Exploring the availability and impact of antenatal point-of-care ultrasound services in rural and remote communities: A scoping review

The urgent need to extend the appropriate use of ultrasound in Africa and worldwide. Overview, experiences and perspectives

It is known that in African countries the health condition is problematic, both from a diagnostic and therapeutic point of view. Patients have to travel long distances to access medical care. Many cannot afford the cost of transportation to a medical facility. Ultrasound its into the scenario of healthcare imaging with limited resources, as an effective, economical, repeatable diagnostic tool, requiring low maintenance. Ultrasound tools in fact are relatively cheap and machines are easy to move, making them adapt to be taken to a rural setting where they are most needed. However ultrasound exams are not easy to perform and they need an adequate training. The spread of POCUS (point-of-care "focused" ultrasound) worldwide could be useful in Africa to identify high-risk patients. These cases selected in rural setting by POCUS can be referred to hospitals for further treatment. To deal with these situations it is necessary to form doctors and/or paramedical staff capable of guaranteeing a qualitatively adequate service. Therefore the need for basic training is greater in developing countries. Sharing successful educational strategies should advance the integration of ultrasound into the university medical school curricula. This will ensure that recently qualified doctors can practice their basic skills accurately and independently.

Antenatal ultrasound needs-analysis survey of Australian rural/remote healthcare clinicians: recommendations for improved service quality and access

BACKGROUND

Ultrasound is the primary diagnostic tool in pregnancy, capable of identifying high-risk pregnancies and life-threatening conditions, allowing for appropriate management to prevent maternal and fetal morbidity and mortality. Women and babies from rural and remote Australia and low-resource areas worldwide experience poorer health outcomes and barriers to accessing antenatal care and imaging services. Healthcare clinicians working in these regions face significant challenges practising with limited resources and accessing training opportunities.

OBJECTIVE

To perform an exploratory needs-analysis survey investigating the availability, accessibility and use of antenatal ultrasound in rural Australia, exploring rural clinicians' interest in and access to ultrasound training opportunities.

METHODS

The survey tool for this cross-sectional study was designed and distributed as an anonymous online questionnaire targeting healthcare clinicians (doctors, nurses, midwives, clinic managers, Aboriginal healthcare workers) providing antenatal care in rural regions. Descriptive analysis was applied to quantitative data and thematic analysis was used to explore qualitative components.

RESULTS

A total of 114 valid survey responses were analysed. Overall, 39% (43/111) reported ultrasound was not used when providing antenatal care to patients at their clinic, stating 'Lack of ultrasound equipment (73%,29/40) and inaccessibility of training opportunities (47%,19/40) as the main reasons. For those with ultrasound (61%,68/111), estimating due date (89%,57/64) was the main use, and limited training/skills to operate the equipment (59%,38/64) and inaccessibility/distance of training opportunities (45%,29/64) were the most commonly reported barriers. Clinicians described a lack of childcare options (73%,74/102), long distances to reach ultrasound services (64%,65/102), appointment (59%,60/102) and transport availability/times (46%,47/102) as the main obstacles to patient access. Increased attendance, compliance with care directives, parental bonding and improved lifestyle choices were described by respondents as positive outcomes of antenatal ultrasound use.

CONCLUSIONS

Future efforts to combat inequitable service access must adopt a coordinated approach to meet the needs of pregnant women in low-resource settings. Providing portable ultrasound equipment, training in antenatal Point-of-Care ultrasound (PoCUS) with ongoing support/mentoring and accreditation of health professionals could strengthen rural workforce capacity. This, along with addressing the complex economic, environmental and socio-cultural barriers faced by patients, could improve service access and pregnancy outcomes in rural and remote communities.

Emergency Point-of-Care Ultrasound Stewardship - A Joint Position Paper by EuSEM and EFSUMB and Endorsed by IFEM and WFUMB

Emergency Medicine Point-of-Care Ultrasound (EMPoCUS) is a convincing concept. It has spread rapidly because of its intuitive, simple applicability and low equipment costs. The speed of its emerging growth frequently outpaces the development of quality assurance and education. Indeed, education standards vary worldwide, and in some cases seem to neglect the principles of modern competence-based education. Additional challenges are encountered such as remote or low resource medical practice. Here, EMPoCUS might be the only ad-hoc imaging modality available. Once mastery of EMPoCUS is achieved, emergency physicians should be able to independently and efficiently care for their patients using a variety of PoCUS skills. However, most curricula only define these tasks as non-binding and in general terms or use outdated measures, such as length of training and self-reporting of achieved examinations with variable oversight, or administrative measures to create educational milestones. This threatens to take quality assurance down the wrong path. It created a scenario in which concrete EMPoCUS skill outcome measures that would realistically reflect the training objectives and simultaneously would be easily observable and verifiable are lacking. In view of the dangers of poorly controlled EMPoCUS dissemination and the current lack of European guidelines, we would like to set central standards for European EMPoCUS stewardship based on a critical review of the current situation. This position paper, which was jointly developed by EuSEM and EFSUMB and endorsed by IFEM and WFUMB, is also intended to accompany the EFSUMB/EuSEM guidelines on PoCUS currently being prepared for publication.

