Medical Right Watch

UltraLove - Part 1

The Medical Right Falls Hard for Ultrasound, Despite Lack of Evidence

Click here for Part 2

Summary (Part 1)

Ultrasound - an important medical diagnostic technology - is increasingly being used as a propaganda tool in the abortion wars. Crisis pregnancy centers are investing heavily in this serious medical technology in order to influence women who are considering an abortion. Although abortion opponents claim ultrasound images dissuade women from having an abortion, there is no reliable evidence that this is case. However, there is research indicating that ultrasounds can cause harm, both because of the nature of the ultrasound imaging technology and the faulty operation of equipment or interpretation of results.

No action has been taken against crisis pregnancy centers that freely use sonograms for their propaganda and evangelical purposes, and there is little evidence of regulatory oversight by state licensing agencies and the FDA. In some cases, the government has even aided crisis pregnancy centers to buy the equipment. As a result, vulnerable pregnant women are largely left to fend for themselves, sorting out potential health threats, the sufficiency of the exams, and their own personal needs.

Part I of this report looks at the strategy of using fetal imagery as a tool to pressure women who are considering abortion. Part 2 discusses the new wave of bills introduced in state legislatures and Congress, requiring women to have songrams before an abortion.

A pin-up calendar being sold by Arkansas Right-to-Life shows the current rage of the anti-abortion movement: ultrasound imaging. The calendar, called “Life Before Birth,” features monthly side-by-side pictures of a newborn baby and a 3-D sonogram of a fetus.

This new fetal imagery is part of a vast multimillion-dollar immersion of the anti-abortion movement into the non-medical use of ultrasound equipment as a propaganda tool. What is unclear is if it is successful, or ethical.

The anti-abortion movement has fallen head-over-heels for ultrasound technology or sonography. They call it “window to the womb,” also the name of a video that is widely circulated in the Religious Right. God Tube is also loaded up with fetal ultrasound videos.

This love-fest with ultrasound seeks to convince the public that the fetus is equal to an infant and women that they must bear a child rather than seek an abortion. With sonograms in hand, anti-choice advocates aim to persuade legislators to further restrict abortion. In addition, they tout the equipment in their fundraising drives.

Crisis pregnancy centers are using the new attention to ultrasound as bait to draw women into their centers and conduct ultrasounds for evangelical purposes or propaganda purposes. The woman who is the target of this misuse of ultrasound imaging is rarely aware of the purpose: to convince her she must bear a child rather than seek an abortion.

The Strategy

Advocates for the non-medical use of sonograms have two basic strategies. One is to equip the thousands of so-called crisis pregnancy centers across the country with ultrasound machines, in some cases garnering government aid to pay for them . The other, to be covered in part two of this report, is a wave of proposed laws under the guise of “informed consent,” which would require abortion clinics and doctors to conduct ultrasounds on pregnant women before providing abortion services. Some of these proposed laws go so far as to require that women view the images.

The expansive use of ultrasound for non-medical purposes is not benign. There are concerns about potential harm to a developing fetus and the ethics of using a medical diagnostic product for propaganda purposes.

What is Ultrasound?

Ultrasound is a tool for medical diagnostic imaging. It works by using high-frequency sound waves and their echoes. In medical imaging, a probe sends pulses into the body and when the waves hit a boundary, such as tissue or an organ, echoes are reflected back to a computer that calculates the distances and type of boundary, creating an image visible on a screen. Each image involves millions of pulses and reflections. Ultrasound equipment has varying decibel levels (2 to 10 MHz), and ultrasound produces vibrations and heat, both of which rise with higher frequencies or extended exposure. Some ultrasound machines can produce 3-D or 4-D images, along the lines of a video, and Doppler ultrasound can make it possible to hear the fetal heartbeat.

Ultrasound equipment is considered a prescription medical device and is regulated by the federal Food and Drug Administration. The FDA sets the standard for the level of energy to be used for fetal ultrasounds.The newest ultrasound equipment - and there are many varieties - is as compact as a laptop computer. Prices range from $20,000 to $50,000, although more elaborate models can cost as much as $200,000.

The U.S. ultrasound market hit $1.33 billion in revenues in 2006, according to Klein Biomedical Consultants, the leading industry analyst, and sales are expected to reach $1.76 billion annually by 2011. Four companies control the U.S. market: GE Healthcare, Philips Medical Systems, Siemans Medical Solutions and SonoSite. In addition, a substantial amount of used equipment is available for purchase on an open and largely unregulated market.

