Some expectant parents don't want to wait for hospital scans and so book their own, writes SHEILA WAYMAN
TWO-YEAR-OLD Scott Dunne giggles as he watches the sonographer smear gel on his mother’s belly. He and his parents are about to get a sneak preview of the impending addition to their family.
Like increasing numbers of expectant couples, Barbra Hodson and Robert Dunne from Lucan, Co Dublin, are availing of the services of a private ultrasound clinic to see 3D images of their baby. They did it when she was pregnant with Scott too.
“I wanted my first kid to be a boy and we only found that out with the 3D scan,” explains Robert (24). This time they are pretty sure it is a girl but they want that confirmed today at Ultrasound Dimensions in Blackrock, Co Dublin.
Barbra (24), who is 28 weeks pregnant, just had a dating scan, which checks the heartbeat, estimates the delivery date and looks for multiple pregnancies, at 12 weeks in the Coombe.
As Monica Healy runs the scanner over Barbra’s abdomen, the first images of the foetus appear on the large, plasma screen in the corner. The ultrasound machine is sending soundwaves through the body which are reflected back and converted into images.
She soon confirms it is a girl. In 3D mode, the baby’s facial features fill the screen.
“Look Scott, there’s your sister’s face; that is the baby in mammy’s belly,” Robert tells the slightly bemused toddler.
It is extraordinary how technology now enables us to observe a baby in such detail long before he or she is born.
Ultrasound started being used in obstetrics in the 1960s and has gradually transformed the care of women during pregnancy.
Every woman should be getting two scans during their pregnancy, according to the Irish training body for obstetricians. But the lack of resources in the Republic’s overstretched maternity units means that some women are not getting even one.
As a consequence, private ultrasound clinics are stepping in to fill the gap. Women are paying up to €200 to get the scan they want in what is an unregulated sector.
“Ideally, any patient going into the hospital they are going to deliver in really should be able to get a scan in the first trimester to confirm that everything is fine and a scan at around 20 weeks to confirm the baby’s anatomy,” explains Prof Fergal Malone, speaking to The Irish Times on behalf of the Institute of Obstetricians and Gynaecologists at the Royal College of Physicians in Ireland. “A two-scan regime is what we subscribe to.”
The reality is that there are insufficient sonographers to perform the scans and not enough doctors to review them.
“To the best of our knowledge, the Rotunda Hospital and the National Maternity Hospital in Dublin are the only two hospitals that are even guaranteeing the anomaly scan, the 20-week scan,” says Malone, who is a consultant obstetrician at the Rotunda.
“In most of the other units, because of the resources issue, scans tend to be done on a perceived need basis. Your history is reviewed and if it looks like there is something there, a scan is done.
“The reason the Royal College has endorsed a two-scan regime is because many problems are picked up in women with no symptoms, so to rely on the history or the patient to ask for it isn’t really the way to go.”
Every mother attending the Coombe Women and Infants University Hospital in Dublin has an early pregnancy dating scan, according to the Master, Dr Chris Fitzpatrick, but at present a 20-week anomaly scan is not provided for all patients. However, the hospital is recruiting extra staff for its new perinatal ultrasound department, which opened in April.
“We expect to be in a position soon to offer all mothers who attend the hospital both a routine dating and a structural scan,” he says.
The lack of scanning capacity in hospitals has led to a booming business in private ultrasound clinics, but the lack of regulation means there is no distinction between the excellent ones and others that may not observe best practice.
“I suppose they are meeting a need but the reality is that everybody would, I’m sure, support the view that it would be better if all these scans that are needed by patients, certainly the foetal two-scan minimum, would be provided in their maternity unit,” says Malone.
Services offered to pregnant women at the private clinics range from early dating medical scans before 14 weeks to the so-called “entertainment”, non-medical 3D/4D scans after 22 weeks, which include a DVD of moving images to take away.
The phenomenon of the “worried well” undoubtedly adds to attendances. “We would not want patients panicked into seeking scans beyond what good medical evidence suggests there is a role for,” says Malone.
He sees “entertainment” scans as a separate issue. “Our main concern with what you might call the entertainment scan industry, meaning scans done for no medical reasons, just for a putative entertainment value, is the lack of quality control and supervision.”
Fitzpatrick is concerned at the increasing commercialisation of ultrasound scans by private clinics, with direct marketing of routine 3D and 4D scans (without clinical indications) to mothers. “There is no evidence that the routine use of complex ultrasound scans such as 3D scans [which are expensive] are of any clinical benefit in the antenatal care of mothers and babies,” he points out.
Malone advises patients attending a private ultrasound clinic to ask about the credentials of the technician performing the scan and the physician interpreting it. You want to be sure there are systems in place, he adds, for the reports to go to a doctor and that there are follow-up arrangements if an abnormality is found.
