This article is part of the following series: Diagnostic stories
This is a photograph of a publicity for a “street corner” obstetrical ultrasound in Brazil. It proclaims: “ultrasound examinations at low prices.” The advertised “low prices” can be indeed be very low: some clinics charge less than US $10 for an ultrasound examination. The aim such examination is to confirm the existence of a pregnancy, provide reassurance, but above all to tell the pregnant woman what the sex of her future child will be, and produce the “baby’s first photograph.” Brazilian professionals who talk to a pregnant woman always speak about a baby; they never use the term fetus. The identification of fetal sex is a key step in recognition of the future child as a part of the family. Once a pregnant woman learns whether she expects a girl or a boy, the future child receives a name and becomes officially part of the family. Professionals will, from this moment on, speak to the pregnant woman about Paco or Martita, not about a generic unborn child. Among middle and lower middle class Brazilians the integration of the future child into the family is expressed mainly through consumption. As soon as the sex of the fetus is known, families start to buy girl or boy clothes and sex-appropriate accessories such as toys and decorations for the baby’s room.
Brazil has a national health service (Sistema Único de Saúde– SUS) which provides free-of-charge prenatal care to all pregnant women. Such care does not include, however, routine ultrasound examinations. Official Brazilian guidelines explain that ultrasound examinations during pregnancy are unnecessary because they do not improve pregnancy outcomes, defined as the “reduction of perinatal or maternal mortality.” The Brazilian law does not allow abortion for fetal indications, with the sole exception of anencephaly (the absence of the brain). Since abortion is criminalized in Brazil, detection of fetal anomalies during the pregnancy is not seen as a priority. Health professionals often assume that because in the great majority of cases nothing will be done until the child is born, women do not need to be aware of their future children’s inborn impairments in advance, and may as well enjoy a serene pregnancy.
The absence of an official endorsement of obstetrical ultrasound does not mean that Brazilian women do not use this technology. Just the opposite is true. Brazil has an exceptionally high rate of ultrasound examination during pregnancy. It is seen as one of the countries with the highest density of ultrasound specialists and ultrasound facilities worldwide. Such facilities are often weakly regulated, and the skills of their operators may vary greatly. Women who frequent the lower-end private clinics sometimes visit such a clinic before their first (and not infrequently belated) prenatal consultation in a public hospital or clinic. Women often go to an ultrasound consultation accompanied not only by their partner but by other family members as well; everybody wants to see the new baby. When an ultrasound operator in a private facility detects a fetal anomaly, s/he may advise the woman to undergo a more advanced examination in a specialized public center. One of the goals of such referral is to allow the ultrasound operator to escape the non-enviable task of being the bearer of bad news during an event originally destined to be a celebration of a new life. The “low price” in publicity for ultrasound facilities do not include the provision of counseling to women diagnosed with fetal anomalies. Upper class women who are followed in high-end – and very expensive – private clinics usually receive some kind of counseling following a visualisation of a fetal anomaly, although the quality of such counseling is highly variable. Fetal impairment is a danger-fraught topic because they directly linked it with an unspoken, but omnipresent issue of the termination of pregnancy.
Pregnant women who undergo ultrasound examinations are not prepared to receive bad news, and many minimize the gravity of fetal malformation by selectively assimilating only a part of the ultrasound operator’s message. Those referred to a specialized public center for a further assessment, frequently believe that the referral’s aim is to fix the observed anomaly. The latter belief may be intermingled with religious feelings. Pregnant women may hope that a combination of medical expertise and prayers will cure their future child; at the same time many also express apprehension about their child’s future. Such attitudes may be reinforced by the experts’ tendency to accentuate diagnostic uncertainty. Fetal medicine specialists who work in the public sector tend to be evasive about the precise nature of the detected problem. They often explain that they will know for sure what the child’s difficulties are only after s/he will be born, even in cases in which an ultrasound examination allows an accurate diagnosis of an inborn condition with well-studied consequences.
The focus on diagnostic uncertainty, including in cases in which the expert has a reasonably good idea what the nature of the child’s impairment will be, is probably a coping strategy. The option to terminate a pregnancy cannot be openly mentioned in a prenatal consultation. Moreover, physicians know that only women who can afford to travel abroad or pay for an very expensive but safe illegal abortion in Brazil, can choose a termination without putting their health and life at risk. Criminalization of abortion, and the awareness that only affluent women can decide whether they wish to continue a pregnancy after a diagnosis of severe fetal impairment, creates a very difficult situation for fetal medicine experts. Their insistence that it is impossible to know how severe the child’s problems will be attenuates this difficulty. A high level of certainty grounded in the experts’ professional knowledge is frequently transformed in their discourse into an absence of certainty. Legal and socioeconomic variables disconnect in Brazil the use of ultrasound dia/gnosis – knowing through – from its use for pro/gnosis –knowing in advance.
Ilana Löwy is research director at the CNRS. Trained as a biologist and as a historian of science and medicine, her research focuses on the relationship between laboratory investigations and clinical practices during the twentieth century, starting with the bacteriological revolution; the history of bacteriology and immunology; the history of medicine and the biomedical sciences in “peripheral” countries (Latin American and Eastern European countries); and gender and biomedicine. In addition, she has a long-standing interest in the epistemology developed by Ludwik Fleck. She is author, most recently, of Imperfect Pregnancies: A History of Birth Defects and Prenatal Diagnosis (Johns Hopkins University Press, 2017) and Tangled Diagnoses: Prenatal Testing, Women, and Risk (University of Chicago Press, 2018).
Diagnostic stories follows the emerging world of devices, instruments, protocols and machines that make up the world of global health diagnostics. Through the telling of stories about specific technological artefacts it traces the rise of diagnosis as a global health concern and offers a critical perspective on the device-focused approach of many attempts to improve diagnostic infrastructure in the Global South. The series is edited by Alice Street.