Women’s experiences of ultrasound 29 2.4.2 Routine scans 33 2.4.3 Private 3/4D ultrasound scans 39 2.5 Conclusions 45 Chapter 3 Psychological constructs: control, bonding and anxiety 47 3.1 Introduction 47 i 3.2 Control 47 3.2.1 Control in pregnancy 47 3.2.2 Ultrasound scans and control 49 3.2.3 Private 3/4D scans and control 50 3.3 Bonding 51 3.3.1 Bonding in pregnancy 51 3.3.2 Ultrasound scans and bonding 53 3.3.3 Private 3/4D scans and bonding 55 3.4 Anxiety 58 3.4.1 Anxiety in pregnancy 58 3.4.2 Ultrasound scans and anxiety 59 3.4.3 Private 3/4D scans and anxiety 62 3.5 Conclusions 63 Chapter 4 The study 65 4.1 Evolution of this study 65 4.2 Research rationale, aims and objectives 67 4.2.1 Research rationale and aims 67 4.2.2 Research objectives 68 4.3 Research approaches 69 4.4 Philosophical standpoint 73 4.4.1 Social constructionism and critical realism 73 4.4.2 Methodological pluralism 75 4.5 Quality 78 4.5.1 Quality in qualitative research 78 4.5.2 Transparency 78 4.5.3 Reflexivity 79 4.5.4 Triangulation 79 4.5.5 Representativeness 80 4.5.6 Sensitivity to context 81 Chapter 5 Critical discourse analysis of scanning company websites 82 5.1 Introduction 82 5.1.1 The importance of analysing language 82 ii 5.1.2 Discourse analysis 82 5.1.3 Critical Discourse Analysis 84 5.2 Methodology and analysis 86 5.2.1 Interdiscursive analysis 86 5.2.2 Intertextuality and assumptions 87 5.2.3 Linguistic and semiotic analysis 87 5.2.4 Multimodal critical discourse analysis 89 5.2.5 Analytical template 89 5.2.6 Selection of sample websites 90 5.3 Results 92 5.3.1 Identities 92 5.3.2 Discourses 114 5.3.3 Genres 121 5.4 Discussion 124 5.4.1 Differences between websites 124 5.4.2 Complementarity and conflict: identities, 124 discourses, genres 5.4.3 Discourses and 3/4D scans 128 Chapter 6 Methodology: IPA and case studies 129 6.1 Introduction 129 6.2 Study design 130 6.2.1 Original study design 130 6.2.2 Changes made to the original design 131 6.3 Timepoints 133 6.4 Questionnaires 134 6.4.1 Demographic and pregnancy information 134 6.4.2 3/4D scans: reasons, expectations and 135 experiences 6.4.3 Attitude to pregnancy 135 6.4.4 Fetal health locus of control 136 6.4.5 Bonding 137 6.4.6 Anxiety and depression 139 6.5 Interviews 140 iii 6.5.1 Interview schedules 140 6.5.2 Conducting interviews 142 6.6 Ethical considerations 143 6.6.1 Ethics approval 143 6.6.2 Potential problems 143 6.6.3 Data protection and confidentiality 144 6.7 Recruitment 144 6.7.1 Inclusion criteria 144 6.7.2 Recruitment procedure 145 6.7.3 Challenges with recruitment 146 6.8 Participants 148 Chapter 7 Interpretative phenomenological analysis 150 7.1 Introduction 150 7.2 Analysis 152 7.2.1 Analytical steps 152 7.2.2 Transcription 153 7.2.3 Formatting and reading of transcripts 153 7.2.4 Initial notes 153 7.2.5 Emergent themes 154 7.2.6 Ordering emergent themes 154 7.2.7 Identifying patterns across participants 155 7.3 Results: superordinate themes, themes and sub- 155 themes 7.4 ‘Getting to know the baby’: results and discussion 157 7.4.1 The visual baby 157 7.4.2 Getting in touch with the baby 204 7.4.3 Imagining the baby 215 7.5 ‘Experiences of pregnancy’: results and discussion 225 7.5.1 Feelings about being pregnant and the 225 emotional impact of pregnancy 7.5.2 Control 237 7.5.3 Identity 245 iv 7.6 Overall discussion 254 7.6.1 Unique experiences of pregnancy 254 7.6.2 Getting to know the baby: seeing and feeling 255 7.6.3 Experiences and significance of 3/4D scans 258 7.6.4 Concluding thoughts 260 Chapter 8 Case studies 262 8.1 Introduction 262 8.2 Analysis 263 8.2.1 Data sources 263 8.2.2 3/4Dscan: reasons, expectations and 265 experiences 8.2.3 Impact on