The commodification of obstetric ultrasound scanning in Hanoi, Viet Nam

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.

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.

Preference and Disclosure of Fetal Gender to Pregnant Women during Prenatal Ultrasonography in South South Nigeria

BACKGROUND

Ultrasound scan (USS) in pregnancy has become a common diagnostic tool used in the assessment of pregnancy in recent time. In the course of routine pregnancy assessment using USS, some pregnant women will request to know the sex of their unborn babies. Their reasons for wanting to know the gender of their baby could be either for social reason like planning for an unborn child or their desire for a preferred gender.

AIM

The aim of the study was to evaluate gender preferences and disclosure of foetal sex at prenatal USS.

METHODS

This was a cross-sectional study conducted at the antenatal clinic of Central Hospital Agbor, Delta State, Nigeria. A total of 235 consecutive consenting women who came for antenatal care (ANC) registration were recruited for the study after obtaining their informed written consent. Questionnaire was used to seek for their sociodemographic characteristics, preference and desires for foetal gender disclosure, reasons for gender disclosure, and awareness of USS accuracy for gender determination.

RESULTS

The desire to know the sex of baby was high (99.6%). The major reason for wanting to know the sex of baby was to plan for the unborn child (47.7%) and maternal curiosity (37.0%). Majority of the women (57.4%) had no gender preference. Sixty percent (60%) were not aware that USS sex diagnosis could be wrong.

CONCLUSION

There is a strong desire by pregnant women to know the sex of their babies at routine USS. Considering the fact that many of the women were not aware that there could be wrong diagnosis at prenatal ultrasound, it is suggested that adequate counselling be given before fetal sex disclosure.

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.

Overdiagnosis and overuse of diagnostic and screening tests in low-income and middle-income countries: a scoping review

OBJECTIVE

Overdiagnosis and overuse of healthcare services harm individuals, take resources that could be used to address underuse, and threaten the sustainability of health systems. These problems are attracting increasing attention in low-income and middle-income countries (LMICs). Unaware of any review of relevant evidence, we conducted a scoping review of the evidence around overdiagnosis and overuse of diagnostic and screening tests in LMICs.

DESIGN

Scoping review.

METHODS

We searched PubMed, Embase, PsycINFO, Global Index Medicus for relevant studies published until 24 May 2021, with no restrictions on date or language. We categorised included studies by major focus (overdiagnosis, overuse of tests, or both) and main themes (presence or estimates of extent; drivers; consequences and solutions).

RESULTS

We identified 2763 unique records and included 162 articles reporting on 154 studies across 55 countries, involving over 2.8 million participants and/or requests for tests. Almost half the studies focused on overdiagnosis (70; 45.5%), one-third on overuse of tests (61; 39.6%) and one-fifth on both (23; 14.9%). Common overdiagnosed conditions included malaria (61; 39.6%) and thyroid cancer (25; 16.2%), estimated to be >70% in China. Overused tests included imaging (n=25 studies) such as CT and MRI; laboratory investigations (n=18) such as serological tests and tumour markers; and procedures (n=14) such as colonoscopy. Drivers included fear of conflict with patients and expanding disease definitions. Common consequences included unnecessary treatments such as antimalarials, and wasted resources, with costs of malaria overdiagnosis estimated at US$86 million in Sudan in 1 year alone. Only 9% of studies discussed solutions, which included addressing inappropriately lowered diagnostic thresholds and reforming test-ordering processes.

CONCLUSIONS

Overdiagnosis and overuse of tests are widespread in LMICs and generate significant harm and waste. Better understanding of the problems and robust evaluation of solutions is needed, informed by a new global alliance of researchers and policy-makers.

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

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.

Pregnant women's knowledge, attitude, and associated factors toward obstetric ultrasound in public hospitals, Ethiopia, 2021: Multi-centered cross-sectional study

BACKGROUND

Obstetric ultrasound is a harmless, cheap, and noninvasive imaging modality that helps to scan a pregnant mother and delivers parents with a real-time image of the fetus. As the number of pregnancies rises globally, the demand for obstetric ultrasound becomes even more pressing.

OBJECTIVES

To assess pregnant women's knowledge, attitude, and associated factors toward obstetric ultrasound in public hospitals, Ethiopia.

METHODS

Institutional based cross-sectional study was employed. Systematic random technique was used to select 419 pregnant women from 10 April 2021 through 2 June 2021. A structured questionnaire was used to collect data during a face-to-face interview. Then the data were coded, cleaned, and entered into Epidemiological data version (EPIDATA) 3.1 and exported to the statistical package for Social Science version 23.0 for analyses. Bivariate and multivariable logistic regression model was used to identify statistically significant associations between dependent and independent variables. The odds ratio at 95% confidence interval with p-value 0.05% was considered statistically significant.

RESULT

The majority of the study participants, 179 (42.8%), have ages ⩾ 25 years. Magnitude of having good knowledge and positive attitude of pregnant women toward obstetric ultrasound was 35.5% and 69.5%, respectively. Residence (adjusted odds ratio: 3.934; 95% confidence interval: 3.125-6.761), educational status (adjusted odds ratio: 3.614; 95% confidence interval: 1.986-5.964), and parity (adjusted odds ratio: 2.7621; 95% confidence interval: 1.68-3.275) were significantly associated with knowledge. Whereas exposure to obstetrical ultrasound in current pregnancy (adjusted odds ratio: 2.726; 95% confidence interval: 1.632-3.629), knowledge on obstetrical ultrasound (adjusted odds ratio: 3.92; 95% confidence interval: 1.324-3.120), and educational status (adjusted odds ratio: 2.84; 95% confidence interval: 1.337-3.381) were significantly associated with attitude.

