The ultrasound scene in abortion care: practices and meanings in a public maternity hospital in Salvador, Bahia State, Brazil

Mariana Ramos Pitta Lima Cecilia Anne McCallum Greice M. S. Menezes About the authors

Resumo:

O objetivo deste artigo é analisar as práticas e significados em torno da ultrassonografia obstétrica (USG) em mulheres com abortamento na maternidade pública em Salvador, Bahia, Brasil. Trata-se de uma pesquisa qualitativa, etnográfica, que envolveu observação participante das interações entre mulheres, profissionais de saúde médicos e não médicos, na sala de USG de uma maternidade pública, durante três meses. A USG ocupa um lugar central no itinerário abortivo das mulheres e sua prática é incorporada à rotina institucional e definidora de condutas na atenção ao abortamento na maternidade em estudo. Nesse contexto, são produzidas categorias distintas de “mulheres com aborto”, cujo acionamento depende da interpretação da imagem ecográfica. A forma de significar o estado de saúde e a condição moral de uma mulher com suspeita de aborto se relaciona com a presença ou não de um feto vivo no seu útero, além da idade gestacional em que a tentativa ou efetivação do aborto aconteceu. Concluímos que, quando as evidências ecográficas indicam que houve (provavelmente) um aborto em estágios iniciais de uma gravidez, os próprios profissionais colaboram com as mulheres em desativar o processo semiótico que levaria à atribuição de um sentido de natureza humana ao concepto. Quanto mais tarde se interrompeu uma gestação, mais provável é que o processo de significação sobre as imagens sustente a ideia de que ali havia uma Pessoa. A moral hegemônica sobre aborto e sua criminalização modulam as construções simbólicas e as práticas em torno do exame de USG em mulheres com abortamento.

Palavras-chave:
Aborto; Ultrassonografia; Gênero e Saúde; Maternidades

Resumen:

El objetivo de este artículo es analizar las prácticas y significados en torno a la ultrasonografía obstétrica (USG) con mujeres que abortaron en la maternidad pública en Salvador, Bahía, Brasil. Se trata de una investigación cualitativa, etnográfica, que implicó observación participante de las interacciones entre mujeres, profesionales de salud médicos y no médicos, en la sala de USG de una maternidad pública, durante tres meses. La USG ocupa un lugar central en el itinerario abortivo de las mujeres y su práctica está incorporada a la rutina institucional y definitoria de conductas en la atención del aborto en la maternidad en estudio. En ese contexto, se producen categorías distintas de “mujeres que abortan”, cuyo inicio del proceso depende de la interpretación de la imagen ecográfica. La forma de dar significado al estado de salud y la condición moral de una mujer, sospechosa de abortar, se relaciona con la presencia o no de un feto vivo en su útero, además de la edad gestacional en la que la tentativa o realización del aborto se produjo. Concluimos que, cuando las evidencias ecográficas indican que hubo (probablemente) un aborto en estadios iniciales de un embarazo, los propios profesionales colaboran con las mujeres en desactivar el proceso semiótico que conduciría a la atribución de un sentido de naturaleza humana al concepto. Cuanto más tarde se interrumpió una gestación, lo más probable es que el proceso de significación sobre las imágenes sustente la idea de que allí había un ser humano. La moral hegemónica sobre el aborto y su criminalización modulan las construcciones simbólicas y las prácticas en torno al examen de USG en mujeres que abortaron.

Palabras-clave:
Aborto; Ultrasonografía; Género y Salud; Maternidades

Abstract:

This article aims to analyze the practices and meanings involved in obstetric ultrasound (USG) in women undergoing abortion at public maternity hospital in Salvador, Bahia, Brazil. This is a qualitative ethnographic study that included three months of participant observation in the interactions between these women and medical and non-medical staff in the USG room of a public maternity hospital. USG has a central place in women’s abortion itinerary, and its practice is incorporated into the institution’s routine and the definition of approaches to abortion care at the maternity hospital studied here. In this context, distinct categories of “women with abortion” are produced and mobilized according to the interpretation of the USG images. The way the health condition and moral status of a woman with suspected abortion are defined depends on the presence or absence of a live fetus in her uterus, in addition to the gestational age at which the attempted or completed abortion occurred. We conclude that when the USG evidence indicates that there was (probably) an abortion in the initial stages of a pregnancy, the health professionals themselves help the women by disconnecting the semiotic process that would result in assigning a sense of human nature to the embryo. The later a pregnancy is terminated, the more likely the process of defining the images will sustain the idea that there was a person there. The hegemonic morals on abortion and its criminalization in Brazil modulate the symbolic constructions and practices involved in the USG test in women experiencing abortion.

Keywords:
Abortion; Ultrasonography; Gender and Health; Maternity Hospitals

Introduction

In Brazil, obstetric ultrasound (USG) has become the gold standard for confirmation of a live pregnancy, as well as the diagnosis of abortion. With widespread application in gynecology and obstetrics, USG has become an important tool in prenatal follow-up and cases of abortion (both spontaneous and induced).

Obstetric USG is not only a useful tool in medical care or a mere “scientific advancement”, since the images it produces carry powerful symbolic efficacy. The technology, in constant evolution, has transformed the semiotic field around pregnancy and thus the definitions of the beginning of human life, the body, the embryo and fetus, and, in related fashion, abortion 11. Chazan LK. "Meio quilo de gente": um estudo antropológico sobre ultrassom obstétrico. Rio de Janeiro: Editora Fiocruz; 2007..

This article addresses the practices and meanings involved in obstetric ultrasound, based on discussion of the results of an ethnographic study on interactions between health professionals and women undergoing abortion during the obstetric USG test in a public maternity hospital in Salvador, Bahia. We contend that in this setting of rapid encounters mediated by technology, the notions of pregnancy and fetus are not given a priori, but produced through relations with the obstetric USG. Estimates of the gestation’s timing at the moment of its termination exert an important influence on the process of signification.