Ultrasound imagery has many legitimate medical uses in pregnancy care. Sonography is a valuable diagnostic tool for obstetricians in determining the position of the fetus, whether there are multiple fetuses, ectopic pregnancy or fetal abnormalities.

The equipment is also used in abortion care, and most abortion clinics have ultrasound equipment, according to Vicki Saporta, president of the National Abortion Federation. One particular use is in dating the pregnancy, especially important in a medication or “pill” abortion regimen using RU-486 (Mifeprex).

Use of Sonography for Anti-Abortion Propaganda

Crisis pregnancy centers (also called pregnancy help centers and pregnancy resource centers) across the country have invested heavily in ultrasound equipment as part of their self-proclaimed "ministries" to woo women and convince them to reject abortions. Estimates indicate there are 2,500 to 3,500 crisis pregnancy centers. Many are supported by public funds.

Ultrasound has fueled an independent industry of equipment, training, manuals, insurance, lawyers, fundraising, advertising and promotion for crisis pregnancy crisis. In the past, crisis pregnancy centers offered free pregnancy tests as bait to draw in women and bend their ear, but over-the-counter tests dulled their star power. Sonograms are the 21st century replacement for pregnancy tests.

“Many centers are acknowledging frustration over the fact that their ministries are becoming more social welfare agencies that cutting edge forces to reduce abortion … Centers that add ultrasound, pregnancy diagnosis and other medical services are attracting more abortion-minded women,” wrote Thomas A. Glessner, president of the National Institute of Family & Life Advocates in Virginia, a nonprofit that collected $731,000 in 2006 to provide training and counseling to crisis pregnancy centers that are adding ultrasound equipment.

In a publication called At The Center, Glessner wrote: “Through the use of ultrasound … women will bond with their unborn babies and choose life." NIFLA advisors include Dr. Byron Calhoun, founder of the American Association of Pro-Life Obstetricians and Gynecologists, and Dr. Elizabeth Shadigian, AAPLOG president.

Glessner, who earns $100,000 in salary and benefits at NIFLA, refers to evangelism as “the core” of the pregnancy crisis center. “NIFLA firmly believes that PRC’s (pregnancy centers) should place evangelism and a presentation of the gospel as a top priority in their ministries,” he wrote.

NIFLA works closely with the Religious Right group Focus on the Family, which began its Option Ultrasound Program (OUP) in 2004, investing $4.2 million in a single year to pay for training and ultrasound equipment for crisis pregnancy centers. As of December 2007, the program manager reported that 363 ultrasound machines had been placed in centers and trainings held in 48 states.

Other groups have joined the ultrasound bandwagon. Heartbeat International, which claims 1,100 affiliates, says 460 of its affiliates are now equipped with ultrasound capability.

In New Jersey, Chris Slattery, who runs 15 crisis pregnancy centers and traces his anti-abortion credentials to Operation Rescue, began operating a mobile ultrasound center in a motor home that parks outside abortion clinics. Slattery explained that it would have the additional benefit of providing bathrooms for anti-abortion protestors and he soon began calling for donations to support the effort.

Focus on the Family claims that “research shows” that 89% of women considering abortion change their minds after having an ultrasound and counseling at a crisis pregnancy center. An ultrasound plus counseling convinces more women than counseling alone, wrote Focus on the Family’s Sanctity of Life Director Kim Conroy.

Other claims rely upon anecdotal stories, reprinted in anti-abortion literature, of women at crisis pregnancy centers who change their minds when they see the ultrasound. An Alabama pregnancy center wrote to Heartlink, a Focus on the Family online publication, about a college student who came to its facilities. “As soon as the embryo was located, the screen was turned toward the patient … Tears began roll down her cheeks. It was at that moment that she said she couldn’t go through with the abortion – she would carry and keep the baby.”

These stories and statistics have no scientific basis or support. No reliable study has measured the effect of ultrasound on a woman’s decision whether or not to bear a child, according to a search of literature and inquiries to research organizations, including The Guttmacher Institute.

Vicki Saporta of the National Abortion Federation said that reports from abortion clinics with ultrasound equipment indicate that women do not change their minds about an abortion after seeing an ultrasound. She also knows of no study measuring women’s response.

In fact, some studies undercut the claims of anti-abortion advocates. One indicates that use of fetal sonography results in a higher rate of abortion when fetal abnormalities are detected. “Where detection of fetal abnormality was a specific aim of the examination, the number of terminations of pregnancy for fetal anomaly increased,” according to one study (Neilson JP. Ultrasound for fetal assessment in early pregnancy. Cochrane Database of Systematic Reviews 1995, Issue 2. Art. No.: CD000182. DOI: 10.1002/14651858.CD000182).