Point-of-Care Ultrasound Educational Development in Australasia: A Scoping Review

Point-of-care ultrasound (PoCUS) technology is evolving rapidly and is being adopted by many health professionals in their clinical practice. Ultrasound is a complex skill requiring dedicated training. Appropriate integration of ultrasound education into medical, surgical, nursing and allied health professions is a current challenge worldwide. There are patient safety implications for use of ultrasound without adequate training and frameworks. The purpose of the review was to overview the status of PoCUS education in Australasia; investigate what is being taught and learned about ultrasound across the health professions; and identify potential gaps. The review was limited to postgraduate and qualified health professionals with established or emerging clinical use for PoCUS. A scoping review methodology was used to include literature in peer-reviewed articles, policies, guidelines, position statements, curricula and online material relating to ultrasound education. One hundred thirty-six documents were included. The literature revealed heterogeneity in ultrasound teaching and learning across the health professions. Several health professions lacked any defined scopes of practice, policies or curricula. Significant investment in resourcing ultrasound education is required to address the current needs in Australia and New Zealand.

Institutionalization of limited obstetric ultrasound leading to increased antenatal, skilled delivery, and postnatal service utilization in three regions of Ethiopia: A pre-post study

BACKGROUND

A minimum of one ultrasound scan is recommended for all pregnant women before the 24th week of gestation. In Ethiopia, there is a shortage of skilled manpower to provide these services. Currently, trained mid-level providers are providing the services at the primary healthcare level. The aims of this study were to compare antenatal care 1 (ANC1), antenatal care 4 (ANC4), skilled birth attendance (SBA), and postnatal care (PNC) service utilization before and after institutionalizing Vscan limited obstetric ultrasounds at semi-urban health centers in Ethiopia.

METHODS

A pre and post intervention observational study was conducted to investigate maternal and neonatal health service utilization rates before and after institutionalizing Vscan limited obstetric ultrasound services, between July 2016 and June 2020. The data were extracted from 1st August- 31st December 2020.

RESULTS

The observed monthly increase on the mean rank of first ANC visits after the introduction of Vscan limited obstetric ultrasound services showed a statistically significant difference at KW-ANOVA H (3) = 17.09, P = 0.001. The mean rank of fourth ANC utilization showed a statistically significant difference at KW- ANOVA H (3) = 16.24, P = 0.001. The observed mean rank in skilled birth attendance (SBA) showed a statistically significant positive difference using KW-ANOVA H (3) = 23.6, P<0.001. The mean rank of increased utilization in postnatal care showed a statistically significant difference using KW-ANOVA H (3) = 17.79, P<0.001.

CONCLUSION

The introduction of limited obstetric ultrasound services by trained mid-level providers at the primary healthcare level was found to have improved the utilization of ANC, SBA, and postnatal care (PNC) services. It is recommended that the institutionalization of limited obstetric ultrasound services be scaled up and a further comparative study between facilities with and without ultrasound services be conducted to confirm causality and assess effects on maternal and perinatal outcomes.

Point of care obstetric ultrasound knowledge retention among mid-wives following a training program: a prospective cohort pilot study

BACKGROUND

Obstetric ultrasound has become a routine part of antenatal care in many parts of the world including low income settings. However, there is a shortage of radiologists and sonographers to perform routine obstetric scans in many areas especially in the rural settings of low income countries, despite having equipment available to do this. As a result, Point of care ultrasound (POCUS) has been suggested to bridge this gap by training other health workers such as midwives to perform basic obstetric ultrasound as part of their clinical care.

METHODS

It was a prospective cohort pilot study in which trained midwives in point of care obstetric ultrasound were followed up at 6 months post training to assess their knowledge retention. Eleven trained midwives were purposively selected and followed up for knowledge retention. These were trained for 6 weeks and were given a knowledge assessment immediately after training, then given an assessment at 6 months following training. Data was analyzed using SPSS. Wilcoxon signed rank test was used to compare assessments and perceived knowledge as well as Spearman correlation to test the relationship between the number of scans performed and exam assessments, knowledge and exam assessments, and number of scans and knowledge.

RESULTS

There were eleven midwives, all female with an average age of 42.3 years. The mean exam score (out of 50) was 44.2 at the end of the training and 42.9 at 6-months follow up. The midwives demonstrated higher perceived knowledge at the end of the training when compared to the 6-months follow up. However, this perceived higher knowledge was not statistically significant when correlated with the exam scores either at the end of the training or at the follow up of 6 months.