By conferring a previously absent imagistic presence to the “biological entity” taking shape inside the woman’s body during gestation, the visual technologies have come to occupy a central place in the conceptual and social construction of the conceptus as a “person” in the anthropological sense 22. Mauss M. Uma categoria do espírito humano: a noção de Pessoa, a noção de "Eu". In: Mauss M, organizador. Sociologia e antropologia. São Paulo: Pedagogia Universitária/Editora da Universidade de São Paulo; 1974. p. 367-97.,33. Petchesky RP. Fetal images: the power of visual culture in the politics of reproduction. In: Stanworth M, editor. Reproductive technologies: gender, motherhood and medicine. Minneapolis: University of Minnesota Press; 1987. p. 57-80.,44. Davis-Floyd R, Dumit J. Cyborg babies: from techno-sex to techno tots. New York: Routledge; 1998.. This construction is processed on different global and local scales, from the national collective to daily intersubjective interaction, that is, both in the shared imaginaries and in ordinary situations amenable to observation and recording, as well as in the events forming the daily routine in medical clinics.

Abortion is a common event in Brazilian women’s reproductive life, despite its illegality (it is only allowed in cases of sexual violence, risk to the woman’s life, and more recently, fetal anencephaly). As a consequence of its illegality, unsafe practices in termination of pregnancy place women’s life and health in jeopardy. Half of the women who have undergone clandestine abortion are hospitalized to finalize the abortion or treat its complications 55. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60.. Criminalization of the practice influences women’s delay in seeking care and in the treatment received from health professionals in public services, causing unnecessary suffering 66. Araújo TVB, Aquino EML, Menezes GMS, Alves MTSSB, Almeida MCC, Alves SV, et al. Delays in access to care for abortion-related complications: the experience of women in Northeast Brazil. Cad Saúde Pública 2018; 34:e00168116..

On a broad scale, ultrasound images occupy an important place in political disputes over women’s bodies. Brazil is experiencing a social and political situation of stress from the resurgence of abortion’s moral condemnation, in which those who disapprove of abortion imagine themselves as aiming to ensure the legal protection of human life, which they see as beginning at the moment of conception. This neoconservative strategy aims to repress the plural exercise of sexual and reproductive rights in the name of religious values 77. Machado LZ. O aborto como direito e o aborto como crime: o retrocesso neoconservador. Cad Pagu 2017; 50:e17504.. There are strong ideological clashes over the personhood of the embryo or fetus. Such clashes draw on a visual rhetoric, using fetal images to propagate messages against abortion’s decriminalization 88. Luna N. Aborto e corporalidade: sofrimento e violência nas disputas morais através de imagens. Horizontes Antropológicos 2014; 20:293-325.. The main argument is based on defense of the personhood of embryos and fetuses. The smaller scale - as in obstetric USG rooms - is always marked by the collective imaginary, where these ideological positions echo loudly.

Studies that revisit women’s abortion itineraries 99. Santos DLA, Brito RS. Processo decisório do aborto provocado: vivência de mulheres. Physis (Rio J.) 2014; 24:1293-314. have identified the use of obstetric USG in at least three circumstances. In the first, physicians indicate the procedure as a complementary diagnostic method to attest to the existence of a live pregnancy, and women have used it as the last confirmatory resource 1010. Diniz D, Medeiros M. Itinerários e métodos do aborto ilegal em cinco capitais brasileiras. Ciênc Saúde Colet 2012; 17:1671-81.. In the second, women turn to ultrasound after induction of abortion, as a way of verifying whether the abortion was complete 1111. McCallum CA, Menezes G, Reis AP. The dilemma of a practice: experiences of abortion in a public maternity hospital in the city of Salvador, Bahia. Hist Ciênc Saúde-Manguinhos 2016; 23:37-56.,1212. Porto RM, Sousa CHD. "Percorrendo caminhos da angústia": itinerários abortivos em uma capital nordestina. Revista Estudos Feministas 2017; 25:593-616.. The third situation is when the test is performed in the hospital 1111. McCallum CA, Menezes G, Reis AP. The dilemma of a practice: experiences of abortion in a public maternity hospital in the city of Salvador, Bahia. Hist Ciênc Saúde-Manguinhos 2016; 23:37-56.,1212. Porto RM, Sousa CHD. "Percorrendo caminhos da angústia": itinerários abortivos em uma capital nordestina. Revista Estudos Feministas 2017; 25:593-616., aimed at identifying whether there is fetal viability and defining the diagnosis of type of abortion (complete, incomplete, retained, other) and as a follow-up test after the uterine evacuation procedure. The data in our analysis were produced in this third circumstance.

Anthropological and collective health studies on USG are recent and are mostly concentrated in the Northern Hemisphere (USA, Europe) and among women during prenatal care that intended to carry the pregnancy to term 33. Petchesky RP. Fetal images: the power of visual culture in the politics of reproduction. In: Stanworth M, editor. Reproductive technologies: gender, motherhood and medicine. Minneapolis: University of Minnesota Press; 1987. p. 57-80.,1313. Beynon-Jones SM. Re-visioning ultrasound through women's accounts of pre-abortion care in England. Gend Soc 2015; 29:694-715.,1414. Kimport K, Johns NE, Upadhyay UD. Women's experiences of their preabortion ultrasound image printout. Contraception 2018; 97:319-23.,1515. Howes-Mischel R. "With this you can meet your baby": fetal personhood and audible heartbeats in Oaxacan Public Health. Med Anthropol Q 2016; 30:186-202.,1616. Mitchel LM, Georges E. Baby's first picture: the cyborg fetus of ultrasound imaging. In: Davis-Floyd R, Dumit J, editors. Cyborg babies: from techno-Sex to techno-tots. Abingdon: Routledge; 1998. p. 105-24.. The few studies in Brazil focus on women that want to continue the pregnancy 11. Chazan LK. "Meio quilo de gente": um estudo antropológico sobre ultrassom obstétrico. Rio de Janeiro: Editora Fiocruz; 2007.,1717. Chazan LK, Faro LFT. "Exame bento" ou "foto do bebê"? biomedicalização e estratificação nos usos do ultrassom obstétrico no Rio de Janeiro. Hist Ciênc Saúde-Manguinhos 2016; 23:57-78.,1818. Macedo U. "Útero em cena": implicações e desdobramentos do uso da ultra-sonografia obstétrica [Monografia de Conclusão de Curso]. Salvador: Universidade Federal da Bahia; 2005.. Research on USG and abortion is important, especially in Latin America, where legal restrictions on the practice still persist. The current study aims to help fill this gap.