CONCLUSION

The level of good knowledge and positive attitude toward obstetric ultrasound was 35.5% and 69.5%, respectively, and it can be improved with appropriate interventions like ensuring the practice of obstetric ultrasound scan to all antenatal women. Obstetric care providers at the antenatal care units should advice pregnant women for obstetric ultrasound scan as per World Health Organization recommendations of one obstetric ultrasound scan before 24 weeks of gestation.

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.

Audit of the appropriateness of the indication for obstetric sonography in a tertiary facility in Ghana

INTRODUCTION

the use of ultrasound is one of the most vital tools in the management of pregnancies and contributes significantly in improving maternal and child health. Certain indications in pregnancy, guide the obstetrician as to which obstetric scan deems appropriate. The full realization of the benefits of ultrasound depends on whether it is being used appropriately or not, and hence this study aimed at auditing for the appropriate indications for obstetric ultrasound.

METHODS

a review of all request forms for obstetric scan between June 2019 and July 2020 was performed to assess the appropriateness of requests for obstetric ultrasound at the Cape Coast Teaching Hospital. The data obtained was analyzed using SPSS (SPSS Inc. Chicago, IL version 20.0). A Chi-squared test of independence was used to check for statistically significant differences between variables at p ≤ 0.05.

RESULTS

three hundred and fourteen (314) out of the 527 request forms had clinical indications stated. 174 (81.7%) of requests from Cape Coast Teaching Hospital and 39 (18.3%) from other health centers did not indicate patients clinical history/indication on the request forms. Majority 76 (68.5%) of scans in the first trimester were done without indications/history. Only 29 of requests with clinical history were inappropriate.

CONCLUSION

practitioners should be mindful of adequately completing request forms for obstetric investigations since a large number of practitioners do not state the history/indications for the scans. There should be continuous medical education on the importance of appropriate indication for obstetric ultrasound.

Sex ratio at birth in Vietnam among six subnational regions during 1980-2050, estimation and probabilistic projection using a Bayesian hierarchical time series model with 2.9 million birth records

The sex ratio at birth (SRB, i.e., the ratio of male to female births) in Vietnam has been imbalanced since the 2000s. Previous studies have revealed a rapid increase in the SRB over the past 15 years and the presence of important variations across regions. More recent studies suggested that the nation's SRB may have plateaued during the 2010s. Given the lack of exhaustive birth registration data in Vietnam, it is necessary to estimate and project levels and trends in the regional SRBs in Vietnam based on a reproducible statistical approach. We compiled an extensive database on regional Vietnam SRBs based on all publicly available surveys and censuses and used a Bayesian hierarchical time series mixture model to estimate and project SRB in Vietnam by region from 1980 to 2050. The Bayesian model incorporates the uncertainties from the observations and year-by-year natural fluctuation. It includes a binary parameter to detect the existence of sex ratio transitions among Vietnamese regions. Furthermore, we model the SRB imbalance using a trapezoid function to capture the increase, stagnation, and decrease of the sex ratio transition by Vietnamese regions. The model results show that four out of six Vietnamese regions, namely, Northern Midlands and Mountain Areas, Northern Central and Central Coastal Areas, Red River Delta, and South East, have existing sex imbalances at birth. The rise in SRB in the Red River Delta was the fastest, as it took only 12 years and was more pronounced, with the SRB reaching the local maximum of 1.146 with a 95% credible interval (1.129, 1.163) in 2013. The model projections suggest that the current decade will record a sustained decline in sex imbalances at birth, and the SRB should be back to the national SRB baseline level of 1.06 in all regions by the mid-2030s.

Achieving universal access to obstetric ultrasound in resource constrained settings: A narrative review

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.

Perception of Ghanaian Primigravidas Undergoing Their First Antenatal Ultrasonography in Cape Coast

Ultrasound scans have become an essential requirement of pregnancy care in countries with developed health services and increasingly being used in medical practice in Ghana as well. The aim of this study was to find out the perception of primigravidas experiencing antenatal ultrasonography for the first time in Cape Coast. This was a descriptive, prospective study which employed the use of a questionnaire to obtain data from 384 consented respondents, who were primigravidas experiencing antenatal ultrasonography for the first time in three selected public health facilities in Cape Coast Metropolis over a six-month period. Sociodemographic data, reasons for undergoing antenatal ultrasound, their expectations, knowledge in fetal abnormalities, and suggestions to help improve their future experiences were collected. The data were analyzed using SPSS software, version 20.0 (SPSS Inc., Chicago, IL, USA). Out of a total number of 384 respondents, 87.8% of them knew about what ultrasound is used for. 87.5% scanned because a doctor or midwife requested for the scan whilst 53.9% scanned to check for fetal abnormalities. 98.4% indicated that ultrasound scanning has positive effects on pregnancy outcome. An expensive service was stated as a negative reason that would influence the decision to undergo the examination next time; nonetheless, 90.4% would recommend it to other women and suggested showing the fetus on monitor while scanning and providing accurate findings would make their future experiences better. The perception of the primigravidas was largely positive. Checking for fetal abnormalities was a major reason for the scans, although their knowledge in specific fetal abnormalities was low. They expected to know the fetal sex, but that was not a major reason for scanning. Showing them the monitor was the most frequent suggestion to make future experience better.

