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Weimer JM, Kuhn E, Ludwig M, Malle GL, Kapipi G, Schäfer VS, Sadiq A, Henke O. Effectiveness of an ultrasound basic cancer training program through on-site training and virtual case discussions in rural Tanzania: a proof-of-concept study. Ecancermedicalscience 2024; 18:1722. [PMID: 39026658 PMCID: PMC11257097 DOI: 10.3332/ecancer.2024.1722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Indexed: 07/20/2024] Open
Abstract
Introduction Cancer rates are rising in low- and middle-income countries. While point-of-care ultrasound is now available globally and could serve to mitigate against this rise, its use in diagnosing cancers is inconsistent in lower-resourced healthcare contexts. This proof-of-concept study investigates the feasibility of an ultrasound training concept in a low-resource setting. It evaluates whether this educational concept led to improved knowledge and application of ultrasound diagnostics, cancer screening and staging and patient care. Material and methods The curriculum was developed through expert exchange and is based on the World Health Organisation's Manual of Diagnostic Ultrasound. It consisted of two didactic components: an on-site training phase across 5 days for a total of 24 hours, and a digital follow-up phase involving the meeting of a bi-weekly tumor board online. The learning objectives of the on-site training were normal imaging and recognition of common pathologies of the abdominal organs, vessels, lymph nodes, female breasts and lungs. The virtual tumour boards met to discuss cases and ultrasound findings, thus aiding continuing professional development after the training sessions had concluded. The face-to-face course component was accompanied by tests given before and after training as well as an evaluation sheet (Likert-scale with 1 = 'completely/very good' and 7 'not at all/very poor'). Results Of 20 participants from a rural hospital in Tanzania, a total of 16 were included in the analysis (clinical officers n = 6; medical officers n = 10). A significant increase in knowledge (p < 0.01) was measured both in the subjective self-assessment and in the theoretical competence tests. In multivariate linear regression, the status 'medical officers yes' (β = 5.4; p = 0.04) had a significant influence on theory test results at T2. During the 24 virtual tumour board meetings, 28 cases were discussed and a continuous improvement in image acquisition quality was observed. Conclusion The ultrasound education concept comes with a sustainable increase in clinical competence and improved oncological ultrasound screening locally. There is potential for the transfer of the concept to other locations, which can be explored in the future.
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Affiliation(s)
- Johannes Matthias Weimer
- Rudolf -Frey Learning Clinic, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz 55131, Germany
| | - Eva Kuhn
- Section Global Health, Institute of Hygiene and Public Health, University Hospital Bonn, Bonn 53127, Germany
| | - Michael Ludwig
- Section Global Health, Institute of Hygiene and Public Health, University Hospital Bonn, Bonn 53127, Germany
- Department of Internal Medicine I, Hospital of the German Armed Forces, Berlin 10115, Germany
| | | | - Godfrid Kapipi
- Marangu Lutheran Hospital, PO Box 107, Marangu, Tanzania
| | - Valentin Sebastian Schäfer
- Department of Rheumatology and Clinical Immunology, Clinic of Internal Medicine III, University Hospital Bonn, Bonn, Germany
| | - Adnan Sadiq
- Kilimanjaro Christian Medical University College, Moshi 2240, Tanzania
| | - Oliver Henke
- Section Global Health, Institute of Hygiene and Public Health, University Hospital Bonn, Bonn 53127, Germany
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Tefera M, Mezmur H, Jemal M, Assefa N. Midwives' experiences of performing obstetric ultrasounds in antenatal care in eastern Ethiopia: Qualitative exploratory study. WOMEN'S HEALTH (LONDON, ENGLAND) 2024; 20:17455057241228135. [PMID: 38366806 PMCID: PMC10874160 DOI: 10.1177/17455057241228135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 12/12/2023] [Accepted: 01/04/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND In 2016, the World Health Organization recommended inclusion of an ultrasound scan as part of routine antenatal care to improve pregnancy outcomes. However, most rural women in Ethiopia do not have access to ultrasound scanning as part of their routine antenatal care. Recently, ultrasonography services were introduced at health centers in Harar, Kersa, and Haramaya districts in Eastern Ethiopia. This expoloratory study aimed to examine experiences of pregnancy surveillance midwives in the Child Health and Mortality Prevention Surveillance (CHAMPS) who performed ultrasonography at health centers that are in the catchment area of Health and Demographic Surveillance Systems, in Eastern Ethiopia. OBJECTIVE To explor midwives' experiences across 14 health centers in Eastern Ethiopia, located in the Kersa, Haramaya, and Harar Health and Demographic Surveillance Systems from February to April 2022. DESIGN Exploratory qualitative study. METHODS The methods used were based on the Standards for Reporting Qualitative Research framework. Purposeful sampling was used to explore experiences of midwives who performed ultrasonography at selected health centers. The Midwives are recurited, trained and stationed at the health ceners to do ultrasound scanning and other activities by the Child Helath and Mortality Prevention Surveillance (CHAMPS) pregancny surveillance activities. Among 17 midwives who had undergone ultrasonography training and who were actively involved in ultrasound scanning at health centers in Kersa, Haramaya, and Harar Health and Demographic Surveillance Systems, three midwives who worked at health centers with no power or near a hospital were excluded. Using tape recordings and note-taking, data were collected through in-depth interviews based on a semi-structured interview guide. Thematic analysis used for data categorization, and the trustworthiness of data was kept throughout the procedure using credibility, dependability, confirmability, and transferability. RESULTS In this study, we identified five main themes: Ultrasonography positively impacts midwives trained as sonographers; performing ultrasound scans enhances the skills and confidence of midwives, improving their professional development, Individual perception of self-efficacy; midwives' belief in their abilities to perform ultrasound scans effectively influences their job satisfaction and motivation, Provision of care; integrating ultrasound into antenatal care enhances the quality, therapeutic communication, and personalized nature of care provided to pregnant women, Barriers to providing ultrasonography services; challenges such as shortage of ultrasonography-trained staff and workload can hinder the delivery of ultrasound services in rural areas, Community acceptance; the level of community understanding, trust, and support towards ultrasound technology and midwives as sonographers impacts the successful implementation and sustainability of ultrasound services. CONCLUSION Ultrasonography performed by midwives at rural health centers had a considerable impact on antenatal care services and incareased confidence of midwives.
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Affiliation(s)
- Maleda Tefera
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Haymanot Mezmur
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Mohammed Jemal
- Child Health and Mortality Prevention Surveillance, College of Health and Medical Sciences Haramaya University, Harar, Ethiopia
| | - Nega Assefa
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
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Bergström C, Ngarina M, Abeid M, Kidanto H, Edvardsson K, Holmlund S, Small R, Sengoma JPS, Ntaganira J, Lan PT, Mogren I. Health professionals' experiences and views on obstetric ultrasound in Tanzania: A cross-sectional study. WOMEN'S HEALTH (LONDON, ENGLAND) 2024; 20:17455057241273675. [PMID: 39206633 PMCID: PMC11363060 DOI: 10.1177/17455057241273675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 06/25/2024] [Accepted: 07/04/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Obstetric ultrasound is considered important for determining gestational age, identifying single or multiple pregnancies, locating the placenta and fetal anomalies and monitoring fetal growth and pregnancy-related complications in order to improve patient management. OBJECTIVES To explore health professionals' perspectives on different aspects of obstetric ultrasound in Tanzania regarding self-reported skills in performing ultrasound examinations and what could improve access to and utilization of obstetric ultrasound in the clinical setting. DESIGN Cross-sectional study. MATERIAL AND METHODS Data was collected between November and December 2017 using a questionnaire based on previous qualitative research results from the CROss Country UltraSound Study (CROCUS Study). Seventeen healthcare facilities in 5 urban and semiurban municipalities in the Dar-es-Salaam region were included, with 636 health professionals participating (physicians, n = 307 and midwives/nurses, n = 329). RESULTS Most health professionals (82% physicians, 81% midwives/nurses) believed that obstetric ultrasound was decisive in the clinical management of pregnancy. Results indicate proficiency gaps across disciplines: 51% of physicians and 48.8% of midwives/nurses reported no or low-level skills in assessing cervical length. Similarly, deficiencies were observed in evaluating the four-chamber view of the fetal heart (physicians: 51%, midwives/nurses: 61%), aorta, pulmonary artery (physicians: 60.5%, midwives/nurses: 65%) and Doppler assessments (umbilical artery: physicians 60.6%, midwives/nurses 56.1%). Compared to midwives/nurses, physicians were significantly more likely to agree or strongly agree that utilization would improve with more ultrasound machines (odds ratio (OR) 2.13; 95% confidence intervals (CI) 1.26-3.61), better quality of ultrasound machines (OR 2.27; 95% CI 1.10-4.69), more training for health professionals currently performing ultrasound (OR 2.11; 95% CI 1.08-4.17) and more physicians trained in ultrasound (OR 2.51; 95% CI 1.30-4.87). CONCLUSIONS Improving the provision of obstetric ultrasound examinations in Tanzania requires more and better-quality ultrasound machines, enhanced training for health professionals and an increased number of physicians trained in ultrasound use. To further increase the accessibility and utilization of obstetric ultrasound in maternity care in Tanzania, it is essential to provide training for midwives in basic obstetric ultrasound techniques.
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Affiliation(s)
- Cecilia Bergström
- Department of Clinical Sciences, Obstetrics and Gynaecology, Umeå University, Umeå, Sweden
| | - Matilda Ngarina
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania
- Department of Obstetrics and Gynaecology, Muhimbili National Hospital, Dar-es-Salaam, Tanzania
| | - Muzdalifat Abeid
- Department of Obstetrics and Gyneacology, Aga Khan University, Dar-es-Salaam, Tanzania
| | - Hussein Kidanto
- Department of Obstetrics and Gyneacology, Aga Khan University, Dar-es-Salaam, Tanzania
| | - Kristina Edvardsson
- Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Melbourne, VIC, Australia
| | - Sophia Holmlund
- Department of Clinical Sciences, Obstetrics and Gynaecology, Umeå University, Umeå, Sweden
- Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Melbourne, VIC, Australia
- Department of Nursing, Umeå University, Umeå, Sweden
| | - Rhonda Small
- Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Melbourne, VIC, Australia
- Department of Women’s and Children’s and Reproductive Health, Karolinska Institutet, Stockholm, Sweden
| | | | - Joseph Ntaganira
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Pham Thi Lan
- Department of Dermatology and Venereology, Hanoi Medical University, Hanoi, Vietnam
| | - Ingrid Mogren
- Department of Clinical Sciences, Obstetrics and Gynaecology, Umeå University, Umeå, Sweden
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Kim C, Wagle K, Shrestha B, Bhatta S, Maharjan S, Dhakal L, Rizal R, Kristensen S. Perceptions of service providers, service recipients and female community health volunteers on a rural obstetric ultrasound program in rural Nepal: a qualitative study. BMC Pregnancy Childbirth 2023; 23:574. [PMID: 37563558 PMCID: PMC10413490 DOI: 10.1186/s12884-023-05876-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/26/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND In rural Nepal, where women face financial and geographic barriers in accessing ultrasound scans, the government initiated a Rural Obstetric Ultrasound Program (ROUSG) to train skilled birth attendants (SBAs) in rural birthing centers and expand access to routine ultrasound scans for local pregnant women. This study explores the perceived benefits and limitations of the training and implementation of this program. METHODS A qualitative study was conducted in 15 primary care facilities in Bhojpur and Dhading, two rural districts of Nepal. The research team conducted in-depth interviews with 15 trained SBAs and focus group discussions with 48 service recipients and 30 FCHVs to gain insight into their perceptions. All interviews and focus group discussions were recorded, reviewed, and manually coded into MS Excel. RESULTS Overall, our findings indicated that the ROUSG program was very well received among all our study participants, though critical gaps were identified, mostly during the training of the SBAs. These included insufficient guidance or practice opportunities during training and the challenges of implementing the mobile obstetric ultrasound service. Most importantly, though, our results suggest that the implementation of the ROUSG program increased access to prenatal care, earlier identification and referrals for abnormal scans, as well as reduced pregnancy-related stress. There was also a notable anecdotal increase in antenatal care utilization and institutional deliveries, as well as high satisfaction in both service providers and recipients. CONCLUSION Our findings highlighted that while the training component could use some strengthening with increased opportunities for supervised practice sessions and periodic refresher training after the initial 21-days, the program itself had the potential to fill crucial gaps in maternal and newborn care in rural Nepal, by expanding access not only to ROUSG services but also to other MNH services such as ANC and institutional deliveries. Our findings also support the use of ultrasound in areas with limited resources as a solution to identify potential complications at earlier stages of pregnancy and improve timely referrals, indicating the potential for reducing maternal and neonatal morbidities. This initial study supports further research into the role ROUSG can play in expanding critical MNH services in underserved areas and improving broader health outcomes through earlier identification of potential obstetric complications.