Methodology

This qualitative ethnographic study involved observation of the daily routine in the obstetric USG service at a public maternity hospital under the Brazilian Unified National Health System (SUS) in Salvador, hereinafter the “public maternity hospital in Salvador”, one of the healthcare units that sees the most patients undergoing abortion in the city. For three months, from November 2014 to January 2015, the principal investigator observed some 200 ultrasound tests of women, 51 with abortion.

The ultrasound service was operating normally from Monday to Saturday, 07:30 a.m. to 5:00 p.m., with six ultrasonographers, two women and four men, all white. Two black employees were doubling as receptionists and ultrasound assistants (race/skin color classified by the researcher). They received the women and performed all the tasks involved in the obstetric USG, including scheduling and recording the tests. About 20 tests were performed per shift. The ultrasonographers will be identified here with a “U”. We assigned fictitious names to the patients (Rita, Úrsula, Tarsila, Janaína, Raquel, Virgínia, Joana, Laís, Bruna, Camille, and Maria) in order to ensure anonymity.

The observations were made by one of the researchers and were concentrated in the USG room and in the corridor, where the women waited for their tests. The ethnographer came to the maternity hospital two or three times a week and entered the room wearing a white coat (a requirement in the service) and took notes. Her presence was scarcely noticed by the patients, who entered and left the room in front of her without displaying any embarrassment or discomfort, by all accounts mistaking her for just one more health professional. Their embarassment only appeared when they wanted to ask questions of the physician: some addressed the researcher or the assistant, which we interpreted as the power hierarchy’s effects on patient-staff relations.

The observations and field diary records were used to produce a dense description of the obstetric USG service. The resulting data were submitted to anthropological analysis, consisting of detailed readings of the material by three researchers. The ethnographic data provided the basis for elaborating the analytical categories 1919. Geertz C. A interpretação das culturas. Rio de Janeiro: Zahar; 1989..

The study complied with the ethical principles defined in Resolution n. 466/2012 2020. Conselho Nacional de Saúde. Resolução nº 466, de 12 de dezembro de 2012. Diretrizes e normas regulamentadoras para pesquisas envolvendo seres humanos. Diário Oficial da União 2013; 13 jun. of the Brazilian National Health Council and was approved by the Institutional Review Board of the Institute of Collective Health, UFBA (protocol n. 856.978/CEP-ISC).

From the emergency ward to the ultrasound room

In the corridor, the space mainly occupied by the women, they shared their stories on the reasons the test had been ordered and their own reproductive histories. A woman asks Rita (a young, low-income black woman, like most of the patients in the service) if she is pregnant. Rita says no, and talks naturally about her abortion: “It was a ‘loss’, so I’m going to have the ultrasound to see if they need to do the ‘collection’ (sic -curettage)”. “Loss” was the recurrent term the women used to refer to the abortion. Rita is not hospitalized in the maternity hospital, and is apparently in good health and “has no belly (sic)” from a pregnancy. She had come the night before in pain and with bleeding, but was not admitted, “because I had to have an ultrasound to see, and last night by the time I got here they were not doing the test, so they told me to go home and come back today”. Rita’s story illustrates the trajectory of other women, with miscarriages or induced abortions (usually after the use of Cytotec). They come to the emergency departments at the maternity hospitals to finalize the abortion. Her story also reveals the central place occupied by obstetric USG in abortion care in this service; it is common in the care provided to these cases in the public maternity hospitals in Salvador, as the physician’s assistant said: “When the woman comes (to the maternity hospital), she goes through here (the USG room)!”.

Ultrasound, abortion, and personhood

“There’s no pregnancy or remnants”: complete abortion, ambiguity, and reproductive continuum

The women who came to the service with bleeding and “without a belly” were generally classified in advance as those with abortion. When the obstetric USG test was performed and did not produce any image consistent with pregnancy or abortion, whether spontaneous or induced, there was no definition of a precise diagnosis. When interpreting the image projected on the screen, the professionals said, “There’s nothing there”, or “I don’t see anything”. They turned to the patient’s clinical history and the result of the pregnancy laboratory test (BhCG) to elaborate their diagnostic suspicions, open to various possibilities. Ursula (18 years, white) was one such case:

Ursula entered the room to have the transvaginal obstetric USG test. She had mild bleeding and “no belly”. The ultrasonographer greeted her by name, read the order, and said, “Your beta came back positive, and when you don’t see anything on the ultrasound, it’s either a pregnancy outside the uterus, or it’s very small, or you lost it. Let’s start the test to see”. The sonographer started the test and looked at the screen in silence. A few seconds later he said, “I don’t see a pregnancy. You’re going to see the doctor, and he’ll examine you, but as far as I’m concerned you had an abortion. Let me see your beta. Here, your beta has already dropped”.

U: “You’ve already done another beta, and it must be a lot lower, so that clinches it”.