the experience of pregnancy 266 8.2.4 Impact on how women relate to the fetus 266 8.2.5 Presentation of case studies 267 8.3 Quantitative results 268 8.3.1 Demographic background 268 8.3.2 Pregnancy information 268 8.3.3 Attitude to pregnancy 270 8.3.4 3/4D scans: reasons, expectations and 270 experiences 8.3.5 Fetal health locus of control 277 8.3.6 Bonding 280 8.3.7 Anxiety and depression 281 8.4 Individual case studies: results and discussion 282 8.4.1 Isabel 282 8.4.2 Nikki 289 8.4.3 Sarah 294 8.4.4 Jane 299 8.4.5 Naomi 304 8.4.6 Claire 311 8.5 Cross-case discussion 316 v 8.5.1 3/4D scan: reasons, expectations and 317 experiences 8.5.2 Impact of the 3/4D scan on the experience of 322 pregnancy 8.5.3 Impact on relating to the fetus 325 8.5.4 Quantitative and qualitative evidence 328 Chapter 9 Discussion 330 9.1 Introduction 330 9.2 Strengths and limitations 330 9.2.1 Strengths 330 9.2.2 Limitations 332 9.3 The psychological impact of 3/4D scans 335 9.3.1 Claims made regarding the psychological 335 impact of 3/4D scans 9.3.2 What this research adds 336 9.3.3 A social rather than a psychological 341 experience? 9.3.4 The significance of 3/4D scans 344 9.4 Bonding: 3/4D scans, conceptual and 347 methodological challenges 9.4.1 ‘Bonding scans’ and women’s narratives 347 9.4.2 3/4D scans and bonding 349 9.4.3 Conceptualising bonding 351 9.5 Knowing the fetus: haptic and optic 357 9.5.1 Uncertainty and the desire to know 357 9.5.2 Haptic and optic ways of knowing 358 9.5.3 Integrating optic and haptic 360 9.6 3/4D scans: different perspectives and discourses 363 9.6.1 Different perspectives on 3/4D scans 363 9.6.2 Conflicting discourses 364 9.6.3 Pregnant women’s experiences of 3/4D 365 scans 9.7 Reflexive statement 366 vi Chapter 10 Conclusions 368 10.1 Towards a theory of 3/4D scans 368 10.2 3/4D scans: good, bad or just a bit of fun? 371 10.2.1 3/4D scans as beneficial 371 10.2.2 3/4D scans as harmful 372 10.2.3 A nice experience 372 10.2.4 3/4D scans: good, bad or just a bit of fun? 373 10.3 Implications 375 10.3.1 Implications for practice 375 10.3.2 Implications for further research 375 References 378 Appendices 409 Appendix 1 Sample analytical template for the critical 409 discourse analysis Appendix 2 Questionnaires 418 Appendix 3 Interview schedules 427 Appendix 4 Ethics approval letter 428 Appendix 5 Information leaflet 429 Appendix 6 Consent forms 432 Appendix 7 Sources of support 433 Appendix 8 Analysis of interview extract 434 Total word count: 100,514 vii Abstract This study explores discourses around private three- and four-dimensional (3/4D) ultrasound scans in pregnancy, the experiences of women who have 3/4D scans and what impact these scans may have on pregnant women. A critical discourse analysis of scanning company websites was undertaken to explore the discourses, identities and genres set up on the websites. Longitudinal interviews exploring women’s experiences of 3/4D scans were analysed using interpretative phenomenological analysis. Case studies, using longitudinal questionnaire and interview data, were used to investigate the psychological impact of 3/4D scans on pregnant women. The critical discourse analysis revealed mixed discourses, identities and genres. While 3/4D scans are not overtly medical, they nevertheless contain medical aspects. They are promoted as enhancing bonding and reassurance. In the interview analysis, two superordinate themes emerged: ‘Getting to know the baby’ and ‘Experiences of pregnancy’. While the women’s physical and emotional experiences of pregnancy varied considerably, there were more convergences in the desire to ‘get to know’ the fetus and how women approached this.