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BABY'S FIRST PICTURE
ULTRASOUND AND THE POLITICS OF FETAL SUBJECTS

Appearing through developments in medicine, in volatile debates over

abortion rights, in popular guides to pregnancy, and in advertisements
for cars and long-distance telephone plans, the fetus has become an in-
creasingly familiar part of our social landscape in Canada. Lisa Mitchell
provides a critical anthropological perspective on the fetal subject, par-
ticularly as it emerges through the practice of ultrasound imaging.
'Seeing the baby' is now a routine and expected part of pregnancy
and prenatal care in Canada. Conventionally understood as a neutral
and passive technology, ultrasound appears to be a 'window' through
which to observe fetal sex, age, size, physical normality, and behaviour.
However, Mitchell argues, what is seen through ultrasound is neither
self-evident nor natural, but historically and culturally contingent and
subject to a wide range of interpretation.
Drawing upon fieldwork conducted over the past ten years, the au-
thor includes observations at ultrasound clinics, interviews with preg-
nant women and their partners, and a discussion on how ultrasound's
echoes become meaningful as 'baby's first picture' - a snapshot of the
fetus in utero.
Throughout, Mitchell probes our acceptance of this technology, our
willingness to take fetal imaging for granted, and illuminates the links
between this technologically mediated 'fetal reality' and the 'politics of
gender and reproduction in Canada.

LISA M. MITCHELL is an assistant professor in the Department of Anthro-

pology at the University of Victoria in British Columbia.
Photograph courtesy of the author
Baby's First Picture
Ultrasound and the Politics of
Fetal Subjects

LISA M. MITCHELL

UNIVERSITY OF TORONTO PRESS

Toronto Buffalo London
 www.utppublishing.com

c University of Toronto Press Incorporated 2001

Toronto Buffalo London
Printed in Canada

ISBN 0-8020-4810-2 (cloth)

ISBN 0-8020-8349-8 (paper)

@
Printed on acid-free paper

National Library of Canada Cataloguing in Publication Data

Mitchell, Lisa Meryn
Baby's first picture : ultrasound and the politics of fetal subjects
Includes bibliographical references and index.
ISBN 0-8020-4810-2 (bound) ISBN 0-8020-8349-8 (pbk.)
1. Fetus - Ultrasonic imaging - Social aspects. 2. Fetus - Ultra-
sonic imaging - Quebec (Province) - Montreal - Case studies.
3. Pregnant women - Quebec (Province) - Montreal - Attitudes.
4. Medical personnel - Quebec (Province) - Montreal - Attitudes.
I. Title.
RG527.5.U48M57 2001 618.3'207543 C2001-930695-4

This book has been published with the help of a grant from the Humanities
and Social Sciences Federation of Canada, using funds provided by the Social
Sciences and Humanities Research Council of Canada.

The University of Toronto Press acknowledges the financial assistance to its

publishing program of the Canada Council for the Arts and the Ontario Arts
Council.

University of Toronto Press acknowledges the financial support for its

publishing activities of the Government of Canada through the Book Publish-
ing Industry Development Program (BPIDP).
'Ultrasound Sold as Baby's First Picture'

(Vancouver, Canada) Ultrasound videos of fetuses are being marketed

as 'family entertainment' by an ultrasound technician. At any stage in
their pregnancies, expectant mothers pay Derek Kirkham, president of
First Moments Video Productions, $49.95 to 'capture baby's first pic-
tures on video.' The setting for the 10-minute shoot can be anywhere -
a hotel room or the customer's kitchen. Kirkham narrates and lets
parents participate by talking to the baby, playing music or reading.
Toronto Star, 12 January 1993: Cl

To: 'Lisa M. Mitchell'

Subject: Woman Breaks all Bladder Retention Records! News at 11:00!