Ursula: “But you found nothing, right?”.

U: “No pregnancy here”.

Ursula remarked later, “Good thing there was no child in there! What a relief!”. Other women in similar situations (not recognizing a “child” on the screen) reported this same emotion.

The lack of any visible sign of a fetus on the screen allowed the women not to acknowledge the pregnancy and abortion as such, thus shaping an ambiguity on what had transpired. Based on the points of view of health professionals and women in Bahia, we propose the analytical category of “inauthentic pregnancy”, understood as resulting from a process that takes place when the bleeding (and other signs) are present in a uterus void of embryonic remnants, and especially without a live fetus, providing the possibility for the health professionals to avoid entering the symbolic and moral terrain of an “authentic pregnancy” and an abortion. The data reveal the transformation of a “possible live pregnancy” into an “inauthentic pregnancy” with the contribution of the imaging technology, occupying here the superior position in the hierarchy of relations, without minimizing the biological reality of the procreative processes. Agreeing with the knowledge already obtained in the field of anthropology of the body, this process is “simultaneously social, cultural, and physical, that is, not only a meaning conferred post facto, in the discourse, as part of the interpretative tradition, but rather as something experienced intensely during the physiological process itself2121. McCallum C. Sem nome: pessoa como processo na dinâmica racial e de gênero brasileira. In: Cabral JP, Viegas SM, organizadores. Nomes: gênero, etnicidade e família. Coimbra: Editorial Almedina; 2007. p. 265-89. (p. 1.490).

Strathern 2222. Strathern M. Sobre o espaço e a profundidade. Cadernos de Campo 2011; 20:241-58. argues that the content of a uterus “revealed” in the USG image is always translated by an agent. What is seen is not the photograph of a fetus, but movements captured by echoes interpreted as images: “Those who look at an ultrasound can do nothing but interpret it” (p. 249). It is precisely this interpretation that erases a live pregnancy that existed, when what is projected on the screen is “nothing” or, on the contrary, when it confers personhood to embryos and fetuses.

The interpretation generated an explanation for the women, creating a distance from the idea that there had been a pregnancy, and without referring to an “embryo”, “fetus”, or “baby”. For Ana, the doctor’s last word obviously erased the abortion:

U: “I’m not seeing a pregnancy or remnants. When a person loses (the pregnancy) very early, sometimes no remnants are left. When there’s a lot of bleeding, there are no remnants. Anyway, you’re not pregnant now. You’ve never had surgery, have you?”.

Ana: “No”.

U: “The test is normal, see? There’s still a little bleeding”.

Gerber 2323. Gerber EG. Deconstructing pregnancy: RU486, seeing "eggs", and the ambiguity of very early conceptions. Med Anthropol Q 2002; 16:92-108. conducted a study in France, where termination of pregnancy is legal and some abortions are performed early with medication. The author discusses the reproductive process as a continuum, showing that for the women there is a gray area between being and not being pregnant, beyond the biological signs of pregnancy. Access to abortion in the early stages of gestation is emphasized since it does not exhibit a human shape in the abortion’s product, either during the uterine evacuation or on ultrasound. This produces a knowledge of the body that is antinomic to the construct of the conceptus as a person, along with an ambiguity between pregnancy and non-pregnancy.

The notion of Authoritative Knowledge elaborated by Brigitte Jordan 2424. Jordan B. Authoritative knowledge and its construction: introductory remarks to symposium on 'Birth in twelve cultures: papers in honor of Brigitte Jordan'. In: Annual Meeting of the American Anthropological Association. Palo Alto: Xerox Palo Alto Research Center; 2001. p. 1-5. on the basis of studies on labor and childbirth in different contexts is useful for understanding the bodily knowledge that creates the “inauthentic pregnancy”. For Jordan, this kind of knowledge is produced through collaboration or conflict between different ways of viewing the world, through hierarchical interactions involving continuous consensus-building.

In the symbolic process in which an “inauthentic pregnancy” is created in agreement with women’s expectations, the apparatus contributes definitively to the non-recognition of the existence of a pregnancy and an abortion, as in Tarsila’s ultrasound.

U: “If there’s a pregnancy, if it’s lost, if there are remnants, we can see it”.

Tarsila: “Pregnancy! Don’t say that word!”.

U: “But you’re not pregnant”.

Tarsila: “Oh, thank God!”.

U: “There’s no pregnancy, and no remnants”.

Tarsila: “Oh my God, thank you! You just made me so happy, because I went to Curuzu (a public primary care clinic), and the doctor told me I may have had an instantaneous (sic) abortion!”.

U: “It’s possible, sometimes it bleeds a lot and there are no remnants left. But it’s fine, you can wait outside and we’ll bring you the test result”.

No one challenged the health professional’s words, and both the patient and the ultrasonographer collaborated to deconstruct the possibility of a pregnancy that existed before the test.

“There are remnants”: incomplete abortion

Most of the women received a diagnosis of incomplete abortion. They had experienced a partially successful abortion, without total expulsion of the product of conception, which had forced them to come to the maternity hospital for its finalization via the uterine evacuation procedure. The term that emerged in the field to refer to the embryonic, ovular, or placental products that remained in the uterus and that was shared by the staff and the women to refer to what they saw on the screen was “remnants”:

Janaína: “I had two ‘colletages’ (sic), and it’s bleeding nonstop! I had one ‘colletage’ in August, and I had bleeding and a lot of pain. Then I got an infection, and two days later I had the second one”.

U: “Let’s see if there are still any remnants. Yes, you still have remnants. Fine, you may get dressed”.,

Janaína: “I don’t have to have another ‘colletage’, do I, doctor?”.

U: “Take the test result to your doctor, and she’s going to tell you, there are still remnants”.

