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Thayyil S, Bauserman M, Valentine G, Patterson JK, Hoffman M, Aagaard K, Ramji S, Lokangaka A, Mhango J, Bhutta ZA, Shankaran S. Design and Conduct of Global Health Research in Low- and Middle-Income Countries. J Pediatr 2024:114268. [PMID: 39216623 DOI: 10.1016/j.jpeds.2024.114268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 07/26/2024] [Accepted: 08/26/2024] [Indexed: 09/04/2024]
Affiliation(s)
| | - Melissa Bauserman
- Gillings School of Global Public Health, University of North Carolina School of Medicine, USA
| | - Gregory Valentine
- Departments of Pediatrics, Oral Health Sciences & Mechanical Engineering, University of Washington & Seattle Children's Hospital, Seattle, WA, and Department of Obstetrics & Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Jackie K Patterson
- Department of Pediatrics, University of North Carolina School of Medicine, USA
| | - Matthew Hoffman
- Department of Obstetrics and Gynecology, Christiana Care, Newark, DE, USA
| | - Kjersti Aagaard
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Siddarth Ramji
- Former Department of Neonatology, Maulana Azad Medical College, New Delhi, India
| | | | - Joseph Mhango
- Baylor College of Medicine Children's Foundation, Malawi
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
| | - Seetha Shankaran
- University of Texas at Austin, Austin, TX and Wayne State University, Detroit, MI, USA.
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Groos J, Walter A, Wittek A, Strizek B, Gembruch U, Recker F. Shaping ultrasound in midwifery: towards an evidence-based training framework for enhanced prenatal care. Arch Gynecol Obstet 2024; 310:23-43. [PMID: 38771531 PMCID: PMC11169037 DOI: 10.1007/s00404-024-07558-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 05/15/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Academic advancement of the midwifery profession highlights the need to establish standardized qualifications in obstetric ultrasound diagnosis, being a central part of prenatal care. Thus, introduction of an evidence-based training program is warranted. We aimed to reviewed curriculum designs used in midwifery ultrasound education. METHODS A systematic literature research was conducted. Embase, PubMed and Google Scholar database was reviewed for publications using the terms "[midwife], [midwives], [midwifery students], [obstetric ultrasound], [midwife sonographer] and [education], [teaching], [program], [course], [curriculum] and [learning]". Papers with full description of curriculum designs or educational programs on obstetrical ultrasound for midwives were included and scrutinized against pre-defined criteria according to the PICO (Population, Intervention, Comparator, Outcomes) scheme. RESULTS 29 publications were included. Studies demonstrated a significant disparity according to course concepts being used. Differing parameters included: Duration, structure, learning approaches, course content, examination concepts and target groups (practising midwives vs. midwives in education). CONCLUSION An evidence-based ultrasound educational program for midwives remains to be developed, including further educational guidelines. Clinical applications by midwives, as well as the distinctions from medical practise, particularly in terms of legal considerations, needs to be defined.
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Affiliation(s)
- Julia Groos
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Adeline Walter
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Agnes Wittek
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Brigitte Strizek
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Ulrich Gembruch
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Florian Recker
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany.
