J Clin Ultrasound 24:21-24, January 1996 0 1996 by John Wiley & Sons, Inc. CCC 0091-27511961010021-04

The Effect of the Amount of Feedback on Anxiety Levels During Ultrasound Scanning

Zoli Zlotogorski, PhD,* Ofer Tadmor, MD,t Eduardo Duniec, MA,* Ron Rabinowitz, MD,? and Yoram Diamant, MDt

Abstract: This study examined the influence of different levels of feedback and of other situational and buffering variables on the psychological effects of ultrasound examinations of 211 pregnant women. The patients were randomly assigned to two different experimental conditions: high feedback and low feedback. The subjects' levels of anxiety (both trait- and state-anxiety) were measured immediately before and after the ultrasound examination. Overall, there was a significant decrease in the level of state-anxiety, which could not be explained by the different levels of feedback provided. Situational and buffering variables were not found to be related to the degree of psy- chological benefit produced by the scan. 0 1996 John Wiley & Sons, Inc. Indexing Words: Anxiety . Feedback during Pregnancy . ultrasound scanning

Ultrasound (US) scanning has important diag- nostic benefits in obstetrics. The procedure can be used to detect fetal abnormalities, diagnose mul- tiple pregnancy, and accurately define fetal age,' and is useful in sex determination.2 Moreover, these diagnostic benefits are not compromised by potential risks to the fetus, and the procedure has been found to be safe.3 A major review of the stud- ies on the effects of US exposure on human fe- tuses reported no significant correlation between exposure and birth weight, hearing loss, or major congenital anomal ie~ .~ In addition, some authors have suggested that the procedure seems to have important psychological benefits for the future parent^.^'^

It has been widely reported in the literature that women show increased levels of anxiety and other negative emotions during pregnancy. Sev- eral prospective studies have found that pregnant women generally experience considerable stress and heightened levels of anxiety compared to pre- pregnancy stress levels. The changes in emotion-

From the *Department of Psychology, The Hebrew University of Jerusalem, and the tDepartment of Obstetrics and Gyne- cology, Sha'are Zedek Medical Center, Jerusalem, Israel. For reprints contact Ofer Tadmor, MD, Department of Obstetrics and Gynecology, Sha'are Zedek Medical Center, POB 3235, Je- rusalem 910318, Israel.

VOL. 24, NO. 1, JANUARY 1996

a1 life during pregnancy have been attributed to both physiological and psychological factors. Changes in hormonal levels, increased preoccupa- tion with health and with the consequence of body changes, and intense concern for the well-being of the fetus are the most important factors cited in the

Several studies have evaluated the effects of US scanning on the heightened level of psycho- logical distress in pregnant women. Michelacci and her colleagues'' reported significant de- creases in reported anxiety, depression, somatic symptoms, and hostility after each one of three US examinations. In another study, Tsoi et all2 found that ratings of physical discomfort of preg- nant women significantly decreased after they had completed the US examination. In a later study,13 they reported that the decrease in anxi- ety level was accompanied by an improved atti- tude toward pregnancy immediately following the scan. However, in a follow-up, it was found that there was a tendency for the psychological parameters to return to pre-scan levels within a 4 to 5 week period.

Langer and his ~olleagues'~ investigated per- ceptions of child image. They reported a brisker, more active, and more familiar view after the scanning. Brown' conducted a study in which 35 expectant fathers attended a routine US screen- ing. It was found that fetal imaging had a positive

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ZLOTOGORSKI ET AL.

emotional effect on the subjects, greatly reducing the level of parental stress.

A review of the literature reveals that two pos- sible mechanisms have been proposed to explain the beneficial impact of US examination. The first considers the scanning itself as being respon- sible for the beneficial psychological effects; the second focuses on the broader context of the pa- tient-doctor (or staff) interaction. Some re- searchers have focused on the beneficial effect of the vivid imagery of US scanning;14 while others have cited such factors as examination results15 or the supportive feedback provided by clinic

In an attempt to determine the role played by feedback on anxiety reduction, Reading and his colleagues conducted a series of experiments in which the subjects were randomly divided into high- and low-feedback conditions. High-feedback consisted of both verbal and visual feedback; low- feedback consisted of verbal feedback only. Their results indicated that higher levels of feedback increased the patient’s readiness to follow good health care behavior during pregnancy,17 and elicited a significantly more positive attitude to- ward the US examination.16 However their inves- tigation did not report differential levels of anxi- ety reduction for the two feedback conditions. They argued that the low-risk nature of their sample might explain their finding^.^

