Abstract

In this article we investigate the situation of pre-abortion ultrasound examination in a context of illegality, attending to the discursive practices of professionals who mediate viewing experiences, from the perspective of the experiences and interpretive repertoires of young women who were submitted to the examination. In-depth interviews were conducted with 25 women who had an abortion in the university period and who did a pre-abortion ultrasound. The material was transcribed and analyzed from the interpretive paradigm. Abortion is ignored in the examination situation through a particular discursive practice of professionals around the personification of the fetus and the naturalization of the maternal-fetal bond. The examination encourages the woman to see and meet the fetus, while she rejects the invitation to participate in the visualization. This women do not produce the hegemonic or dominant link between images, languages, and emotions that would make them mothers, but neither do they produce an alternative link that allows them to experience ultrasound consistent with the decision to interrupt the pregnancy. In this way, the ultrasound situation translates into an experience of normative violence for women.

Keywords:
Ultrasonography; Induced Abortion; Criminal Abortion

Introduction

Since few decades ago, feminist studies have made ultrasonography in pregnancy, especially that which precedes abortion, an object of research. The social practices by which knowledge, representations and meanings of images are constructed have been mapped and deconstructed (Beynon-Jones, 2015BEYNON-JONES, S. M. Re-visioning ultrasound through women’s accounts of pre-abortion care in England. Gender & Society, Thousand Oaks, v. 29, n. 5, p. 694-715, 2015.; Hopkins; Zeedyk; Raitt, 2005HOPKINS, N.; ZEEDYK, S.; RAITT, F. Visualising abortion: emotion discourse and fetal imagery in a contemporary abortion debate. Social Science & Medicine, Amsterdam, v. 61, n. 2, p. 393-403, 2005.; Palmer, 2009PALMER, J. Seeing and knowing: ultrasound images in the contemporary abortion debate. Feminist Theory, Thousand Oaks, v. 10, n. 2, p. 173-189, 2009. ; Petchesky, 1987PETCHESKY, R. Fetal images: the power of visual culture in the politics of reproduction. Feminist Studies, Ann Arbor, v. 13, n. 2, p. 263-292, 1987.; Roberts, 2012ROBERTS, J. The visualised foetus: a cultural and political analysis of ultrasound imagery. Farnham: Ashgate, 2012.; Taylor, 2008TAYLOR, J. S. The public life of the fetal sonogram: technology, consumption, and the politics of reproduction. London: Rutgers University Press, 2008.; Vacarezza, 2013VACAREZZA, N. Política de los afectos, tecnologías de visualización y usos del terror en los discursos contrarios a la legalización del aborto. In: ZURBRIGGEN, R.; ANZORENA, C. (Ed.). El aborto como derecho de las mujeres: otra historia es posible. Buenos Aires: Herramienta, 2013. p. 209-223.). In demonstrating the social practices by which the meanings of these images are constructed, the tension between “seeing and knowing,” especially present in some anti-abortion arguments, has been discussed (Beynon-Jones, 2015BEYNON-JONES, S. M. Re-visioning ultrasound through women’s accounts of pre-abortion care in England. Gender & Society, Thousand Oaks, v. 29, n. 5, p. 694-715, 2015.; Vacarezza, 2013VACAREZZA, N. Política de los afectos, tecnologías de visualización y usos del terror en los discursos contrarios a la legalización del aborto. In: ZURBRIGGEN, R.; ANZORENA, C. (Ed.). El aborto como derecho de las mujeres: otra historia es posible. Buenos Aires: Herramienta, 2013. p. 209-223.).

In recent decades, this technology acquired a strategic place in the universalization of the categorization of the fetus as a person, in the naturalization - essentialization - of the maternal-fetal bond and, consequently, in the denaturalization of abortion (Hopkins; Zeedyk; Raitt, 2005HOPKINS, N.; ZEEDYK, S.; RAITT, F. Visualising abortion: emotion discourse and fetal imagery in a contemporary abortion debate. Social Science & Medicine, Amsterdam, v. 61, n. 2, p. 393-403, 2005.). Therefore, ultrasonography has been defined as a socio-technical practice (Beynon-Jones, 2015BEYNON-JONES, S. M. Re-visioning ultrasound through women’s accounts of pre-abortion care in England. Gender & Society, Thousand Oaks, v. 29, n. 5, p. 694-715, 2015.), with a particularly political character (Hopkins; Zeedyk; Raitt, 2005HOPKINS, N.; ZEEDYK, S.; RAITT, F. Visualising abortion: emotion discourse and fetal imagery in a contemporary abortion debate. Social Science & Medicine, Amsterdam, v. 61, n. 2, p. 393-403, 2005.; Lamm, 2012LAMM, E. La imposición legal de una ecografía como requisito del consentimiento informado de la mujer en materia de aborto: otra restricción al aborto; otra violación a los derechos de las mujeres. Buenos Aires: Abeledo Perrot, 2012. ; Siegel, 2009SIEGEL, R. Introduction: the constitutional law and politics of reproductive rights. The Yale Law Journal, New Haven, v. 118, p. 1312-1317, 2009.; Sullivan, 2002SULLIVAN, P. A. Public perceptions and politics: when diagnostic medical ultrasound is employed as a nondiagnostic tool. Journal of Diagnostic Medical Sonography, Thousand Oaks, v. 18, n. 4, p. 216-217, 2002.; Taylor, 2008TAYLOR, J. S. The public life of the fetal sonogram: technology, consumption, and the politics of reproduction. London: Rutgers University Press, 2008.; Venner, 1995VENNER, F. Hitler a tué seulement six millions de juifs: sur le discours des adversaires de l’avortement. Mots, París, v. 44, p. 57-71, 1995. Disponível em: <Disponível em: https://bit.ly/3kxPkXA >. Acesso em: 7 out. 2020.
https://bit.ly/3kxPkXA... ).

