The WRISK project regularly asks contributors to share their perspectives on a range of issues related to risk communication in pregnancy to further understanding of the challenges faced by scientists, clinicians, policy makers, and of course women themselves when trying to navigate risk messaging. These represent individual and personal viewpoints, and are aimed at encouraging reflection and discussion, rather than reaching conclusions.

Aimee Middlemiss is completing a PhD in Sociology at the University of Exeter which analyses the reproductive politics of second trimester pregnancy loss in England. The research she draws on in this blog was published by Berghahn in Navigating Miscarriage: Social, Medical and Conceptual Practices, 2020, edited by Dr Susie Kilshaw. This research was funded by the Economic and Social Research Council.

Aimee tweets at @almiddlemiss.

 

Women who have experienced antenatal care or given birth in the NHS in the last 40 years will have memories of the sounds of foetal heartbeats, replicated by handheld foetal Doppler devices. The small speakers can fill a room with crackling, popping, swooshing noises as the transducer wand is pressed around the pregnant woman’s belly, searching for the rapid, steady, tocking and thudding of the foetal heart sound. The sounds are heard during labour as midwives check for foetal distress, and often also in antenatal care appointments, despite recommendations that routine midwife Doppler listening should not be carried out because it does not affect birth outcome (National Institute for Health and Care Excellence, 2008).

 

The technology is now widely available for sale and rent for private use in the UK (Hale, 2007). Foetal Dopplers circulate between households and are resold on internet marketplaces. At the same time, several charities express concern about the use of the products by pregnant women (see for example, https://www.kickscount.org.uk/why-we-want-home-doppler-sales-to-be-regulated, and https://www.tommys.org/pregnancy-information/blogs-and-stories/im-pregnant/tommys-midwives/word-us-home-dopplers ). In 2017, an attempt was made in the House of Commons to ban their sale, which was eventually abandoned. There is a perception that the devices themselves are a risk to pregnancy, based on a single case of possible misuse reported in the BMJ over a decade ago (Chakladar & Adams, 2009), which I have discussed elsewhere (https://blogs.lse.ac.uk/politicsandpolicy/fetal-dopplers-bill/).

 

Doppler use in risky pregnancies

Yet foetal Dopplers are widespread and commonly used at home in pregnancy, as found in research I carried out in Cornwall in 2017 (Middlemiss, 2020). In qualitative interviews with 15 women about their use of the technology, it became clear that women turn to foetal Dopplers in pregnancies they perceive to be risky and uncertain. These are women who have experienced previous miscarriage, women who are experiencing worrying symptoms such as vaginal bleeding or abdominal pain, women who cannot feel foetal movement due to anterior placenta, women who have increased risk factors such as age. The motivating factor behind the acquisition of a foetal Doppler for home use was anxiety and perceived risk of pregnancy loss.

 

Dopplers as a rational response to perceived risk

Women turned to Doppler technology because it was available to them and relatively inexpensive. It resonated with prevalent cultural ideas about responsibly monitoring one’s own health through technology (Lupton, 2013, 2016; Neff & Nafus, 2016), such as the use of heartrate monitors in sports, or the self-tracking of sleep quality. It resonated with cultural ideas about women’s responsibility for the outcomes of their pregnancies (Longhurst, 1999; Lupton, 1999; Weir, 1996) and the health of their children (Bordo, 2003; Foucault, 1998). Women also turned to Doppler technology because it was familiar from its use in healthcare settings, and this gave them a level of trust in the information it provided. As one participant, Olivia[1], asked, ‘why do midwives use them? If they’re not a reliable source of information for the health of the baby?’

 

The use of Dopplers at home also took place in the context of a perceived lack of interest in early pregnancy from midwives and antenatal care provision in the NHS. Women felt that until the foetus was known to be viable there was limited access to NHS antenatal checkups, and they felt under pressure from medical and midwifery staff to be undemanding in their consumption of pregnancy healthcare. The solution in an anxious pregnancy was to carry out checks at home, using a domestic foetal Doppler.