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Affiliation(s)
| | | | | | | | | | | | - Rajiv Rizal
- AMDA-Nepal, AMDA Hospital, Damak, Jhapa, Nepal
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Knights S, Prasad S, Kalafat E, Dadali A, Sizer P, Harlow F, Khalil A. Impact of point-of-care ultrasound and routine third trimester ultrasound on undiagnosed breech presentation and perinatal outcomes: An observational multicentre cohort study. PLoS Med 2023; 20:e1004192. [PMID: 37023211 PMCID: PMC10079042 DOI: 10.1371/journal.pmed.1004192] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 02/07/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND Accurate knowledge of fetal presentation at term is vital for optimal antenatal and intrapartum care. The primary objective was to compare the impact of routine third trimester ultrasound or point-of-care ultrasound (POCUS) with standard antenatal care, on the incidence of overall and proportion of all term breech presentations that were undiagnosed at term, and on the related adverse perinatal outcomes. METHODS AND FINDINGS This was a retrospective multicentre cohort study where we included data from St. George's (SGH) and Norfolk and Norwich University Hospitals (NNUH). Pregnancies were grouped according to whether they received routine third trimester scan (SGH) or POCUS (NNUH). Women with multiple pregnancy, preterm birth prior to 37 weeks, congenital abnormality, and those undergoing planned cesarean section for breech presentation were excluded. Undiagnosed breech presentation was defined as follows: (a) women presenting in labour or with ruptured membranes at term subsequently discovered to have a breech presentation; and (b) women attending for induction of labour at term found to have a breech presentation before induction. The primary outcome was the proportion of all term breech presentations that were undiagnosed. The secondary outcomes included mode of birth, gestational age at birth, birth weight, incidence of emergency cesarean section, and the following neonatal adverse outcomes: Apgar score <7 at 5 minutes, unexpected neonatal unit (NNU) admission, hypoxic ischemic encephalopathy (HIE), and perinatal mortality (including stillbirths and early neonatal deaths). We employed a Bayesian approach using informative priors from a previous similar study; updating their estimates (prior) with our own data (likelihood). The association of undiagnosed breech presentation at birth with adverse perinatal outcomes was analyzed with Bayesian log-binomial regression models. All analyses were conducted using R for Statistical Software (v.4.2.0). Before and after the implementation of routine third trimester scan or POCUS, there were 16,777 and 7,351 births in SGH and 5,119 and 4,575 in NNUH, respectively. The rate of breech presentation in labour was consistent across all groups (3% to 4%). In the SGH cohort, the percentage of all term breech presentations that were undiagnosed was 14.2% (82/578) before (years 2016 to 2020) and 2.8% (7/251) after (year 2020 to 2021) the implementation of universal screening (p < 0.001). Similarly, in the NNUH cohort, the percentage of all term breech presentations that were undiagnosed was 16.2% (27/167) before (year 2015) and 3.5% (5/142) after (year 2020 to 2021) the implementation of universal POCUS screening (p < 0.001). Bayesian regression analysis with informative priors showed that the rate of undiagnosed breech was 71% lower after the implementation of universal ultrasound (RR, 0.29; 95% CrI 0.20, 0.38) with a posterior probability greater than 99.9%. Among the pregnancies with breech presentation, there was also a very high probability (>99.9%) of reduced rate of low Apgar score (<7) at 5 minutes by 77% (RR, 0.23; 95% CrI 0.14, 0.38). There was moderate to high probability (posterior probability: 89.5% and 85.1%, respectively) of a reduction of HIE (RR, 0.32; 95% CrI 0.0.05, 1.77) and extended perinatal mortality rates (RR, 0.21; 95% CrI 0.01, 3.00). Using informative priors, the proportion of all term breech presentations that were undiagnosed was 69% lower after the initiation of universal POCUS (RR, 0.31; 95% CrI 0.21, 0.45) with a posterior probability greater of 99.9%. There was also a very high probability (99.5%) of a reduced rate of low Apgar score (<7) at 5 minutes by 40% (RR, 0.60; 95% CrI 0.39, 0.88). We do not have reliable data on number of facility-based ultrasound scans via the standard antenatal referral pathway or external cephalic versions (ECVs) performed during the study period. CONCLUSIONS In our study, we observed that both a policy of routine facility-based third trimester ultrasound or POCUS are associated with a reduction in the proportion of term breech presentations that were undiagnosed, with an improvement in neonatal outcomes. The findings from our study support the policy of third trimester ultrasound scan for fetal presentation. Future studies should focus on exploring the cost-effectiveness of POCUS for fetal presentation.
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Affiliation(s)
- Samantha Knights
- Department of Obstetrics and Gynaecology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom
| | - Smriti Prasad
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Erkan Kalafat
- Department of Statistics, Middle East Technical University, Faculty of Arts and Sciences, Ankara, Turkey
- Department of Obstetrics and Gynaecology, Koc University, School of Medicine, Istanbul, Turkey
| | - Anahita Dadali
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Pam Sizer
- Department of Obstetrics and Gynaecology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom
| | - Francoise Harlow
- Department of Obstetrics and Gynaecology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom
| | - Asma Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, United Kingdom
- Fetal Medicine Unit, Liverpool Women's Hospital, Liverpool, United Kingdom
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Institutionalization of limited obstetric ultrasound leading to increased antenatal, skilled delivery, and postnatal service utilization in three regions of Ethiopia: A pre-post study. PLoS One 2023; 18:e0281626. [PMID: 36791077 PMCID: PMC10045583 DOI: 10.1371/journal.pone.0281626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 01/29/2023] [Indexed: 02/16/2023] Open
Abstract
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.
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Viner AC, Malata MP, Mtende M, Membe-Gadama G, Masamba M, Makwakwa E, Bamuya C, Lissauer D, Stock SJ, Norman JE, Reynolds RM, Magowan B, Freyne B, Gadama L, Cunningham-Burley S, Nyondo-Mipando L, Chipeta E. Implementation of a novel ultrasound training programme for midwives in Malawi: A mixed methods evaluation using the RE-AIM framework. FRONTIERS IN HEALTH SERVICES 2023; 2:953677. [PMID: 36925815 PMCID: PMC10012721 DOI: 10.3389/frhs.2022.953677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 11/11/2022] [Indexed: 01/19/2023]
Abstract
Introduction Despite recommendation that all women receive an ultrasound in pregnancy prior to 24 weeks', this remains unavailable to many women in low-income countries where trained practitioners are scarce. Although many programmes have demonstrated efficacy, few have achieved longterm sustainability, with a lack of information about how best to implement such programmes. This mixed-methods study aimed to evaluate the implementation of a novel education package to teach ultrasound-naive midwives in Malawi basic obstetric ultrasound, assessing its impact in the context of the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework. Methods The study ran across six sites in Malawi between October 2020 and June 2021, encompassing three phases; pre-implementation, implementation and post-implementation. Twenty nine midwives underwent a bespoke education package with matched pre and post course surveys assessed their knowledge, attitudes and confidence and "hands on" assessments evaluating practical skills. Training evaluation forms and in-depth interviews explored their satisfaction with the package, with repeat assessment and remote image review evaluating maintenance of skills. Results 28/29 midwives completed the training, with significant increases in knowledge, confidence and practical skills. Adherence to the education package varied, however many changes to the proposed methodology were adaptive and appeared to facilitate the efficacy of the programme. Unfortunately, despite reporting approval regarding the training itself, satisfaction regarding supervision and follow up was mixed, reflecting the difficulties encountered with providing ongoing in-person and remote support. Conclusion This programme was successful in improving trainees' knowledge, confidence and skill in performing basic obstetric ultrasound, largely on account of an adaptive approach to implementation. The maintenance of ongoing support was challenging, reflected by trainee dissatisfaction. By evaluating the success of this education package based on its implementation and not just its efficacy, we have generated new insights into the barriers to sustainable upscale, specifically those surrounding maintenance.
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Affiliation(s)
- Alexandra C. Viner
- MRC Centre for Reproductive Health, The University of Edinburgh, Edinburgh, United Kingdom
| | - Monica P. Malata
- Centre for Reproductive Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Medrina Mtende
- Centre for Reproductive Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Gladys Membe-Gadama
- Department of Obstetrics and Gynaecology, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Martha Masamba
- Department of Obstetrics and Gynaecology, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Enita Makwakwa
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Catherine Bamuya
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - David Lissauer
- Centre for Reproductive Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Faculty of Health and Life Sciences, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Sarah J. Stock
- Centre for Medical Informatics, Usher Institute, The University of Edinburgh, Edinburgh, United Kingdom
| | - Jane E. Norman
- Faculty of Health Sciences, The University of Bristol, Bristol, United Kingdom
| | - Rebecca M. Reynolds
- Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, United Kingdom
| | - Brian Magowan
- Borders General Hospital, NHS Borders, Melrose, United Kingdom
| | - Bridget Freyne
- Faculty of Health and Life Sciences, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Luis Gadama
- Department of Obstetrics and Gynaecology, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Sarah Cunningham-Burley
- Centre for Medical Informatics, Usher Institute, The University of Edinburgh, Edinburgh, United Kingdom
| | - Linda Nyondo-Mipando
- Centre for Reproductive Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Effie Chipeta
- Centre for Reproductive Health, Kamuzu University of Health Sciences, Blantyre, Malawi
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Viner A, Membe-Gadama G, Whyte S, Kayambo D, Masamba M, Martin CJH, Magowan B, Reynolds RM, Stock SJ, Freyne B, Gadama L. Midwife-Led Ultrasound Scanning to Date Pregnancy in Malawi: Development of a Novel Training Program. J Midwifery Womens Health 2022; 67:728-734. [PMID: 36527397 PMCID: PMC10108168 DOI: 10.1111/jmwh.13442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 07/26/2022] [Accepted: 08/16/2022] [Indexed: 12/23/2022]
Abstract
The use of ultrasound to determine gestational age is fundamental to the optimum management of pregnancy and is recommended for all women by the World Health Organization. However, this modality remains unavailable to many women in low-income countries where trained practitioners are scarce. Although previous initiatives have demonstrated efficacy in training midwives and technicians to perform antenatal ultrasound, these programs have often been too long and too complex to be realistic within the specific constraints of this context, highlighting the need for a novel and pragmatic approach. We describe the development and piloting of a bespoke course to teach midwives 3 fundamental components of early antenatal ultrasound scanning: (1) to identify the number of fetuses, (2) to confirm fetal viability, and (3) to determine gestational age. Having established that 5 days is insufficient, we propose that the minimum duration required to train ultrasound-naive midwives to competency is 10 days. Our completed program therefore consists of one and one-half days of didactic teaching, followed by 8 and one-half days of supervised hands-on practical training in which trainees are assessed on their skills. This package has subsequently been successfully implemented across 6 sites in Malawi, where 28 midwives have achieved competency. By describing the processes involved in our cross-continental collaboration, we explain how unexpected challenges helped shape and improve our program, demonstrating the value of preimplementation piloting and a pragmatic and adaptive approach.