Indeed, ultrasound has been represented as an “objective” form of knowledge about the fetus¹1In fact, the recently fertilized egg is known as “zygote” and from the moment it implants itself in the wall of the uterus it is called “embryo” (passing through the blastocyst stage). From the eighth week on, it is considered a “fetus.” For reasons of simplicity, we generally use the term “fetus” to refer to the being in gestation in all its stages. (Beynon-Jones, 2015BEYNON-JONES, S. M. Re-visioning ultrasound through women’s accounts of pre-abortion care in England. Gender & Society, Thousand Oaks, v. 29, n. 5, p. 694-715, 2015.), despite the fact that the realization of the examination involves processes of image construction (Condit, 1990CONDIT, C. M. Decoding abortion rhetoric: communicating social change. Chicago: University of Illinois Press, 1990.; Petchesky, 1987PETCHESKY, R. Fetal images: the power of visual culture in the politics of reproduction. Feminist Studies, Ann Arbor, v. 13, n. 2, p. 263-292, 1987.; Stabile, 1998STABILE, C. Shooting the mother: fetal photography and the politics of disappearance. In: TREICHLER, P. (Ed.). The visible woman: imaging technologies, gender and science. New York: New York University Press, 1998. p. 171-197.), a matter that is usually obscured (Petchesky, 1987PETCHESKY, R. Fetal images: the power of visual culture in the politics of reproduction. Feminist Studies, Ann Arbor, v. 13, n. 2, p. 263-292, 1987.). It also represents ultrasound as an event that occurs directly between the woman and the image, however, it is always mediated by her interaction with the professional (Palmer, 2009PALMER, J. Seeing and knowing: ultrasound images in the contemporary abortion debate. Feminist Theory, Thousand Oaks, v. 10, n. 2, p. 173-189, 2009. ; Roberts, 2012ROBERTS, J. The visualised foetus: a cultural and political analysis of ultrasound imagery. Farnham: Ashgate, 2012.), being the knowledge that the woman acquires mediated by this other person (Mitchell, 2001MITCHELL, L. M. Baby’s first picture: ultrasound and the politics of fetal subjects. London: University of Toronto Press, 2001.; Sanger, 2008SANGER, C. Seeing and believing: mandatory ultrasound and the path to a protected choice. UCLA Law Review, Amsterdam, v. 56, p. 351-408, 2008.; Sullivan, 2002SULLIVAN, P. A. Public perceptions and politics: when diagnostic medical ultrasound is employed as a nondiagnostic tool. Journal of Diagnostic Medical Sonography, Thousand Oaks, v. 18, n. 4, p. 216-217, 2002.; Taylor, 2002TAYLOR, J. S. The public life of the fetal sonogram and the work of the sonographer. Journal of Diagnostic Medical Sonography , Thousand Oaks, v. 18, n. 6, p. 368-369, 2002.).

In fact, the visualization of the images is often associated with a particular categorization of the fetus as a person, producing a visual representation of a biological organism as objective evidence of a human person (Steinberg, 1991STEINBERG, D. L. Adversarial politics: the legal construction of abortion. In: FRANKLIN, S.; LURY, C.; STACEY, J. (Ed.). Off-centre: feminism and cultural studies. London: HarperCollins Academic, 1991. p. 175-189.). The practice of ultrasound results, then, in a “prenatal paradox” (Taylor, 1998TAYLOR, J. S. Image of contradiction: obstetrical ultrasound in American culture. In: FRANKLIN, S.; RAGONÉ, H. (Ed.). Reproducing reproduction: kinship, power and technological innovation. Philadelphia: University of Pennsylvania Press, 1998. p. 15-45.) according to which the fetus is simultaneously objectified and personified as a separate individual, autonomous from the pregnant woman (Vacarezza, 2013VACAREZZA, N. Política de los afectos, tecnologías de visualización y usos del terror en los discursos contrarios a la legalización del aborto. In: ZURBRIGGEN, R.; ANZORENA, C. (Ed.). El aborto como derecho de las mujeres: otra historia es posible. Buenos Aires: Herramienta, 2013. p. 209-223.). This paradoxical character is connected to the fact that the bodies of pregnant women are excluded from the visualization practices (Petchesky, 1987PETCHESKY, R. Fetal images: the power of visual culture in the politics of reproduction. Feminist Studies, Ann Arbor, v. 13, n. 2, p. 263-292, 1987.).

The attribution of personality is subject to various practices of social recognition that are socially and historically variable in communities, institutions and societies (Morgan, 1989MORGAN, L. M. When does life begin? A cross-cultural perspective. In: DOERR, E.; PRESCOTT, J. (Ed.). Abortion and fetal personhood. Long Beach: Centerline Press. 1989. p. 97-114.). In this sense, the categorization of the fetus is a social option (Condit, 1990CONDIT, C. M. Decoding abortion rhetoric: communicating social change. Chicago: University of Illinois Press, 1990.; Hopkins; Zeedyk; Raitt, 2005HOPKINS, N.; ZEEDYK, S.; RAITT, F. Visualising abortion: emotion discourse and fetal imagery in a contemporary abortion debate. Social Science & Medicine, Amsterdam, v. 61, n. 2, p. 393-403, 2005.).

At the same time, this practice operates under the assumption of the generalization of maternal desire; even if there were previous ambivalence regarding motherhood, it would be resolved there, when the woman is confronted with the proof of the existence of the fetus (Siegel, 2009SIEGEL, R. Introduction: the constitutional law and politics of reproductive rights. The Yale Law Journal, New Haven, v. 118, p. 1312-1317, 2009.). This excludes the possibility that a fetus and pregnancy have different meanings for a woman (Taylor, 2008TAYLOR, J. S. The public life of the fetal sonogram: technology, consumption, and the politics of reproduction. London: Rutgers University Press, 2008.), even though research has shown that personalization in the visualization and activation of a maternal bond is not intrinsic to the ultrasound experience (Hopkins; Zeedyk; Raitt, 2005HOPKINS, N.; ZEEDYK, S.; RAITT, F. Visualising abortion: emotion discourse and fetal imagery in a contemporary abortion debate. Social Science & Medicine, Amsterdam, v. 61, n. 2, p. 393-403, 2005.; Siegel, 2009SIEGEL, R. Introduction: the constitutional law and politics of reproductive rights. The Yale Law Journal, New Haven, v. 118, p. 1312-1317, 2009.).