CONCLUSION

This pilot study has demonstrated that training midwives in point of care obstetric ultrasound can result into acceptable levels of knowledge retention that assist the midwives to apply this knowledge when making routine clinical decisions in relation to pregnant women.

Evaluation of antenatal point-of-care ultrasound training workshops for rural/remote healthcare clinicians: a prospective single cohort study

BACKGROUND

There is limited access to life-saving antenatal ultrasound in low-resource rural and remote settings worldwide, including Australia, mainly due to shortages in skilled staff. Point-of-care ultrasound (PoCUS) offers a viable solution to this service deficit, however, rural clinicians face many barriers accessing training and professional development critical to advancing their clinical practice. Standards for PoCUS training and competency assessment are unclear. Regulation is lacking globally, allowing untrained and inexperienced clinicians to practice PoCUS clinically.

METHODS

This prospective single cohort study aimed to evaluate antenatal PoCUS training workshops for General Practitioners (GPs) and Midwives/Nurses (M/Ns) from rural/remote Australia, assessing the impact of the training on trainees' knowledge, confidence and translation of PoCUS into clinical practice. Two-day antenatal ultrasound workshops were delivered at the University of South Australia (UniSA) in 2018 and 2019 to 41 rural/remote clinicians . The training was designed and evaluated using the New world Kirkpatrick Evaluation Framework. Sixteen GPs and 25 M/Ns with mixed prior ultrasound experience were funded to attend. The course consisted of lectures interspaced with hands-on training sessions using high-fidelity simulators and live pregnant models. Pre- and post-knowledge assessments were performed. Post-workshop evaluation and follow-up surveys (3- and 6-month post-training) assessed the workshops and changes to trainees' clinical practice. A 2-day follow-up training session was conducted 12 months after the workshops for 9 trainees.

RESULTS

Pre/post knowledge testing demonstrated a 22% mean score improvement (95% CI 17.1 to 27.8, P < 0.0001). At 6 months, 62% of trainees were performing PoCUS that had assisted in patient management and clinical diagnosis, and 46% reported earlier diagnosis and changes to patient management. 74% of trainees had increased scanning frequency and 93% reported improved scanning confidence.

CONCLUSION

This study demonstrated intensive 2-day workshops can equip clinicians with valuable antenatal PoCUS skills, offering a viable solution to assist in the assessment and management of pregnant women in the rural/resource-poor setting where access to ultrasound services is limited or non-existent. Geographical isolation and lack of onsite specialist supervision poses an ongoing challenge to the continuing professional development of remote trainees and the implementation of PoCUS.

Point-of-care ultrasound: An emerging clinical tool to enhance physical assessment

ABSTRACT

Point-of-care ultrasound (PoCUS) is a cost-effective diagnostic technology that, with training, is accessible, portable, and a convenient diagnostic modality to complement physical assessments. PoCUS is beneficial in that it can reduce the number of imaging tests required, while also mitigating barriers to healthcare for rural and remote communities.

Implementation and evaluation of a pilot antenatal ultrasound imaging programme using tele-ultrasound in Ethiopia

INTRODUCTION

Ultrasound imaging is an important aspect of antenatal care, though access to antenatal ultrasound imaging is limited in many developing countries. The objective of this study was to evaluate a pilot programme which aimed to improve access to antenatal ultrasound for rural Ethiopians through enhanced training of healthcare providers (including midwives, nurses and clinical officers) with support remotely provided by obstetricians using a tele-ultrasound platform.

METHODS

Thirteen healthcare providers in the North Shoa Zone in Ethiopia completed training to enable them to perform antenatal ultrasound with the remote supervision of an obstetrician via a tele-ultrasound platform. Pregnant women attending an antenatal appointment at two facilities were offered an antenatal ultrasound exam performed by one of the healthcare providers. Image interpretations between obstetricians and healthcare providers were compared. Participants and healthcare providers were invited to complete a questionnaire regarding their experience with tele-ultrasound, and participants, healthcare providers and obstetricians were interviewed regarding their experience with the tele-ultrasound pilot programme.

RESULTS

2795 pregnant women had an antenatal ultrasound exam. Of 100 exams randomly selected to assess concordance between healthcare providers' and obstetricians' image interpretations, concordance ranged from 79% to 100% for each parameter assessed. 99.4% of participants surveyed indicated that they would recommend antenatal ultrasound using tele-ultrasound to friends and family. Themes relating to participants' experiences of having a tele-ultrasound exam were reduced travel and cost, equivalence in quality of virtual care to in-person care and empowerment through diagnostic information.