In the present study we examined the effect of feedback received during the US scanning on lev- els of anxiety reduction.

staff.12,13,1G

METHOD

Subjects

Subjects for the present study were 211 pregnant women who underwent an US examination at Sha’are Zedek Medical Center. Women under- went the examination to evaluate the course of their pregnancy as part of their routine prenatal care. Participation in the study was voluntary. Three subjects with findings of congenital malfor- mation of the fetus or other pathological signs were excluded from the study. In addition, 10 sub- jects who dropped out at different stages of the study and 15 subjects who failed to complete the questionnaires were also excluded.

The final sample of 182 subjects were married women, aged between 19 and 42 years (mean = 29.16 years; SD = 5.37) in their fourth to forty- first week of pregnancy (mean = 21.47 weeks; SD = 9.57). Their present pregnancy was between their first to their ninth (mean = 3.32; SD =

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2.12), and they had undergone between 0 and 9 US examinations (mean = 2.37; SD = 2.05) dur- ing the course of their obstetrical history. The over-all number of US examinations during both the present and past pregnancies was between 0 and 25 (mean = 3.88; SD = 4.73). The subjects’ level of education fell between 8 and 21 years of study (mean = 13.49 years; SD = 2.23).

Procedure

All subjects completed a demographic question- naire and Spielberger’s State-Trait Anxiety In- ventory” prior to the US examination. The State- Trait Anxiety Inventory (STAI) is a self-report instrument that consists of a series of 40 state- ments that describe emotional states. On a four- point scale a rating of 4 indicates the presence of a high level of anxiety for some items (eg, “I feel tense”) and the absence of anxiety for the remain- ing items (eg, “I feel calm”). The STAI measures both state and trait anxiety. The former is mea- sured by 20 items that ask the subject to describe her emotional state at a particular moment in time. Trait anxiety is measured by 20 items that ask the subject to describe her usual emotional state. Subject scores on either scale can range from 20 to 80 points. A higher score indicates higher levels of anxiety. The STAI has been used extensively in research studies, and its reported reliability and validity have been quite high. l8

The subjects were randomly assigned to one of two feedback conditions, and underwent ultra- sound examination performed by a physician. In the high feedback condition, subjects were shown the monitor screen during the US examination and were provided with standardized visual and verbal feedback of fetal head, heart, and limbs. The doctor pointed at these organs on the screen and said: “this is the head . . . and it is normal”; “this is the heart . . . and it is normal”; “these are the arms. . . and they are normal”; “these are the legs . . . and they are normal.” By means of a Doppler instrument, the subject heard the fetal heart beat, and she was told that “this is the heart blood flow . . . and it is normal.” Finally, printed pictures of what was seen on the monitor screen were handed to the subject by the staff.

In the low feedback condition, subjects were not able t o see the monitor screen and the doctor lim- ited himself to providing standardized verbal feedback: “head. . . normal”; “heart . . . normal”; “arms . . . normal”; “legs . . . normal”; “every- thing. . . normal.” Subjects were not handed printed pictures of what was seen on the monitor screen.

JOURNAL OF CLINICAL ULTRASOUND

FEEDBACK AND ANXIETY DURING ULTRASOUND

Upon completion of the US examination, all subjects once again completed the State-Trait Anxiety Inventory. Written results of the US ex- amination were then handed to the subject and a more full explanation of the objectives of the study was offered.

RESULTS Table 1 presents the means and standard devia- tions for the decrease in levels of trait and state anxiety after the US examination was completed. A one-tailed Student t-test was performed and re- vealed a significant ( t = 2.54; p < .012) reduction of state anxiety and a nonsignificant change in trait anxiety levels, for p = .05.

The data revealed a differential decrease in state-anxiety levels between the high feedback (mean = 2.92) and the low feedback (mean = 1.00) conditions (Table 2). However a two-tailed Student t-test was performed that indicated that this difference was not significant ( t = 1.22; p < .2233), f o r p = .05.