Situating Moral Agency: How Postphenomenology Can Benefit Engineering Ethics

This article identifies limitations in traditional approaches to engineering ethics pedagogy, reflected in an overreliance on disaster case studies. Researchers in the field have pointed out that these approaches tend to occlude ethically significant aspects of day-to-day engineering practice and thus reductively individualize and decontextualize ethical decision-making. Some have proposed, as a remedy for these defects, the use of research and theory from Science and Technology Studies (STS) to enrich our understanding of the ways in which technology and engineering practice are intricated in social and institutional contexts. While endorsing this approach, this article also argues that STS scholarship may not sufficiently address the kinds of questions about normativity and agency that are essential to engineering ethics. It proposes making use of the growing body of research in a field called "postphenomenology," an approach that combines STS research with the traditional phenomenological concern with the standpoint of lived-experience. Postphenomenology offers a method of inquiry that combines STS's investigation into social and institutional dimensions of technology with phenomenological reflection on our lived experience of embodied engagement with technical objects and sociotechnical systems, particularly the ways in which these involvements affect our moral perception and agency. The aim in using this approach in engineering ethics is thus to illuminate moral dimensions of everyday professional life of which practitioners may not typically be aware. The article concludes with some concrete curricular interventions for engineering ethics classrooms.

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

OBJECTIVE

To explore Vietnamese midwives' experiences and views on the role of obstetric ultrasound in relation to clinical management, including ethical aspects.

METHODS

Using a qualitative design, content analysis of focus group discussions with midwives (N = 25) working at Departments of Obstetrics and Gynecology at three hospitals in urban, semi-urban and rural parts of Hanoi were performed.

RESULTS

Obstetric ultrasound was reported as being a highly valuable tool, although replacing ordinary antenatal care surveillance with ultrasound examinations and misuse of ultrasound without medical indication was perceived as troubling. Participants generally viewed the fetus as a human being already at an early stage of pregnancy. However, when complications occurred, the pregnant woman's health was mostly prioritised.

CONCLUSION

Although the use of ultrasound has many benefits during pregnancy, replacing ordinary antenatal care surveillance with ultrasound examinations and misuse of ultrasound without medical indication is concerning and needs to be addressed. There is also a need to communicate the benefits of adequate antenatal care to pregnant women and caution about the non-beneficial use of repeated ultrasound examinations without medical indication. Additionally, non-medical ultrasounds consume limited healthcare resources and its use needs to be better regulated in Vietnam.

Health professionals' experiences and views on obstetric ultrasound in Vietnam: a regional, cross-sectional study

OBJECTIVES

Obstetric ultrasound is an important part of antenatal care in Vietnam, although there are great differences in access to antenatal care and ultrasound services across the country. The aim of this study was to explore Vietnamese health professionals' experiences and views of obstetric ultrasound in relation to clinical management, resources and skills.

DESIGN

A cross-sectional questionnaire study was performed as part of the CROss Country UltraSound study.

SETTING

Health facilities (n=29) in urban, semiurban and rural areas of Hanoi region in Vietnam.

PARTICIPANTS

Participants were 289 obstetricians/gynaecologists and 535 midwives.

RESULTS

A majority (88%) of participants agreed that 'every woman should undergo ultrasound examination' during pregnancy to determine gestational age. Participants reported an average of six ultrasound examinations as medically indicated during an uncomplicated pregnancy. Access to ultrasound at participants' workplaces was reported as always available regardless of health facility level. Most participants performing ultrasound reported high-level skills for fetal heart rate examination (70%), whereas few (23%) reported being skilled in examination of the anatomy of the fetal heart. Insufficient ultrasound training leading to suboptimal pregnancy management was reported by 37% of all participants. 'Better quality of ultrasound machines', 'more physicians trained in ultrasound' and 'more training for health professionals currently performing ultrasound' were reported as ways to improve the utilisation of ultrasound.

CONCLUSIONS

Obstetric ultrasound is used as an integral part of antenatal care at all selected health facility levels in the region of Hanoi, and access was reported as high. However, reports of insufficient ultrasound training resulting in suboptimal pregnancy management indicate a need for additional training of ultrasound operators to improve utilisation of ultrasound.

Magnitude and correlates of caesarean section in urban and rural areas: A multivariate study in Vietnam

Caesarean section (CS) can prevent maternal and neonatal mortality and morbidity. However, it involves risks and high costs that can be a burden, especially in low and middle income countries. The aim of this study is to assess its magnitude and correlates among women of reproductive age in the urban and rural areas of Vietnam. We analyzed microdata from the national Multiple Indicator Cluster Survey (MICS) conducted in 2014 by using a representative sample of households at the national level in both urban and rural areas. A total of 1,350 women who delivered in institutional settings in the two years preceding the survey were included. Frequency and percentage distributions of the variables were performed. Bivariate and multivariate logistic regression analyses were undertaken to identify the factors associated with CS. Odds ratios with a 95% confidence interval were used to ascertain the direction and strength of the associations. The overall CS rate among the women who delivered in healthcare facilities in Vietnam has rapidly increased and reached a high level (29.2%). After controlling for significant characteristics, living in urban areas doubles the likelihood of undergoing a CS (OR = 1.98; 95% CI 1.48 to 2.67). Maternal age at delivery over 35 years is a major positive correlate of CS. Beyond this common phenomenon, different distinct lines of socioeconomic and demographic cleavage operate in urban compared with rural areas. The differences regarding the correlates of CS according to the place of residence suggest that specific measures should be taken in each setting to allow women to access childbirth services that are appropriate to their needs.

Obstetric ultrasound use in low and middle income countries: a narrative review

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.