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Affiliation(s)
- Alexandra Viner
- The MRC Centre for Reproductive Health, Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Gladys Membe-Gadama
- Obstetrics and Gynaecology, Queen Elizabeth Central Hospital, College of Medicine, Blantyre, Malawi
| | - Sonia Whyte
- Liverpool Clinical trials Centre, University of Liverpool, Liverpool, United Kingdom
| | - Doris Kayambo
- Obstetrics and Gynaecology, Mzuzu Central Hospital, Mzuzu, Malawi
| | - Martha Masamba
- Obstetrics and Gynaecology, Queen Elizabeth Central Hospital, College of Medicine, Blantyre, Malawi
| | | | - Brian Magowan
- Obstetrics and Gynaecology, Borders General Hospital, Melrose, United Kingdom
| | - Rebecca M Reynolds
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Sarah J Stock
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Bridget Freyne
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Luis Gadama
- Obstetrics and Gynaecology, Queen Elizabeth Central Hospital, University of Malawi, College of Medicine, Blantyre, Malawi
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Student Competency for Midtrimester Obstetrics Scan upon Completion of the Master’s Degree in Medical Sonography. Obstet Gynecol Int 2022; 2022:2625242. [PMID: 36339017 PMCID: PMC9633199 DOI: 10.1155/2022/2625242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 10/03/2022] [Accepted: 10/11/2022] [Indexed: 11/22/2022] Open
Abstract
Objectives To evaluate the competency of medical sonographer students who have completed training to estimate the gestational age (GA) and perform fetal biometric measurements compared to obstetricians. Methods We conducted a cross-sectional observational study at the end of the medical sonographer students' practice sessions. In total, 80 midtrimester (18–28 weeks) pregnant women were recruited, and an ultrasound was performed according to the International Society of Sonography in Obstetrics and Gynecology (ISUOG) guideline. Estimated GA calculated from fetal biometric measurements was compared between medical sonographer students and qualified obstetricians. Subsequently, images were randomly evaluated by maternal-fetal medicine specialists to assess the measurement performance. Results There was no significant difference in the estimated GA between the medical sonographer students and obstetricians (mean difference, 0.01 ± 2.92 day, p = 0.89). However, there was a significant difference in the measurement of the head circumference (HC) and abdominal circumference (AC) (p < 0.001). The overall image quality of the fetal head, abdomen, and femur was considered a good to excellent score (77.5%–80%). There was a perfect and nearly perfect agreement regarding the presence of the placenta previa, adequacy of amniotic fluid, and position of the placenta (k = 0.9–1.0). Conclusions The medical sonographer students demonstrated competency in GA estimation by fetal biometry measurement similar to obstetricians. However, the quality of the acquired images, according to the ISUOG recommendation, needs improvement, and this should be emphasized in the sonography course curriculum. The results suggest that medical sonographers can relieve obstetricians' workload for ultrasound screening in midtrimester pregnancies.
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Jauniaux E, McCarthy C, Coombe H, Zarnfaller S. Ensuring proper standards in digital technology for surgery in low resource settings. BMJ 2022; 377:o1368. [PMID: 35649542 DOI: 10.1136/bmj.o1368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Eric Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
- Medical Aid Films, Doctors of the World, London, UK
| | | | - Helen Coombe
- Medical Aid Films, Doctors of the World, London, UK
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Viner AC, Membe-Gadama G, Whyte S, Kayambo D, Masamba M, Makwakwa E, Lissauer D, Stock SJ, Norman JE, Reynolds RM, Magowan B, Freyne B, Gadama L. Training in Ultrasound to Determine Gestational Age (TUDA): Evaluation of a Novel Education Package to Teach Ultrasound-Naive Midwives Basic Obstetric Ultrasound in Malawi. Front Glob Womens Health 2022; 3:880615. [PMID: 35449708 PMCID: PMC9017789 DOI: 10.3389/fgwh.2022.880615] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 03/11/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Although ultrasound to determine gestational age is fundamental to the optimum management of pregnancy and is recommended for all women by the World Health Organisation, it remains unavailable to many women in low-income countries where trained practitioners are scarce. This study aimed to evaluate a novel, context-specific education package to teach midwives basic obstetric ultrasound, including the determination of gestational age by measurement of fetal femur length. Methods The study was conducted across six sites in Malawi in January 2021. Following a virtual "training of the trainers", local teams delivered a 10-day programme encompassing both didactic and "hands on" components. Matched pre and post course tests assessed participants' knowledge of key concepts, with Objective Structured Clinical Examinations used to evaluate practical skills. To achieve a pass, trainees were required to establish the gestational age to within ±7 days of an experienced practitioner and achieve an overall score of >65% on five consecutive occasions. A matched pre and post course survey explored participants' attitudes and confidence in performing ultrasound examinations. Results Of the 29 midwives who participated, 28 finished the programme and met the criteria specified to pass. 22 midwives completed the matched knowledge tests, with the mean (SD) score increasing from 10.2 (3.3) to 18 (2.5) after training (P <0.0001). Mean difference 7.9, 95% CI 6.5-9.2. Midwives passed 87% of the Observed Structured Clinical Examinations, establishing the gestational age to within ±7 days of an experienced practitioner in 89% of assessments. Beliefs regarding the importance of antenatal ultrasound increased post course (p = 0.02), as did confidence in performing ultrasound examinations (p <0.0001). Conclusion This study demonstrates not only that ultrasound-naive practitioners can be taught to perform basic obstetric ultrasound dating scans, confidently and competently, after 10 days of training, but also that local teams can be orientated to successfully deliver the programme virtually. Previous ultrasound training initiatives, while often more comprehensive in their syllabus, have been of considerably longer duration and this is likely to be a barrier to upscaling opportunities. We propose that this focused training increases the potential for widescale and sustainable implementation.
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Affiliation(s)
- Alexandra C. Viner
- Medical Research Council (MRC) Centre for Reproductive Health, The University of Edinburgh, Edinburgh, United Kingdom
| | - Gladys Membe-Gadama
- Department of Obstetrics and Gynaecology, University of Malawi College of Medicine, Blantyre, Malawi
| | - Sonia Whyte
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, United Kingdom
| | | | - Martha Masamba
- Department of Obstetrics and Gynaecology, University of Malawi College of Medicine, Blantyre, Malawi
| | - Enita Makwakwa
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - David Lissauer
- Malawi-Liverpool-Wellcome Research Programme, Blantyre, Malawi
- Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Sarah J. Stock
- Usher Institute, The University of Edinburgh, Edinburgh, United Kingdom
| | - Jane E. Norman
- Faculty of Health Sciences, The University of Bristol, Bristol, United Kingdom
| | - Rebecca M. Reynolds
- Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, United Kingdom
| | - Brian Magowan
- Borders General Hospital, National Health Service (NHS) Borders, Melrose, United Kingdom
| | - Bridget Freyne
- Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Luis Gadama
- Department of Obstetrics and Gynaecology, University of Malawi College of Medicine, Blantyre, Malawi
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Roro MA, Aredo AD, Kebede T, Estifanos AS. Enablers and barriers to introduction of obstetrics ultrasound service at primary care facilities in a resource-limited setting: a qualitative study in four regions of Ethiopia. BMC Pregnancy Childbirth 2022; 22:278. [PMID: 35366824 PMCID: PMC8976309 DOI: 10.1186/s12884-022-04609-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 03/22/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The World Health Organization (WHO) recommends a minimum of eight ANC contacts during pregnancy, of which having one ultrasound examination before 24 weeks of gestation is indicated. Ultrasound plays a significant role in the surveillance and management of high-risk pregnancies. However, the obstetric ultrasound coverage in resource limited settings remains low. Evidence examining the barriers and facilitators to obstetrics ultrasound use in a resource-limited setting like Ethiopia is lacking. This qualitative study explored the facilitators and barriers to introducing obstetric Vscan Access ultrasound in primary health care facilities in Ethiopia.
Methods
The study employed a qualitative descriptive exploratory study design using in-depth interviews (IDIs) and focus group discussions (FGDs). The study participant were mothers who have had recent birth, community members, maternal and newborn service providers, and their managers. We employed an inductive thematic analysis to analyze the data.
Result
We conducted a total of ten FGDs, three with community members and seven with maternal and newborn service providers, and 52 IDIs with the service providers and health facility managers. Two major themes, health system related and client-related factors, emerged from the analysis. The health system related enablers include increased knowledge and skill of the providers, improved mothers and providers’ motivation, increased service utilization, and improved quality of maternal and newborn care (MNC), and enhanced referral system. The health system related barriers include service interruption, staff shortage/workload, and the providers’ limited capacity. Under the main theme of client-related factors, barriers include perceived limited knowledge and skills of providers and the small size of the ultrasound machine while the facilitators include mothers’ needs and interest in ultrasound scan, availability of free of charge ultrasound service, and increased demand for ultrasound scan service.
Conclusion
Our data suggest that the health system provides an enabling context to introduce limited obstetric ultrasound service and routinely provide the service through mid-level maternal care providers at primary health care level in resource limited settings. Overcoming the health system and client related barriers will maximize and sustain the use of the technology.
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Viner AC, Okolo ID, Norman JE, Stock SJ, Reynolds RM. Training in Ultrasound to Determine Gestational Age in Low- and Middle- Income Countries: A Systematic Review. Front Glob Womens Health 2022; 3:854198. [PMID: 35368997 PMCID: PMC8971706 DOI: 10.3389/fgwh.2022.854198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 02/18/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionEstablishing an accurate gestational age is essential for the optimum management of pregnancy, delivery and neonatal care, with improved estimates of gestational age considered a public health priority by the World Health Organization (WHO). Although ultrasound is considered the most precise method to achieve this, it is unavailable to many women in low- and middle- income countries (LMICs), where the lack of trained practitioners is considered a major barrier. This systematic review explores what initiatives have previously been undertaken to train staff to date pregnancies using ultrasound, which were successful and what barriers and facilitators influenced training.MethodsThe systematic review was conducted according to PRISMA guidelines and the protocol registered (PROSPERO CRD42019154619). Searches were last performed in July 2021. Studies were screened independently by two assessors, with data extracted by one and verified by the other. Both reviewers graded the methodological quality using the Mixed Methods Assessment Tool. Results were collated within prespecified domains, generating a narrative synthesis.Results25/1,262 studies were eligible for inclusion, all of which were programme evaluations. Eighteen were undertaken in Africa, three in South-East Asia, one in South America, and three across multiple sites, including those in Africa, Asia, and South America. Five programs specified criteria to pass, and within these 96% of trainees did so. Trainee follow up was undertaken in 18 studies. Ten met recommendations for training outlined by the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) but only 1 met the current standards set by the WHO.DiscussionThis systematic review is the first to evaluate this topic and has uncovered major inconsistencies in the delivery and reporting of basic obstetric ultrasound training in LMICs, with the majority of programs not meeting minimum recommendations. By identifying these issues, we have highlighted key areas for improvement and made recommendations for reporting according to the RE-AIM framework. With an increasing focus on the importance of improving estimates of gestational age in LMICs, we believe these findings will be of significance to those seeking to develop and expand the provision of sustainable obstetric ultrasound in LMICs.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019154619, PROSPERO CRD42019154619.
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Affiliation(s)
- Alexandra C. Viner
- Medical Research Council (MRC) Centre for Reproductive Health, The University of Edinburgh, Edinburgh, United Kingdom
- *Correspondence: Alexandra C. Viner
| | - Isioma D. Okolo
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States
| | - Jane E. Norman
- Faculty of Health Sciences, The University of Bristol, Bristol, United Kingdom
| | - Sarah J. Stock
- Usher Institute, The University of Edinburgh, Edinburgh, United Kingdom
| | - Rebecca M. Reynolds
- Centre for Cardiovascular Science, The University of Edinburgh, Edinburgh, United Kingdom
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Argaw MD, Abawollo HS, Tsegaye ZT, Beshir IA, Damte HD, Mengesha BT, Gebremedhin ZK, Heyi AF, Guteta AA, Mamo TT, Anara AA, Emiru ZY, Yadeta FS, Wami AB, Kibret MA, Desta BF. Experiences of midwives on Vscan limited obstetric ultrasound use: a qualitative exploratory study. BMC Pregnancy Childbirth 2022; 22:196. [PMID: 35272631 PMCID: PMC8915526 DOI: 10.1186/s12884-022-04523-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/28/2022] [Indexed: 12/04/2022] Open
Abstract
Background Ethiopia is a low-income country located in the horn of Africa’s sub-Saharan region, with very high incidences of maternal and neonatal mortality. Quality antenatal care improves perinatal health outcomes. The USAID funded Transform: Primary Health Care Activity in collaboration with the Ministry of Health and GE Healthcare introduced Vscan limited obstetric ultrasound services in 120 health centers in Ethiopia. So far, the experiences and opinions of midwives on their use have not been explored and described within the local context. This study therefore aims to explore and describe the experiences and opinions of midwives on Vscan limited obstetric ultrasound services at health centers within Ethiopia. Methods An exploratory and descriptive qualitative study was conducted in Amhara, Oromia, and Southern Nations, Nationalities and Peoples’ (SNNP) regions of Ethiopia. Twenty-four participants were selected through a purposeful sampling technique. In-depth individual interviews with trained midwives with practical hands-on limited obstetric ultrasound service provision experience were conducted. The thematic analysis was conducted manually. Results The qualitative data analysis on the experiences and opinions of midwives revealed three themes, namely: individual perception of self-efficacy, facilitators, and barriers of limited obstetric ultrasound services. The basic ultrasound training, which was unique in its organization and arrangement, prepared and built the self-efficacy of trainees in executing their expected competencies. Support of health systems and health managers in dedicating space, availing essential supplies, and assigning human resources emerged as facilitators of the initiated limited obstetric ultrasound services, whereas high workload on one or two ultrasound trained midwives, interruption of essential supplies like paper towels, gel, and alternative power sources were identified as barriers for limited ultrasound services. Conclusion This study explored the experiences and opinions of midwives who were trained on the provision of limited obstetric ultrasound services and served the community in health centers in rural parts of Ethiopia. The results of this study revealed the positive impacts of the intervention on the perceived self-efficacy, facilitation, and breaking-down of barriers to obstetric ultrasound services. Before scaling-up limited obstetric ultrasound interventions, health managers should ensure and commit to availing essential supplies (e.g., paper towels, ultrasound gel, and large memory hard discs), arranging private rooms, and training other mid-level health professionals. In addition, improving pregnant women’s literacy on the national schedule for ultrasound scanning services is recommended. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-04523-3.
