Scans, misogyny, and miscarriageBMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d7960 (Published 08 December 2011) Cite this as: BMJ 2011;343:d7960
- Andrew Moscrop, clinical researcher in primary care, Department of Primary Health Care, University of Oxford
“The needs of women who miscarry are being neglected by the NHS,” the Independent claimed in October (www.independent.co.uk/life-style/health-and-families/health-news/women-who-miscarry-are-neglected-by-health-service-2368100.html). The story described the Better Miscarriage Care campaign, launched by parents who founded the “Mumsnet” website. The campaign calls for better support and information and faster access to ultrasonography for women experiencing miscarriage (www.mumsnet.com/Talk/site_stuff/1315331-Mumsnet-campaign-for-Better-Miscarriage-Care-starts-NOW-get-involved-here). The Mumsnet campaign was covered in the tabloid newspapers, the BBC online news, and on BBC Radio 4’s Women’s Hour programme (www.bbc.co.uk/programmes/b015n3bc#p00l23jw).
While varying degrees of blame were directed at the NHS, the Guardian hinted at an issue of wider relevance than simply healthcare providers, referring to the suggestion by Mumsnet’s cofounder that miscarriage “needs generally to be talked about more” (www.guardian.co.uk/society/2011/oct/10/mumsnet-campaign-nhs-care-miscarriage?newsfeed=true).
Just four days later, miscarriage was being talked about in the media again, but the misinformation and scaremongering over ultrasonography in early pregnancy cannot have been what the Mumsnet campaigners had in mind. “Hundreds of healthy babies aborted every year in miscarriage test errors” was the front page headline that met London commuters who picked up the free Metro (www.metro.co.uk/news/878555-hundreds-of-healthy-babies-aborted-every-year-in-miscarriage-test-errors). The Daily Mail proclaimed: “Fears hundreds of healthy babies are being aborted every year simply because of scan blunders” (www.dailymail.co.uk/health/article-2048911/Fears-hundreds-women-aborting-healthy-babies-scan-blunders.html). Daily Telegraph readers were greeted with a similarly angled account, together with an opinion piece entitled, “Doctors’ attitude to miscarriage is casual and misogynist” (http://blogs.telegraph.co.uk/news/cristinaodone/100111046/doctors-attitude-to-miscarriage-is-casual-and-misogynist/).
The NHS, now accused of inept ultrasound scanning and emotional insensitivity over miscarriage, endeavoured to tend to the wounds left by the media’s rough handling of the issue. A placatory article was posted on the NHS Choices website under the heading “Scares over miscarriage scans unjustified” (www.nhs.uk/news/2011/10october/pages/ultrasound-scan-miscarriage-early-pregnancy.aspx). The article clarified the study findings behind the alarmist media reports, explaining how researchers had shown that current UK guidelines on the ultrasound diagnosis of miscarriage during the first few weeks of pregnancy might lead to misclassification of pregnancies that were, in fact, viable. The article also pointed out that “while the researchers did suggest there may be around 400 cases of misdiagnosis each year, there is no indication that the majority of them would be terminated, as newspapers have reported.” Nevertheless the Royal College of Obstetricians and Gynaecologists, responding to the new research findings, issued an amendment to its guidelines on management of early pregnancy loss and suggested that “a more cautious approach is warranted.”
The story of uncertain ultrasound diagnoses is likely to unsettle women who have had and those who will have ultrasound investigations for suspected miscarriage. Although news of “scan blunders” and “miscarriage test errors” was apt to induce anxiety, headlines such as those of the Daily Mail and Metro seemed to suggest shock and scandal at “healthy babies aborted.” These reports also muddied the distinction between miscarriage and abortion that patient support organisations such as the Miscarriage Association have sought to clarify. Such clarification ensures that each type of experience is suitably acknowledged and seeks to distance our language and attitudes from the era depicted in Mike Leigh’s 2004 film Vera Drake (BMJ doi:10.1136/bmj.329.7474.1107), when abortion was illegal and considered immoral and when miscarriage evoked suspicions of improper interventions.
The images featured alongside these recent media stories were inaccurate and clumsily emotive: many write-ups were accompanied by ultrasound pictures of late stage fetuses far more developed than the few week old, 2 cm gestational sacs that were the subject of the reported research. The Daily Telegraph’s medical misogyny article unashamedly used Lennart Nilsson’s iconic image of a 5 month old fetus, a photograph made famous by its 1965 appearance in Life magazine and subsequently much favoured by antiabortionists for its implication of an autonomous person within the womb. The inclusion of such obviously evocative imagery is unlikely to help women wishing to comprehend and come to terms with their loss.
Despite the efforts of the Better Miscarriage Care campaign, October’s media coverage may have only added to the uncertainty and isolation felt by women experiencing miscarriage. Furthermore, the thoughtless muddling of miscarriage and abortion and the unrestrained recourse to fetal imagery brings us no closer to resolving the fundamental dilemma underlying discussion of these issues: how can we, as a society, wilfully permit (and, as doctors, partake in) the deliberate termination of one fetus while empathising with the grief that may surround the loss of another?
Health professionals who have worked in early pregnancy assessment units will have seen uterine pathologies (gestational trophoblastic diseases) that cause many of the symptoms of pregnancy—indeed are often thought initially to be pregnancies—and that, once recognised, cause upset and grief equal to loss of a pregnancy. In such instances, as in miscarriage, the loss is not simply, perhaps not even, a fetus: it is a loss of anticipated motherhood, loss of a child imagined, and loss of apparent certainties. These and other meanings can be understood only through conversation with women who have experienced these losses.
Confronting the difficulties of these conversations and meanings is essential if we are to counter the supposition that the legitimacy of abortion diminishes the experience of miscarriage; to challenge the cultural taboo that inhibits the support and social acknowledgement afforded to bereaved parents; and to provide the better miscarriage care that has been called for.
Cite this as: BMJ 2011;343:d7960
Competing interests: AM has worked in an early pregnancy assessment unit and is now conducting a study of women’s healthcare experiences in early pregnancy.