Well, I could not simply walk in there 'unawares' - so despite the

intense agony (my bladder was 'ready' for 10:40, I was only seen at
11:30), I kept looking for signs of the meaning of our communication. I
was so tense though (I mean this was too much for me!), that she had
a hard time seeing anything (also the bladder was too full!). Anyway,
it was always 'the baby': 'see how the baby is moving about', 'look at
what the baby is doing now'. I cried. Well, what else could I do? That
first image is overwhelming. But it was still hard to imagine that this
was happening inside of me (oh, quit looking at me like fodder now).
Seeing that I was nervous, she engaged me more and more with the
experience: 'come on, scoot down a bit on the table so you can see the
screen better. Oh, good, here is a good picture, let me capture that one
for you.' Then, thankfully after being able to relieve myself, she did a
transvaginal, which gives much better images anyway. Then, with the
pictures so clear, I really got into looking at the images. Weird, weird,
weird. She kept talking about the limbs and organs that she could see
(she then said, 'look here's the heart, let me turn on the audio.' I cried
again.) I took all that chit-chat as a very good sign. So, how did I do?

Love,
N.
This page intentionally left blank
Contents

ACKNOWLEDGMENTS IX

1. Introducing Ultrasound Fetal Imaging 3

2. Opening the Black Box: The Ontology of Fetal Ultrasound

Images 22

3. The View from the Field 50

4. Being Pregnant and Coming to Know the Fetus 69

5. 'Showing the Baby': Sonographers' Accounts of Fetal Images 108

6. 'Seeing the Baby': Women's Perspectives on Ultrasound 137

7. Reconnections: Women, Ultrasound, And Reproductive Politics

169

8. Re-Visions: Other Ways of Seeing 201

APPENDIX 211
NOTES 213
REFERENCES 225
INDEX 251
This page intentionally left blank
Acknowledgments

As I was writing this book, an American woman ovulated. What made

this event worthy of international media coverage was that the woman,
Margaret Lloyd-Hart, who had gone through premature menopause,
produced the egg from her recently defrosted and reimplanted ovary.
A few days later, a second woman had ovarian tissue transplanted
into her forearm - apparently to make egg retrieval easier for in vitro
fertilization. Stories, like this one, about the technological mastery over
fetal production, or what used to be called 'having a baby,' are prolif-
erating. But the fetus is becoming public in more common, everyday
sites within our landscape - in advertisements for cars, telephone com-
panies, and television programming, in posters warning of the dan-
gers of smoking during pregnancy, in violent confrontations over the
issue of abortion, in proudly displayed ultrasound photos, in movies,
in the tiny pink plastic wombs of Mummy-to-Be dolls, and elsewhere.
In this book I focus on one of the most widely used, but no less
fascinating, sites of fetal production - ultrasound imaging. The core of
the material grew out of my doctoral research conducted at an ultra-
sound clinic in Montreal. When I came back to the dissertation some
time later with a book in mind, it was clear to me that my thinking
about the intersections of gender, reproduction, and technology had
changed. I went back to the original interview transcripts and field
notes, spread them out on the floor, and started again. What resulted
is this book.
Many people have contributed to the conception, gestation, and birth
of this book. I am particularly grateful to the many women and men
who have talked so openly with me about both the intimate and the
public aspects of pregnancy and ultrasound. I extend a sincere thank
x Acknowledgments

you to the sonographers, physicians, and others at the hospital where

I conducted the primary fieldwork and at other sites where I have
observed ultrasound. For stimulating discussion, frankly worded com-
mentary, and unwavering encouragement, as well as child care, shel-
ter, and diversions over the years, I am particularly indebted to Naomi
Adelson, Marjorie Mitchell, Donald Mitchell, Eugenia Georges, Joel
Minion, and my colleagues at the University of Victoria. The initial
research and the writing of the dissertation on which this book is
based benefited greatly from the tutelage of Allan Young, Atwood
Gaines, and Jill Korbin. For assistance with the transition from disser-
tation to book, I am grateful for the assistance and comments given by
the editors at University of Toronto Press and by anonymous review-
ers. The research assistance provided by Renae Satterly, Louise Cote,
and Theresa Ford in tracking down documents and odd bits of infor-
mation and the formatting help provided by Karen-Marie Woods is
much appreciated.
I wish to thank the Medical Research Council of Canada and the
Wenner-Gren Foundation for Anthropological Research for providing
financial support for graduate study and doctoral fieldwork. My con-
tinuing research has been generously supported by the Vancouver
Foundation and National Science Foundation.
This book is for my family, my kids, and my companion.
BABY'S FIRST PICTURE
This page intentionally left blank
Chapter One