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Affiliation(s)
- Mesele Damte Argaw
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia.
| | - Hailemariam Segni Abawollo
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia
| | - Zergu Taffesse Tsegaye
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia
| | - Ismael Ali Beshir
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia
| | - Heran Demissie Damte
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia
| | - Birhan Tenaw Mengesha
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia
| | - Zenawork Kassa Gebremedhin
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia
| | - Atrie Fekadu Heyi
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia
| | - Asfaw Adugna Guteta
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia
| | - Tsega Teferi Mamo
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia
| | - Amare Assefa Anara
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia
| | - Zelalem Yilma Emiru
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia
| | - Feyisa Serbessa Yadeta
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia
| | - Almaz Bekele Wami
- USAID Transform: Primary Health Care Activity, Pathfinder International, Addis Ababa, Ethiopia
| | - Mengistu Asnake Kibret
- USAID Transform: Primary Health Care Activity, Pathfinder International, Addis Ababa, Ethiopia
| | - Binyam Fekadu Desta
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia
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Abrokwa SK, Ruby LC, Heuvelings CC, Bélard S. Task shifting for point of care ultrasound in primary healthcare in low- and middle-income countries-a systematic review. EClinicalMedicine 2022; 45:101333. [PMID: 35284806 PMCID: PMC8904233 DOI: 10.1016/j.eclinm.2022.101333] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/03/2022] [Accepted: 02/16/2022] [Indexed: 12/17/2022] Open
Abstract
Low-and middle-income countries (LMIC) are faced with healthcare challenges including lack of specialized healthcare workforce and limited diagnostic infrastructure. Task shifting for point-of-care ultrasound (POCUS) can overcome both shortcomings. This review aimed at identifying benefits and challenges of task shifting for POCUS in primary healthcare settings in LMIC. Medline and Embase were searched up to November 22nd, 2021. Publications reporting original data on POCUS performed by local ultrasound naïve healthcare providers in any medical field at primary healthcare were included. Data were analyzed descriptively. PROSPERO registration number CRD42021223302. Overall, 36 publications were included, most (n = 35) were prospective observational studies. Medical fields of POCUS application included obstetrics, gynecology, emergency medicine, infectious diseases, and cardiac, abdominal, and pulmonary conditions. POCUS was performed by midwives, nurses, clinical officers, physicians, technicians, and community health workers following varying periods of short-term training and using different ultrasound devices. Benefits of POCUS were yields of diagnostic images with adequate interpretation impacting patient management and outcome. High cost of face-to-face training, poor internet connectivity hindering telemedicine components, and unstable electrici'ty were among reported drawbacks for successful implementation of task shifting POCUS. At the primary care level in resource-limited settings task shifting for POCUS has the potential to expand diagnostic imaging capacity and impact patient management leading to meaningful health outcomes.
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Affiliation(s)
- Seth Kofi Abrokwa
- Institute of Tropical Medicine and International Health, Charité-Universitätsmedizin Berlin, Germany
- Corresponding author.
| | - Lisa C. Ruby
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | | | - Sabine Bélard
- Institute of Tropical Medicine and International Health, Charité-Universitätsmedizin Berlin, Germany
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
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Horn D, Edwards E, Ssembatya R, DeStigter K, Dougherty A, Ehret D. Association between antenatal ultrasound findings and neonatal outcomes in rural Uganda: a secondary analysis. BMC Pregnancy Childbirth 2021; 21:756. [PMID: 34749679 PMCID: PMC8573986 DOI: 10.1186/s12884-021-04204-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 10/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although the use of prenatal ultrasound services has increased in low- income and lower middle-income countries, there has not been a concurrent improvement in perinatal mortality. It remains unknown whether individual ultrasound findings in this setting are associated with neonatal death or the need for resuscitation at delivery. If associations are identified by ultrasound, they could be used to inform the birth attendant and counsel the family regarding risk, potentially altering delivery preparedness in order to reduce neonatal mortality. METHODS This was a secondary analysis of data collected from a prospective cohort. Data was gathered at Nawanyago Health Centre III in Kamuli District, Uganda. Participants included pregnant women who received second and third trimester prenatal ultrasound scans and delivered at that center between July 2010 and August 2018. All ultrasounds were performed at Nawanyago and deliveries were attended solely by midwives or nurses. Predictor variables included the following ultrasound findings: fetal number, fetal presentation, and amniotic fluid volume. The primary outcome was bag-mask ventilation (BMV) of the neonate at delivery. The secondary outcome was stillbirth or neonatal death in the delivery room. RESULTS Primary outcome data was available for 1105 infants and secondary outcome data was available for 1098 infants. A total of 33 infants received BMV at delivery. The odds of receiving BMV at delivery was significantly increased if amniotic fluid volume was abnormal (OR 4.2, CI 1.2-14.9) and there were increased odds for multiple gestation (OR 1.9, CI 0.7-5.4) and for non-vertex fetal presentation (OR 1.4, CI 0.6-3.2) that were not statistically significant. Stillbirth or neonatal death in the delivery room was diagnosed for 20 infants. Multiple gestation (OR 4.7, CI 1.6-14.2) and abnormal amniotic fluid volume (OR 4.8, CI 1.0-22.1) increased the odds of stillbirth or neonatal death in the delivery room, though only multiple gestation was statistically significant. CONCLUSION Common findings that are easily identifiable on ultrasound in low- and lower middle-income countries are associated with adverse perinatal outcomes. Education could lead to improved delivery preparedness, with the potential to reduce perinatal mortality. This was a preliminary study; larger prospective studies are needed to confirm these findings.
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Affiliation(s)
- Delia Horn
- Pediatrics, The Larner College of Medicine at the University of Vermont, 89 Beaumont Avenue, Burlington, VT, 05405, USA.
| | - Erika Edwards
- The Larner College of Medicine at the University of Vermont, 89 Beaumont Avenue, Burlington, VT, 05405, USA
| | - Renny Ssembatya
- Imaging the World Africa, Plot 435, Naalya-Namugongo Road, Kampala, Uganda
| | - Kristen DeStigter
- Radiology, The Larner College of Medicine at the University of Vermont, 89 Beaumont Avenue, Burlington, VT, 05405, USA
| | - Anne Dougherty
- Obstetrics and Gynecology, The Larner College of Medicine at the University of Vermont, 89 Beaumont Avenue, Burlington, VT, 05405, USA
| | - Danielle Ehret
- Pediatrics, The Larner College of Medicine at the University of Vermont, 89 Beaumont Avenue, Burlington, VT, 05405, USA
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Gage DC, Lugossy AM, Mollura DJ, England RW. Estimating Catchment Populations of Global Health Radiology Outreach Using Geographic Information Systems Analysis. J Am Coll Radiol 2021; 19:76-83. [PMID: 34699775 DOI: 10.1016/j.jacr.2021.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 08/22/2021] [Accepted: 09/01/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The purpose of this study was to design, develop, and test geographic information systems (GIS) analytic methods for quantifying and characterizing catchment populations across all sites served by a radiology global health organization. METHODS The analysis included populations served by 78 low-resource medical facilities in 32 countries partnered with radiology nonprofit organization, RAD-AID International. Three constraints were used to approximate patient catchment areas: (1) 1-hour driving time, (2) 1-hour walking time, and (3) 10-mile circular radius. GIS calculated populations within each constraint using publicly available geospatial input databases, including a global digital elevation model, population and land cover data, and road locations from OpenStreetMap. Demographic and health data from the World Health Organization were incorporated to provide further characteristics of covered populations. RESULTS The total populations served by all RAD-AID sites as measured by driving time, walking time, and 10-mile radius were 189,241,193 (47.8% female), 26,190,117 (48.7% female), and 110,884,095 (48.1% female), respectively. For individual locations, median population within 1-hour driving time was 1,795,977 (range: 8,742-30,630,800), with an average life expectancy of 68.4 ± 5.8 years. Median child mortality before age 5 was 3.8% (range: 0.9%-8.3%), and median prevalence of human immunodeficiency virus infection was 3.1% (range: 0.7%-10.9%). CONCLUSION In this study, GIS provided a robust multisite analysis for estimating the potential global population reached by an international radiology outreach organization with targeted individual site measurements. Given heightened needs to accurately characterize global outreach populations, this GIS-based approach may be useful for analysis, outreach planning, and resource allocation among global health organizations.
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Affiliation(s)
- David C Gage
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland
| | | | - Daniel J Mollura
- Chief Executive Officer, RAD-AID International, Chevy Chase, Maryland
| | - Ryan W England
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland; Manager, GIS Research and Medical Hybrid Airship Programs, RAD-AID International, Chevy Chase, Maryland.
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Akpan E, Kitundu J, Ekpo E. Public Health Radiography: A Scoping Review of Benefits, and Growth Opportunities for Radiographers. J Med Imaging Radiat Sci 2021; 52:615-625. [PMID: 34531164 DOI: 10.1016/j.jmir.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 06/17/2021] [Accepted: 08/06/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION There is growing adoption of radiographic techniques in public health to improve outcomes of chronic and communicable diseases. This review examines the applications, benefits, and implications of radiography in public health. It also examines the challenges and potential advanced practice roles for radiographers in public health radiography (PHR). METHODOLOGY Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Scoping review extension (PRISMA- ScR) checklist was employed, and the search was conducted using PubMed, Medline, Web of Science, ScienceDirect, and Google Scholar to identify relevant articles that explored the concept of radiography in public health. Evidence was analysed using an inductive iterative approach. RESULTS Radiographic imaging modalities such as ultrasound, computed tomography, and plain X-ray had wide applicability in public health fields of preventive cardiology, preventive oncology, maternal health, infectious disease epidemiology, and radiographic informatics. PHR effectively reduced mortality, improved outcomes, informed lifestyle changes to mitigate the risk of impending disease. PHR also helped in monitoring disease progression and predicting treatment outcomes. However, evidence establishing a competency framework that supports PHR is scarce. CONCLUSION Radiography makes a significant contribution to public health in reducing mortality and morbidity. Therefore, developing a PHR competency framework can accentuate the contribution Radiographers make to solving public health issues.
