Sub-optimal use of ultrasound examinations may result in underperformance of Vietnamese maternity care - A qualitative study of midwives' experiences and views

Childbearing Women's Experiences of and Interactions With the Health System in Vietnam: A Critical Interpretive Synthesis

Scholars have long argued that the care experience is shaped by context, and by evolutions in this context. Using Vietnam as a case, we critically interrogate the literature on women's experiences with maternity care to unpack whether and if it engages with the major social, economic, and health system impacts of the Doi Moi reforms in Vietnam and with what consequences for equity. We conducted a critical interpretive synthesis of this literature in light of the social, economic, and health system transformations driven by the Doi Moi reforms. We offer three critiques: (1) an overwhelming focus on public maternity care provision in rural/mountainous regions of Vietnam, (2) a narrow focus on women's ethnic identity, and (3) a misplaced preoccupation with women's limited autonomy and agency. We argue that future research needs to consider the impact of Vietnam's shift towards market-oriented care provision, and the broader societal and health system changes impacting both rural and urban areas, as well as ethnic minority and Kinh majority populations.

"A Picture Paints a Thousand Words"-A Systematic Review of the Ethical Issues of Prenatal Ultrasound

Prenatal ultrasound is a non-invasive diagnostic examination. Despite the recognized diagnostic value, this technology raises complex ethical questions. The aim of this study is to provide a comprehensive analysis that coherently maps the ethical challenges raised by prenatal ultrasound examination, both 2D and 3D. We performed a systematic literature review. Six databases were systematically searched. The results highlight how concerns related to beneficence, informed consent, and autonomy are mainly related to routine use of prenatal ultrasound in the clinical context, while considerations linked to overmedicalization of pregnancy, discrimination, and fetal ontology were often reported in relation to the impact ultrasound is having on medicine and society. Ethical issues in the context of pre-abortion ultrasound, obstetric practices in low-income settings, and keepsake ultrasound imaging were also greatly discussed. Since prenatal ultrasound practices critically impact pregnant people's autonomy and their role within pregnancy, we conclude that information providing strategies should be developed to appropriately inform pregnant people about the nature, purpose, risks, and choices revolving around prenatal ultrasound. In addition, as it is becoming increasingly difficult to separate the social and clinical dimensions of prenatal ultrasound, future research should focus on examining if and how such dimensions should be reconciled.

The best healthcare (commodity) available (for purchase): provider-induced demand for obstetric ultrasonography among ethnic minority women in rural northern Vietnam

Despite Vietnam's overall progress on maternal health indicators, marginalized ethnic minorities in remote areas face lower access to antenatal care and higher maternal mortality rates relative to the Kinh (majority ethnic group). Last year, we conducted fieldwork for 2 qualitative research projects that aimed to address maternal health inequities among pregnant ethnic minority women in rural Northern Vietnam. Although not the focus of our research, the use of ultrasonography services at for-profit private clinics was ubiquitous in participants' healthcare-seeking accounts. Ultrasound scans from for-profit clinics were a major component of ethnic minority women's antenatal care: many purchased 8 to 10 scans during pregnancy at $6.15 US dollars per scan, despite their limited agricultural income of $120 to $205 per month. Women were unaware of how many scans were recommended and their medically indicated scheduling, but purchased frequent scans to assuage pregnancy anxieties and access what they experienced as the highest-quality antenatal service. In tandem, for-profit ultrasonography providers offered broader opening hours, immediate results, and rich technological scans, which seemed to deliver poor families the most tangible "value" for their hard-earned money. Previous literature documented the concerning overuse of ultrasonography among Kinh women in urban Vietnam: What are the implications of this trend extending to affect rural-dwelling ethnic minority women who face lower education, economic marginalization, and a 4-fold higher maternal mortality rate? Our findings raise concerns related to safety, financial vulnerability and provider-induced demand, and broader health policy questions regarding healthcare commodities in low-resource settings. Critically, there is no evidence of the effect of obstetrical ultrasound on reducing maternal mortality in low- and middle-income countries, and its excess use could burden available resources and detract from evidence-based services. Our findings suggest that health system gaps are driving poor women toward frequent purchases of a single insufficient maternal health commodity: this will not improve their pregnancy outcomes or health equity for marginalized ethnic minorities. We argue that addressing this overuse of ultrasonography due to provider-induced demand requires a multipronged response that meets women's growing expectations. Our findings highlight the need for investment in health education, health promotion, and reliable high-quality public maternal healthcare for ethnic minority communities in Vietnam.

Ultrasound imaging and the culture of pregnancy management in low-and middle-income countries: A systematic review

BACKGROUND

Obstetric ultrasound imaging is a relatively new, but rapidly expanding, technology in low- and middle-income countries (LMICs). Given that new technologies modify practices, the influence of ultrasound on pregnancy management in LMICs is not comprehensively understood.