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Viswanathan AV, Pokaprakarn T, Kasaro MP, Shah HR, Prieto JC, Benabdelkader C, Sebastião YV, Sindano N, Stringer E, Stringer JSA. Deep learning to estimate gestational age from fly-to cineloop videos: A novel approach to ultrasound quality control. Int J Gynaecol Obstet 2024; 165:1013-1021. [PMID: 38189177 PMCID: PMC11214162 DOI: 10.1002/ijgo.15321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 12/05/2023] [Accepted: 12/10/2023] [Indexed: 01/09/2024]
Abstract
OBJECTIVE Low-cost devices have made obstetric sonography possible in settings where it was previously unfeasible, but ensuring quality and consistency at scale remains a challenge. In the present study, we sought to create a tool to reduce substandard fetal biometry measurement while minimizing care disruption. METHODS We developed a deep learning artificial intelligence (AI) model to estimate gestational age (GA) in the second and third trimester from fly-to cineloops-brief videos acquired during routine ultrasound biometry-and evaluated its performance in comparison to expert sonographer measurement. We then introduced random error into fetal biometry measurements and analyzed the ability of the AI model to flag grossly inaccurate measurements such as those that might be obtained by a novice. RESULTS The mean absolute error (MAE) of our model (±standard error) was 3.87 ± 0.07 days, compared to 4.80 ± 0.10 days for expert biometry (difference -0.92 days; 95% CI: -1.10 to -0.76). Based on simulated novice biometry with average absolute error of 7.5%, our model reliably detected cases where novice biometry differed from expert biometry by 10 days or more, with an area under the receiver operating characteristics curve of 0.93 (95% CI: 0.92, 0.95), sensitivity of 81.0% (95% CI: 77.9, 83.8), and specificity of 89.9% (95% CI: 88.1, 91.5). These results held across a range of sensitivity analyses, including where the model was provided suboptimal truncated fly-to cineloops. CONCLUSIONS Our AI model estimated GA more accurately than expert biometry. Because fly-to cineloop videos can be obtained without any change to sonographer workflow, the model represents a no-cost guardrail that could be incorporated into both low-cost and commercial ultrasound devices to prevent reporting of most gross GA estimation errors.
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Affiliation(s)
- Ambika V Viswanathan
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Teeranan Pokaprakarn
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
- Department of Biostatistics, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Margaret P Kasaro
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
- UNC Global Projects - Zambia LLC, Lusaka, Zambia
| | - Hina R Shah
- Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Juan C Prieto
- Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Chiraz Benabdelkader
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Yuri V Sebastião
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | | | - Elizabeth Stringer
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
- UNC Global Projects - Zambia LLC, Lusaka, Zambia
| | - Jeffrey S A Stringer
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
- UNC Global Projects - Zambia LLC, Lusaka, Zambia
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Patel A, Bann CM, Thorsten VR, Rao SR, Lokangaka A, Tshefu Kitoto A, Bauserman M, Figueroa L, Krebs NF, Esamai F, Bucher S, Saleem S, Goldenberg RL, Chomba E, Carlo WA, Goudar S, Derman R, Koso-Thomas M, McClure E, Hibberd PL. Can the date of last menstrual period be trusted in the first trimester? Comparisons of gestational age measures from a prospective cohort study in six low-income to middle-income countries. BMJ Open 2023; 13:e067470. [PMID: 37730415 PMCID: PMC10514667 DOI: 10.1136/bmjopen-2022-067470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 07/26/2023] [Indexed: 09/22/2023] Open
Abstract
OBJECTIVES We examined gestational age (GA) estimates for live and still births, and prematurity rates based on last menstrual period (LMP) compared with ultrasonography (USG) among pregnant women at seven sites in six low-resource countries. DESIGN Prospective cohort study SETTING AND PARTICIPANTS: This study included data from the Global Network's population-based Maternal and Newborn Health Registry which follows pregnant women in six low-income and middle-income countries (Democratic Republic of the Congo, Guatemala, India, Kenya, Pakistan and Zambia). Participants in this analysis were 42 803 women, including their 43 230 babies, who registered for the study in their first trimester based on GA estimated either by LMP or USG and had a live or stillbirth with an estimated GA of 20-42 weeks. OUTCOME MEASURES GA was estimated in weeks and days based on LMP and/or USG. Prematurity was defined as GA of 20 weeks+0 days through 36 weeks+6 days, calculated by both USG and LMP. RESULTS Overall, average GA varied ≤1 week between LMP and USG. Mean GA for live births by LMP was lower than by USG (adjusted mean difference (95% CI) = -0.23 (-0.29 to -0.17) weeks). Among stillbirths, a higher GA was estimated by LMP than USG (adjusted mean difference (95% CI)= 0.42 (0.11 to 0.72) weeks). Preterm birth rates for live births were significantly higher when dated by LMP (adjusted rate difference (95% CI)= 4.20 (3.56 to 4.85)). There was no significant difference in preterm birth rates for stillbirths. CONCLUSION The small differences in GA for LMP versus USG in the Guatemalan and Indian sites suggest that LMP may be a useful alternative to USG for GA dating during the first trimester until availability of USG improves in those areas. Further research is needed to assess LMP for first-trimester GA dating in other regions with limited access to USG. TRIAL REGISTRATION NUMBER NCT01073475.