High prevalence of cesarean section births in private sector health facilities- analysis of district level household survey-4 (DLHS-4) of India

Background

Worldwide rising cesarean section (CS) births is an issue of concern. In India, with increase in institutional deliveries there has also been an increase in cesarean section births. Aim of the study is to quantify the prevalence of cesarean section births in public and private health facility, and also to determine the factors associated with cesarean section births.

Methods

We analyzed data from district level household survey data 4 (DLHS-4) combined individual level dataset for 19 states/UTs of India comprising 24,398 deliveries resulting in 22,111 live births for year 2011. The percentages and Chi-square has been computed for the select variables viz. Socio demographic, maternal, antenatal care and delivery related based on type of births (CS Vs normal births). The multiple logistic regression model has been used to identify the potential risk factors associated with CS births.

Results

Of 22,111 live birth analyzed 49.2% were delivered at public sector, 31.9% at private sector and 18.9% were home deliveries. Prevalence of CS births were 13.7% (95% CI; 13.0- 14.3%) and 37.9% (95% CI; 36.7- 39.0%) in the public and private sectors, respectively. Higher odds of CS births were observed with- delivery at private health facility (OR 3.79; 95% C.I 3.06-4.72), urban residence (OR 1.15; 95% C.I 1.00- 1.35), first delivery after 35 years of maternal age (OR 5.5; 95% C.I 1.85- 16.4), hypertension in pregnancy (OR 1.32; 95% C.I 1.06- 1.65) and breach presentation (OR 2.37; 95% C.I. 1.63- 3.43).

Conclusions

Our findings shows that CS births are nearly three times more in private as compared to public sector health facilities.The higher rates of CS births, especially in private sector, not only increase the cost of care but may pose unnecessary risks to women (when there is no indications for CS). The government of India need to take measures to strengthen existing public health facilities as well as ensure that cesarean sections are performed based upon medical indications in both public and private sector health facilities.

Ultrasound as a technology of reassurance? How pregnant women and health care professionals articulate ultrasound reassurance and its limitations

The premise that ultrasound technologies provide reassurance for pregnant women is well-rehearsed. However, there has been little research about how this reassurance is articulated and understood by both expectant mothers and health care professionals. In this article, we draw on two qualitative UK studies to explore the salience of ultrasound reassurance to women's pregnancy experiences whilst highlighting issues around articulation and silence. Specifically, we capture how expectant parents express a general need for reassurance and how visualisation and the conduct of professionals have a crucial role to play in accomplishing a sense of reassurance. We also explore how professionals have ambiguities about the relationship between ultrasound and reassurance, and how they subsequently articulate reassurance to expectant mothers. By bringing two studies together, we take a broad perspectival view of how gaps and silences within the discourse of ultrasound reassurance leave the claims made for ultrasound as a technology of reassurance unchallenged. Finally, we explore the implications this can have for women's experiences of pregnancy and health care professionals' practices.

Opportunities and Challenges in Realizing Universal Access to Obstetric Ultrasound in Sub-Saharan Africa

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.

The claim that China's fertility restrictions contributed to the use of prenatal sex selection: A sceptical reappraisal

Most observers assume that China's fertility restrictions contribute to the use of prenatal sex selection. I question the logic and evidence underlying that assumption. Experts often stress that China's low fertility is largely voluntary, and that fertility restrictions are an unneeded safety valve. Others claim that China's '1.5-child' loophole, common throughout rural areas, reinforces son preference or intensifies prenatal sex discrimination by hardening fertility constraints. These claims defy logic upon closer examination. Moreover, almost two-thirds of the exceptional distortion of the sex ratio in 1.5-child areas results from excess underreporting of daughters and enforced sex-specific stopping. Prenatal sex selection may explain the remaining third but probably reflects the stronger rural son preference that led to the 1.5-child loophole itself. The recent surge in sex selection of first births that has perpetuated the distortions also seems unrelated to policy. Some son-preferring parents who formerly wanted two children may now genuinely want only one.

Improved maternity care if midwives learn to perform ultrasound: a qualitative study of Rwandan midwives' experiences and views of obstetric ultrasound

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.

Community survey on awareness and use of obstetric ultrasonography in rural Sarlahi District, Nepal

OBJECTIVE

To assess levels of awareness and use of obstetric ultrasonography in rural Nepal.

METHODS

Between March 2014 and March 2015, a cross-sectional survey was conducted among married women aged 15-40years residing in rural Sarlahi District, Nepal, regarding their knowledge and use of obstetric ultrasonography during their most recent pregnancy. Regression analyses were conducted to identify reproductive health, socioeconomic, and other characteristics that increased the likelihood of undergoing an obstetric ultrasonographic examination.

RESULTS

Among 6182 women, 1630 (26.4%) had undergone obstetric ultrasonography during their most recent pregnancy, of whom 1011 (62.0%) received only one examination. Odds of receiving an ultrasonographic examination were higher among women with post-secondary education than among those with none (≥11years' education: adjusted odds ratio [aOR] 10.28, 95% confidence interval [CI] 5.55-19.04), and among women whose husbands had post-secondary education than among those with husbands with none (≥11years' education: aOR 1.99, 95% CI 1.47-2.69). Odds were lower among women younger than 18years than among those aged 18-34years (aOR 0.72, 95% confidence interval 0.59-0.90).

CONCLUSION

Utilization of obstetric ultrasonography in rural Nepal was very limited. Further research is necessary to assess the potential health impact of obstetric ultrasonography in low-resource settings, while addressing limitations such as cost and misuse.