The study of women’s experiences with pre-abortion ultrasound scan has been a focus of interest for feminism, traditionally concentrating on women’s perceptions and/or reactions to seeing a pre-abortion scan. This line of research has been extended to the study about their experiences and the conditions that make this practice possible, the terms in which it is possible to give it meaning and to represent its significance (Beynon-Jones, 2015BEYNON-JONES, S. M. Re-visioning ultrasound through women’s accounts of pre-abortion care in England. Gender & Society, Thousand Oaks, v. 29, n. 5, p. 694-715, 2015.). Following this line of inquiry, a woman could refuse to participate in the visualization of ultrasonic images because in such conditions her participation would be incompatible with the experience of abortion (Siegel, 2009SIEGEL, R. Introduction: the constitutional law and politics of reproductive rights. The Yale Law Journal, New Haven, v. 118, p. 1312-1317, 2009.), on the understanding that the search for visual encounters would require a pregnancy context in which the woman actively seeks to build a maternal-fetal bond (Beynon-Jones, 2015BEYNON-JONES, S. M. Re-visioning ultrasound through women’s accounts of pre-abortion care in England. Gender & Society, Thousand Oaks, v. 29, n. 5, p. 694-715, 2015.).

However, in the opposite direction, the expectations and dominant representations associated with this socio-technical practice could be subverted using what Beynon-Jones (2015)BEYNON-JONES, S. M. Re-visioning ultrasound through women’s accounts of pre-abortion care in England. Gender & Society, Thousand Oaks, v. 29, n. 5, p. 694-715, 2015. calls an interpretive repertoire of “situated visual relationship.” A type of tool that would allow an emotionally significant visualization conducive to the interruption of the pregnancy (Bamigboye et al., 2002BAMIGBOYE, A. et al. Should women view the ultrasound image before first-trimester termination of pregnancy? South African Medical Journal, Bethesda, v. 92, n. 6, p. 430-432, 2002.; Beynon-Jones, 2015BEYNON-JONES, S. M. Re-visioning ultrasound through women’s accounts of pre-abortion care in England. Gender & Society, Thousand Oaks, v. 29, n. 5, p. 694-715, 2015.; Kimport et al., 2012KIMPORT, K. et al. Women’s perspectives on ultrasound viewing in the abortion care context. Women’s Health Issues, New York, v. 22, n. 6, p. E513-E517, 2012., ²⁰¹³KIMPORT, K. et al. Patient viewing of the ultrasound image prior to abortion. Contraception , Amsterdam, v. 88, n. 5, p. 666-670, 2013.; Mitchell, 2001MITCHELL, L. M. Baby’s first picture: ultrasound and the politics of fetal subjects. London: University of Toronto Press, 2001.; Wiebe; Adams, 2009WIEBE, E. R.; ADAMS, L. Women’s perceptions about seeing the ultrasound picture before an abortion. The European Journal of Contraception and Reproductive Health Care, Abingdon, v. 14, n. 2, p. 97-102, 2009.). Or through an interpretive repertoire of “medical objectification,” which would be an act of exploration of the body and of the fetus decoupled from fetal personification processes, as an opportunity to satisfy scientific curiosity about the biological events that occur inside women’s bodies, and evidence that the embryo/fetus inside their bodies was insignificant from a moral and development perspective (Beynon-Jones, 2015BEYNON-JONES, S. M. Re-visioning ultrasound through women’s accounts of pre-abortion care in England. Gender & Society, Thousand Oaks, v. 29, n. 5, p. 694-715, 2015.). The set of these studies was developed in contexts where abortion is a legal practice. However, in those places where this practice remains prohibited, the conditions in which the examination is possible are very different, since women are subject to the possibility of denunciation and are exposed to criminalization if they communicate their decision to interrupt the pregnancy.

The purpose of this article is to explore the situation of pre-abortion ultrasound examination in a context of illegality. Considering the discursive practices of professionals who mediate visualization experiences, from the perspective of the experiences and interpretative repertoires of young women who are undergone to such examinations. From the reports of women who underwent a pre-abortion ultrasound, the discursive practices of health professionals are reconstructed and the women’s interpretative repertoires are examined.

The research is focused on Chile, where the ultrasound prior to the termination of pregnancy is performed in a context of clandestinity from the perspective of the woman, because in the period in which this study was conducted, legislation prohibited abortion in all circumstances, placing it among the countries in the world with the highest restrictions (Center for Reproductive Rights, 2014CENTER FOR REPRODUCTIVE RIGHTS. The world’s abortion laws: fact sheet 2014. New York, 2014. Disponível em: <Disponível em: https://bit.ly/3kyqqH5 >. Acesso em: 2 dez. 2018.
https://bit.ly/3kyqqH5... ). Since 1989, Chile has maintained a complete criminalization of abortion, a situation that was partially modified with the enactment in 2017 of the Voluntary Interruption of Pregnancy Act on three occasions, Law 21.030.²2Woman at vital risk; embryo or fetus with an acquired or genetic congenital pathology incompatible with independent extra-uterine life of a lethal nature; and pregnancy resulting from rape (Chile, 2017). Despite the prohibition, Chile has historically had high rates of abortion. It is estimated that 109,200 induced abortions are currently performed each year (Molina-Cartes et al., 2013MOLINA-CARTES, R. et al. Profile of abortion in Chile, with extremely restrictive law. Open Journal of Obstetrics and Gynecology, Irvine, v. 3, n. 10, p. 732-738, 2013.), but in a context of significant declines in maternal morbidity and mortality due to abortion (Donoso; Carvajal, 2012DONOSO E.; CARVAJAL, C. El cambio del perfil epidemiológico de la mortalidad materna en Chile dificultará el cumplimiento del 5º objetivo del milenio. Revista Médica de Chile, Santiago, v. 140, n. 10, p. 1253-1262, 2012.), data suggest that this is practiced with safer methods and in contexts of lower health risk. In spite of the recent legal modification, the practices studied continue to be illegal, since they are outside the three indications covered by this law.