The silence, which is common in this setting, is broken by the women’s curiosity on the presence of “remnants”, one of the few questions the women address to the ultrasound staff. As did Raquel:

U: (reading from the patient’s chart) “You didn’t have an ultrasound, and you took the medicine to lose it without having had an ultrasound”.

Raquel: “Right... How far along was it?”.

U: “Two months”.

Raquel gets up and looks sheepishly at the screen: “Are there still remnants?”.

U: “Yes”.

For the women, the USG after the abortion served to “view everything from the inside”, to see whether the situation was “all clean”. The remnants had to be cleaned out with the uterine evacuation procedure, or the “colletage” (sic), as the women refer to the curettage at the public maternity hospital in Salvador.

The presence of “remnants” confirmed the abortion, acknowledging that a pregnancy had been terminated and that a biological product had been partially expelled, as we see in Virginia’s test.

U: “Did it bleed a lot?”.

Virgínia: “No, pieces came out”.

U: “After the test, pieces came out?”.

Virgínia: “Right”.

U: “Remnants of pregnancy, the same thing as yesterday. Okay, you can get up”.

The women used the term “pieces” to refer to what they saw when the product of the abortion was expelled. Other terms that appeared were “pieces of blood”, “little clot”, and “clot of blood”. There was no reference to something with a life, or to the “fetus-person” construct. Even with the observation that there had been a pregnancy, based on the “remnants”, whenever the objective visual presence of a fetus was not detected, especially due to the absence of heartbeats, the discourse of deconstruction of the person was produced again. The physician remarked during Juliana’s test, “It is likely that you had a pregnancy and lost it,” and during Clarice’s test, “There’s no little heart here, just an image of remnants”.

The guarantee that when they reach the hospital they will be told “there are only images of remnants” on the obstetric USG partly explains why women have the test in private clinics before they are admitted to hospital. This is both to get a step ahead of their mandatory request to the hospital and to be certain that when they reach the hospital there will no longer be a fetus, that the abortion occurred. The women are familiar with the institutional policy of saving the fetus’s life, regardless of their own decision on the pregnancy. They have an obstetric USG before coming to the public maternity hospital in Salvador to avoid the activation of a process of person fabrication in the hospital during the diagnostic imaging test.

“The pregnancy is here, there are heartbeats”: threatened abortion and discovery of fetal vitality

Tests in women with bleeding and “without a belly” in which a live fetus has been found received the diagnosis of “threatened abortion”. The ultrasound scanner produced images showing the objective presence of the fetus, which generated different practices from those adopted in the face of the “inauthentic pregnancy”, as occurred in Joana’s test:

U: “The pregnancy is here, see? A live fetus, the pregnancy is here”.

Joana wept. She appeared to be upset by the observation of fetal vitality. It was possible to see the silhouette similar to the human form, although quite small, and to identify in the image something similar to the head, arms, spinal column, and legs.

U: “Three months on the dot. The ‘baby’s’ heart (turns on the Doppler, the device that allows listening to the fetal heartbeats, and Joana wept even more). He’s moving his arm, waving hello! Did you take medicine to lose it?”.

Joana: “I’m against that kind of thing”.

The ultrasonographer turned the screen so Joana could see, which is not common at this service. He pointed to the screen and described the image: “Little eyes, little mouth, little nose. Pronto, now you can go for prenatal care to follow the pregnancy. You can wait outside”.

The health professional’s performance 2525. Mol A. The body multiple: ontology in medical practice. Durham: Duke University Press; 2002. with the ultrasound scanner defines the pregnancy’s presence. If they say, “The pregnancy is here”, they call attention to the presence of fetal life, conferring it with the agency and attributes of a social subject, such as, “He’s moving his arm, waving hello”. An immediate change occurred in the test’s status, proceeding from that point on as tests in a pregnancy that will be carried to term.

We propose the analytical category of “authentic pregnancy” to define the process that occurs when a possible pregnancy is confirmed by the image, and when the fetus’s physical objectivity (and personhood) are created through a set of discursive, imagistic, and sonorous practices. The confirmation of a pregnancy via visualization of a live fetus produces an imposition, by the health professional, of meanings and moral values on the women - silenced in their desire to not continue the pregnancy, and pertaining to the abortion.

The physician asks the woman about induction of the abortion: “Did you take something to lose it?”. Among the cases in which the test detected fetal life, only Laís admitted to having induced the abortion.

U: “When did you take Cytotec?”.

Laís: “Saturday”.

U: “But did you expel the fetus?”.

Laís: “Uh-huh”.

U: “We’re going to take a look, because sometimes there are remnants of placenta”.

The physician prepared the scanner, started the test, and said: “It’s still very tiny. What you had was a threatened abortion, the embryo is alive, here’s the head, the little body, and the heart beating”.

Macedo 1818. Macedo U. "Útero em cena": implicações e desdobramentos do uso da ultra-sonografia obstétrica [Monografia de Conclusão de Curso]. Salvador: Universidade Federal da Bahia; 2005., in an ethnography in Salvador, argues that the ultrasound test functions as a tool to back attitudes of moral condemnation. Employing a kind of forced friendly language with the woman, the health professionals talk about (and on behalf of) the “little baby” to activate the woman’s “maternal instinct”. There is a symbolic violence here. The sonographer describes parts of the embryo’s or fetus’s body, usually employing words in the diminutive form, condescendingly affectionate in Portuguese, and the sounds of the fetal heartbeats, reinforcing the fetus’s social presence 1616. Mitchel LM, Georges E. Baby's first picture: the cyborg fetus of ultrasound imaging. In: Davis-Floyd R, Dumit J, editors. Cyborg babies: from techno-Sex to techno-tots. Abingdon: Routledge; 1998. p. 105-24.. The terms to refer to the conceptus included “embryo”, “fetus”, and “baby”, always highlighting its condition as a living being.