The policy on scans varies from hospital to hospital, and in some a backlog in appointments leaves women waiting longer than in others. For instance, in the Rotunda, women with no significant medical/surgical or obstetrical history are usually offered two routine scans in pregnancy.
In Cork University Maternity Hospital, the policy for low-risk pregnancies is one scan, routinely the 12-14 week dating scan. “This is provided to all patients equally, both public and private, and currently there should be no delay in obtaining this scan once the hospital has been contacted on time by either GP or patient directly,” says a spokesman.
Couples who go to private clinics typically cannot wait any longer for visual proof that they are pregnant, or want reassurance that everything is well. Some also go to find out the sex of their baby or just to enjoy that astonishing glimpse into the world of the womb.
Healy, a medical diagnostic sonographer who opened Ultrasound Dimensions 18 months ago, sees patients from all over the country. They tell her that they cannot get the scans they want, when they want them, in the hospitals.
That day she had a woman in who was 10 weeks pregnant and her first scan was scheduled for when she would be 21 weeks. “She just said ‘I can’t wait that long. I need it now. I want reassurance’,” says Healy.
The maternal fetal ultrasound unit at the Charter Medical Group in Smithfield, Dublin, is “flooded” with women who are looking for a first scan, because they are not being offered one by their maternity hospital during the first trimester, says radiographer Sheila Briody.
Some pregnant women are not being seen at all by maternity hospitals until they are 15-16 weeks, she says, leaving them very anxious.
The situation in Ireland regarding private scanning is “very dodgy”, she suggests. “Anybody can buy an ultrasound machine, you don’t have to register.”
Although no radiation is involved, as in X-ray machines, there are safety factors, she stresses, particularly in scanning during the first trimester.
Briody says she feels sorry for patients who are walking blindly into places and don’t know the qualification of the person scanning, especially his or her obstetric experience, and don’t know who, if anybody, is interpreting and reporting the images.
The Charter Medical Group unit follows protocol laid down by the British Medical Ultrasound Society. There are two radiographers who have trained in obstetric scanning and every scan is seen by an obstetrician specialising in foetal medicine, she explains, either Prof Malone at the Rotunda or Prof Sean Daly at the Coombe.
The private hospital Mount Carmel in Dublin opened an early pregnancy unit two years ago that could offer scans to women attending other hospitals as well as to its own patients. It does 20 scans a day, and more than half of those would be women coming from outside, says the manager of the obstetric ultrasound department, Roisin Phelan.
Even at the height of the boom, public hospitals did not have resources to routinely provide sufficient scans to women, she points out. So the demand for a private scanning service is likely to grow.
“I think it is terrible that people have to pay for it but at least it is there,” she says. Any woman having a scan at Mount Carmel will be referred to a consultant, at no extra cost, if a problem is detected.
Healy, who trained and worked in Canada for many years, has roughly 50 appointments a week for obstetric scans at her Blackrock office, which is open seven days a week. Prices range from €135 to €195.
Hibernian Aviva Health enables its members to get 28 per cent of the cost of a 3D/4D scan back if they attend either Ultrasound Dimensions or Inner Vision Ultrasound in Castlebar, Co Mayo.
After medical scans, patients leave with pictures and a report which they can pass on to their healthcare providers if they want to, Healy explains. She has a radiologist working with her who does official reports for doctors.
Sometimes Healy has to deliver bad news to women who come for an early scan, for instance that there is no baby. “You can have an empty sac; the sac is growing, it is responding to hormones – a blighted ovum would be a good way to say it.”
Even in the non-medical, 3D/4D scans she may come across an abnormality. “That did happen last week for the first time. Most of them who come to me at that time have had their anomaly scan and they know everything is fine.
“It wasn’t a major abnormality or anything like that but it was something that needed attention,” she says. She explained it to the couple and told them she was going to issue a report to their doctor.
“This particular person just had a very early scan and the reason she came for a 3D/4D was that they were not going to scan her again.
“An anomaly scan isn’t done typically until 18 weeks and if they have their scan weeks before that, it only stands to reason it would not have been picked up.”
If couples what to find out the sex of their baby, the pregnancy needs to be at least 18 weeks. “If I am not confident,” says Healy, “I won’t charge them and tell them to come back in two weeks as I have to be 100 per cent confident.”
She hasn’t had anybody coming back to her saying she got it wrong, she reports, looking for a wooden table to touch. As some patients make appointments with her a week before flying to New York for shopping, they would face a long journey to exchange all those pink clothes for blue ones.
For more information, see: www.ultrasounddimensions.ie; www.babycheck.ie; www.pregnancyultrasound.ie; www.corkwomensclinic.com