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Affiliation(s)
- Archana Patel
- Lata Medical Research Foundation, Nagpur, Nagpur, Maharashtra, India
| | - Carla M Bann
- Statistics Division, RTI International, Research Triangle Park, North Carolina, USA
| | - Vanessa R Thorsten
- Statistics Division, RTI International, Research Triangle Park, North Carolina, USA
| | - Sowmya R Rao
- School of Public Health, Boston University, Boston, Massachusetts, USA
| | - Adrien Lokangaka
- School of Public Health, University of Kinshasa, Kinshasa, Congo (the Democratic Republic of the)
| | - Antoinette Tshefu Kitoto
- School of Public Health, University of Kinshasa, Kinshasa, Congo (the Democratic Republic of the)
| | - Melissa Bauserman
- School of Medicine, University of North Carolina, Chapel Hill, Carolina, USA
| | - Lester Figueroa
- Institute of Nutrition of Central America and Panama, Guatemala, Guatemala, Guatemala
| | - Nancy F Krebs
- School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Fabian Esamai
- Alupe University College, Busia, Western Kenya, Kenya
| | - Sherri Bucher
- Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sarah Saleem
- Department of Community Health Sciences, The Aga Khan University, Karachi, Sindh, Pakistan
| | | | - Elwyn Chomba
- University of Zambia University Teaching Hospital, Lusaka, Lusaka, Zambia
| | - Waldemar A Carlo
- Division of Neonatology, University of Alabama at Birmingham Department of Pediatrics, Birmingham, Alabama, USA
| | - Shivaprasad Goudar
- Women's and Children's Health Research Unit, J N Medical College Belagavi, Belagavi, Karnataka, India
| | - Richard Derman
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Marion Koso-Thomas
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, USA
| | - Elizabeth McClure
- Statistics Division, RTI International, Research Triangle Park, North Carolina, USA
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Bucher S, Nowak K, Otieno K, Tenge C, Marete I, Rutto F, Kemboi M, Achieng E, Ekhaguere OA, Nyongesa P, Esamai FO, Liechty EA. Birth weight and gestational age distributions in a rural Kenyan population. BMC Pediatr 2023; 23:112. [PMID: 36890485 PMCID: PMC9993805 DOI: 10.1186/s12887-023-03925-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 02/21/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND With the increased availability of access to prenatal ultrasound in low/middle-income countries, there is opportunity to better characterize the association between fetal growth and birth weight across global settings. This is important, as fetal growth curves and birthweight charts are often used as proxy health indicators. As part of a randomized control trial, in which ultrasonography was utilized to establish accurate gestational age of pregnancies, we explored the association between gestational age and birthweight among a cohort in Western Kenya, then compared our results to data reported by the INTERGROWTH-21st study. METHODS This study was conducted in 8 geographical clusters across 3 counties in Western Kenya. Eligible subjects were nulliparous women carrying singleton pregnancies. An early ultrasound was performed between 6 + 0/7 and 13 + 6/7 weeks gestational age. At birth, infants were weighed on platform scales provided either by the study team (community births), or the Government of Kenya (public health facilities). The 10th, 25th, median, 75th, and 90th BW percentiles for 36 to 42 weeks gestation were determined; resulting percentile points were plotted, and curves determined using a cubic spline technique. A signed rank test was used to quantify the comparison of the percentiles generated in the rural Kenyan sample with those of the INTERGROWTH-21st study. RESULTS A total of 1291 infants (of 1408 pregnant women randomized) were included. Ninety-three infants did not have a measured birth weight. The majority of these were due to miscarriage (n = 49) or stillbirth (n = 27). No significant differences were found between subjects who were lost to follow-up. Signed rank comparisons of the observed median of the Western Kenya data at 10th, 50th, and 90th birthweight percentiles, as compared to medians reported in the INTERGROWTH-21st distributions, revealed close alignment between the two datasets, with significant differences at 36 and 37 weeks. Limitations of the current study include small sample size, and detection of potential digit preference bias. CONCLUSIONS A comparison of birthweight percentiles by gestational age estimation, among a sample of infants from rural Kenya, revealed slight differences as compared to those from the global population (INTERGROWTH-21st). TRIAL REGISTRATION This is a single site sub-study of data collected in conjunction with the Aspirin Supplementation for Pregnancy Indicated Risk Reduction In Nulliparas (ASPIRIN) Trial, which is listed at ClinicalTrials.gov , NCT02409680 (07/04/2015).