CONCLUSION

Healthcare provider-performed antenatal ultrasound - supported by obstetricians via tele-ultrasound - showed high levels of concordance, was well-received by participants and provided rural Ethiopian women with enhanced access to antenatal imaging.

Analysis of Rural Disparities in Ultrasound Access

Purpose

This work aims to conduct a geospatial analysis of recent ultrasound access and usage within the United States, with a particular focus on disparities between rural and urban areas.

Methods/Materials

Multiple public datasets were merged on a county level, including US Department of Agriculture economic metrics and Centers for Medicare Services data using the most recent years available (2015-2019). From these databases, 39 total variables encompassing the socioeconomic, health, and ultrasound characteristics of each county were obtained. Current Procedural Terminology (CPT) codes incorporated included ultrasound-guided procedures and diagnostic exams. Three thousand eleven counties were included. The combined dataset was then exported to GeoDa for network-based analysis and to produce map visualizations. To identify statistically significant (p < 0.05) hotspots and coldspots in point-of-care ultrasound (POCUS) prevalence, Moran’s I was used. Choropleth maps were created for visualization. ANOVA was run across the four Moran’s I groups for each of 39 variables of interest.

Results

A total of 30,135,085 ultrasound-related CPT codes were billed to Medicare over 2015-2019, with 26.55% of codes being ultrasound-guided procedures and 73.45% being diagnostic exams. 38.84% of rural counties had access to POC ultrasound compared to 88.56% of metropolitan counties and 74.19% of counties overall. Hotspots of POCUS were in Southern California and the Eastern US (average of 1,441 per 10,000 Medicare members per year). Coldspot areas were seen in the Great Plains and Midwest (average of 7.43 per 10k Medicare members per year). Hotspot clusters, when compared to coldspot clusters, were significantly (p < 0.001) more dense (703.6 to 14.9 people per square mile), more urbanized (3.5 to 7.1 Rural-Urban Continuum (RUC)), more college-educated (25.1% to 20.0%), more likely to have an Emergency Department (ED) visit (725.8 to 616.9 visits per 1,000 Medicare members), more likely to be obese (19.0% to 12.9%), less likely to be uninsured (10.1% to 13.0%), had more Black representation (8.5% to 3.4%), and less Hispanic representation (2.6% to 5.5%).

Conclusions

Ultrasound access and usage demonstrate significant geospatial trends across the United States. Hotspot and coldspot counties differ on several key sociodemographic and economic variables.

Health Pregnancy, Healthy Baby: testing the added benefits of pregnancy ultrasound scan for child development in a randomised control trial

BACKGROUND

The 2016 World Health Organization Antenatal Guidelines and the 2015 South African Maternal and Child Health Guidelines recommend one early antenatal ultrasound scan to establish gestational age and to detect multiple pregnancies and fetal abnormalities. Prior research indicates that ultrasound scan can also increase parental-fetal attachment. We aim to establish whether, compared to routine care, messages to promote parental attachment and healthy child development, conducted during one or two pregnancy ultrasound scans, improve early child development and growth, exclusive breastfeeding, parental-child interactions and prenatal and postnatal clinic attendance.

METHODS

The effect of messages to sensitise mothers and fathers to fetal development will be tested in a three-armed randomised trial with 100 mothers and their partners from Soweto, Johannesburg in each arm. The primary outcome is child development at 6 months postnatally. Secondary outcomes include infant feeding, parental attachment and interaction, parental mental health and infant growth, assessed at 6 weeks and 6 months. Parents in Arm 1 receive a fetal ultrasound scan < 25 weeks during routine antenatal care at tertiary hospitals, and a second standard ultrasound scan at the research site within 2 weeks. Arm 2 participants receive the routine antenatal ultrasound scan and an additional ultrasound scan < 25 weeks at the research site, together with messages to promote parental attachment and healthy child development. Arm 3 participants receive the routine ultrasound scan and two additional ultrasound scans at the research site, < 25 weeks and < 36 weeks, together with messages to promote parental attachment and healthy child development.

DISCUSSION

Evidence from high-income countries suggests that first-time prospective mothers and fathers enjoy seeing their fetus during ultrasound scan and that it is an emotional experience. A number of studies have found that ultrasound scan increases maternal attachment during pregnancy, a predictor of positive parent-infant interactions which, in turn, promotes healthy infant development. It is generally agreed that studies are needed which follow up parental-child behaviour and healthy child development postnatally, include fathers and examine the construct in a wider diversity of settings, especially in low and middle-income countries. Testing the added benefits of pregnancy ultrasound scan for child development is a gap that the proposed trial in South Africa seeks to address.

TRIAL REGISTRATION

Pan African Clinical Trials Registry, PACTR201808107241133. Registered on 15 August 2018.