Letters to the Editor
558
MIA scale
Adjusted mean (SE) 3D 4D (n = 79) (n = 68) Difference
Quality of attachment 32.7 (0.3) 32.6 (0.3)
Difference (95% CI)
0.1
Hostility
16.1 (0.2) 16.2 (0.2) –0.1
Interaction
23.4 (0.2) 23.8 (0.2) –0.4 2 1 0 –1 –2 Favors 3D Favors 4D
Figure 1 Forest plot of difference in maternal–infant attachment (MIA) questionnaire variable scores in pregnant women exposed to three-dimensional (3D) ultrasound stills vs four-dimensional (4D) ultrasound video. Shading represents differences of clinical unimportance (< 0.5 SD).
Effect of three- vs four-dimensional ultrasonography on maternal attachment Maternal attachment begins during early pregnancy with thoughts of and feelings for the unborn baby gradually increasing, and attachment intensifying in the first weeks after birth1 . The maternal antenatal attachment scale (MAAS)2 was developed to assess maternal emotional attachment to the fetus, and the maternal–infant attachment (MIA) questionnaire3 to assess the attachment
Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
between mother and infant post-delivery. The MIA questionnaire has 19 items, is self-reported and has acceptable levels of internal consistency and test–retest reliability; it covers factors including quality of attachment, absence of hostility and pleasure in interaction2 . Our earlier work demonstrated that, in the first half of pregnancy, three-dimensional (3D) ultrasound image exposure does not enhance maternal attachment compared with two-dimensional ultrasound image exposure4 . The current study was undertaken in third-trimester pregnancies (at the 28–30-week routine scan) to evaluate the effect on maternal attachment of exposure to a real-time four-dimensional (4D) fetal ultrasound video vs 3D ultrasound stills of the fetal face. This was based on a suggestion made by Stuart Campbell1 that providing parents with a video of 4D fetal ultrasound in the third trimester might reinforce maternal attachment. After obtaining ethical approval, 300 women were recruited, of which 150 were randomized to 3D ultrasound image exposure and 150 to 4D ultrasound video exposure. As per study protocol, the exclusion criteria were: fetal abnormality, fetal position that precluded obtaining a 3D image or 4D real-time scan of the face, obstetric and medical complications during pregnancy, existing (diagnosed) mental disorder and 3D group participant having a 4D scan performed elsewhere prior to delivery (exclusion from post-delivery assessments). This study was approved by the local institutional review board and was exempt from ANZCTR (Australia and New Zealand Clinical Trials Registry) registration as it was not a clinical intervention trial. High-resolution 3D and 4D imaging were performed in all participants. Voluson E8 ultrasound machines (GE Medical Systems, Sydney, NSW, Australia) were used and scans were performed by three accredited senior sonographers. After the 28–30-week scan, women in the 3D group were provided with a DVD of six 3D ultrasound stills that were considered to be the best images of the fetal face. Those in the 4D group were given a DVD of approximately 2 minutes’ real-time scanning of the fetal face and facial expressions. Participants in both groups were given their DVD after their scan was complete. Stipulating control over how many times the
Ultrasound Obstet Gynecol 2018; 51: 556–560.
Letters to the Editor
559
DVD contents were viewed by participants therefore was not possible. The progression of participants through the study is shown in Figure S1. No significant differences were found between the 3D and 4D ultrasound groups in baseline characteristics, including demographic variables. Based on a sample of 147 women who returned the MIA questionnaire postdelivery, there was no statistically significant difference in quality of attachment scores between the groups (Figure 1). Confidence intervals for the plausible difference were within a clinically unimportant range (< 0.5 SD). Our findings do not support the suggested advantage of real-time 4D over still 3D ultrasound for improving the quality of attachment of a mother to her newborn child. R. J. Benzie1,2* , V. Starcevic2,3 , K. Viswasam2,3 , N. J. Kennedy1 , B. J. Mein1 , D. A. Wye1 and A. Martin2 1 Christopher Kohlenberg Department of Perinatal Ultrasound, Nepean Hospital, Sydney, New South Wales, Australia; 2 University of Sydney, Sydney Medical School Nepean, Sydney, New South Wales, Australia; 3 Department of Academic Psychiatry, Nepean Hospital, Sydney, New South Wales, Australia *Correspondence. (e-mail:
[email protected]) DOI: 10.1002/uog.17567
References 1. Campbell S. 4D and prenatal bonding: Still more questions than answers. Ultrasound Obstet Gynecol 2006; 27: 243–244. 2. Condon JT, Corkindale CJ. The assessment of parent-to-infant attachment: Development of a self-report questionnaire. J Reprod Infant Psychol 1998; 16: 57–76. 3. Condon JT. The assessment of antenatal emotional attachment: Development of a questionnaire instrument. Br J Med Psychol 1993; 66: 167–183. 4. Sedgeman B, McMahon C, Cairns D, Benzie RJ, Woodfield RL. The impact of two-dimensional versus three-dimensional ultrasound exposure on maternal-fetal attachment and maternal health behaviour in pregnancy. Ultrasound Obstet Gynecol 2006; 27: 245–251.
SUPPORTING INFORMATION ON THE INTERNET The following supporting information may be found in the online version of this article: Figure S1 CONSORT flowchart of progression of study in which participants were exposed to three-dimensional (3D) ultrasound stills or four-dimensional (4D) ultrasound video.
Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
Ultrasound Obstet Gynecol 2018; 51: 556–560.