In some countries, sonography is utilized - in a universally condemned practice - to identify the gender of the fetus, after which females are aborted.

"Visual Politics"

Responses to fetal imagery may be in the eye of the beholder. Feminist scholars who have analyzed the use of fetal imagery in the anti-abortion movement’s drive to establish the personhood of the fetus point out that the images are dependent upon interpretation and context. They are “visual politics,” according to Dr. Carol Mason of Oklahoma State University, author of “Killing for Life: The Apocalyptic Narrative of Pro-Life Politics.” Mason points out that sonography images used in public materials generally show a late-term fetal image, which more closely resembles a baby after birth. Earlier pictures may show a profile, and rarely present a fetus until the eighth week when the eyes come to the front of the face.

Sonograms, unlike the fetal images on posters and trucks, show pictures of an individual fetus. But the fetus is still seen as an independent being, separate from the woman carrying the pregnancy. Understanding the ultrasound picture is also heavily dependent upon the interpretation of a sonographer or doctor. “Such pictures can show autonomy or dependence, humanity or animality, depending on the context in which it is presented,” according to “Images of Embryos Used by Anti-Abortion Activists,” an online companion to Developmental Biology.

Studies do show that happily pregnant parents appreciate and rely upon ultrasound. One study by D. H. Petorius published in the Journal of Ultrasound in Medicine found that expectant parents felt more bonded to a fetus after 3/4D sonography, and a 2007 review in the British Journal of Midwifery found that expectant parents appreciated the assurance that the pregnancy was progressing as it should.

But a Canadian study published in the Journal of Perinatalogy reported on interviews of a small number of women with unexpected diagnoses (multiple births or fetal abnormality) and found that women’s experiences of ultrasound were influenced by physical and environmental factors and the behavior of the examiner. Of note, women identified “being objectified by the examination" as a factor influencing their response.

Fetal Imagery Used in Pursuit of Evangelical or Entertainment Purposes

The professional organization for sonography rejects non-diagnostic uses as does the FDA, which regulates the equipment. But no action has been taken against crisis pregnancy centers that freely use sonograms for their propaganda and evangelical purposes, and there is little evidence of regulatory oversight.

The American Institute of Ultrasound in Medicine objected to the purchase of ultrasound equipment by actor Tom Cruise for personal use in monitoring the pregnancy of partner Katie Holmes. AIUM reaffirmed a statement of “prudent use” that “strongly discourages the non-medical use of ultrasound for psychosocial or entertainment purposes. The use of either two-dimensional (2D) or three-dimensional (3D) ultrasound to only view the fetus, obtain a picture of the fetus, or determine the fetal gender without a medication indication is inappropriate and contrary to responsible medical practice.” The statement, published in the January 2006 “Sound Waves,” was endorsed by the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine, and several other medical organizations.

AIUM also opposed the operation of portrait studios that make “keepsake” fetal sonograms.

In 2004, the FDA warned against the “keepsake” nonmedical uses of fetal ultrasound, calling it “risky business.” “Expectant women and their families need to know that the long-term effects of repeated ultrasound exposures on the fetus are not fully known. In light of all that remains unknown, having a prenatal ultrasound for non-medical reasons is not a good idea,” according to the FDA magazine.

At the time, the FDA supposedly cracked down on the “keepsake” facilities for promoting a device for other than its approved use, and for using a prescription device without a prescription. But a trade publication reported that a new Bush appointee later softened the warning letters that stopped “keepsake” fetal portrait studios. Some insiders reportedly said that anti-abortion politics played a role.

Now the fetal portrait studios are back. Many, such as Miracles in Progress in Las Vegas or First Look Sonogram in California, advertise on the Internet. Fetal Fotos operates in seven states, offers franchises, and is linked online by ProLife.com and Life Dynamics, a virulently anti-abortion group in Texas.

Ultrasounds -- Harm or no?

Harm from ultrasound imagery can occur both because of the nature of the ultrasound and faulty operation of equipment or interpretation of results.

Laboratory studies have looked at harm from excessive fetal exposure to ultrasound but more research is needed.

In 2004, the FDA noted that fetal ultrasound scanning is considered safe, but “can’t be considered completely innocuous.” The FDA wrote: “Ultrasound is a form of energy, and even at low levels, laboratory studies have shown it can produce physical effects in tissue, such as jarring vibrations and a rise in temperature.”