Introducing Ultrasound Fetal Imaging

The beginning of life - the time when new flesh must be interpreted,
shaped, and transformed into socially meaningful forms - is especially
revealing of how competing views of personhood are 'worked through
the body.'
Conklin and Morgan (1996: 663)

One of the most common rituals of pregnancy in late twentieth-cen-

tury urban North America begins when a woman and her partner are
ushered into a small room by a white-coated person known as 'the
sonographer.' The room is dark, illuminated only by the glowing screen
of a machine. The sonographer asks the woman to lie down on a table,
then squirts her belly with a cool blue gel, moves a device over her
abdomen, and taps at a keyboard. Suddenly, a greyish blur appears
on a luminescent screen. Customarily during this ritual, the couple
smile, laugh, and point at the screen, even though they often do not
recognize anything in the blur. The sonographer taps at the keyboard
again and looks closely at the grey-and-white blur. She measures parts
of it and calculates its age, weight, and expected date of delivery. She
observes the couple closely to see if they like the blur and show signs
of 'bonding' with it. The couple also look closely at the sonographer,
anxious in case she finds something wrong with the blur. Sometimes,
when the blur seems really pleasing, the sonographer talks to it, strokes
it, and congratulates the couple. After about fifteen minutes, the blur
is turned off, and the gel wiped away, and the couple are given a copy
of the greyish blur to take home. This copy is known as 'Baby's First
Picture/ or as 'Baby's First Video' if they get the moving version. It is
often shown to other people, who are also expected to smile at it.
4 Baby's First Picture

This book offers a critical anthropological perspective on these blurs,

or, as they are more widely called, sonograms or ultrasound fetal
images. In particular, I investigate what these blurs mean to sono-
graphers and pregnant women at one hospital in Montreal, Canada. I
look at ultrasound images not as neutral windows onto the fetus but
rather as artefacts emerging out of particular historical, social, and
cultural contexts. I explain in detail how ultrasound's patterns of ech-
oes become culturally meaningful as 'Baby's First Picture/ a snapshot
of the individual in utero. If we are to understand this process, we
must also consider the extent to which fetal images may engage, con-
test, and transform other meanings, for example, about nature, tech-
nology, identity, normality, gender, and motherhood. I examine sev-
eral of the many semiotic and material practices through which fetal
images are produced, interpreted, and experienced; for this purpose, I
discuss changes in ultrasound technology, contemporary sonographic
practice, contests over abortion rights, and the embodied ideas and
practices of pregnant women. Throughout this book, my concerns are
two: first, to show how these collections of echoes have become taken
for granted as windows onto fetal reality, and second, to illuminate the
links between this technologically mediated reality and the politics of
gender and reproduction. Talk about the fetus and ultrasound is in-
separable from talk about women and power.
For several decades, ultrasound imaging has been widely regarded
by medical professionals as 'the most important antepartum diagnos-
tic technique available' (Gabbe 1988: I).1 Popular because it is consid-
ered to be a 'non-invasive' technique, ultrasound is said to open 'a
window of unsurpassed clarity into the gravid uterus ... capable of
providing exquisite detail regarding the fetus and the intrauterine en-
vironment' (Pretorius and Mahony 1990: 1). Claims about what can be
seen through this window are numerous: the state of fetal anatomy,
fetal growth and development, hundreds of fetal pathologies, fetal sex
as early as eleven weeks, and fetal sleep, rest, and activity patterns
(Graham 1983; Pretorius and Mahony 1990). There are even claims of
witnessing fetal masturbation (Meizner 1987). Finally, as Lisa Cart-
wright (1993) has pointed out, enough fetal behaviour has been ob-
served for one psychiatrist to begin the practice of fetal psychoanaly-
sis (Piontelli 1992). Ultrasound is thought to reduce maternal anxiety
and to stimulate the parents' emotional 'bond' to the fetus; in this
regard, it offers a means for influencing women into complying with
prenatal care recommendations about food, cigarette, alcohol and/or
drug intake.2
 Introducing Ultrasound Fetal Imaging 5