Material and method

We studied a group of young women from the university system of Santiago city, in Chile. For this purpose, we used an intentional sampling of theoretical type, using the snowball method and an advertisement in university centers and institutional Facebook, trying to use access techniques to subjects who operate in conditions of clandestinity. We constituted a sample of 33 participants who had an abortion (or the first one of them) during the university period. The women were born between 1980 and 1990; they had their abortions between the ages of 17 and 26, between 2004 and 2016. They were all single at the time of the abortion. The women were from middle and lower middle class backgrounds and came from various careers and universities (Catholic and secular, state and private).³3The institution of membership was not a criterion for inclusion in the sample. It should be noted that given the heterogeneity of the Chilean university system, this data does not allow the articulation of any differential hypothesis with respect to the interviewees, and only serves to characterize a certain heterogeneity within the composition of the sample of interviewees. Thirty students used the medical method, two the surgical method and one used a traditional technique. Once the pregnancy was diagnosed using a self-applied test, 28 women went to a specialized medical consultation and 25 made an ultrasound examination. In this article we include the 25 women underwent an ultrasound examination.

There are two reasons for the selection of the sample studied. First, the group of university students allowed to reduce the difficulties of access to issues involved in practices subject to social and penal criminalization. The second is due to the characteristics of this group that are related to a more individualized biographical orientation in matters of sexuality, reproduction and conjugality (Palma, 2012PALMA, I. Las nuevas generaciones de mujeres, el embarazo no previsto, las edades y la segmentación social en la sociedad chilena. Revista Médica de Chile , Santiago, n. 140, n. 3, p. 319-325, 2012. ), and who, despite their limited economic autonomy, have supports and networks provided by the same university context, which can become a resource for those seeking an abortion. In this sense, the experience of women university students is more favorable than that of other groups of women, especially those who have not access to higher education.

The in-depth interview in face-to-face format was used in combination with a record of the trajectory associated with the practice, using a thematic script defined from the objectives, research questions, theoretical inputs and background available in the literature. The interviews were conducted between January 2013 and August 2016 by the group that is signing this article. The material was recorded and transcribed for analysis.

We seek to rescue the perspective of the actor; therefore, the study is framed in the assumptions of the interpretative paradigm (Vasilachis de Gialdino, 2006VASILACHIS DE GIALDINO, I. (Coord.). Estrategias de investigación cualitativa. Barcelona: Gedisa, 2006.). This choice is justified because it allows us to explore and understand the subjectivity, senses and representations of individuals about facts, processes and events that are part of their lives in a particular social context (Iñiguez-Rueda, 2003IÑIGUEZ-RUEDA, L. (Ed.). Análisis del discurso: manual para las ciencias sociales. Barcelona: UOC, 2003.; Kornblit, 2007KORNBLIT, A. L. Historias y relatos de vida: una herramienta clave en metodologías cualitativas. In: KORNBLIT, A. L. (Coord.). Metodologías cualitativas en ciencias sociales: modelos y procedimientos de análisis. Buenos Aires: Biblos, 2007. p. 15-33.). At the same time, it allows for research into practices as described, defined, signified and interpreted by the actors. We use a logic of analysis of the singularity and particularity of each interviewee, and a transversal logic, which allows, from certain continuities and discontinuities of the singular phase, to determine relevant thematic and analytical axes and comprehensive transversal hypotheses. The analysis of the material was carried out by the authors.

The research was approved by the Committee on Ethics in Social Science Research of the Universidad de Chile. Confidentiality of identification is safeguarded and identities are preserved. We also had to decide whether or not to apply the legal prescription period for the crime of induced abortion (5 years in Chile), and we chose not to consider it in order to reflect recent practices.

Results

Rationality in the ultrasound use

Ultrasound is not a mandatory medical indication for first-trimester abortion, however, most women interviewed choose to have it.⁴4Date of last menstrual period and physical examination are very effective in determining women’s eligibility for early termination of pregnancy with mifepristone and misoprostol (Bracken et al., 2011), and can be safely and effectively performed up to sixty-three days of gestation without the routine use of ultrasound (Kaneshiro et al., 2011). If it is not a medical requirement to have an abortion, then why do women resort to it? The use of ultrasound is part of a design for the management of abortion by women, who consider it a fundamental tool (Palma et al., 2018PALMA, I. et al. Experience of clandestine use of medical abortion among university students in Chile: a qualitative study. Contraception , Amsterdam, v. 97, n. 2, p. 100-107, 2018.). In their perception, pre-abortion ultrasound is an important resource, as it would make the difference between a successful and a failed abortion. It is used specifically for the generation of knowledge about the electivity of the method, especially regarding the decision to use the medical method, as they believe that this should be done early, no after the 12th week.

Without an institutional provider, when women begin to search for information, their sources are primarily friends and internet sites selling misoprostol. It is fundamentally the result of the transmission of an accumulated knowledge in the sociability between peers on the use of the medical method. Most of the women already knew other women who had done a medical abortion, either friends or colleagues. One of them reports: My best friend had had an abortion, and she was the first person I went to. I said, “She’s going to help me, she’s got some information.” She gave me the data, and got it from a feminist collective in my College. She gave me the number of a person, she made the contact and I called her and bought (E11).

On the Internet there is in the same space, in a contradictory way, the knowledge destined to manage the medical method. Unknown women communicate their own experience, fundamentally motivated to warn others about various risks. In the same situation, they find manuals and instructions that circulate around the medical method that indicate to evaluate the conditions of the pregnancy by means of an ultrasound, especially the time, since they define a limit moment for its application.

It also happens that, in the consultation situation, the doctors indicate the ultrasonography, which in Chile is facilitated because the state norms of pre-natal attention contemplate a late first trimester ultrasonography, between 11-13+6 weeks (Chile, 2015CHILE. Ministerio de Salud. Guía perinatal 2015. Santiago, 2015. Disponível em: <Disponível em: https://bit.ly/3jxvlab >. Acesso em: 2 dez. 2018.
https://bit.ly/3jxvlab... ).

