Symphysis-fundus growth measurement followed by umbilical artery Doppler velocimetry to screen for placental insufficiency

Introducing a Mobile-Connected Umbilical Doppler Device (UmbiFlow™) into a Primary Care Maternity Setting: Does This Reduce Unnecessary Referrals to Specialised Care? Results of a Pilot Study in Kraaifontein, South Africa

OBJECTIVES

UmbiFlow™ is a mobile-connected Doppler device that utilises a continuous waveform to measure resistance in the umbilical artery. The main aim of this pilot study was to determine whether the use of UmbiFlow™ for umbilical artery Doppler in patients with a suspected decreased symphysis fundal (SF) growth could safely lead to a decreased number of patients requiring referral to a more specialised level of care. A secondary aim of the study was to evaluate the effectiveness of UmbiFlow™ Doppler as a screening tool for concealed placental insufficiency in late bookers by using a single screening cut-off value that will be abnormal for any gestation >28 weeks.

METHODS

The cohort comprised two groups of patients: The first group included all follow-up patients with suspected intra-uterine growth restriction (a decreased symphysis-fundus measurement based on serial assessment) who underwent on-site UmbiFlow™Doppler testing performed by the midwife directly after the clinical examination. The second group included late bookers, where gestation was uncertain; but estimated >28 weeks based on clinical grounds. This group was comprised of unselected patients who report to antenatal care late for the first time and received an UmbiFlow™Doppler test for concealed placental insufficiency.

RESULTS

UmbiFlow™Doppler could reduce the number of false referrals to hospital by 55%. A single UmbiFlow™Doppler test in late bookers appeared to identify a group of women at moderate risk of lower birth weight babies.

Randomised controlled trial of two antenatal care models in rural Zimbabwe

OBJECTIVE

To compare a five-visit antenatal care (ANC) model with specified goals with the standard model in a rural area in Zimbabwe.

DESIGN

Cluster randomised controlled trial with the clinic as the randomisation unit.

SETTING

Primary care setting in a developing country where care was provided by nurse-midwives.

POPULATION

Women booking for ANC in the clinics were eligible.

MAIN OUTCOME MEASURES

Number of antenatal visits, antepartum and intrapartum referrals, utilization of health centre for delivery and perinatal outcomes.

METHODS

Twenty-three rural health centres were stratified prior to random allocation to the new (n = 11) or standard (n = 12) model of care.

RESULTS

We recruited 13,517 women (new, n = 6897 and standard, n = 6620) in the study, and 78% (10,572) of their pregnancy records were retrieved. There was no difference in median maternal age, parity and gestational age at booking between women in the standard model and those in the new model. The median number of visits was four for both models. The proportion of women with five or less visits was 77% in the new and 69% in the standard model (OR 1.5; 95% CI 1.08-2.2). The likelihood of haemoglobin testing was higher in the new model (OR 2.4; 95% CI 1.0-5.7) but unchanged for syphilis testing. There were fewer intrapartum transfers (5.4 versus 7.9% [OR 0.66; 95% CI 0.44-0.98]) in the new model but no difference in antepartum or postpartum transfers. There was no difference in rates of preterm delivery or low birthweight. The perinatal mortality was 25/1000 in standard model and 28/1000 in new model.

CONCLUSION

In Gutu district, a focused five-visit schedule did not change the number of contacts but was more effective as expressed by increased adherence to procedures and better use of institutional health care.