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Affiliation(s)
- Eyo Akpan
- Grayscale International Ltd, Lagos, Nigeria.
| | - Jane Kitundu
- Vijibweni District Hospital, Kigamboni Municipal, Dar es Salaam, Tanzania
| | - Ernest Ekpo
- Image Optimisation and Perception Group, Discipline of Medical Imaging Science, School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Cumberland Campus C42
- 75 East Street, Lidcombe, NS, W
- 2141
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Mapuranga H, Pitcher RD, Jakanani GC, Banhwa J. An audit of Zimbabwean public sector diagnostic ultrasound services. Pan Afr Med J 2021; 39:99. [PMID: 34466201 PMCID: PMC8379399 DOI: 10.11604/pamj.2021.39.99.28342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 05/13/2021] [Indexed: 11/28/2022] Open
Abstract
Introduction the provision of basic diagnostic imaging services is pivotal to achieving universal health coverage. An estimated two-thirds of the world's population have no access to basic diagnostic imaging. Accurate data on current imaging equipment resources are required to inform health delivery strategy and policy at national level. This is an audit of Zimbabwean public sector diagnostic ultrasound resources and services. Methods utilising the Ministry of Health and Child Care (MHCC) database, sequential interviews were conducted with provincial health authorities and local facility managers. Ultrasound equipment, personnel and services in all hospitals and clinics, nationally were recorded, collated, and analysed for the whole country, and by province. Results of the 1798 Zimbabwean public sector healthcare facilities, sixty-six (n=66, 3.67%) have ultrasound equipment. Ninety-nine (n=99) ultrasound units are distributed across the sonar facilities, representing a national average of 8 units per million people. More than half the equipment units (n=53, 54%) are in secondary-level healthcare facilities (district and mission hospitals), and approximately one-fifth (n=22, 22%) in the central hospitals (quaternary level). The best-resourced province has twice the resources of the least resourced. One-hundred and forty-two (n=142) healthcare workers, from six different professional groups, provide the public sector ultrasound service. Most facilities with sonar equipment (n=64/66, 97%) provide obstetrics and gynaecology services, while general abdominal scanning is available at one third (n=22, 33%). Two facilities with ultrasound equipment have no capacity to offer a sonography service. Conclusion in order to reach the WHO recommendation of 20 sonar units per million people, an estimated 140 additional sonar units are required nationally. The need is greatest in Masvingo, Midlands and Mashonaland East Provinces. Task-shifting plays a key role in the provision of Zimbabwean sonar services. Consideration should be given to formal training and accreditation of all healthcare workers involved in sonar service delivery.
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Affiliation(s)
- Humphrey Mapuranga
- Division of Radiodiagnosis, Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Richard Denys Pitcher
- Division of Radiodiagnosis, Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | | | - Josephat Banhwa
- Department of Medical Physics and Imaging Sciences, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
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20
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Hall EA, Matilsky D, Zang R, Hase N, Habibu Ali A, Henwood PC, Dean AJ. Analysis of an obstetrics point-of-care ultrasound training program for healthcare practitioners in Zanzibar, Tanzania. Ultrasound J 2021; 13:18. [PMID: 33829362 PMCID: PMC8026796 DOI: 10.1186/s13089-021-00220-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 03/20/2021] [Indexed: 11/10/2022] Open
Abstract
Background A point-of-care ultrasound education program in obstetrics was developed to train antenatal healthcare practitioners in rural Zanzibar. The study group consisted of 13 practitioners with different training backgrounds: physicians, clinical officers, and nurse/midwives. Trainees received an intensive 2-week antenatal ultrasound course consisting of lectures and hands-on practice followed by 6 months of direct supervision of hands-on scanning and bedside education in their clinical practice environments. Trainees were given a pre-course written exam, a final exam at course completion, and practical exams at 19 and 27 weeks. Trainees were expected to complete written documentation and record ultrasound images of at least 75 proctored ultrasounds. The objective of this study was prospectively to analyze the success of a longitudinal point-of-care ultrasound training program for antepartum obstetrical care providers in Zanzibar. Results During the 6-month course, trainees completed 1338 ultrasound exams (average 99 exams per trainee with a range of 42–128 and median of 109). Written exam scores improved from a mean of 33.7% (95% CI 28.6–38.8%) at pre-course assessment to 77.5% (95% CI 71–84%) at course completion (P < 0.0001). Practical exam mean scores improved from 71.2% at course midpoint (95% CI 62.3–80.1%) to 84.7% at course completion (95% Cl 78.5–90.8%) (P < 0.0005). Eight of the 13 trainees completed all training requirements including 75 proctored ultrasound exams. Conclusion Trainees improved significantly on all measures after the training program. 62% of the participants completed all requirements. This relatively low completion rate reflects the challenges of establishing ultrasound capacity in this type of setting. Further study is needed to determine trainees’ long-term retention of ultrasound skills and the impact of the program on clinical practice and health outcomes.
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Affiliation(s)
- Elizabeth A Hall
- Department of Emergency Medicine, Providence St. John's Health Center, 2121 Santa Monica Blvd, Santa Monica, CA, 90404, USA. .,Point-of-Care Ultrasound in Resource-Limited Environments (PURE), Malvern, PA, USA.
| | - Danielle Matilsky
- Point-of-Care Ultrasound in Resource-Limited Environments (PURE), Malvern, PA, USA.,Department of Emergency Medicine, Howard County General Hospital, John Hopkins University, Baltimore, MD, USA
| | - Rachel Zang
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Naomasa Hase
- Obstetrics & Gynecology, Wayne State University, Detroit, MI, USA
| | | | - Patricia C Henwood
- Point-of-Care Ultrasound in Resource-Limited Environments (PURE), Malvern, PA, USA.,Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Anthony J Dean
- Point-of-Care Ultrasound in Resource-Limited Environments (PURE), Malvern, PA, USA.,Emergency Medicine and Emergency Medicine in Radiology, University of Pennsylvania, Philadelphia, PA, USA.,World Interactive Network for Focused Ultrasound (WINFOCUS), Philadelphia, PA, USA
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21
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Dougherty A, Kasten M, DeSarno M, Badger G, Streeter M, Jones DC, Sussman B, DeStigter K. Validation of a Telemedicine Quality Assurance Method for Point-of-Care Obstetric Ultrasound Used in Low-Resource Settings. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:529-540. [PMID: 32770709 DOI: 10.1002/jum.15429] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 05/28/2020] [Accepted: 06/04/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES A remote quality assurance and improvement protocol for point-of-care obstetric ultrasound in low-resource areas was validated against the standard of care for obstetric ultrasound in the United States. METHODS Compressed movie clip ultrasound images (obstetric sweep protocol) obtained by minimally trained personnel were read and interpreted by physicians with training in obstetric ultrasound. Observed findings were compared among readers and between each reader and the gold standard ultrasound scan report. Descriptive statistics were used for the analysis. RESULTS The agreements among readers and between readers and the gold standard, for the anterior and posterior variables of the placental location were excellent, with Cohen κ values of 0.81 to 0.88 and 0.77 to 0.9, respectively. Cohen κ values were slight or slight/fair for other placental locations (left, right, fundal, and low), and the sensitivity and specificity ranged widely. The agreement among readers and between readers and the gold standard for fetal number comparisons was also excellent, with Cohen κ values ranging from 0.82 to 1, sensitivity from 0.83 to 1, and specificity from 0.99 to 1. The agreement among readers for fetal presentation comparisons, according to the Cohen κ, ranged from 0.79 to 0.85 and between readers and the gold standard had values of 0.43 to 0.49. For biometric parameters and estimated gestational age calculations based on these parameters, inter-reader reliability ranged from 0.79 to 0.85 for all parameters except femur length. Greater than 94% of obstetric sweep protocol ultrasound ages were within 7 days of the corresponding gold standard age. CONCLUSIONS Movie clip ultrasound images provided adequate information for remote readers to reliably determine the placental location, fetal number, fetal presentation, and pregnancy dating.
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Affiliation(s)
- Anne Dougherty
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | | | - Michael DeSarno
- Department of Medical Biostatistics and Bioinformatics, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Gary Badger
- Department of Medical Biostatistics and Bioinformatics, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Mary Streeter
- Department of Radiology, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - David C Jones
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Betsy Sussman
- Department of Radiology, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Kristen DeStigter
- Department of Radiology, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
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22
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Valderrama CE, Ketabi N, Marzbanrad F, Rohloff P, Clifford GD. A review of fetal cardiac monitoring, with a focus on low- and middle-income countries. Physiol Meas 2020; 41:11TR01. [PMID: 33105122 PMCID: PMC9216228 DOI: 10.1088/1361-6579/abc4c7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
There is limited evidence regarding the utility of fetal monitoring during pregnancy, particularly during labor and delivery. Developed countries rely on consensus 'best practices' of obstetrics and gynecology professional societies to guide their protocols and policies. Protocols are often driven by the desire to be as safe as possible and avoid litigation, regardless of the cost of downstream treatment. In high-resource settings, there may be a justification for this approach. In low-resource settings, in particular, interventions can be costly and lead to adverse outcomes in subsequent pregnancies. Therefore, it is essential to consider the evidence and cost of different fetal monitoring approaches, particularly in the context of treatment and care in low-to-middle income countries. This article reviews the standard methods used for fetal monitoring, with particular emphasis on fetal cardiac assessment, which is a reliable indicator of fetal well-being. An overview of fetal monitoring practices in low-to-middle income counties, including perinatal care access challenges, is also presented. Finally, an overview of how mobile technology may help reduce barriers to perinatal care access in low-resource settings is provided.
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Affiliation(s)
- Camilo E Valderrama
- Data Intelligence for Health Lab, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Nasim Ketabi
- Department of Biomedical Informatics, Emory University, Atlanta, GA, United States of America
| | - Faezeh Marzbanrad
- Department of Electrical and Computer Systems Engineering, Monash University, Clayton, VIC, Australia
| | - Peter Rohloff
- Wuqu' Kawoq, Maya Health Alliance, Santiago Sacatepéquez, Guatemala
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Gari D Clifford
- Department of Biomedical Informatics, Emory University, Atlanta, GA, United States of America
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, United States of America
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23
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Luntsi G, Ugwu AC, Nkubli FB, Emmanuel R, Ochie K, Nwobi CI. Achieving universal access to obstetric ultrasound in resource constrained settings: A narrative review. Radiography (Lond) 2020; 27:709-715. [PMID: 33160820 DOI: 10.1016/j.radi.2020.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/30/2020] [Accepted: 10/13/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The potential benefits and challenges of achieving universal access to obstetric ultrasound services in resource constrained settings were reviewed, with a view to making some recommendations to address the huge burden of avoidable maternal and child morbidity and mortality. KEY FINDINGS In most resource-poor settings of the world, antenatal ultrasound is available only to a privileged few in urban centres, while the majority of the population living in rural areas have little or no access to diagnostic imaging services. There is also the extreme shortage of sonographers and doctors with specialist training in sonography. A comprehensive regulation must be put in place to achieve maximum benefits and to ensure quality assurance; appropriate use and application of ethics and training must be comprehensive. CONCLUSION Ultrasound service provision, in resource-scarce settings, has the potential to improve access and quality of health care services in areas like the point of care ultrasound service provision and in the fields of obstetrics and gynaecology. A comprehensive regulation must be put in place to achieve maximum benefits and to ensure quality assurance. IMPLICATIONS FOR PRACTICE Making ultrasound technology available and affordable in resource scare settings has the potential to improve access to diagnostic imaging services and reduce avoidable maternal and child death in resource constrained settings.