There was virtually no mention of the fetus’s sex. Most of the tests were performed either in the initial stages of pregnancy or when there was no longer an embryo o fetus. Considering that determination of the sex “crystallizes the transformation of the fetus into a person11. Chazan LK. "Meio quilo de gente": um estudo antropológico sobre ultrassom obstétrico. Rio de Janeiro: Editora Fiocruz; 2007. (p. 213), turning it into “people” by naming it as “he” or “she”, it is understandable why the women were scarcely curious about this detail.

Routine diagnosis of abortion with obstetric USG is the space in which discourses circulate on what it means to be a “good mother”. When fetal vitality is detected, the health professionals immediately suggest that the woman “goes to prenatal care”, a symbol of the start of ideal infant care. This mobilizes and reconfirms the obstetrician’s primary mission to help women bring new lives into the world 2626. Harris LH, Grossman D. Confronting challenge of unsafe second-trimester abortion. Int J Gynaecol Obstet 2011; 115:77-9..

McCallum et al. 1111. McCallum CA, Menezes G, Reis AP. The dilemma of a practice: experiences of abortion in a public maternity hospital in the city of Salvador, Bahia. Hist Ciênc Saúde-Manguinhos 2016; 23:37-56., show the central place of labor and childbirth in specialized public hospitals, the “maternity hospitals”. These places, whose main function is to produce mothers, also treat women who are experiencing abortion. The latter are suspected, in principle, of being “antimothers”. When fetal life was detected in the public maternity hospital in Salvador, there was a movement of transformation of “antimother” into “mother”. The woman was no longer an autonomous person, as occurs in cases of “inauthentic pregnancy”, and the test’s attention turned to the fetus. Let us see an example of how this happened with Bruna (who was pregnant and sick):

U: “What are you feeling?”.

Bruna: “Diarrhea, vomiting, headache, and fever”.

The accompanying person, Bruna’s mother, said, “Is the baby alright? He’s the normal size, isn’t he, doctor?”.

U: “Everything’s fine with the baby”.

Bruna said, upset, “But it’s not fine with me!” (Everyone stood on silently, ignoring Bruna).

The process of creating fetal personhood itself is integrated into this redirecting of symbolic action in the interaction between subjects and images in the obstetric USG room. The woman, in whose uterus a viable fetus is seen, shifts out of the category of “antimother”, because she is still pregnant, despite the bleeding that indicates a possible abortion.

The physician’s performance confers not only human status to the uterine content, but through this same act, a dual personhood to the woman herself. She is no longer a single person, morally diminished because the images of her uterus raise the suspicion of a history of assault on another human being’s life. The fact that she “still” contains another human being inside her body renews her right to be considered truly human. What we observed is the attribution of a multiple personhood that empowers her own humanity, since it does not suffice just to be a suffering individual to achieve this status; rather, the woman needs to be encompassed in the moral community of humans through the condition of the maternity hospital. Thus, the woman’s personhood within the institutional context depends on what is found in her uterus. All attention focuses on the “baby” as soon as fetal vitality is detected, and the woman’s personhood depends on the personhood of the baby she carries, and her moral status depends on the latter.

The ultrasound room is a place of performances. The health professionals’ practices and discourses constitute “performative acts”, as do those of the women. In the discourse on fetuses with life as volitional persons (“waving hello”), we find a performance about what it means to be an ethical health professional, for example. Women who find themselves in an asymmetrical position in power relations, characteristic of the USG room, are either forced to take a performative stance as “mothers”, or (in most of the cases we documented) to remain effaced and silent as agents in the interaction. There is no room for a unique autonomous person with the right to care specifically for her, when another life is discovered inside the “patient” (as in Bruna’s case). When demanding attention for her fever and pains rather than being moved by the presence of her “child” (as did a mother watching on in the obstetric USG room), she enunciates herself in full color as a “heartless mother”, since the agents in this interaction are not allowed to step out of the moral roles assigned to them.

“There’s one on the gurney to see.”: second-trimester abortion

The women closest to the position of “antimothers” were those with second-trimester abortions. Two women came to the USG room, wheeled from the wards on gurneys, since they were extremely debilitated. Each had a different outcome. The first was Maria:

There’s one on the gurney to see”, announces the ultrasound assistant. The room is small and the gurney occupies almost all of the space. Maria has been wheeled from the emergency ward, her belongings (clothing and documents) inside a clear plastic bag, the bedsheet bloody. She is pale and alone. An ultrasound test with the woman on the gurney requires reorganizing the room; although I have not been asked explicitly to assist in this reorganization, I feel compelled to participate. The ultrasonographer has to stand to reach the woman’s body, since the gurney is too high for him to handle the scanner while seated.

The mobilization triggered by performing the procedure in this extreme situation is expressed by the reconfiguration of the room’s physical and structural aspects and the tense, uncomfortable air hanging over the staff and the women.

U: “And your menstruation, when did it come?”.

Maria answers drily: “In September. I actually didn’t know. I went to the gynecologist, and the baby was practically born inside my belly (moans in pain as the physician moves the intravaginal scanner) “Ouch, ouch!”.

U: “You didn’t avoid it, did you?”.

Maria: “I was taking the pill, but I forgot two days”.

U: “Now you’re going to avoid it, aren’t you? Can you tilt your hips up a little higher?”.

Maria: “My doctor was very clear that I can’t get pregnant”.

U: “Did you see the fetus come out at home?”.

Maria nods, without saying a word.

U: “Already big, right?”.

Maria: “No, I only saw it when it came out”.

U: “Did you see the belly come out, the little arms?”.

Maria: “No, I didn’t see it until it came out”.