 

The limitations of foetal Doppler use

My research found that narratives which assume pregnant women use foetal Dopplers unthinkingly or frivolously are both incorrect and patronising. Women used the technology to manage anxiety for which help was not available elsewhere. They did not use Dopplers instead of antenatal care, but as a supplement where they felt this was lacking. They combined the knowledge they gained with other knowledge, such as foetal movement, and tended to discontinue Doppler use if and when foetal movement became detectable and antenatal appointments were more frequent. They educated themselves about the limitations of the practice using online resources, and they were aware that the information Dopplers offered about pregnancy was specific and time-bound.

 

At the same time, however, foetal Doppler use at home has its limitations in terms of managing risky pregnancies. The information a Doppler provides is not a mitigation of risk to the foetus in pregnancy. Doppler technology cannot guarantee, or even affect, the outcome of a pregnancy, as NICE has pointed out. If the foetal heart sound is heard, all that tells the pregnant woman is that right now, at this point, there is foetal life.

 

However, sometimes for the pregnant woman, this knowledge of foetal life now, today, may be enough. The issue here is that there are two different forms of risk. One is whether foetal Doppler use affects foetal outcome. In pre-viable pregnancy, it cannot and does not. In post-viable pregnancy, there is perhaps a chance that false reassurance might be a threat to the pregnancy, though in my research most women were no longer relying on foetal Dopplers by this point in pregnancy.

 

The other risk in pregnancy which foetal Doppler use addresses is the anxiety of the pregnant woman in a pregnancy which she perceives to be under threat. All the women in my research had considered how they would feel if they could not find a foetal heartbeat, but felt this was a risk worth taking for the reassurance when they did hear that familiar sound. As Claire said, ‘you know it’s there, and it’s alive’. For the pregnant women in my research, rather than addressing foetal outcome, foetal Doppler use was about getting themselves through early pregnancy, and keeping themselves on an emotional even keel. They were primarily addressing a different risk with their use of foetal Dopplers. As a consequence, until NHS antenatal care has the resources to provide care for women which addresses the aftermath of previous pregnancy loss, or anxiety about threatened pregnancies, pregnant women will continue to seek reassurance for themselves at home using foetal Dopplers.

 

References

Bordo, S. (2003). Are mothers persons? Reproductive rights and the politics of subject-ivity. In Unbearable weight: Feminism, Western culture and the body (pp. 71-97). Berkeley, Los Angeles, London: University of California Press.

Chakladar, A., & Adams, H. (2009). Dangers of listening to the fetal heart at home. British Medical Journal 339(b4308). doi:10.1136/bmj.b4308

Foucault, M. (1998). The history of sexuality, vol.1: The will to knowledge (R. Hurley, Trans.). London: Penguin Books.

Hale, R. (2007). Fetal monitoring and the use of doppler. British Journal of Midwifery, 15(7), 449-452. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=106196345&site=ehost-live

Longhurst, R. (1999). Pregnant bodies, public scrutiny: ‘Giving’ advice to pregnant women. In E. Kenworthy Teather (Ed.), Embodied geographies: Spaces, bodies and rites of passage (pp. 77-89). London, New York: Routledge.

Lupton, D. (1999). Risk and the ontology of pregnant embodiment. In D. Lupton (Ed.), Risk and sociocultural theory: New directions and perspectives (pp. 59-85). Cambridge: Cambridge University Press.

Lupton, D. (2013). The digitally engaged patient: Self-monitoring and self-care in the digital health era. Social Theory & Health, 11(3), 256-270. doi:10.1057/sth.2013.10

Lupton, D. (2016). The quantified self: A sociology of self-tracking. Cambridge: Polity Press.

Middlemiss, A. L. (2020). ‘It felt like the longest time of my life’: Using foetal Dopplers at home to manage anxiety about miscarriage. In S. Kilshaw & K. Borg (Eds.), Navigating miscarriage: Social, medical and conceptual perspectives (pp. 160-183). New York, Oxford: Berghahn.

National Institute for Health and Care Excellence. (2008). Antenatal care for uncomplicated pregnancies. Retrieved from https://www.nice.org.uk/guidance/cg62/chapter/1-Guidance#fetal-growth-and-wellbeing

Neff, G., & Nafus, D. (2016). Self-tracking. Cambridge, MA, London: The MIT Press.

Weir, L. (1996). Recent developments in the government of pregnancy. Economy and Society, 25(3), 373-392. doi:10.1080/03085149600000020

[1] In this research participants were given pseudonyms to ensure privacy in a small community.