Further analyses of the data were conducted to determine whether the decreases in levels of state-anxiety could be explained by background variables. For the continuous variables (age, years of education, number of previous pregnan- cies, number of previous abortions, number of children, week of gestation, number of US scans in present pregnancy, and overall number of US) Pearson’s product moment correlation coefficients were calculated, but none of them was found to be significant at the p = .05. significance level.

For the discrete variables (country of birth, mother’s country of birth, religious beliefs, pro- fession, husband’s profession, reason for referral for the present scan, and medical background in- formation directly related to the pregnancy state, squared-etha tests were performed. Again none of these variables attained the required level of sig- nificance.

DISCUSSION In the present study, US scanning significantly reduced pregnant women’s level of state-anxiety.

TABLE 1 Decreases in Levels of Trait and State Anxiety After

Ultrasound Examination

Decrease in Level of Trait-Anxiety

Decrease in Level of Sate-Anxiety

M 0.62 M 2.00 SD 4.99 SD 10.48 N 182 N 177

M = mean. SD = standard deviation. N = number of subjects.

VOL. 24, NO. 1, JANUARY 1996

TABLE 2 Decreases in Levels of State Anxiety as a Function of

Levels of Feedback

High Feedback Low Feedback ~ ~~

Mean 2.92 Mean 1 .oo SD 8.96 SD 1.88 n 92 n 85

For trait-anxiety measures, such reductions did not occur. These results replicate earlier stud- ies,11,13 which reported that US scanning reduces the level of anxiety of pregnant women. Our data indicate that this reduction seems to occur only for state-anxiety levels rather than trait-anxiety. This is consistent with the conceptual difference that exists between state- and trait-anxiety. Trait-anxiety is a stable dispositional character- istic, and is thought to be less affected by situa- tional variables or circumstances. State-anxiety, on the other hand, refers to a transitory emo- tional state and is much more sensitive to the influence of current events.lg

However, the amount of feedback did not seem to have an influence on the psychological benefits of the scan. This finding is relevant to the ongoing debate regarding the factors responsible for the beneficial psychological effects of US scanning- in other words, the question of what exactly in the procedure is responsible for these effects. Our findings support those of Reading et a15 who ar- gued that the amount of feedback received during the scanning did not seem to be critical.

In the present study, the difference between high and low feedback consisted of the additional availability of visual imagery. Therefore, our re- sults do not support Langer’s contention that “vivid imagery” is critical in producing the scan’s beneficial psychological effects.14

The reduction in anxiety levels for all subjects in the present study tends to support the notion of the critical effect of r e a s ~ u r a n c e . ~ ~ , ~ ~ The actual quality of the critical information was similar for all participants, namely “the fetus is normal”.

It is important to note that none of the control variables (demographic, medical, or situational) was significantly related to the reduction of state- anxiety levels. State-anxiety levels were undiffer- entially reduced for the entire range of gestation. Contrary to popular opinion, pregnant women were found to continuously benefit from the scan, without regard to the number of previous US ex- aminations. Our study found no support for the notion of the “novelty effect” of the procedure as a critical variable for the psychological beneficial effects of the scan. In other words, the level of

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ZLOTOGORSKI ET AL.

familiarity with the procedure had no significant impact on levels of anxiety reduction.

Analysis of our data indicated that the benefi- cial psychological effects of US scanning are not dependent on the current level of risk at the time of the scan. The indication for the present US ex- amination, the medical background directly re- lated to the pregnancy state, and the woman’s number of previous abortions were not found to affect or to be related to the decrease in state- anxiety levels. Reading et a15 argued that the level of risk played a crucial role in the lack of difference in post-examination levels of anxiety between high and low feedback groups. Our re- sults found a uniform effect of anxiety reduction, regardless of level of risk.

A note of caution should be mentioned as to the generality of our findings. Post-scan levels of anx- iety were assessed immediately after the US ex- amination. There is some evidence13 to suggest that this reduction in anxiety levels is transitory. Clearly, future research is needed, and the per- formance of several lagged post-scan measure- ments of anxiety levels is advised. A return to pre-scan anxiety levels might constitute a possi- ble explanation for the lack of relationship be- tween the number of previous US scans under- gone and the decrease in the level of state- anxiety.

Finally, it is important to note that the results indicate that critical feedback involves a simple clear statement as to the well-being of the fetus. This information may allow for a more useful re- organization of time, financial, and human re- sources vis-a-vis the US examination.

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