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Affiliation(s)
- G Luntsi
- Department of Medical Radiography, Faculty of Allied Health Sciences, College of Medical Sciences, University of Maiduguri, Borno State, Nigeria.
| | - A C Ugwu
- Department of Radiography and Radiological Sciences, Faculty of Health Sciences, Nnamdi Azikiwe University Awka, Anambra State, Nigeria
| | - F B Nkubli
- Department of Medical Radiography, Faculty of Allied Health Sciences, College of Medical Sciences, University of Maiduguri, Borno State, Nigeria
| | - R Emmanuel
- Department of Medical Radiography, Faculty of Allied Health Sciences, College of Medical Sciences, Bayero University Kano, Kano State, Nigeria
| | - K Ochie
- Department of Radiography and Radiological Sciences, Faculty of Health Sciences, University of Nigeria, Enugu Campus, Enugu State, Nigeria
| | - C I Nwobi
- Department of Medical Radiography, Faculty of Allied Health Sciences, College of Medical Sciences, University of Maiduguri, Borno State, Nigeria
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24
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Raza S, Frost E, Kwait D, Bowerson M, Rugema V, Hategekimana V, Umwizerwa A, Shabani K, Shulman L, Lee YS, Huang CC, Mpunga T, Shyirambere C, Dusengimana JMV, Pace LE. Training Nonradiologist Clinicians in Diagnostic Breast Ultrasound in Rural Rwanda: Impact on Knowledge and Skills. J Am Coll Radiol 2020; 18:121-127. [PMID: 32916158 DOI: 10.1016/j.jacr.2020.08.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/19/2020] [Accepted: 08/20/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess the effectiveness of diagnostic breast ultrasound training provided for general practitioners and nurses in Rwanda via intensive in-person and subsequent online supervision and mentorship. METHODS Four breast radiologists from Brigham and Women's Hospital trained two general practitioner physicians and five nurses in Rwanda over 9 total weeks of in-person training and 20 months of remote mentorship using electronic image review with emailed feedback. Independently recorded assessments were compared to calculate the sensitivity and specificity of trainee assessments, with radiologist assessments as the gold standard. We compared performance in the first versus second half of the training. RESULTS Trainees' performance on written knowledge assessments improved after training (57.7% versus 98.1% correct, P = .03). Mean sensitivity of trainee-performed ultrasound for identifying a solid breast mass was 90.6% (SD 4.2%) in the first half of the training (period 1) and 94.0% (SD 6.7%) in period 2 (P = .32). Mean specificity was 94.7% (SD 5.4%) in period 1 and 100.0% (SD 0) in period 2 (P = .10). Mean sensitivity for identifying a medium- or high-suspicion solid mass increased from 79.2% (SD 11.0%) in period 1 to 96.3% (SD 6.4%) in period 2 (P = .03). Specificity was 84.4% (SD 15.0%) in period 1 and 96.7% (SD 5.8%) in period 2 (P = .31). DISCUSSION Nonradiologist clinicians (doctors and nurses) in a rural sub-Saharan African hospital built strong skills in diagnostic breast ultrasound over 23 months of combined in-person training and remote mentorship. The sensitivity of trainees' assessments in identifying masses concerning for malignancy improved after sustained mentorship. Assessment of impact on patient care and outcomes is ongoing.
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Affiliation(s)
- Sughra Raza
- Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Elisabeth Frost
- Harvard Medical School, Boston, Massachusetts; Associate Director Breast Imaging, Brigham and Women's Hospital, Boston, Massachusetts
| | - Dylan Kwait
- Harvard Medical School, Boston, Massachusetts; Chief of Radiology, Brigham and Women's Faulkner Hospital, Boston, Massachusetts
| | | | - Vestine Rugema
- WCED Project Mentor/Supervisor Butaro Hospital, Butaro, Rwanda; Ministry of Health, Butaro, Rwanda
| | - Vedaste Hategekimana
- Pain Free Hospital Initiative Senior Officer(PFHI), Rwanda Biomedical Center, Rwanda; Ministry of Health, Butaro, Rwanda
| | | | | | - Lawrence Shulman
- Director, Center for Global Cancer Medicine, Abramson, Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Tharcisse Mpunga
- Ministry of Health, Butaro, Rwanda; Director General, Butaro Hospital/CCOE, Butaro, Rwanda
| | | | | | - Lydia E Pace
- Harvard Medical School, Boston, Massachusetts; Director, Global Women's Health Fellowship, Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital, Boston, Massachusetts
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25
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Stewart KA, Navarro SM, Kambala S, Tan G, Poondla R, Lederman S, Barbour K, Lavy C. Trends in Ultrasound Use in Low and Middle Income Countries: A Systematic Review. Int J MCH AIDS 2020; 9:103-120. [PMID: 32123634 PMCID: PMC7031872 DOI: 10.21106/ijma.294] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Evidence on recent trends regarding the impact and cost-benefits of ultrasound in resource-constrained settings is limited. This study presents a systematic review to determine recent trends in the utility and applicability of ultrasound use in low and middle income countries (LMIC). The review includes characterizing and evaluating trends in (1) the geographic and specialty specific use of ultrasound in LMICs, (2) the innovative applications and the accompanying research findings, and (3) the development of associated educational and training programs. METHODS The electronic databases Medline OVID, EMBASE, and Cochrane were searched from 2010 to 2018 for studies available in English, French, and Spanish. Commentaries, opinion articles, reviews and book chapters were excluded. Two categories were created, one for reported applications of ultrasound use in LMICs and another for novel ultrasound studies. RESULTS A total of 6,276 articles were identified and screened, 4,563 studies were included for final review. 287 studies contained original or novel applications of ultrasound use in LMICs. Nearly 70% of studies involved ultrasound usage originating from Southeast Asia and sub-Saharan Africa, the latter being the region with the highest number of innovative ultrasound use. Educational studies, global collaborations, and funded studies were a substantial subset of overall ultrasound research. Our findings are limited by the lack of higher quality evidence and limited number of randomized clinical trials reported. CONCLUSION AND GLOBAL HEALTH IMPLICATIONS Our systematic literature review of ultrasound use in LMICs demonstrates the growing utilization of this relatively low-cost, portable imaging technology in low resource settings.
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Affiliation(s)
- Kelsey A. Stewart
- Department of Obstetrics and Gynecology, University of Minnesota, Minneapolis, USA
| | - Sergio M. Navarro
- Said Business School, Oxford, UK
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sriharsha Kambala
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Gail Tan
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Revanth Poondla
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Sara Lederman
- Department of Obstetrics and Gynecology, University of Minnesota, Minneapolis, USA
| | - Kelli Barbour
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Chris Lavy
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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26
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Terry B, Polan DL, Nambaziira R, Mugisha J, Bisanzo M, Gaspari R. Rapid, remote education for point-of-care ultrasound among non-physician emergency care providers in a resource limited setting. Afr J Emerg Med 2019; 9:140-144. [PMID: 31528532 PMCID: PMC6742845 DOI: 10.1016/j.afjem.2019.05.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 01/31/2019] [Accepted: 05/17/2019] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Access to high-quality emergency care in low- and middle-income countries (LMIC) is lacking. Many countries utilise a strategy known as "task-shifting" where skills and responsibilities are distributed in novel ways among healthcare personnel. Point-of-care ultrasound (POCUS) has the potential to significantly improve emergency care in LMICs. METHODS POCUS was incorporated into a training program for a ten-person cohort of non-physician Emergency Care Providers (ECPs) in rural Uganda. We performed a prospective observational evaluation on the impact of a remote, rapid review of POCUS studies on the primary objective of ECP ultrasound quality and secondary objective of ultrasound utilisation. The study was divided into four phases over 11 months: an initial in-person training month, two middle month blocks where ECPs performed ultrasounds independently without remote electronic feedback, and the final months when ECPs performed ultrasounds independently with remote electronic feedback. Quality was assessed on a previously published eight-point ordinal scale by a U.S.-based expert sonographer and rapid standardised feedback was given to ECPs by local staff. Sensitivity and specificity of ultrasound exam findings for the Focused Assessment with Sonography for Trauma (FAST) was calculated. RESULTS Over the study duration, 1153 ultrasound studies were reviewed. Average imaging frequency per ECP dropped 61% after the initial in-person training month (p = 0.01) when ECPs performed ultrasound independently, but rebounded once electronic feedback was initiated (p = 0.001), with an improvement in quality from 3.82 (95% CI, 3.32-4.32) to 4.68 (95% CI, 4.35-5.01) on an eight-point scale. The sensitivity and specificity of FAST exam during the initial training period was 77.8 (95% CI, 59.2-83.0) and 98.5 (95% CI, 93.3-99.9), respectively. Sensitivity improved 88% compared to independent, non-feedback months whereas specificity was unchanged. CONCLUSIONS Remotely delivered quality assurance feedback is an effective educational tool to enhance provider skill and foster continued and sustainable use of ultrasound in LMICs.
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Affiliation(s)
- Benjamin Terry
- University of Massachusetts Medical School, Worcester, MA, United States of America
| | - David L. Polan
- University of Massachusetts Medical School, Worcester, MA, United States of America
| | | | - Julius Mugisha
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Mark Bisanzo
- University of Massachusetts Medical School, Worcester, MA, United States of America
| | - Romolo Gaspari
- University of Massachusetts Medical School, Worcester, MA, United States of America
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27
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Swanson JO, Nathan RO, Swanson DL, Perez KM, Bresnahan BW, Mirza W, Goldenberg RL. Use of ultrasound and mHealth to improve perinatal outcomes in low and middle income countries. Semin Perinatol 2019; 43:267-272. [PMID: 31003635 DOI: 10.1053/j.semperi.2019.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The explosion of mobile health and portable obstetric ultrasound interventions in low- and middle-income countries (LMIC) reflects the optimism that technology can help reduce persistently high rates of maternal and neonatal mortality and morbidity in these settings. While these technology-driven interventions have had success in improving aspects of antenatal and perinatal care, they have not clearly demonstrated reductions in mortality. The expanding synergy between mobile health (mHealth) and ultrasound technology shows promise to enhance care, but it will likely take combining these technological advances with system-wide approaches that also address referral patterns and infrastructure barriers to improve outcomes.
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Affiliation(s)
- Jonathan O Swanson
- Department of Radiology, University of Washington, UW Mailbox 357115, 1959 NE Pacific Street, Seattle, WA 98195, USA.
| | - Robert O Nathan
- Department of Radiology, University of Washington, UW Mailbox 357115, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - David L Swanson
- Department of Radiology, University of Washington, UW Mailbox 357115, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Krystle M Perez
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Brian W Bresnahan
- Department of Radiology, University of Washington, UW Mailbox 357115, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Waseem Mirza
- Department of Radiology, Aga Khan University, Karachi, Pakistan
| | - Robert L Goldenberg
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
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28
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Doig M, Dizon J, Guerrero K, Parange N. Exploring the availability and impact of antenatal point-of-care ultrasound services in rural and remote communities: A scoping review. Australas J Ultrasound Med 2019; 22:174-185. [PMID: 34760554 DOI: 10.1002/ajum.12138] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background There are global disparities in the provision of maternal health care, with women from rural communities and under-resourced countries expecting poorer access to healthcare services. This potentially compounds the existing higher burden of maternal and neonatal morbidity within these populations. In this setting, point-of-care ultrasound (PoCUS) has the potential to improve outcomes while mitigating challenges and barriers associated with the introduction of new medical technology. Objectives To explore the availability and impact of PoCUS use for antenatal care (ANC) in under-resourced settings. Methods Medline, Embase and Scopus were searched with no year limit. Studies were included if the participants were pregnant women undergoing ANC in a rural setting or developing country and if the intervention was PoCUS use or training. Results A total of 3863 unique articles were identified, with 17 meeting the inclusion criteria. Studies originated from Africa, Asia, Central America and Australia. All studies reported that POCUS use for ANC produced positive outcomes. PoCUS introduction into routine ANC resulted in higher antenatal attendance and reduced maternal and neonatal mortality rates. It was demonstrated that it was feasible to provide local healthcare workers with limited training to perform quality scanning and reporting in their clinics. Methods and measures of these three primary outcomes varied between studies. Conclusion Integration of PoCUS into ANC in the settings examined improved outcomes in under-resourced areas. Further research should investigate the availability of PoCUS services at a country level, the clinical impact and economic feasibility.
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Affiliation(s)
- Mikaela Doig
- University of South Australia City East Campus, 108 North Terrace Adelaide South Australia 5001 Australia
| | - Janine Dizon
- University of South Australia City East Campus, 108 North Terrace Adelaide South Australia 5001 Australia
| | - Katherine Guerrero
- University of South Australia City East Campus, 108 North Terrace Adelaide South Australia 5001 Australia
| | - Nayana Parange
- University of South Australia City East Campus, 108 North Terrace Adelaide South Australia 5001 Australia
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29
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Holmlund S, Ntaganira J, Edvardsson K, Lan PT, Semasaka Sengoma JP, Lesio Kidanto H, Ngarina M, Small R, Mogren I. Health professionals' experiences and views on obstetric ultrasound in Rwanda: A cross-sectional study. PLoS One 2018; 13:e0208387. [PMID: 30513102 PMCID: PMC6279039 DOI: 10.1371/journal.pone.0208387] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 11/14/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Implementation of ultrasound in antenatal care (ANC) in low-income countries has been shown to increase pregnant women's compliance with ANC visits, and facilitate detection of high-risk pregnancies. In Rwanda, as in other low-income countries, access to ultrasound has increased significantly, but lack of training is often a barrier to its use. The aim of this study was to investigate Rwandan health professionals' experiences and views of obstetric ultrasound in relation to clinical management, resources and skills. METHODS A cross-sectional questionnaire study was undertaken between November 2016 and March 2017, as part of the CROss Country UltraSound Study (CROCUS). Data were collected at 108 health facilities located in both rural and urban areas of Rwanda, including provincial, referral, district and private hospitals as well as health centres. Participants were obstetricians (n = 29), other physicians (n = 222), midwives (n = 269) and nurses (n = 387). RESULTS Obstetricians/gynecologists/other physicians commonly performed ultrasound examinations but their self-rated skill levels implied insufficient training. Access to ultrasound when needed was reported as common in hospitals, but available to a very limited extent in health centres. The vast majority of participants, independent of health profession, agreed that maternity care would improve if midwives learned to perform basic ultrasound examinations. CONCLUSIONS Barriers to provision of high quality ultrasound services include variable access to ultrasound depending on health facility level and insufficient skills of ultrasound operators. Physicians in general need more training to perform ultrasound examinations. Implementation of a general dating ultrasound examination seems to be a relevant goal as most health professionals agree that pregnant woman would benefit from this service. To further improve maternity care services, the possibility of educating midwives to perform ultrasound examinations should be further explored.