The above is very well described by one of the women:

Who do they consult? Once the pregnancy has been determined by means of a self-applied test, the vast majority of patients consult a doctor (not a midwife or intermediate staff). Within its management route, it was planned to do an ultrasound, then the medical consultation is a means to obtain an examination order. In this sense, they choose to do it. It is a pre-abortion consultation, since they do it having already made the decision to interrupt the pregnancy.

To perform the ultrasound, they go to an unknown or an appointed doctor, and exceptionally to their usual doctor. If they consult an unknown person with plans not to return after the abortion, they do not inform the doctor about the decision and do not ask for him/her collaboration. One of them explains her choice: I made the decision not to go to my doctor, to anyone I know. I made it thinking that, if I was going to have an abortion, I wanted there was no trace of my actions anywhere (E23).

This has its rationality. Not consulting their acquaintance gynecologist is part of a strategy that separates regular medical relationship from the abortion event. The professionals are not seen as a resource for guidance, nor do they want them to know about the existence of the pregnancy so that they do not suspect the decision to abort. There is no prior conversation that allows them to know the policy guidelines of their doctors.

When some women consult an appointed doctor, there is a mediation of a friend. They do this to receive instructions about the procedure, because in a context of illegality it is only possible to act if there is an indication; if they do not do this, they risk not obtaining collaboration and being denounced.

Before the ultrasound is done, the decision to abort has already been discussed and made, which happens early after knowing about the pregnancy.

There are two reasons for consultation. On the one hand, regarding the certainty of the pregnancy, it is requested to determine its state, in particular, the time of gestation. On the other hand, more exceptionally, under the suspicion of being pregnant, the urine test is reported, a doubt is communicated and a request is made to confirm and determine the state and time of the pregnancy.

Rejection of abortion in the ultrasound examination situation

The women interviewed do not communicate to the sonographer their decision to abort. They do the ultrasound without communicating their decision in a logic of security for a clandestine practice, not to avoid being dissuaded, but because communicating it carries the risk of denouncement. But it is also a practice whose legitimacy is not generalized, and not knowing the professional, communicating the decision would entail the risk of exposing themselves to moral censure.

The professionals also do not ask about its origin, if it has been planned or not, nor about the destiny of the pregnancy, if it will be continued or not. Since abortion is illegal, the professional question, in theory, would involve the communication of a crime that will occur after that consultation.⁵5The Code of Criminal Procedure (art. 175) makes it mandatory to report crimes that come to the attention of a wide range of professions, functions and agents of the State in the exercise of their functions (Chile, 2000).

The professional would work considering that the situation may involve many different decisions, but he does not, acting as if all women planned to go ahead with the pregnancy. Beyond the illegality that leaves out the woman’s information and the professional’s question, abortion is not only silenced in communication, it is ignored, excluded, left out in the examination situation, and it happens through a particular discursive practice of the professionals.

Encouragement to see and know

In the situation of ultrasound consultation there is an incitement on the woman to see and know about the fetus. The display is integrated into the practice setting - spatial arrangement of devices (screens) -, as well as for the socio-technical script of the professionals and for their discursive practice.

The narrative of one of the women reveals a framework that contains her participation at the beginning of this setting, as part of - in the terms of Madeleine Akrich (1997AKRICH, M. The de-scription of technical objects. In: WIEBE, E. B.; LAW, J. (Ed.). Shaping technology, building society: studies in sociotechnical change. Cambridge: The MIT Press, 1997. p. 205-224.) - a rigid socio-technical “script.” Before lying down on the litter, the patient instructed the professional not to make her see the image or hear the heartbeat, however, she was in the position of a spectator and the professional in that of a descriptor-interpreter in front of the visualization of the images.

Inside this ambient, the position of each one in the interaction is defined. The woman is put in the place of a spectator who observes some early images, who can only know about the fetus through her interaction with the professional, and the latter in the place of someone who describes and interprets these images. The professional acquires a strategic place in the interaction by making intelligible images that a lay observer does not understand.

Another woman, who is accompanied by her partner, in the examination situation turns her face, just like him, trying to avoid the screen. The professional would have noticed that they were not disposed to be spectators, but he continued to act in the same way. She says:

In both cases (E20 and E23), the women failed in their desire not to see, because having given signs of not wanting to participate - in the first case by making it explicit and in the second by running away - the professionals persisted. So, is a woman’s request not to participate/see admissible from a professional perspective? This dispensable provision transgresses the practitioner’s expectations of what the experience should be for a pregnant woman, and - as Beynon-Jones (2015)BEYNON-JONES, S. M. Re-visioning ultrasound through women’s accounts of pre-abortion care in England. Gender & Society, Thousand Oaks, v. 29, n. 5, p. 694-715, 2015. states - destabilizes the dominant representation of the ultrasound examination by refusing to participate.

Childhood dramatization

Women experience the ultrasound examination in the midst of a discursive practice that rejects abortion as a possibility and a socio-technical script that considers the active participation of women.

In the examination situation, the professional maximizes the similarity between the fetus and a newborn. Shapes his forms when describing it. This, in spite of not always being possible the existence of an anthropomorphic image (between the fourth and eighth weeks, it does not measure two centimeters and its form is more similar to the representation of a sack or an egg). One of women says: He spoke to me as if it were not an embryo. It was a baby for him, really a baby. And scientifically it was an embryo (E4).

Professionals produce in the visualization a separation of the fetus and the woman’s body. Then, as Petchesky (1987PETCHESKY, R. Fetal images: the power of visual culture in the politics of reproduction. Feminist Studies, Ann Arbor, v. 13, n. 2, p. 263-292, 1987.) says, the first becomes an autonomous individual suspended in space, without the woman’s body, her uterus and the umbilical cord to support him. The fetus is simultaneously objectified and personified as an autonomous individual.