Fetal studies of guinea pigs found adverse effects on cell division in bone marrow from the raised temperature in Doppler ultrasound. A 2006 study found disruption of the normal migration of brain cells in fetal mice, which, if it occurred in humans, could potentially cause autism, mental retardation, epilepsy and learning disabilities. The lead researcher, Dr. Pasko Rakic of Yale University School of Medicine, said pregnant women should avoid unnecessary ultrasound scans until more research is done.

Studies of humans exposed to ultrasound have shown possible adverse effects including retarded growth, dyslexia, delayed speech development and greater left-handedness among boys, which may be connected to cognitive problems.

One specialist who has studied the research believes recent studies require a reassessment of safety, especially in light of nonmedical uses.“Until there is such a body of scientific data confirming the benefits of 3D/4D entertainment/bonding ultrasound in unselected patients, its dissemination into commercial facilities should be strongly discouraged,” wrote Dr. David Toms.

Focus on the Family’s Physicians Resource Council issued a statement on the use of Doppler ultrasound in the first trimester in 2005, cautioning that it should only be used in “a case in which the mother is considering the option of abortion but might be more inclined to choose life after hearing the sound of the fetal heart.” Doppler should not be used as a routine test “to ensure that the risk from exposure to ultrasound energy is as low as reasonably possible, especially in the first trimester.”

A second concern about harm arises from the operation of fetal sonography by untrained or inexperienced operators who fail to diagnose or inform a woman about a serious condition. “Failure to diagnose” a fetal sonogram has been the reason for a large number of medical malpractice claims.

“Missing an anomaly on a sonogram performed for a standard indication, such as dating, is the most frequent type of litigation,” according to the abstract of a 1998 article in Annals of the New York Academy of Sciences.

Highly-qualified personnel are essential to accurate interpretation. The AIUM policy on Interpretation of Ultrasound Examinations states: “Ultrasound studies shall be supervised and interpreted by a physician with training and experience in the specific area of sonography .… Although a sonographer may play a critical role in extracting the information … the rendering of the final diagnosis of ultrasound studies represents the practice of medicine, and, therefore, is the responsibility of the supervising physician.”

In some medical circles, discussion arises as to which medical personnel should interpret fetal sonograms - radiologists or obstetricians, both medical doctors. But sonographers, or those who take the pictures, should not be doing primary interpretation, these experts say, while admitting that there is dismal or no regulation. The regulation of medical practices, including sonography, is left to the states. Experts concurred that ultrasound posed a “buyer beware” situation and that patients need to understand that there are big differences in qualifications and equipment.

While NIFLA advises pregnancy centers that ultrasound can be performed only by trained personnel and by a doctor’s recommendation, first-hand accounts of crisis pregnancy center workers indicate that physicians may be distant participants in the process, if involved at all. At a national conference, a crisis pregnancy staff member described unease about ultrasound and said that she knew at least one clinic was allowing untrained volunteers to perform ultrasounds. A first-hand story carried online by Heartlink, the Focus on the Family ultrasound website, describes a center in which an impatient woman sought an ultrasound. The story describes how a sonographer came from home to do it. “The sonographer never knows what she’ll see when she does a scan …. This window into her womb showed her a darling little 14 week, 1 day old, bouncing, dancing baby,” the article reports. Nowhere in the piece is the slightest indication of a doctor ordering the ultrasound or interpreting it.

Aside from liability issues, a survey published in the Journal of Ultrasound Medicine highlighted another potential problem: patients who forgo medical and diagnostic ultrasounds because they have had a nonmedical ultrasound. A majority of those surveyed - obstetricians and radiologists in Maine - found this to be a worry. Majorities also believed that nonmedical ultrasounds might leave fetal anomalies undetected and give patients false reassurances. More than one-third believed that licensing boards should discipline those conducting the nonmedical ultrasounds.

Conclusion

With these questions, why does the Religious Right staunchly support ultrasound technology for non-medical uses? At its core, ultrasound relies on the same fetal imagery that has roiled the anti-abortion community from the outset - whether “The Silent Scream” or giant fetus posters hoisted outside abortion clinics. Ultrasound represents a high-tech maneuver to raise the status of the fetus above that of a woman .

This use of ultrasound technology may be one of the only areas in which sophisticated medical imaging equipment is used for propaganda purposes, and despite any serious evidence that it has any effect.

While the Religious Right has fallen for this equipment, state licensing agencies and the FDA have fallen flat in oversight responsibilities. In some cases, the government has even aided crisis pregnancy centers to buy the equipment. As a result, vulnerable pregnant women are largely left to fend for themselves, sorting out potential health threats, the sufficiency of the exams, and their own personal needs.

Cynthia L. Cooper
February 4, 2008
Updated February 5 and 13, 2008

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