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Affiliation(s)
- Sophia Holmlund
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden
| | - Joseph Ntaganira
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Kristina Edvardsson
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden
- Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Melbourne, Australia
| | - Pham Thi Lan
- Department of Dermatology and Venereology, Hanoi Medical University, Hanoi, Vietnam
| | - Jean Paul Semasaka Sengoma
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Hussein Lesio Kidanto
- Department of Obstetrics and Gynecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Matilda Ngarina
- Department of Obstetrics and Gynecology, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Rhonda Small
- Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Melbourne, Australia
- Department of Women’s and Children’s and Reproductive Health, Karolinska Institutet, Stockholm, Sweden
| | - Ingrid Mogren
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden
- Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Melbourne, Australia
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Kim ET, Singh K, Moran A, Armbruster D, Kozuki N. Obstetric ultrasound use in low and middle income countries: a narrative review. Reprod Health 2018; 15:129. [PMID: 30029609 PMCID: PMC6053827 DOI: 10.1186/s12978-018-0571-y] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 07/13/2018] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Although growing, evidence on the impact, access, utility, effectiveness, and cost-benefit of obstetric ultrasound in resource-constrained settings is still somewhat limited. Hence, questions around the purpose and the intended benefit as well as potential challenges across various domains must be carefully reviewed prior to implementation and scale-up of obstetric ultrasound technology in low-and middle-income countries (LMICs). MAIN BODY This narrative review discusses these issues for those trying to implement or scale-up ultrasound technology in LMICs. Issues addressed in this review include health personnel capacity, maintenance, cost, overuse and misuse of ultrasound, miscommunication between the providers and patients, patient diagnosis and care management, health outcomes, patient perceptions and concerns about fetal sex determination. CONCLUSION As cost of obstetric ultrasound becomes more affordable in LMICs, it is essential to assess the benefits, trade-offs and potential drawbacks of large-scale implementation. Additionally, there is a need to more clearly identify the capabilities and the limitations of ultrasound, particularly within the context of limited training of providers, to ensure that the purpose for which an ultrasound is intended is actually feasible. We found evidence of obstetric uses of ultrasound improving patient management. However, there was evidence that ultrasound use is not associated with reducing maternal, perinatal or neonatal mortality. Patients in various studies reported to have both positive and negative perceptions and experiences related to ultrasound and lastly, illegal use of ultrasound for determining fetal sex was raised as a concern.
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Affiliation(s)
- Eunsoo Timothy Kim
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC 27516 USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Carolina Square, Suite 210, 123 West Franklin St, Chapel Hill, NC 27516 USA
| | - Kavita Singh
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC 27516 USA
- MEASURE Evaluation, Carolina Population Center, University of North Carolina at Chapel Hill, Carolina Square, Suite 330, 123 West Franklin St, Chapel Hill, NC 27516 USA
| | - Allisyn Moran
- US Agency for International Development, 1300 Pennsylvania Avenue, NW, Washington, DC 20523 USA
| | - Deborah Armbruster
- US Agency for International Development, 1300 Pennsylvania Avenue, NW, Washington, DC 20523 USA
| | - Naoko Kozuki
- International Rescue Committee, 1730 M St. NW Suite 505, Washington, DC 20036 USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD 21205 USA
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Monitoring fetal growth in settings with limited ultrasound access. Best Pract Res Clin Obstet Gynaecol 2018; 49:29-36. [DOI: 10.1016/j.bpobgyn.2018.02.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 02/15/2018] [Indexed: 11/19/2022]
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Ahmadzia H, Cigna S, Namagembe I, Macri C, Galerneau F, Magriples U. Teaching obstetric ultrasound at Mulago Hospital - Kampala, Uganda. Afr Health Sci 2018; 18:166-171. [PMID: 29977270 PMCID: PMC6016987 DOI: 10.4314/ahs.v18i1.21] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Mulago Hospital is a high volume referral hospital under the Makerere University School of Medicine and Health Sciences. Basic obstetric ultrasound is a useful skill that can aid patient care. Objectives The purpose of the study was to assess the effectiveness of an intervention implemented to teach basic ultrasound skills to medical students and house officers at Mulago Hosptial, Kampala, Uganda. Methods Forty participants, including medical students, junior house officers (JHOs), and senior house officers (SHOs) were enrolled in the study. A didactic and practical hands-on teaching session was evaluated using a pre- and post-test that was administered to all participants. Results Participants included 12 medical students, 23 JHOs, and 5 SHOs. A significant difference in pre- and post-test scores was demonstrated in the medical students and JHOs (34% to 76%, p <0.0001) and this was retained when the results were stratified into the basic definitions and practical sections of the survey (33% to 71%, p<0.0001). The scores for the senior house officers had a mean increase of 2.3 points. Conclusion This original teaching intervention is an effective method to improve knowledge and skills for medical students and house officers at Mulago Hospital in the area of basic obstetric ultrasound.
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Affiliation(s)
- Homa Ahmadzia
- The George Washington University Medical Faculty Associates, Department of Obstetrics and Gynecology, 2150 Pennsylvania Avenue NW, Room 6A 412, Washington, DC 20037
- Yale University, New Haven, CT
| | - Sarah Cigna
- The George Washington University Medical Faculty Associates, Department of Obstetrics and Gynecology, 2150 Pennsylvania Avenue NW, Room 6A 412, Washington, DC 20037
| | | | - Charles Macri
- The George Washington University Medical Faculty Associates, Department of Obstetrics and Gynecology, 2150 Pennsylvania Avenue NW, Room 6A 412, Washington, DC 20037
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Haider SJA, diFlorio-Alexander R, Lam DH, Cho JY, Sohn JH, Harris R. Prospective Comparison of Diagnostic Accuracy Between Point-of-Care and Conventional Ultrasound in a General Diagnostic Department: Implications for Resource-Limited Settings. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2017; 36:1453-1460. [PMID: 28339133 DOI: 10.7863/ultra.16.06084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 09/29/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To compare the diagnostic accuracy of hand-held point-of-care (POC) versus conventional sonography in a general diagnostic setting with the intention to inform medical providers or clinicians on the rational use of POC ultrasound in resource limited settings. METHODS Over 3 months in 2010, 47 patients were prospectively enrolled at a single academic center to obtain 54 clinical conventional ultrasound examinations and 54 study-only POC ultrasound examinations. Indications were 48% abdominal, 26% retroperitoneal, and 24% obstetrical. Nine blinded readers (sonographers, residents, and attending radiologists) sequentially assigned diagnoses to POC and then conventional studies, yielding 476 interpreted study pairs. Diagnostic accuracy was obtained by comparing POC and conventional diagnoses to a reference diagnosis established by the unblinded, senior author. Analysis was stratified by study type, body mass index (BMI), diagnostic confidence, and image quality. RESULTS The mean diagnostic accuracy of conventional sonography was 84% compared with 74% for POC (P < .001). This difference was constant regardless of reader, exam type, or BMI. The sensitivity and specificity to detect abnormalities with conventional was 85 and 83%, compared with 75 and 68% for POC. The POC sonography demonstrated greater variability in image quality and diagnostic confidence, and this accounted for lower diagnostic accuracy. When image quality and diagnostic confidence were similar between POC and conventional examinations, there was no difference in accuracy. CONCLUSIONS Point-of-care was nearly as accurate as conventional sonography for basic, focused examinations. Observed differences in accuracy were attributed to greater variation in POC image quality.
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Affiliation(s)
- Steffen J A Haider
- Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | | | - David H Lam
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Joo Y Cho
- Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Jae Ho Sohn
- Department of Radiology & Biomedical Imaging, University of California San Francisco Medical Center, San Francisco, California, USA
| | - Robert Harris
- Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
- Human Resources and Health Program, Centre Hospitalier Universitaire, Kigali, Rwanda, Africa
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Wanyonyi SZ, Mariara CM, Vinayak S, Stones W. Opportunities and Challenges in Realizing Universal Access to Obstetric Ultrasound in Sub-Saharan Africa. Ultrasound Int Open 2017; 3:E52-E59. [PMID: 28596999 PMCID: PMC5462610 DOI: 10.1055/s-0043-103948] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 09/06/2016] [Accepted: 01/31/2017] [Indexed: 10/19/2022] Open
Abstract
The potential benefits of obstetric ultrasound have yet to be fully realized in sub-Saharan Africa (SSA), despite the region bearing the greatest burden of poor perinatal outcomes. We reviewed the literature for challenges and opportunities of universal access to obstetric ultrasound and explored what is needed to make such access an integral component of maternity care in order to address the massive burden of perinatal morbidity and mortality in SSA. Original peer-reviewed literature was searched in various electronic databases using a 'realist' approach. While the available data were inconclusive, they identify many opportunities for potential future research on the subject within the region that can help build a strong case to justify the provision of universal access to ultrasound as an integral component of comprehensive antenatal care.
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Affiliation(s)
| | | | | | - William Stones
- St Georgeʼs, University of London, Molecular & Clinical Sciences Research Institute and Medical college, University of Malawi
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Holmlund S, Ntaganira J, Edvardsson K, Lan PT, Semasaka Sengoma JP, Åhman A, Small R, Mogren I. Improved maternity care if midwives learn to perform ultrasound: a qualitative study of Rwandan midwives' experiences and views of obstetric ultrasound. Glob Health Action 2017; 10:1350451. [PMID: 28764602 PMCID: PMC5645676 DOI: 10.1080/16549716.2017.1350451] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 06/21/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Obstetric ultrasound has become an indispensable part of antenatal care worldwide. Although the use of ultrasound has shown benefits in the reduction of maternal and foetal morbidity and mortality, it has also raised many ethical challenges. Because of insufficient numbers of midwives in Rwanda, uncomplicated pregnancy care is usually provided by nurses in local health centres. Obstetric ultrasound is generally performed by physicians at higher levels of healthcare, where midwives are also more likely to be employed. OBJECTIVES To explore Rwandan midwives' experiences and views of the role of obstetric ultrasound in relation to clinical management, including ethical aspects. METHODS A qualitative study design was employed. Six focus group discussions were held in 2015 with 23 midwives working in maternity care in rural and urban areas of Rwanda, as part of the CROss Country Ultrasound Study (CROCUS). RESULTS Obstetric ultrasound was experienced as playing a very important role in clinical management of pregnant women, but participants emphasised that it should not overshadow other clinical examinations. The unequal distribution of ultrasound services throughout Rwanda was considered a challenge, and access was described as low, especially in rural areas. To increase the quality of maternity care, some advocated strongly for midwives to be trained in ultrasound and for physicians to receive additional training. In general, pregnant women were perceived both as requesting more ultrasound examinations than they received, and as not being satisfied with an antenatal consultation if ultrasound was not performed. CONCLUSIONS Obstetric ultrasound plays a significant role in maternity care in Rwanda. Increasing demand for ultrasound examinations from pregnant women needs to be balanced with medical indication and health benefits. Training of midwives to perform obstetric ultrasound and further training for physicians would help to address access to ultrasound for greater numbers of women across Rwanda. RESPONSIBLE EDITOR Virgilio Mariano Salazar Torres, Karolinska Institute, Sweden.
