The reasons most commonly cited for wanting a sonogram were: (1) to determine the sex of the fetus, (2) to ensure that the baby was healthy, (3) for general reassurance, and (4) to rule-out specific fetal abnormalities ([Table 2]). Other reasons included “seeing the baby,” and determining the due date, the number of fetuses, and the size and position of the baby.
Fifty-one (37%) of the respondents stated that they were willing to go elsewhere to pay for a sonogram if one was not ordered by their clinician. They were willing to pay an average of $85 per sonogram.
The number of sonograms patients wanted varied widely. The median number of sonograms desired was 2 per pregnancy. The reasons women listed for wanting prenatal sonograms, their willingness to pay, and the number of sonograms wanted did not vary according to age, race, rank, or previous pregnancy.
Discussion
The value of diagnostic testing is typically discussed in the context of clinical decision making. That is, how does a diagnostic test help a physician to rule in or rule out disease? Diagnostic tests are also described as being cost-effective or cost-ineffective relative to what information they provide versus the resources they require. Berwick and Weinstein14 propose an interesting decision-making model that divides information provided by diagnostic testing into what is useful to the physician and what is useful to the patient. Using this model to describe prenatal ultrasound, 44% of the value of the examination was outside of the realm of medical decision making. In that study from the Boston area in 1985, prenatal patients were willing to pay an average of more than $700 per sonogram to obtain this information. That is much more than the women in our study were willing to pay. This discrepancy is most likely attributable to socioeconomic variances in the populations studied and the different reimbursement climates sampled.
Prenatal sonography is unique among diagnostic tests, because many patients appear to enjoy the examination, many expect it, and some even demand it.12,13 Given its increasing availability, screening prenatal sonography runs the risk of becoming the de facto standard of care without supportive clinical evidence.15 Our results reinforce the popular demand of prenatal sonography.
Our study also suggests that many of the reasons women cite for wanting a prenatal sonogram (eg, wanting to know the sex of the baby, general maternal reassurance, and so forth) are outside the realm of traditional medical decision making. The information that the patient seeks may not help the physician clinically manage the pregnancy; patients often want different information than their physicians need. In an age of increasing patient autonomy, physicians should carefully balance patient desires and expectations against the clinical usefulness of the information provided by prenatal sonography.
In our study, more than one third of the patients wanted a prenatal sonogram for reasons generally associated with maternal reassurance. This is an important point for physicians to consider when counseling patients. The probability of delivering a child without major birth defects in low-risk prenatal patients is 97% to 98%.16-18 Data from the Routine Antenatal Diagnostic Imaging Ultrasound Study indicate that the sensitivity of prenatal sonography for detecting a fetus with a major anomaly before delivery is 35%.8 Extrapolating this to low-risk pregnancies, the reassurance provided by a normal sonogram increases the likelihood of a normal outcome (defined as delivering a fetus without a major birth defect) by less than 1%. Thus, it is possible that patients might overestimate the value of sonography for purposes of maternal reassurance in low-risk pregnancies.
In our study of pregnant patients who are accustomed to free health care, more than half were willing to pay for a sonogram during their pregnancy. To achieve this patients were willing to leave the boundaries of the traditional physician-patient relationship to obtain the examination. Those patients wanting a sonogram whose clinicians did not order one would have to find a third party willing to perform the examination and would have to pay the full cost of the sonogram. This represents a potentially significant conflict between physician integrity (not wanting to order an unindicated test) and patient autonomy (wanting to have a prenatal sonogram).19
Although prenatal sonography unquestionably plays a central role in the management of complicated pregnancies, its role in routine low-risk pregnancies remains controversial. In routine pregnancies, popular demand may not coincide with scientific utility. Some women will want multiple sonograms when that is not clinically indicated, and some women may assume that sonography is a routine part of prenatal care. Physicians must carefully consider whether to obtain a prenatal sonogram within the context of each pregnancy. In arriving at the decision of whether to perform prenatal sonography for each patient, care must be taken to preserve the patient right to autonomy while respecting the intellectual and scientific integrity of the physician.