'Women think pregnancy management means obstetric ultrasound': Vietnamese obstetricians' views on the use of ultrasound during pregnancy

Objective

To explore Vietnamese obstetricians’ experiences and views on the role of obstetric ultrasound in clinical management of complicated pregnancy and in situations where maternal and fetal health interests conflict.

Design

Seventeen obstetricians in northern Vietnam were interviewed as part of the CROss-Country Ultrasound Study (CROCUS) project in 2013. Data were analysed using qualitative content analysis.

Results

The participants described ultrasound as a central tool in prenatal care, although they called for increased training and resources to prevent inappropriate management. A prevailing overuse driven by women's request and increased commercialisation was described. Other clinical examinations were seen as being disregarded by women in favour of ultrasound, resulting in missed opportunities for identifying potential pregnancy complications. The use of ultrasound for sex selection purposes raised concern among participants. Visualisation of human features or heartbeat during ultrasound was commonly described as the point where the fetus became regarded as a ‘person’. Women were said to prioritise fetal health interests over their own health, particularly if a woman had difficulties becoming pregnant or had undergone assisted fertilisation. The woman's husband and his family were described as having an important role in decision-making in situations of maternal and fetal health conflicts.

Conclusions

This study provides insight into issues surrounding ultrasound use in contemporary Vietnam, some of which may be specific to this low-income context. It is clear that ultrasound has become a central tool in prenatal care in Vietnam and that it has also been embraced by women. However, there seems to be a need to balance women's demands for obstetric ultrasound with better recognition of the valuable contribution to be made by the full range of clinical examinations in pregnancy, along with a more strategic allocation of resources, that is, use of obstetric ultrasound based on clinical indications. Better regulation of private obstetric practice also appears to be needed. While the root causes of sex selection need to be addressed at societal level, efforts are also required more immediately to find ways to combat the inappropriate use of ultrasound for the purpose of sex selection.

Survey of point of care ultrasound usage in emergency medicine by Vietnamese physicians

OBJECTIVES

Emergency medicine (EM) is rapidly developing as a specialty in Vietnam. Point of care ultrasound (POCUS) is currently taught as part of formal EM curriculums though limited literature exists to describe current POCUS usage in EDs in Vietnam. A survey was developed to understand current POCUS utilisation and guide future training efforts.

METHODS

A survey was administered to 104 Vietnamese physicians attending a national emergency medicine symposium regarding POCUS utilisation, access, training and preference. Data were analysed using multiple logistic regression to identify independent variables associated with POCUS usage.

RESULTS

Increased access to ultrasound machines was significantly associated with increased POCUS usage, with 'all the time' access (OR = 92.9, 95% CI 7.15-1207.6, P = 0.001) being more strongly associated than 'sometimes' access (OR = 41.4, 95% CI 4.08-419.8, P = 0.002). Formal training did not significantly increase POCUS usage and 50.0% of respondents who regularly used POCUS had no formal training. There was no significant difference in physician preference or comfort for any single application of POCUS. There were 98.0% of trainees and 96.3% of independently practising physicians who reported a desire for additional POCUS training.

CONCLUSIONS

Regular access to ultrasound machines increases the frequency of POCUS usage in EDs in Vietnam. POCUS training was not as clearly associated with POCUS usage as those without formal training were equally likely to use POCUS as those with formal training. No single POCUS application stood out as strongly preferred by physicians in this survey.

The Ghanaian woman's experience and perception of ultrasound use in antenatal care

OBJECTIVE

To evaluate how Ghanaian women perceive the use, and their assessment of the experience, of antenatal ultrasound scanning.

DESIGN

Cross-sectional study, using interviewer-administered questionnaire, from 25th February to 16th April, 2011.

SETTING

Obstetrics Units of Korle Bu Teaching Hospital, Accra, University of Ghana Hospital, Legon and Ga South District Hospital, Weija.

METHODS

A total of 337 clients were randomly selected after delivery and interviewed. Issues addressed included why women went for antenatal ultrasound, their knowledge of the uses of ultrasound in pregnancy, information provided by health care providers, clients' eagerness to know the sex of their fetuses, and their overall assessment of the ultrasound scanning experience.

RESULTS

The mean number of scans was 2.2(1.1). Most were performed on the request of a doctor or midwife; 154(45.7%) were not told the reasons for the request and 185(54.9%) did not have the results explained to them. For 239(70.9%) women the sonographer did not explain the procedure before the examination; 89(26.4%) were allowed to ask questions and 61(18.1%) were allowed to see their fetuses on the monitor. One hundred and sixty respondents (47.5%) asked for and were told the sex of their fetuses, with accuracy at delivery of 86.5%.

CONCLUSION

Most respondents perceived antenatal ultrasound as a useful tool. There is lack of information flow from health care providers to clients concerning the indications for the ultrasound, the processes involved and the results of the procedure. Improvements in these areas are needed to enhance the experience of antenatal ultrasound among Ghanaian women.

Why do women seek ultrasound scans from commercial providers during pregnancy?

The commercial availability of ultrasound scans for pregnant women has been controversial yet little is known about why women make use of such services. This article reports on semi-structured interviews with women in the UK who have booked a commercial scan, focusing on the reasons women gave for booking commercially provided ultrasound during a low-risk pregnancy. Participants' reasons for booking a scan are presented in five categories: finding out the sex of the foetus; reassurance; seeing the baby; acquiring keepsakes and facilitating bonding. Our analysis demonstrates that women's reasons for booking commercial scans are often multiple and are shaped by experiences of antenatal care as well as powerful cultural discourses related to 'good' parenting and the use of technology in pregnancy. Sociological and public debate about the availability of commercial ultrasound and its social and personal impacts should consider the wider sociocultural context that structures women's choices to make use of such services.