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Affiliation(s)
- Sherri Bucher
- School of Medicine, Indiana University, Indianapolis, IN, USA.
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Indianapolis, IN, USA.
| | - Kayla Nowak
- RTI International, 3040 E. Cornwallis Road, Research Triangle Park, Durham, NC, USA
| | - Kevin Otieno
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya
| | - Constance Tenge
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya
| | - Irene Marete
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya
| | - Faith Rutto
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya
| | - Millsort Kemboi
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya
| | - Emmah Achieng
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya
| | | | - Paul Nyongesa
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya
| | - Fabian O Esamai
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya
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Kurjak A, Medjedovic E, Stanojević M. Use and misuse of ultrasound in obstetrics with reference to developing countries. J Perinat Med 2023; 51:240-252. [PMID: 36302110 DOI: 10.1515/jpm-2022-0438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 10/04/2022] [Indexed: 11/15/2022]
Abstract
Maternal and neonatal health is one of the main global health challenges. Every day, approximately 800 women and 7,000 newborns die due to complications during pregnancy, delivery, and neonatal period. The leading causes of maternal death in sub-Saharan Africa are obstetric hemorrhage (28.8%), hypertensive disorders in pregnancy (22.1%), non-obstetric complications (18.8%), and pregnancy-related infections (11.5%). Diagnostic ultrasound examinations can be used in a variety of specific circumstances during pregnancy. Because adverse outcomes may also arise in low-risk pregnancies, it is assumed that routine ultrasound in all pregnancies will enable earlier detection and improved management of pregnancy complications. The World Health Organization (WHO) estimated in 1997 that 50% of developing countries had no access to ultrasound imaging, and available equipment was outdated or broken. Unfortunately, besides all the exceptional benefits of ultrasound in obstetrics, its inappropriate use and abuse are reported. Using ultrasound to view, take a picture, or determine the sex of a fetus without a medical indication can be considered ethically unjustifiable. Ultrasound assessment when indicated should be every woman's right in the new era. However, it is still only a privilege in some parts of the world. Investment in both equipment and human resources has been clearly shown to be cost-effective and should be an obligatory step in the improvement of health care. Well-developed health systems should guide developing countries, creating principles for the organization of the health system with an accent on the correct, legal, and ethical use of diagnostic ultrasound in pregnancy to avoid its misuse. The aim of the article is to present the importance of correct and appropriate use of ultrasound in obstetrics and gynecology with reference to developing countries.