OBJECTIVES

To map how ultrasound technology may be modulating the culture of pregnancy management in LMICs.

SEARCH STRATEGY

A search of five databases up to November 18, 2022.

SELECTION CRITERIA

Original, peer-reviewed articles from LMICs, published in English from 2000 to 2022.

DATA COLLECTION AND ANALYSIS

All articles were assessed for quality using the GRADE approach. Data were analyzed thematically to generate new interpretive constructs and explanations.

RESULTS

Forty articles involving 113 000 respondents suggests that obstetric ultrasound is becoming the preferred method of pregnancy surveillance, replacing clinically important components of prenatal care. Mothers overestimate ultrasound as an all-powerful diagnostic and "therapeutic" tool that can deliver the perfect baby. For-profit providers are driving medically unnecessary scans while the poor do not receive the recommended scans.

CONCLUSION

Ultrasound technology has modified the culture of pregnancy management in LMICs in unintended and possibly harmful ways. Private health services are pushing the detrimental trends. Limitations include generalizability of qualitative studies and insufficient attention to inequities.

First and second trimester ultrasound in pregnancy: A systematic review and metasynthesis of the views and experiences of pregnant women, partners, and health workers

Background

The World Health Organization (WHO) recommends one ultrasound scan before 24 weeks gestation as part of routine antenatal care (WHO 2016). We explored influences on provision and uptake through views and experiences of pregnant women, partners, and health workers.

Methods

We undertook a systematic review (PROSPERO CRD42021230926). We derived summaries of findings and overarching themes using metasynthesis methods. We searched MEDLINE, CINAHL, PsycINFO, SocIndex, LILACS, and AIM (Nov 25th 2020) for qualitative studies reporting views and experiences of routine ultrasound provision to 24 weeks gestation, with no language or date restriction. After quality assessment, data were logged and analysed in Excel. We assessed confidence in the findings using Grade-CERQual.

Findings

From 7076 hits, we included 80 papers (1994–2020, 23 countries, 16 LICs/MICs, over 1500 participants). We identified 17 review findings, (moderate or high confidence: 14/17), and four themes: sociocultural influences and expectations; the power of visual technology; joy and devastation: consequences of ultrasound findings; the significance of relationship in the ultrasound encounter. Providing or receiving ultrasound was positive for most, reportedly increasing parental-fetal engagement. However, abnormal findings were often shocking. Some reported changing future reproductive decisions after equivocal results, even when the eventual diagnosis was positive. Attitudes and behaviours of sonographers influenced service user experience. Ultrasound providers expressed concern about making mistakes, recognising their need for education, training, and adequate time with women. Ultrasound sex determination influenced female feticide in some contexts, in others, termination was not socially acceptable. Overuse was noted to reduce clinical antenatal skills as well as the use and uptake of other forms of antenatal care. These factors influenced utility and equity of ultrasound in some settings.

Conclusion

Though antenatal ultrasound was largely seen as positive, long-term adverse psychological and reproductive consequences were reported for some. Gender inequity may be reinforced by female feticide following ultrasound in some contexts. Provider attitudes and behaviours, time to engage fully with service users, social norms, access to follow up, and the potential for overuse all need to be considered.

A Curriculum Model for Multidisciplinary Training of Midwife Sonographers in a Low Resource Setting

In many low-resource settings, less than 5% of pregnant women can access ultrasound during pregnancy. Thus, gestational age is often difficult to determine, multiple pregnancies are diagnosed late and foetal and pregnancy-related anomalies can go undetected. A pilot solution was designed beyond the traditional approach of increasing numbers of qualified radiologists, gynaecologists and sonographers. An innovative Human Resource for Health (HRH) task sharing, and maternal child health (MCH) workforce training and capacity building initiative was designed, involving development and testing of a curriculum to train midwife sonographers via a teleradiology innovation platform and a partnership between specialist radiologists, sonographers and midwives. The setting was a tertiary-level private university hospital in Nairobi with implementation in three outreach locations. Direct oversight, support and supervision of specialist radiologists and ultrasonographers effectively addressed issues of quality and safety across the 3-week training period and project implementation. Concepts from sociocultural learning theory informed an initial interactive e-learning module for each midwife at their respective site. Midwives were introduced to ultrasound equipment with a series of didactic and interactive lectures delivered by an expert sonographer at the tertiary hospital teaching site. Lectures were supported by hands-on practical experience, role modelling and mentoring over a four-week period. Assessments included both written examination and practical assessment with an exit examination requiring demonstration of competency in both written and practical format. Final confirmation of scanning accuracy was confirmed with post-delivery verification of results. The pilot was highly successful with an image interpretation accuracy of 99.63% for the midwives. Lessons from this initiative provides guidance in the curriculum development process along with a curriculum outline; pedagogical framework; teaching methods; assessment processes; credentialing; resourcing; and other considerations in scaling up the program. Importantly, the paper details processes for maintaining a high level of quality control and patient safety.