Attitude of expectant mothers on the use of ultrasound in pregnancy in a tertiary institution in South East of Nigeria

Background:

With the world-wide availability of ultrasound services even in the developing countries, routine ultrasonography in pregnancy remains a controversial issue. However, in this era of reproductive health right and evidence-based medicine, the views of women need to be ascertained.

Aims:

The aim is to assess the attitude of antenatal women toward sonography in pregnancy.

Subjects and Methods:

A descriptive self-administered questionnaire-based cross-sectional study using 208 women that booked for antenatal care from January 1, 2009 to June 30, 2009 at the University of Nigeria Teaching Hospital, Enugu.

Results:

The number of respondents who had ultrasonography in their previous pregnancies was 58.7% (122/208). Although many reasons were given for personal ultrasound requests, 19.7% (24/122) of the women who had obstetric scan in their previous pregnancies thought it was a normal booking test done for every pregnant woman. When compared with other booking investigations, 60.1% (125/208), mainly civil servants .expressed the views that ultrasound in pregnancy is costly, while 24.4% (59/208) felt it is cheap, 9.1% (19/208) said it is very costly, while the remaining 2.4% (5/208) thought it is not affordable. Apart from visualizing the images of their babies, 17.8% (37/208) of the cases wanted to know the sexes of their babies while 15.4% (32/208) was for determination of fetal position. Out of 110, 52.9% (110/208) were of the opinion that women can decide when to request for sonography.

Conclusion:

The attitude of Nigerian women to sonography is good. Majority of them request ultrasound for fetal observation and gender determination.

Does autonomization of public hospitals and exposure to market pressure complement or debilitate social health insurance systems? Evidence from a low-income country

Granting public hospitals greater autonomy and creating organizational arrangements that mimic the private sector and encourage competition is often promoted as a way to increase efficiency and public accountability and to improve quality of care at these facilities. The existence of good-quality health infrastructure, in turn, encourages the population to join and support the social health insurance system and achieve universal coverage. This article provides a critical review of hospital autonomization, using Vietnam's experience to assess the influence of hospital autonomy on the sustainability of Vietnam's social health insurance. The evidence suggests that a reform process based on greater autonomy of resource mobilization and on the retention and use of own-source revenues can create perverse incentives among managers and health care providers, leading to the development of a two-tiered provision of clinical care, provider-induced supply of an inefficient service mix, a high degree of duplication, wasteful investment, and cost escalation. Rather than complementing social health insurance and helping the country to achieve universal coverage, granting public hospitals greater autonomy that mimics the private sector may indeed undermine the legitimacy and sustainability of social health insurance as health care costs escalate and higher quality of care remains elusive.

A low-cost ultrasound program leads to increased antenatal clinic visits and attended deliveries at a health care clinic in rural Uganda

Background

In June of 2010, an antenatal ultrasound program to perform basic screening for high-risk pregnancies was introduced at a community health care center in rural Uganda. Whether the addition of ultrasound scanning to antenatal visits at the health center would encourage or discourage potential patients was unknown. Our study sought to evaluate trends in the numbers of antenatal visits and deliveries at the clinic, pre- and post-introduction of antenatal ultrasound to determine what effect the presence of ultrasound at the clinic had on these metrics.

Methods and Findings

Records at Nawanyago clinic were reviewed to obtain the number of antenatal visits and deliveries for the 42 months preceding the introduction of ultrasound and the 23 months following. The monthly mean deliveries and antenatal visits by category (first visit through fourth return visit) were compared pre- and post- ultrasound using a Kruskal-Wallis one-way ANOVA. Following the introduction of ultrasound, significant increases were seen in the number of mean monthly deliveries and antenatal visits. The mean number of monthly deliveries at the clinic increased by 17.0 (13.3–20.6, 95% CI) from a pre-ultrasound average of 28.4 to a post-ultrasound monthly average of 45.4. The number of deliveries at a comparison clinic remained flat over this same time period. The monthly mean number of antenatal visits increased by 97.4 (83.3–111.5, 95% CI) from a baseline monthly average of 133.5 to a post-ultrasound monthly mean of 231.0, with increases seen in all categories of antenatal visits.

Conclusions

The availability of a low-cost antenatal ultrasound program may assist progress towards Millennium Development Goal 5 by encouraging women in a rural environment to come to a health care facility for skilled antenatal care and delivery assistance instead of utilizing more traditional methods.

Birth weight and delivery practice in a Vietnamese rural district during 12 year of rapid economic development

BACKGROUND

Since the Doi Moi reform 1986 economic conditions in Vietnam have changed significantly and positive health and health care developments have been observed. International experience shows that improved economic conditions in a country can reduce the risk of perinatal mortality, decrease the risk of low birth weight and increase the mean birth weight in newborns. The Health and Demographic Surveillance Site (HDSS) FilaBavi in Bavi district outside Hanoi city has been operational since 1999. An open cohort of more than 12,000 households (52,000 persons) has been followed primarily with respect to demography, economy and education. The aim of this research is to study trends in birth weight as well as birth and delivery practices over the time period 1999-2010 in FilaBavi in relation to the social and economic development.

METHODS

Information about birth weight, sex, place and method of delivery, mother's age and education as well as household economy of 10,114 children, born from 1999 to 2010, was obtained from the routine data collection in the HDSS.