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Affiliation(s)
- Sophia Holmlund
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden
| | - Joseph Ntaganira
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Kristina Edvardsson
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden
- Judith Lumley Centre, La Trobe University, Melbourne, Australia
| | - Pham Thi Lan
- Department of Dermatology and Venereology, Hanoi Medical University, Hanoi, Vietnam
| | - Jean Paul Semasaka Sengoma
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Annika Åhman
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden
| | - Rhonda Small
- Judith Lumley Centre, La Trobe University, Melbourne, Australia
| | - Ingrid Mogren
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden
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Nathan RO, Swanson JO, Swanson DL, McClure EM, Bolamba VL, Lokangaka A, Pineda IS, Figueroa L, López-Gomez W, Garces A, Muyodi D, Esamai F, Kanaiza N, Mirza W, Naqvi F, Saleem S, Mwenechanya M, Chiwila M, Hamsumonde D, Wallace DD, Franklin H, Goldenberg RL. Evaluation of Focused Obstetric Ultrasound Examinations by Health Care Personnel in the Democratic Republic of Congo, Guatemala, Kenya, Pakistan, and Zambia. Curr Probl Diagn Radiol 2016; 46:210-215. [PMID: 28057388 PMCID: PMC5413583 DOI: 10.1067/j.cpradiol.2016.11.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 10/19/2016] [Accepted: 11/02/2016] [Indexed: 11/29/2022]
Abstract
Prior studies have suggested that obstetrical (OB) ultrasound in low- and middle-income countries has aided in detection of high-risk conditions, which in turn could improve OB management. We are participating in a cluster-randomized clinical trial of OB ultrasound, which is designed to assess the effect of basic OB ultrasound on maternal mortality, fetal mortality, neonatal mortality, and maternal near-miss in 5 low-income countries. We designed a 2-week course in basic OB ultrasound, followed by 12 weeks of oversight, to train health care professionals with no prior ultrasound experience to perform basic OB ultrasound to screen for high-risk pregnancies. All patients with high-risk pregnancies identified by the trainees were referred to higher-level health facilities where fully trained sonographers confirmed the diagnoses before any actions were taken. Although there have been several published studies on basic OB ultrasound training courses for health care workers in low- and middle-income countries, quality control reporting has been limited. The purpose of this study is to report on quality control results of these trainees. Health care workers trained in similar courses could have an adjunctive role in ultrasound screening for high-risk OB conditions where access to care is limited. After completion of the ultrasound course, 41 trainees in 5 countries performed 3801 ultrasound examinations during a 12-week pilot period. Each examination was reviewed by ultrasound trainers for errors in scanning parameters and errors in diagnosis, using predetermined criteria. Of the 32,480 images comprising the 3801 examinations, 94.8% were rated as satisfactory by the reviewers. There was 99.4% concordance between trainee and reviewer ultrasound diagnosis. The results suggest that trained health care workers could play a role in ultrasound screening for high-risk OB conditions.
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Affiliation(s)
- Robert O Nathan
- Department of Radiology, Harborview Medical Center, University of Washington Medical Center, Seattle, WA.
| | - Jonathan O Swanson
- Department of Radiology, Harborview Medical Center, University of Washington Medical Center, Seattle, WA.
| | - David L Swanson
- Department of Radiology, Harborview Medical Center, University of Washington Medical Center, Seattle, WA.
| | | | - Victor Lokomba Bolamba
- Department of Obstetrics, Kinshasa University, Kinshasa, Democratic Republic of the Congo.
| | - Adrien Lokangaka
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo.
| | - Irma Sayury Pineda
- Fundación para la Alimentación y Nutrición de Centro América y Panamá (FANCAP), Guatemala City, Guatemala.
| | - Lester Figueroa
- Fundación para la Alimentación y Nutrición de Centro América y Panamá (FANCAP), Guatemala City, Guatemala.
| | - Walter López-Gomez
- Department of Obstetrics and Gynecology, San Carlos University Medical School, Guatemala City, Guatemala.
| | - Ana Garces
- Fundación para la Alimentación y Nutrición de Centro América y Panamá (FANCAP), Francisco Marroquin University, Guatemala City, Guatemala.
| | - David Muyodi
- Department of Pediatrics, Moi University School of Medicine, Eldoret, Kenya.
| | - Fabian Esamai
- Department of Pediatrics, Moi University School of Medicine, Eldoret, Kenya.
| | - Nancy Kanaiza
- Sonographer, Department of Radiology, Moi University School of Medicine, Eldoret, Kenya.
| | - Waseem Mirza
- Department of Radiology, Aga Khan University, Karachi, Pakistan.
| | - Farnaz Naqvi
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan.
| | - Sarah Saleem
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan.
| | | | - Melody Chiwila
- Project Coordinator, Global Network for Women's and Children's Health Research, University Teaching Hospital, Lusaka, Zambia.
| | - Dorothy Hamsumonde
- Lead Sonographer, Radiology Department, University Teaching Hospital, Lusaka, Zambia.
| | - Dennis D Wallace
- Department of Statistics and Epidemiology, RTI International, Durham, NC.
| | - Holly Franklin
- Department of Statistics and Epidemiology, RTI International, Durham, NC.
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Crispín Milart PH, Diaz Molina CA, Prieto-Egido I, Martínez-Fernández A. Use of a portable system with ultrasound and blood tests to improve prenatal controls in rural Guatemala. Reprod Health 2016; 13:110. [PMID: 27618939 PMCID: PMC5020539 DOI: 10.1186/s12978-016-0237-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 09/01/2016] [Indexed: 11/16/2022] Open
Abstract
Background Maternal and neonatal mortality figures remain unacceptably high worldwide and new approaches are required to address this problem. This paper evaluates the impact on maternal and neonatal mortality of a pregnancy care package for rural areas of developing countries with portable ultrasound and blood/urine tests. Methods An observational study was conducted, with intervention and control groups not randomly assigned. Setting: Rural areas of the districts of Senahu, Campur and Carcha, in Alta Verapaz Department (Guatemala). The control group is composed by 747 pregnant women attended by the community facilitator, which is the common practice in rural Guatemala. The intervention group is composed by 762 pregnant women attended under the innovative Healthy Pregnancy project. That project strengthens the local prenatal care program, providing local nurses training, portable ultrasound equipment and blood and urine tests. The information of each pregnancy is registered in a medical exchange tool, and is later reviewed by a gynecology specialist to ensure a correct diagnosis and improve nurses training. Results No maternal deaths were reported within the intervention group, versus five cases in the control group. Regarding neonatal deaths, official data revealed a 64 % reduction for neonatal mortality. A 37 % prevalence of anemia was detected. Non-urgent referral was recommended to 70 pregnancies, being fetal malpresentation the main reported cause. Conclusion Impact data on maternal mortality (reduction to zero) and neonatal mortality (NMR was reduced to 36 %) are encouraging, although we are aware of the limitations of the study related to possible biasing and the small sample size. The major reduction of maternal and neonatal mortality provides promising prospects for these low-cost diagnostic procedures, which allow to provide high quality prenatal care in isolated rural communities of developing countries. Trial registration This research was not registered because it is an observational study where the assignment of the medical intervention was not at the discretion of the investigators.
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Affiliation(s)
| | | | - Ignacio Prieto-Egido
- EHAS Foundation, ESTI de Telecomunicación, Ciudad Univesitaria s/n, 28040, Madrid, Spain.
| | - Andrés Martínez-Fernández
- Higher Technical School of Telecommunications Engineering, Rey Juan Carlos University, Madrid, Spain
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Screening obstetric ultrasound training for a 5-country cluster randomized controlled trial. Ultrasound Q 2015; 30:262-6. [PMID: 25415862 DOI: 10.1097/ruq.0000000000000096] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
With decreased equipment cost, provision of ultrasound is now feasible in some low resource settings. Screening obstetric ultrasound may identify potential pregnancy complications and, with this knowledge, allow women to plan to deliver at the appropriate level of care. In this article, we describe a 10-day course with quality assurance activities to train ultrasound-naïve, nonphysician healthcare professionals at midlevel health facilities to perform screening obstetric ultrasound. Those trained will participate in a cluster randomized controlled trial to assess the impact of screening obstetric ultrasound on maternal and newborn outcomes.
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McClure EM, Nathan RO, Saleem S, Esamai F, Garces A, Chomba E, Tshefu A, Swanson D, Mabeya H, Figuero L, Mirza W, Muyodi D, Franklin H, Lokangaka A, Bidashimwa D, Pasha O, Mwenechanya M, Bose CL, Carlo WA, Hambidge KM, Liechty EA, Krebs N, Wallace DD, Swanson J, Koso-Thomas M, Widmer R, Goldenberg RL. First look: a cluster-randomized trial of ultrasound to improve pregnancy outcomes in low income country settings. BMC Pregnancy Childbirth 2014; 14:73. [PMID: 24533878 PMCID: PMC3996090 DOI: 10.1186/1471-2393-14-73] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 02/05/2014] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND In high-resource settings, obstetric ultrasound is a standard component of prenatal care used to identify pregnancy complications and to establish an accurate gestational age in order to improve obstetric care. Whether or not ultrasound use will improve care and ultimately pregnancy outcomes in low-resource settings is unknown. METHODS/DESIGN This multi-country cluster randomized trial will assess the impact of antenatal ultrasound screening performed by health care staff on a composite outcome consisting of maternal mortality and maternal near-miss, stillbirth and neonatal mortality in low-resource community settings. The trial will utilize an existing research infrastructure, the Global Network for Women's and Children's Health Research with sites in Pakistan, Kenya, Zambia, Democratic Republic of Congo and Guatemala. A maternal and newborn health registry in defined geographic areas which documents all pregnancies and their outcomes to 6 weeks post-delivery will provide population-based rates of maternal mortality and morbidity, stillbirth, neonatal mortality and morbidity, and health care utilization for study clusters. A total of 58 study clusters each with a health center and about 500 births per year will be randomized (29 intervention and 29 control). The intervention includes training of health workers (e.g., nurses, midwives, clinical officers) to perform ultrasound examinations during antenatal care, generally at 18-22 and at 32-36 weeks for each subject. Women who are identified as having a complication of pregnancy will be referred to a hospital for appropriate care. Finally, the intervention includes community sensitization activities to inform women and their families of the availability of ultrasound at the antenatal care clinic and training in emergency obstetric and neonatal care at referral facilities. DISCUSSION In summary, our trial will evaluate whether introduction of ultrasound during antenatal care improves pregnancy outcomes in rural, low-resource settings. The intervention includes training for ultrasound-naïve providers in basic obstetric ultrasonography and then enabling these trainees to use ultrasound to screen for pregnancy complications in primary antenatal care clinics and to refer appropriately. TRIAL REGISTRATION Clinicaltrials.gov (NCT # 01990625).
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Affiliation(s)
- Elizabeth M McClure
- Department of Statistics and Epidemiology, RTI International, Durham, NC, USA
| | - Robert O Nathan
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - Sarah Saleem
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Fabian Esamai
- Department of Pediatrics, Moi University School of Medicine, Eldoret, Kenya
| | - Ana Garces
- Francisco Marroquin University, Guatemala City, Guatemala
| | - Elwyn Chomba
- Department of Pediatrics, University Teaching Hospital, Lusaka, Zambia
| | - Antoinette Tshefu
- University of Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - David Swanson
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - Hillary Mabeya
- Department of Obstetrics, Moi University School of Medicine, Eldoret, Kenya
| | | | - Waseem Mirza
- Department of Radiology, Aga Khan University, Karachi, Pakistan
| | - David Muyodi
- Department of Pediatrics, Moi University School of Medicine, Eldoret, Kenya
| | | | - Adrien Lokangaka
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | | | - Omrana Pasha
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | | | - Carl L Bose
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Waldemar A Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - K Michael Hambidge
- Department of Pediatrics, University of Colorado Health Care System, Denver, CO, USA
| | - Edward A Liechty
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nancy Krebs
- Department of Pediatrics, University of Colorado Health Care System, Denver, CO, USA
| | - Dennis D Wallace
- Department of Statistics and Epidemiology, RTI International, Durham, NC, USA
| | - Jonathan Swanson
- Department of Radiology, University of Washington, Seattle, WA, USA
| | | | | | - Robert L Goldenberg
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
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