Since the technology was first adopted in the late 1950s, ultrasound
fetal imaging has become both an expected and a routine part of preg-
nancy for millions of women around the world. One, two, and some-
times four or five ultrasounds during pregnancy are now common in
many European nations, in urban Australia, and in the United States.
The technology is no longer restricted to women in the industrialized
'West/ and is becoming part of the 'modern' obstetrical repertoire in
many countries around the world. Wherever it is used, it is adapted to
fit with social imperatives and cultural meanings; for example, it is
used for sex determination in India and China (Hartmann 1995; Patel
1989). In Quebec, where I conducted the research for this book, ultra-
sound is widely seen as an 'essential' part of prenatal care, and around
97 per cent of all pregnant women undergo at least one scan (Royal
Commission on New Reproductive Technologies 1993: 816). Yet clini-
cal studies have not clearly demonstrated that the routine use of ultra-
sound in early or late pregnancy is without risk, or that it improves
maternal or fetal outcomes. Even so, its use is covered by all of this
country's provincial health insurance plans, and remarkably, physi-
cians do not have to request a woman's consent for ultrasound.3

Looking through the Window of Ultrasound

Most people - which includes practitioners, pregnant women, and the

wider public - perceive ultrasound as a neutral and passive technol-
ogy, as a 'window' through which the viewer can observe the fetus.
Actually, ultrasound images are highly ambiguous and must be inter-
preted. Sonographers need special training to see the grey reflected
echoes as a pattern of 'landmarks' - the distinctive uterine and fetal
structures that are used to assess the fetus's physical growth and de-
velopment. Several studies, including my own, have found that most
expectant couples have difficulty recognizing fetal shape, anatomy,
and movement in the ultrasound image without the sonographer's
assistance (Kohn et al. 1980; Villeneuve et al. 1988). Paradoxically,
although many parents recognize little or nothing in the fetal image,
they take considerable pleasure in regarding it and are eager to have
and willing to pay for a paper or video copy of the ultrasound image
(Berwick and Weinstein 1985). Ultrasound, then, is firmly lodged in
North American cultural discourses as a 'normal part of pregnancy'
that allows prospective parents a sneak preview of their infant's sex,
age, size, physical normality, and personality. So convincing is the
ultrasound fetus that millions of North American women experience a
6 Baby's First Picture