RESULTS

Over the study period the mean birth weight remained at the same level, about 3,100 g, in spite of increased economic resources and technology development. At the individual child level we found associations between birth weight and household economy as well as the education of the mother. Hospital delivery increased from about 35% to 65% and the use of Caesarian section increased from 2.6% to 10.1%.

CONCLUSION

During the twelve years studied, household income as well as the use of modern technology increased rapidly. In spite of that, the mean and variation of birth weight did not change systematically. It is suggested that increasing gaps in economic conditions and misallocation of resources, possibly to overuse of technology, are partly responsible.

Sex of newborns associated with place and mode of delivery: a population-based study in northern Vietnam

BACKGROUND

There is increasing evidence of an elevated sex ratio at birth (SRB) in many Asian countries, including Vietnam, and that this prenatal gender inequity is related to sex-selective abortion. However, few studies have investigated the relation between the sex of offspring and delivery care utilization.

OBJECTIVE

The aim of the present study was to relate sex of newborns to place and mode of delivery in a province in northern Vietnam.

METHODS

A population-based surveillance system within the Neonatal Health-Knowledge Into Practice (NeoKIP) project (ISRCTN44599712) recorded all births within eight districts of Quang Ninh province in northern Vietnam from July 2008 to June 2011.

RESULTS

In total, there were 22,377 live births within the study area. SRB was 108 boys per 100 girls. There was a large difference in SRB depending on place of delivery, with 94 boys per 100 girls being delivered at home, whereas 113 boys per 100 girls were delivered at a district-level hospital. Cesarean section (CS) rate was 17%, and within the CS group, the SRB was 135:100.

CONCLUSIONS

We demonstrated an elevated SRB, especially at district hospital level, and that sex of offspring influenced place and mode of delivery. Although mothers to boys were more likely to receive more qualified delivery care, they were at the same time more likely to undergo unnecessary surgery. Correct information to women and family members about CS and stricter implementation of the medical indications for CS are urgently called for.

A review of training opportunities for ultrasonography in low and middle income countries

OBJECTIVE

To review the current training opportunities for ultrasound use for health workers practising in low- and middle-income countries (LMICs).

METHODS

A PubMed search using terms ultrasound, sonography, echocardiography, developing country/countries, developing world, low resource settings, low income country/countries, training and education was conducted. Articles from 2000 to 2011 that included data on ultrasonography training were eligible for inclusion.

RESULTS

This review shows that most ultrasound scans are performed by generalist and obstetric physicians and even non-medical personnel with little to no formal training in ultrasonography. The spectrum of ultrasonography training described spanned from no formal training to formal certification and residency programmes. All courses included some component of didactics and hands-on training. Follow-up of trainee skills ranged from none, to telemedicine case review, to formal re-evaluations and intensive refresher courses. Ultrasonographic training in LMICs often does not meet the WHO criteria such as the number of scans under supervision and length of training programme recommended by WHO. Nevertheless, some programmes manage to have excellent outcomes with regard to diagnostic accuracy and retention of knowledge by trained personnel.

CONCLUSION

Regulation and quality control of training in ultrasound skills for those working in LMICs can be improved. Research on effective training and follow-up should be encouraged.

Refugee and migrant women's views of antenatal ultrasound on the Thai Burmese border: a mixed methods study

Background

Antenatal ultrasound suits developing countries by virtue of its versatility, relatively low cost and safety, but little is known about women’s or local provider’s perspectives of this upcoming technology in such settings. This study was undertaken to better understand how routine obstetric ultrasound is experienced in a displaced Burmese population and identify barriers to its acceptance by local patients and providers.

Methodology/Principal Findings

Qualitative (30 observations, 19 interviews, seven focus group discussions) and quantitative methods (questionnaire survey with 644 pregnant women) were used to provide a comprehensive understanding along four major themes: safety, emotions, information and communication, and unintended consequences of antenatal ultrasound in refugee and migrant clinics on the Thai Burmese border. One of the main concerns expressed by women was the danger of childbirth which they mainly attributed to fetal malposition. Both providers and patients recognized ultrasound as a technology improving the safety of pregnancy and delivery. A minority of patients experienced transitory shyness or anxiety before the ultrasound, but reported that these feelings could be ameliorated with improved patient information and staff communication. Unintended consequences of overuse and gender selective abortions in this population were not common.

Conclusions/Significance

The results of this study are being used to improve local practice and allow development of explanatory materials for this population with low literacy. We strongly encourage facilities introducing new technology in resource poor settings to assess acceptability through similar inquiry.

Utilization of antenatal ultrasound scan and implications for caesarean section: a cross-sectional study in rural Eastern China

Background

Antenatal ultrasound scan is a widely accepted component of antenatal care. Studies have looked at the relationship between ultrasound scanning and caesarean section (CS) in certain groups of women in China. However, there are limited data on the utilization of antenatal ultrasound scanning in the general population, including its association with CS. The purpose of this study is to describe the utilization of antenatal ultrasound screening in rural Eastern China and to explore the association between antenatal ultrasound scan and uptake of CS.

Methods

Based on a cluster randomized sample, a total of 2326 women with childbirth participated in the study. A household survey was conducted to collect socio-economic information, obstetric history and utilization of maternal health services.

Results

Coverage of antenatal care was 96.8% (2251/2326). During antenatal care, 96.1% (2164/2251) women received ultrasound screening and the reported average number was 2.55. 46.8% women received at least 3 ultrasound scans and the maximum number reached 11. The CS rate was found to be 54.8% (1275/2326). After adjusting for socio-demographic and clinical variables, it showed a statistically significant association between antenatal ultrasound scans and uptake of CS by multivariate logistic regression model. High husband education level, high maternal age, having previous adverse pregnant outcome and pregnancy complications during the index pregnancy were also found to be risk factors of choosing a CS.