There is a disconnection between seeing and discovering, and a tension between discovering and defining in this construction of knowledge. As a professor who apparently describes something, the doctor makes the woman “discover,” but what he is doing is an operation of definition: the mutation of the fetus in the newborn. He said: “Hi, let’s see and hear the baby. There’s his heart. Do you see his parts?” I couldn’t see anything. It was just because the pregnancy was still very recent, but he insisted that it was very clear (E22).

Images, words and emotions

The professional uses the terms embryo and fetus for “baby.” He defines a language appropriate to the images: he even uses the terms “baby,” “little seed” and “champion.” In the ultrasound image he makes a “child” visible (Hopkins; Zeedyk; Raitt, 2005HOPKINS, N.; ZEEDYK, S.; RAITT, F. Visualising abortion: emotion discourse and fetal imagery in a contemporary abortion debate. Social Science & Medicine, Amsterdam, v. 61, n. 2, p. 393-403, 2005.). Puts an emotion into words: links the term “baby” with “son,” and projects a mother-fetus emotional bond. Where there is a fetus, builds a mother. But, in fact, while natural, it is represented as something to build. He models the emotions himself. He instructs the woman on how she “should feel’” and then instigates the emotional work required to provoke the natural emotions. Says one woman: There was the little egg, and he said to me: “Look, there’s your little kid.” “What happiness!”. I saw the screen and heard the heart. He was acting like I was super happy. He said, “Congratulations!” That’s what he wanted to transmit to me (E14). Even though a figure cannot be visualized, the professional puts an emotion:

The practice of physicians is a discursive practice that links language and emotions to ultrasound images, which are integrated into the production of an emotional discourse around the fetus (Hopkins; Zeedyk; Raitt, 2005HOPKINS, N.; ZEEDYK, S.; RAITT, F. Visualising abortion: emotion discourse and fetal imagery in a contemporary abortion debate. Social Science & Medicine, Amsterdam, v. 61, n. 2, p. 393-403, 2005.). Images, language and emotions are integral to the construction of a dominant representation that is in the discursive practices of the professionals and models a feminine repertoire of the pregnant woman. So the images, emotions, and languages around ultrasound have a strategic place in the denaturalization of abortion.

This is important, because in general emotions are an integral part of the constitution of moral categories and of the process through which some options are discussed in depth in their context of meaning and in a context of censorship. A moralizing discourse contains “rules of feeling,” which instruct individuals on how they should feel, and then instigate the “emotional work” required to provoke the right emotion (Lee; Ungar, 1989, cited by Hopkins; Zeedyk; Raitt, 2005HOPKINS, N.; ZEEDYK, S.; RAITT, F. Visualising abortion: emotion discourse and fetal imagery in a contemporary abortion debate. Social Science & Medicine, Amsterdam, v. 61, n. 2, p. 393-403, 2005.). In particular, the legitimacy of emotion frames abortion and its decision as a moral issue in which only the continuity of the pregnancy is a sustainable position.

Resistance to seeing

Against the backdrop of a discursive practice that excludes abortion as a possibility and a legal prohibition that exposes women to police denunciation, the women believed that they would not experience the visualization in a way compatible with the decision to interrupt the pregnancy. The women avoided the visualization. Without verbalizing it, they physically refuse to participate in the visualization. They avoid the look, they are silent, they do not respond to their interlocutor. They reject the experience of being “pushed” to the visualization and the union with the fetus, but they do not have the possibility of refusing.

They reverse the dominant link - according to which seeing the image raises a personification of the fetus and a maternal emotional bond -, based precisely on the decision to interrupt the pregnancy. Conversely, it would not be proper for a pregnancy that they would not want to look or hear, call the fetus “baby” or “child,” or feel an emotional connection. It is to the decision to continue a pregnancy that they link the desire to explore the images, to unite emotionally and to use a language that personalizes the fetus.

Thus, in the situation of examination, believing that seeing and hearing is incompatible with their decision, the women are impelled to look and listen, and, forced by the rule of feeling, they perceive the embryo for the first time.

At the moment they do the ultrasound they still do not perceive the embryo or fetus inside their own body through the interoceptive sense; there is no movement, sound or pressure to be perceived. Reports about the process of abortion show that they did the ultrasound at the beginning of the embryonic period: this is at the beginning or middle of the organogenesis; in the formation of rudimentary organs (without defined shape or size). The image is more similar to an egg than to a human figure. Some of the women are in the period when the heartbeat can be heard. The heartbeat, another sign of life, can be heard in the ultrasound examination - through a Doppler that amplifies the sound - as it begins to form in the 5th week of pregnancy, the beats are listened in the ultrasound from the 6th week.

In this situation, those who resist looking, and in doing so may not “see” a human being, however, hearing the heartbeat confronts them with the life-generating process in which their bodies find themselves. One of them relates the experience of hearing:

The fetal heartbeat is for them a perceptive experience different from the fetal image, if a human figure is not revealed, a sign of life emerges. The embryo does not mutate into person, but as a sign of life; they watch that “there is life here” (Siegel, 2009SIEGEL, R. Introduction: the constitutional law and politics of reproductive rights. The Yale Law Journal, New Haven, v. 118, p. 1312-1317, 2009.), however they introduce a distinction between gestation of life and gestation of a child. One of the stories shows this distinction: (The sonographer says): “Hi, let’s listen to the baby. There’s his heart. How beautiful, here is the champion!” I saw the screen, I heard the heart. And I started crying when I heard the heart. It wasn’t a cry of “my son is alive,” but of “I created a being.” It was crying because I recognized myself as being able to give life (E22).