Maria is moaning, apparently in a lot of pain. The scanner is covered with blood, streaming out during the test. Now the test is over. The physician shows the screen to the researcher and says, “She’s lying about it, this is about five months. This image is of a uterus consistent with about five months of pregnancy”. He continues his work, writing his report, turns to the researcher, and says, “This must be one of those cases (of a fetus) that’s flushed (down the toilet), that we read about in the newspapers”.

The description of Maria’s test is the radicalization of what we call “authentic pregnancy”. The situation detected by an image that the abortion occurred in the second trimester was one that most generated moralizing discourses. Contrary to “inauthentic pregnancy”, expressed as termination that occurred “early”, here the fetus takes shape as a person, increasingly evident and material as the pregnancy proceeds.

Cases of abortion with advanced gestational age mobilized the entire service, where the staff soon started sharing their “newspaper” stories. The assistant enters the room and tells the tragic story of an abortion in a neighbor of hers. Her tone conveys moral condemnation of the young girl who had induced an abortion without her parents’ consent: “Her mother didn’t even know. The girl took Cytotec, but her uterus didn’t work. She killed the child, but it didn’t come out. She had to wait for the child to dissolve. Oh, how that girl suffered! Then the phalanges came out one by one...”.

Tension mounts during the ultrasound test when the attempted abortion has failed and fetal vitality is detected, as in Camille’s case. Grayish and whitish images are projected on the screen, and several seconds later the physician says, “Okay, the baby is already big, it’s hard to do transvaginal”, but he proceeds with the scan. He sounds disappointed when he says, “The baby is still alive... did you take something to lose it?”. Camille shakes her head, embarrassed. Although she denies having attempted to induce the abortion, the suspicion in relation to her veracity hangs thick in the air.

The physician continues with his explanation, as if describing a test in a woman with a full-term pregnancy, “This sound you hear is the heart”. He appears uncomfortable, and the woman is embarrassed, silent, staring down, attempting to answer only what is asked of her.

As discussed by Harris & Grossman 2626. Harris LH, Grossman D. Confronting challenge of unsafe second-trimester abortion. Int J Gynaecol Obstet 2011; 115:77-9., although only a small minority of abortions in the world occur in the second trimester, they are the ones that pose the greatest risk to the woman’s life, besides being more stigmatized for the women and health professionals. In a review article, the authors discuss how women are interrogated about the reasons for having waited so long to terminate the pregnancy, and the ways they can be perceived as the most “antimaternal” of all figures. They thus emphasize the importance of measures to favor access to termination of pregnancy in the initial stages in order to reduce the stigma of abortion and women’s mortality from unsafe and clandestine procedures.

Our study confirms that in cases of abortion in more advanced stages of pregnancy, the process of creating the person is more explicit, with more stigma, where ultimately what prevails is the discourse of health professionals backed by the production of images, while silencing the women. Here, now referring to the image as “baby”, the discourse features the most mobilizing parts for the women - “heart”, “little face”.

Final remarks

The ultrasound ethnography in the public maternity hospital in Salvador evidences that pregnancy is understood as a process involving distinct stages. Our analysis indicates that when the pregnancy is terminated in the initial stages, for those involved in the test, what has happened in the body is distinct from the notion of abortion. This extreme includes cases of probable complete abortion, and we contend that this involves a gray area of interpretation in which the process of signifying the images produced in the USG does not confer personhood to the product of conception. Some of these cases do not even require hospitalization, with the woman’s brief passage through the hospital, not requiring uterine evacuation and with few physical consequences.

The opposite extreme includes women that have experienced second-trimester abortion. In such cases we hear the health professionals’ discourse referring to the hegemonic morals and stigma on abortion in Brazilian society, as a condemnable practice. The treatment provided to women due to this interpretation represents a form of institutionalized symbolic violence. The conduct of these agents does not escape the consequences of criminalization of abortion in the country.

The interactions are marked by a distancing that characterizes the relationship between the health professionals and the women experiencing abortion in hospitals, as shown by various studies 55. Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60.,66. Araújo TVB, Aquino EML, Menezes GMS, Alves MTSSB, Almeida MCC, Alves SV, et al. Delays in access to care for abortion-related complications: the experience of women in Northeast Brazil. Cad Saúde Pública 2018; 34:e00168116.,1010. Diniz D, Medeiros M. Itinerários e métodos do aborto ilegal em cinco capitais brasileiras. Ciênc Saúde Colet 2012; 17:1671-81.,1111. McCallum CA, Menezes G, Reis AP. The dilemma of a practice: experiences of abortion in a public maternity hospital in the city of Salvador, Bahia. Hist Ciênc Saúde-Manguinhos 2016; 23:37-56.,1212. Porto RM, Sousa CHD. "Percorrendo caminhos da angústia": itinerários abortivos em uma capital nordestina. Revista Estudos Feministas 2017; 25:593-616.. During USG tests, the health professionals use an instrumental technical language in providing a service whose characteristics allow it to be performed as a serial production. The series only comes to a standstill in front of the image of a fetus, especially a live fetus. A turning point appears, where terms voiced in the diminutive form are used to appeal to the “mother” and to her “maternal instinct”. Here, the health professionals go back to being obstetricians in the maternity hospital, imbued with their mission to help babies be born. The women themselves hardly matter: whether they wanted the pregnancy, lost it spontaneously, are suffering, bleeding, in pain, or afraid of being discovered and arrested. The “baby” becomes the focus of all the care.

This study is an initial effort at mapping the field with the characterization of the ultrasound scene in abortion care and its context and interactions. Since this subject has received little attention in the scientific literature in Brazil, we recommend more in-depth analysis and further studies.

Even before the decriminalization and legalization of abortion, with the regulation of its practice, a change is urgently needed in the model of abortion care in the SUS. It is essential to free these women from the maternity hospitals and ensure humanistic care, changes that entail less suffering and full respect for their reproductive and human rights.