Conclusions

A high use of antenatal ultrasound scan in rural Eastern China is found and is influenced by socio-demographic and clinical factors. Evidence-based guidelines for antenatal ultrasound scans need to be developed and disseminated to clinicians including physicians, nurses and sonographers. Guidance about the appropriate use of ultrasound scans should also be shared with women in order to discourage unreasonable expectations and demands. It is important to monitor the use of antenatal ultrasound scan as well as the indications for caesarean section in rural China.

'Wakey wakey baby': narrating four-dimensional (4D) bonding scans

Commercial companies market 4D ultrasound scans to expectant parents for the stated purpose of reassurance, to promote bonding, and to get 'baby's first picture'. This article describes in detail the process of commercial 4D scanning in the UK, paying particular attention to the discursive exchanges in the scan room. It is argued that sonographers and clients engage in a process of 'collaborative coding' that, despite the realism of 4D, is essential to making the imagery on the screen personally and socially meaningful. While sonographers first help clients to get their bearings, expectant parents and others often engage in a complex process of narrating the images on the screen as they are created. The capacities of 4D ultrasound to image facial features and movements inform stories about fetal experience and family resemblances as well as enabling playfully imagined interactions with the fetus. While these stories are primarily based in experiences of the visual, there is also evidence that pregnant women seek to map the image onto their bodies and to reintroduce some elements of their embodied experiences into the narratives.

Son preference, sex selection, and kinship in Vietnam

This article examines the recent rise in the sex ratio at birth in Vietnam and relates its emergence to kinship systems and ethnic composition using 2009 census micro-data. Presentation of the main socioeconomic and ethnic differentials in birth masculinity is followed by a review of the three intermediate factors leading to increases in the sex ratio at birth: prenatal technology, declining fertility, and gender bias. An indirect measurement of fertility behavior is used to demonstrate the close association between levels of the sex ratio at birth and the intensity of son preference. Data on household composition indicate that Vietnam is characterized by the co-existence of kinship patterns typical of East and Southeast Asia. Son preference in Vietnam is found to be related to the prevalence of more traditional patrilineal systems. The article concludes by considering the implications of the cultural dimensions of prenatal sex selection for policy responses and for the likely future change in the sex ratio at birth.

Review: indications for ultrasound use in low- and middle-income countries

OBJECTIVE

To determine the indications for using ultrasound, in low- and middle-income countries (LMICs) and to assess whether its use alters clinical management.

METHODS

Literature review. We conducted a Pubmed search on the clinical use of ultrasound in LMIC for articles published between January 2000 and December 2010, recording country of origin, speciality and whether ultrasound use led to a change in management.

RESULTS

Fifty-eight articles were identified from 32 countries and represented nine specialties. Ultrasound was most commonly used for assisting with the diagnosis of obstetrical conditions, followed by intra-abdominal conditions such as liver abscesses and intussusceptions. Clinical management was altered in >30% of cases.

CONCLUSION

Ultrasound is a highly valuable diagnostic tool in LMICs and its use should be considered essential for all district medical facilities. The use could be applied more widely, eg., for tropical and non-communicable diseases. Additional research is needed to further characterize the impact of task shifting on ultrasound use in LMICs.

Quality of reproductive health services at commune health stations in Viet Nam: implications for national reproductive health care strategy

This paper presents a qualitative study conducted in 2009 of provider and patient perceptions of primary level reproductive health services provided by commune health stations (CHSs), and the implications for Viet Nam's 2011-2020 National Strategy for Reproductive Health Care. In the three provinces of Thai Nguyen, Thua Thien Hue, and Vinh Long, we interviewed the heads of CHSs, held focus group discussions with midwives and women patients, and observed facilities. Half the 30 CHSs visited were in poor physical condition; the rest were newly renovated. However, the model of service delivery was largely unchanged from ten years before. Many appeared to fall short in meeting patient expectations in terms of modern medical equipment and technology, range of drug supplies, and levels of staff expertise. As a result, many women were turning to private doctors and public hospitals, at least in urban areas, or seeking medication from pharmacies. To make CHS clinics sustainable, promotion of access to reproductive health services should be undertaken concurrently with quality improvement. A responsive payment scheme must also be developed to generate revenues. Efforts should be made to reduce the unnecessary use of more costly services from private clinics and higher level public facilities.

An exploratory study of the views of Ugandan women and health practitioners on the use of sonography to establish fetal sex

INTRODUCTION

Ultrasound is now part of routine care for pregnant women in Uganda, and is one of a range of techniques used in screening during pregnancy. However, it differs from most others screening procedures because it allows women to view their babies. Unfortunately, the recipients of this technology are seldom asked about it. This study aimed at finding out the knowledge, attitudes and practices of pregnant women towards prenatal sonography.

METHODS

The study was exploratory and descriptive, using interviewer-administered questionnaires. Thematic analysis was employed.

RESULTS

The health professionals interviewed discouraged the idea of disclosing fetal sex unless it is justifiably indicated for medical reasons. However, the women in this study supported the idea of being told the sex of the baby in order to plan for the necessary items they need.

CONCLUSION

There is need for a policy to be made not to disclose fetal sex to parents as this raises numerous ethical concerns. Health workers, women and the general public need to be sensitized about the dangers of this practice as well.