The experience can be resolved in a dramatic way. The fetus becomes an “intruder” who has “invaded” the woman’s body, turns into a separate and strange presence inside woman’s body. In her body a battle is fought. The situation is experienced as a struggle between her and an opponent who will not be allowed to continue using that body, and the act of aborting is experienced as a matter of self-defense. One of them reports:

This happens in the consultation setting in an interaction mediated by the professional, and in a discursive practice that also puts the fetus as an opponent. The experience becomes doubly oppressive. One of them says:

Women experienced the imposition of seeing and hearing the fetus, of listening and doing as indicated by the professional, as a violence that is normative, a form of punishment. From the perspective of the woman, in his voice the conservative order is heard, which produces a universalization of the categorization of the fetus as a person, makes an essentialization of the maternal-fetal bond and then denatures abortion. It is a clandestine situation, in which they believe that the intention to abort cannot be communicated, nor they can respond to the dominant discourses, criticize them. One of them tells: I went to do an ultrasound and it was not good. “Hey, take your DVD, you’re going to see your little baby.” “I do not need it.” “Anyway, take it. It’s yours.” He took the report and added it. “Just take it.” it was hard not being able to refuse. We were so unequal there: he imposed that on the exam and I did not have the right to abort in this country. In fact it was what was happening (E7).

Discussion

Our findings show the importance of studying the practices of the pre-abortion ultrasound examination in contexts of illegality. The illegality and social delegitimization of the practice of abortion condition in a particular manner the ways in which the discursive practices of professional sonographers are presented, as well as the interpretive repertoires of women in the face of the examination situation, restricting the possibilities of both to univocal and generalized positions.

In the first place, it is found that the discursive practices of professionals and the repertoires available to women occur on a double rejection of abortion: the silencing of women and the naturalization of the continuity of pregnancy by professionals.

In this study, none of the actors - neither the women nor the professionals - speak directly about motherhood, being a mother or about the body being generated; it is done by means of the embryo/fetus. They also don’t talk about the continuity - they do not simulate it - or about the interruption of pregnancy. The abortion, at the same time that it is hidden by women, it is not considered as a possibility by professionals, without ever being named. It happens, as we have shown, through the discursive practice of professionals.

Secondly, the women interviewed refused the encouraging to participate in the visualization of the fetus, they were focused on “resist and navigate” (Akrich, 1997AKRICH, M. The de-scription of technical objects. In: WIEBE, E. B.; LAW, J. (Ed.). Shaping technology, building society: studies in sociotechnical change. Cambridge: The MIT Press, 1997. p. 205-224.). They make an inversion of the dominant link, according to which seeing the image raises a personification of the fetus, a maternal emotional bond and the continuity of the pregnancy, precisely from the decision to interrupt it. By rejecting the act of looking as inappropriate when they decided to abort, women show that they are not open to the ultrasound experience or to the personalization and maternal-fetal bond, as Beynon-Jones has also found (²⁰¹⁵BEYNON-JONES, S. M. Re-visioning ultrasound through women’s accounts of pre-abortion care in England. Gender & Society, Thousand Oaks, v. 29, n. 5, p. 694-715, 2015.). However, refusing the visualization constitutes a repertoire available to these women that shares with the discursive practices of the professionals the cultural representations that both have about the ultrasound examination. But while professionals naturalize and generalize the woman’s experience in the face of fetal images, they consider the experience of seeing the fetus as corresponding to a pregnancy that will continue. Thus, normative representations of technology are reified as a maternal-fetal bonding tool and visualization in the context of abortion is defined as inappropriate.

The notion of emotional discourse (Edwards, 1990), which has been used in the analysis of ultrasonography in public debates, is useful to understand an emotional element that unites personalization and the maternal-fetal bond present in the discursive practices professionals. It is not just about the properties of the images themselves, but about the production of particular meanings: the personification of the fetus as corresponding to an empirical reality is “attested” by an emotional experience. By this operation, the proof of material existence of a person is constructed.

Its verisimilitude is based, on the one hand, on the idea that it makes a description of an empirical, true, neutral reality, instead of non-universal, interested constructions, and, on the other hand, that it interprets some emotions as unmediated, pre-reflective and genuine, instead of non-universal, interested and deliberate constructions.

If women do not produce the dominant link between images, languages and emotions, they also do not produce an alternative - mobilizing other emotions, other languages - that would allow them to experience ultrasound in a manner compatible with the decision to terminate the pregnancy. Not watching transgresses normative expectations about what a woman should experience, but the opposite - the search for visual encounters with the fetus - also transgresses them.

Then, the question arises, leading us to a third point. Which repertoire or repertoires are available when the pregnancy will not continue, with those discursive practices and with that normative socio-technical script of ultrasound, when the “right not to see” is denied (Lamm, 2012LAMM, E. La imposición legal de una ecografía como requisito del consentimiento informado de la mujer en materia de aborto: otra restricción al aborto; otra violación a los derechos de las mujeres. Buenos Aires: Abeledo Perrot, 2012. ), when abortion is illegal? Could women, but not in this study, subvert dominant expectations and generate alternative representations of ultrasound (Beynon-Jones, 2015BEYNON-JONES, S. M. Re-visioning ultrasound through women’s accounts of pre-abortion care in England. Gender & Society, Thousand Oaks, v. 29, n. 5, p. 694-715, 2015.; Palmer, 2009PALMER, J. Seeing and knowing: ultrasound images in the contemporary abortion debate. Feminist Theory, Thousand Oaks, v. 10, n. 2, p. 173-189, 2009. ; Roberts, 2012ROBERTS, J. The visualised foetus: a cultural and political analysis of ultrasound imagery. Farnham: Ashgate, 2012.), that destabilize such representations (Bamigboye et al., 2002BAMIGBOYE, A. et al. Should women view the ultrasound image before first-trimester termination of pregnancy? South African Medical Journal, Bethesda, v. 92, n. 6, p. 430-432, 2002.; Wiebe; Adams, 2009WIEBE, E. R.; ADAMS, L. Women’s perceptions about seeing the ultrasound picture before an abortion. The European Journal of Contraception and Reproductive Health Care, Abingdon, v. 14, n. 2, p. 97-102, 2009.) and that are part of a positive experience that does not alter their decision about abortion (Graham; Ankrett; Killick, 2010GRAHAM, O.; ANKRETT, S.; KILLICK, S. R. Viewing ultrasound scan images prior to termination of pregnancy: choice for women or conflict for ultrasonographers? Journal of Obstetrics and Gynaecology, Abingdon, v. 30, n. 5, p. 484-488, 2010.; Kimport et al., 2013KIMPORT, K. et al. Patient viewing of the ultrasound image prior to abortion. Contraception , Amsterdam, v. 88, n. 5, p. 666-670, 2013.)? They would challenge the argument of pro-life activism that, if women requesting abortions looked at ultrasound images of their pregnancies, they would inevitably be discouraged from deciding to have the procedure (Hopkins; Zeedyk; Raitt, 2005HOPKINS, N.; ZEEDYK, S.; RAITT, F. Visualising abortion: emotion discourse and fetal imagery in a contemporary abortion debate. Social Science & Medicine, Amsterdam, v. 61, n. 2, p. 393-403, 2005.). However, in the face of a figurative and emotional discourse by professionals, which univocally expresses the use of ultrasound and attributes to it generalized meanings, the women also fail to articulate a broader repertoire of representations regarding the experience of visualizing the fetus as observed in contexts of legalized abortion, neither as a significant loss nor as an objective exploration of the body and/or of the fetus. The interpretative possibilities in the context of the illegality and social delegitimization of abortion are thus restricted to the meaning associated with the desire to see the fetus and the desire for motherhood.