'technological quickening' several weeks before they sense fetal move-

ment in their own bodies (Duden 1992). The ultrasound fetus is so
emotionally compelling that it has become a source of cultural enter-
tainment. It appears in movies (Kaplan 1994), television shows, and
comic strips, as well as in print and electronic advertisements - for
example, for computers, cars (Taylor 1992), telephone companies, and
sports cable networks.
Ultrasound's 'facts' are not simply a technical matter requiring ex-
pert decoding; they are also culturally and socially constructed and
are subject to multiple interpretations. The most controversial aspect
of ultrasound imaging is what this 'window' says about the fetus as a
person. In clinical practice, ultrasound's fetal images are taken as ob-
servations of natural processes that allow physicians to assess fetal
age, development, and normality. These assessments made through
ultrasound are then translated into statements about fetal viability,
diagnoses of normality or abnormality, and recommendations for treat-
ment. What is seen through ultrasound is conditioned as well by legal
statutes and institutional practices regarding birth and death. In
Canada, the delivery of a fetus older than twenty weeks is a 'register-
able' event, and a birth certificate must be issued. In contrast, younger
fetuses are 'products of conception' and not registered as persons.4
For some parents, the ability to see fetal parts - especially the beat-
ing heart — and to see the fetus sucking its thumb, kicking, excreting,
and responding to external stimuli may demonstrate that the fetus is
aware of its surroundings and has the potential for or actually pos-
sesses distinctive human consciousness and personhood. Alternatively,
they may regard ultrasound simply as a diagnostic tool, that offers
information about the progress of the pregnancy; but says little or
nothing about the fetus as a person. Parents may also interpret in
multiple ways ultrasound images in which fetal anomalies are de-
tected. Some couples I have interviewed decide that their fetus does
not have the potential to become a full person, and thus do not feel
morally obligated to carry that fetus to term (see also Drugan et al.
1990). Conversely, they may believe that all fetuses, regardless of de-
velopment stage or abnormality, are persons with the right to life and
to fulfil their distinctive potential as humans. In this latter case, par-
ents may view these rights as imposing certain obligations to nurture
and protect the fetus - obligations that extend to the physician. Some
American lawmakers have attempted to legislate mandatory viewing
of ultrasound fetal images as a means of dissuading pregnant women
 Introducing Ultrasound Fetal Imaging 7

from having an abortion (Lippman 1986: 442). Pro-choice groups gen-

erally argue that decisions related to when fetal 'selfhood' begins are
part of a pregnant woman's right to self-determination over her own
body and involve ultrasound and other 'evidence' only if she so chooses
(Petchesky 1990). A growing number of feminist perspectives on this
issue assert 'a woman's right to choose/ yet also reveal how the very
existence of technologies such as ultrasound tend to structure 'choice'
in ways that 'have increased the potential for others to exercise an
even greater control over women's lives' and to discriminate in par-
ticular against low-income and minority women and people with dis-
abilities (Stanworth 1987: 4; see also Arditte et al. 1984, Corea 1985,
Corea et al. 1987, Himmelweit 1988, Overall 1989, Spallone 1989, among
others). In short, although ultrasound is perceived to be a 'window/ it
is a 'window' through which different groups see different things.5
The implications of what is 'seen' through ultrasound extend far
beyond the clinic, reaching deep into the lived worlds of women, their
partners, and sonographers, and into some of the most volatile cul-
tural struggles in Canada and the United States. In Canada at present,
the fetus is not legally a person and is not specifically included in the
Canadian Charter of Rights and Freedoms (1982). Abortion was de-
criminalized in 1969 and is regarded by Health Canada as 'a medically
necessary procedure that must receive full funding through provincial
health care plans' (Anderson 1999: 4). Nonetheless, Canadian women
are facing increasingly restrictive policies on reproductive rights. A
woman's right to determine what will happen to her body during
pregnancy, or to terminate a pregnancy, or to refuse a medically indi-
cated procedure, is under scrutiny in Canada (Gee 1996; Ginn 1999).
Societal confidence about women's reproductive decisions appears to
be wavering, and conflict between fetal and women's rights is increas-
ing, at the expense of women's control over both their own and fetal
bodies. Several widely publicized court cases have kept the question
of fetal rights and the rights of pregnant women in the Canadian
news. In particular, access to safe abortions is being eroded in the
name of family values, right-wing ,and Christian politics, and budget
cuts. In the face of ongoing harassment, threats, and physical vio-
lence, physicians and hospitals are becoming less and less willing
to provide abortions. Canadian women's access to safe, legal abortions
is tenuous.
In the United States, anti-choice violence has resulted in the deaths
of at least six abortion clinic physicians and workers, and more than
8 Baby's First Picture