Acknowledgements

The authors wish to thank the Bahia State Research Foundation for granting a Master’s scholarship to M. P. L. from 2013 to 2015.

References

  • 1
    Chazan LK. "Meio quilo de gente": um estudo antropológico sobre ultrassom obstétrico. Rio de Janeiro: Editora Fiocruz; 2007.
  • 2
    Mauss M. Uma categoria do espírito humano: a noção de Pessoa, a noção de "Eu". In: Mauss M, organizador. Sociologia e antropologia. São Paulo: Pedagogia Universitária/Editora da Universidade de São Paulo; 1974. p. 367-97.
  • 3
    Petchesky RP. Fetal images: the power of visual culture in the politics of reproduction. In: Stanworth M, editor. Reproductive technologies: gender, motherhood and medicine. Minneapolis: University of Minnesota Press; 1987. p. 57-80.
  • 4
    Davis-Floyd R, Dumit J. Cyborg babies: from techno-sex to techno tots. New York: Routledge; 1998.
  • 5
    Diniz D, Medeiros M, Madeiro A. Pesquisa Nacional de Aborto 2016. Ciênc Saúde Colet 2017; 22:653-60.
  • 6
    Araújo TVB, Aquino EML, Menezes GMS, Alves MTSSB, Almeida MCC, Alves SV, et al. Delays in access to care for abortion-related complications: the experience of women in Northeast Brazil. Cad Saúde Pública 2018; 34:e00168116.
  • 7
    Machado LZ. O aborto como direito e o aborto como crime: o retrocesso neoconservador. Cad Pagu 2017; 50:e17504.
  • 8
    Luna N. Aborto e corporalidade: sofrimento e violência nas disputas morais através de imagens. Horizontes Antropológicos 2014; 20:293-325.
  • 9
    Santos DLA, Brito RS. Processo decisório do aborto provocado: vivência de mulheres. Physis (Rio J.) 2014; 24:1293-314.
  • 10
    Diniz D, Medeiros M. Itinerários e métodos do aborto ilegal em cinco capitais brasileiras. Ciênc Saúde Colet 2012; 17:1671-81.
  • 11
    McCallum CA, Menezes G, Reis AP. The dilemma of a practice: experiences of abortion in a public maternity hospital in the city of Salvador, Bahia. Hist Ciênc Saúde-Manguinhos 2016; 23:37-56.
  • 12
    Porto RM, Sousa CHD. "Percorrendo caminhos da angústia": itinerários abortivos em uma capital nordestina. Revista Estudos Feministas 2017; 25:593-616.
  • 13
    Beynon-Jones SM. Re-visioning ultrasound through women's accounts of pre-abortion care in England. Gend Soc 2015; 29:694-715.
  • 14
    Kimport K, Johns NE, Upadhyay UD. Women's experiences of their preabortion ultrasound image printout. Contraception 2018; 97:319-23.
  • 15
    Howes-Mischel R. "With this you can meet your baby": fetal personhood and audible heartbeats in Oaxacan Public Health. Med Anthropol Q 2016; 30:186-202.
  • 16
    Mitchel LM, Georges E. Baby's first picture: the cyborg fetus of ultrasound imaging. In: Davis-Floyd R, Dumit J, editors. Cyborg babies: from techno-Sex to techno-tots. Abingdon: Routledge; 1998. p. 105-24.
  • 17
    Chazan LK, Faro LFT. "Exame bento" ou "foto do bebê"? biomedicalização e estratificação nos usos do ultrassom obstétrico no Rio de Janeiro. Hist Ciênc Saúde-Manguinhos 2016; 23:57-78.
  • 18
    Macedo U. "Útero em cena": implicações e desdobramentos do uso da ultra-sonografia obstétrica [Monografia de Conclusão de Curso]. Salvador: Universidade Federal da Bahia; 2005.
  • 19
    Geertz C. A interpretação das culturas. Rio de Janeiro: Zahar; 1989.
  • 20
    Conselho Nacional de Saúde. Resolução nº 466, de 12 de dezembro de 2012. Diretrizes e normas regulamentadoras para pesquisas envolvendo seres humanos. Diário Oficial da União 2013; 13 jun.
  • 21
    McCallum C. Sem nome: pessoa como processo na dinâmica racial e de gênero brasileira. In: Cabral JP, Viegas SM, organizadores. Nomes: gênero, etnicidade e família. Coimbra: Editorial Almedina; 2007. p. 265-89.
  • 22
    Strathern M. Sobre o espaço e a profundidade. Cadernos de Campo 2011; 20:241-58.
  • 23
    Gerber EG. Deconstructing pregnancy: RU486, seeing "eggs", and the ambiguity of very early conceptions. Med Anthropol Q 2002; 16:92-108.
  • 24
    Jordan B. Authoritative knowledge and its construction: introductory remarks to symposium on 'Birth in twelve cultures: papers in honor of Brigitte Jordan'. In: Annual Meeting of the American Anthropological Association. Palo Alto: Xerox Palo Alto Research Center; 2001. p. 1-5.
  • 25
    Mol A. The body multiple: ontology in medical practice. Durham: Duke University Press; 2002.
  • 26
    Harris LH, Grossman D. Confronting challenge of unsafe second-trimester abortion. Int J Gynaecol Obstet 2011; 115:77-9.

Publication Dates

  • Publication in this collection
    10 Feb 2020
  • Date of issue
    2020

History

  • Received
    26 Feb 2018
  • Reviewed
    04 Oct 2018
  • Accepted
    25 Oct 2018
Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz Rua Leopoldo Bulhões, 1480 , 21041-210 Rio de Janeiro RJ Brazil, Tel.:+55 21 2598-2511, Fax: +55 21 2598-2737 / +55 21 2598-2514 - Rio de Janeiro - RJ - Brazil
E-mail: cadernos@ensp.fiocruz.br