Final remarks

Finally, a particular contribution we make is related to encouraging reflection on the uses of ultrasound in new legal scenarios. Especially in Chile and Latin America, where some women may have access to legal abortions in health institutions, particularly when it is permitted in cases of rape.

For example, in Chile, the law for abortion indicates it in case of rape. For this purpose, an ultrasound scan is used to establish gestational age.⁶6“In consideration of the time periods stipulated by law - in the case of women over 14 years old, it corresponds to 12 weeks; if she is under 14 years old, to 14 weeks - after the reception, it should be evaluated whether the gestational age allows the woman to access it. The assessment of gestational age will be done by obstetric ultrasound” (Chile, 2018). In this circumstance, the law operates, in the terms of Lamm (2012LAMM, E. La imposición legal de una ecografía como requisito del consentimiento informado de la mujer en materia de aborto: otra restricción al aborto; otra violación a los derechos de las mujeres. Buenos Aires: Abeledo Perrot, 2012. ), on the basis of the right to not see, “the woman will be consulted if she wants to see and hear the ultrasound, explaining to her that it is her right, but not her obligation” (Chile, 2018CHILE. Ministerio de Salud. Acompañamiento y atención integral a la mujer que se encuentra en alguna de las tres causales que regula la Ley 21.030. Santiago, 2018. (Norma Técnica Nacional). Disponível em: <Disponível em: https://bit.ly/3dXpaLa >. Acesso em: 2 dez. 2018.
https://bit.ly/3dXpaLa... , p. 83). Manipulation of the devices is even prescribed to ensure that women do not see or hear anything, and warns against the violence that can be imposed on women: “not becoming an element that violates her emotional state” (Chile, 2018CHILE. Ministerio de Salud. Acompañamiento y atención integral a la mujer que se encuentra en alguna de las tres causales que regula la Ley 21.030. Santiago, 2018. (Norma Técnica Nacional). Disponível em: <Disponível em: https://bit.ly/3dXpaLa >. Acesso em: 2 dez. 2018.
https://bit.ly/3dXpaLa... , p. 83). This rule is aimed at preventing it from operating as a “dissuasive tool” for doctors in the terms indicated by Lamm (2012)LAMM, E. La imposición legal de una ecografía como requisito del consentimiento informado de la mujer en materia de aborto: otra restricción al aborto; otra violación a los derechos de las mujeres. Buenos Aires: Abeledo Perrot, 2012. , whose purpose is to impose a subjectivity that is considered ambivalent in the decision-making process (Siegel, 2009SIEGEL, R. Introduction: the constitutional law and politics of reproductive rights. The Yale Law Journal, New Haven, v. 118, p. 1312-1317, 2009.).

In fact, in other societies ultrasound has become a resource for dissuasive strategies. In fact, in the U.S. there are states where an ultrasound is legally imposed as a requirement for the woman’s informed consent when requesting a pregnancy interruption, and in some cases the woman is required to participate in viewing the images, something that has been the subject of legal claims (Lamm, 2012LAMM, E. La imposición legal de una ecografía como requisito del consentimiento informado de la mujer en materia de aborto: otra restricción al aborto; otra violación a los derechos de las mujeres. Buenos Aires: Abeledo Perrot, 2012. ). The thesis of its implementation as a dissuasive strategy is reinforced by the fact that in states where it is required, women with clinical causes, victims of rape, or minors are not required to participate.

The design to which the Chilean law arrived contains a tension expressed in the parliamentary debate of discussion of the law. Opponents and some supporters of the bill raised suspicions about the abuse of abortion for rape claim: that if the existence of rape was not exhaustively proven, and the only woman’s statement was accepted as evidence, the system would be manipulated into providing an abortion. Although abortion is voluntary, the fact of having to evaluate the occurrence of rape - even if doctors conceptualize in practice that it is a woman’s reproductive decision - introduces a mediation, putting them in the position of deciding if the cause of the pregnancy alleged by the woman is true or not.

These women’s decisions will be made in a tension between clinical practice and public debate. Between the sonographer’s discursive practice and the “pro-life” campaign there is a continuity: that of establishing the fetus as a person using performative practices that seek to produce what they say it represents (Vacarezza, 2013VACAREZZA, N. Política de los afectos, tecnologías de visualización y usos del terror en los discursos contrarios a la legalización del aborto. In: ZURBRIGGEN, R.; ANZORENA, C. (Ed.). El aborto como derecho de las mujeres: otra historia es posible. Buenos Aires: Herramienta, 2013. p. 209-223.). The latter use fetal images from the construction of an emotional discourse that has as its background the emotional discourse prevalent in the clinic. It is extremely important that health professionals are able to understand and act considering the implications of their discourses, deconstructing and denaturalizing the hegemonic views that have been imposed on women, including the role of technologies such as the one described for ultrasonography.

References

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