double that number have been injured (National Abortion Federation

1997). Access to abortion in the United States has decreased dramati-
cally over the past ten years. Medicaid funding for low-income women
is restricted, with over half of all states now enforcing 'parental notifi-
cation laws' and mandatory waiting periods, and fully 84 per cent of
American counties do not have a provider for legal abortions (Na-
tional Abortion Federation 1997). In the latest well-publicized flare-up
in the abortion rights controversy, the U.S. Supreme Court is prepar-
ing to rule on the legality of late-term abortions, or what anti-choice
groups call 'partial birth abortions' (Thomas 1999).
In both Canada and the United States, abortion debates have re-
volved around competing constructions of personhood. Specifically,
the chasm has formed between anti-choice claims, which are primarily
about fetal personhood, and pro-choice claims, which have tended to
focus on women's personhood. Thus, in North America the debate
over abortion has evolved into a fierce struggle between two sets of
rights: those of fetuses to life, and those of women to choose. Within
these Canadian and American debates, despite often sharply diver-
gent positions on abortion and on who should be considered a person,
there is a shared set of assumptions about 'personhood/
One of these assumptions is that the debate over who is a person
and who/what is not can be resolved from a physical, time-based
perspective. Thus, arguments about fetal rights in North America tend
to focus on physical features such as the number of cells, morphologi-
cal completeness, chromosomal composition, and bodily functioning,
as well as on temporal events such as conception, first trimester, 20
weeks, and birth. Implicit in this search for the onset of personhood is
the assumption that personhood is an either/or state. A further sig-
nificant element in the debates surrounding personhood - especially
those which converge on the terrain of abortion rights - is that the
most compelling evidence brought to bear on this question comes
from the practices, technologies, and discourses of medical science.
While many sources of evidence - ethics, religion, feminism, human-
ism, among others - have been marshalled in debates over personhood,
the 'facts' of science and medicine are seen as especially salient and
powerful.
Canadian and American arguments about personhood tend to coa-
lesce around individualism, biology, and technology; in other places,
different configurations have emerged. For example, Beth Conklin and
Lynn Morgan have observed that among the Wari' of Amazonian
 Introducing Ultrasound Fetal Imaging 9

Brazil, pregnancy does not necessarily produce a human, and person-

hood is 'processual' rather than fixed in time and in biology:

In Western biomedical models of conception, once one sperm meets one

egg, the fetal body begins to develop through more or less automatic
biological processes. The Wari', in contrast, see the making of the fetus as
a process that requires the ongoing participation of people other than the
mother. Flesh and bones - the solid parts of the fetal body - are literally
created out of semen and nourished by it ... The idea that semen builds
fetal bodies means that couples should have sex often during pregnancy;
failure to do so is believed to endanger the fetus. (1996: 671)

Being human, then, as far as the Wari' are concerned, is not an

innate state of being; rather, humans are socially created 'through
exchanges of substance between individual bodies' (669). Where fe-
tuses are concerned, repeated acts of sex between the mother and a
man (not necessarily the biological father) have only the potential to
produce a human. Awareness is central to North American notions of
fetal personhood; yet as Conklin and Morgan explain it (678), even
though the Wari' consider fetuses to be aware and 'endowed with
relational capacities, this does not automatically confer personhood on
either the fetus or the newborn.' Significantly, neither does the bio-
logical event of birth. Newborns who do not live long enough to be
nursed are not persons and are not publicly mourned (679). Wari'
personhood is constituted not through that single act of nursing; rather,
it 'is acquired gradually and incrementally as a individual interacts
with other people and incorporates their bodily fluids' (1996: 674).
Similarly, a woman's fertility is a social achievement. A young Wari'
girl does not 'naturally' become a fertile woman once she begins to
bleed vaginally. Instead, her status as an adult female person is cre-
ated socially when the semen introduced into her body during sexual
intercourse makes her 'fatter, taller, and stronger - able to do women's
work' - and stimulates her true menstruation (1996: 674).
In contrast, many Japanese regard the fetus as sentient and aware,
labelling it mizuko, or a newborn baby (Oaks 1994: 515, 516). For this
reason, Japanese women may regard abortion as 'killing a baby.' More-
over, the social status of Japanese women is deeply invested with their
role as mothers and caregivers, and with the notion of ameru or emo-
tional dependence, which is particularly strong between mother and
child (Lock 1980: 77). As Oaks observes, 'Motherhood allows a Japa-
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