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Affiliation(s)
- Asim Kurjak
- Department of Obstetrics and Gynecology, University Hospital "Sveti Duh", Zagreb, Croatia
| | - Edin Medjedovic
- Clinic of Gynecology and Obstetrics, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina.,Department of Gynecology, School of Medicine, Sarajevo School of Science and Technology, Sarajevo, Bosnia and Herzegovina
| | - Milan Stanojević
- Department of Obstetrics and Gynecology, University Hospital "Sveti Duh", Zagreb, Croatia.,Neonatal Unit, Department of Obstetrics and Gynecology, Medical School University of Zagreb, Zagreb, Croatia
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Bidner A, Bezak E, Parange N. Evaluation of antenatal point-of-care ultrasound training workshops for rural/remote healthcare clinicians: a prospective single cohort study. BMC MEDICAL EDUCATION 2022; 22:906. [PMID: 36585662 PMCID: PMC9805197 DOI: 10.1186/s12909-022-03888-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 11/10/2022] [Indexed: 05/25/2023]
Abstract
BACKGROUND There is limited access to life-saving antenatal ultrasound in low-resource rural and remote settings worldwide, including Australia, mainly due to shortages in skilled staff. Point-of-care ultrasound (PoCUS) offers a viable solution to this service deficit, however, rural clinicians face many barriers accessing training and professional development critical to advancing their clinical practice. Standards for PoCUS training and competency assessment are unclear. Regulation is lacking globally, allowing untrained and inexperienced clinicians to practice PoCUS clinically. METHODS This prospective single cohort study aimed to evaluate antenatal PoCUS training workshops for General Practitioners (GPs) and Midwives/Nurses (M/Ns) from rural/remote Australia, assessing the impact of the training on trainees' knowledge, confidence and translation of PoCUS into clinical practice. Two-day antenatal ultrasound workshops were delivered at the University of South Australia (UniSA) in 2018 and 2019 to 41 rural/remote clinicians . The training was designed and evaluated using the New world Kirkpatrick Evaluation Framework. Sixteen GPs and 25 M/Ns with mixed prior ultrasound experience were funded to attend. The course consisted of lectures interspaced with hands-on training sessions using high-fidelity simulators and live pregnant models. Pre- and post-knowledge assessments were performed. Post-workshop evaluation and follow-up surveys (3- and 6-month post-training) assessed the workshops and changes to trainees' clinical practice. A 2-day follow-up training session was conducted 12 months after the workshops for 9 trainees. RESULTS Pre/post knowledge testing demonstrated a 22% mean score improvement (95% CI 17.1 to 27.8, P < 0.0001). At 6 months, 62% of trainees were performing PoCUS that had assisted in patient management and clinical diagnosis, and 46% reported earlier diagnosis and changes to patient management. 74% of trainees had increased scanning frequency and 93% reported improved scanning confidence. CONCLUSION This study demonstrated intensive 2-day workshops can equip clinicians with valuable antenatal PoCUS skills, offering a viable solution to assist in the assessment and management of pregnant women in the rural/resource-poor setting where access to ultrasound services is limited or non-existent. Geographical isolation and lack of onsite specialist supervision poses an ongoing challenge to the continuing professional development of remote trainees and the implementation of PoCUS.
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Affiliation(s)
- Amber Bidner
- Allied Health and Human Performance, The University of South Australia, Corner of North Terrace and Frome Road, GPO Box 2471, Adelaide, SA 5001 Australia
| | - Eva Bezak
- Allied Health and Human Performance, The University of South Australia, Corner of North Terrace and Frome Road, GPO Box 2471, Adelaide, SA 5001 Australia
- Department of Physics, The University of Adelaide, North Terrace, Adelaide, SA 5001 Australia
| | - Nayana Parange
- Allied Health and Human Performance, The University of South Australia, Corner of North Terrace and Frome Road, GPO Box 2471, Adelaide, SA 5001 Australia
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Bidner A, Bezak E, Parange N. Evaluation of antenatal Point-of-Care Ultrasound (PoCUS) training: a systematic review. MEDICAL EDUCATION ONLINE 2022; 27:2041366. [PMID: 35382705 PMCID: PMC8986272 DOI: 10.1080/10872981.2022.2041366] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
INTRODUCTION There is limited access to life-saving antenatal ultrasound in rural and low-resource settings largely due to shortages in skilled staff. Studies have shown healthcare practitioners can be upskilled in PoCUS through focused training, offering a viable solution to this deficit. However, standards for training and competency assessment are unclear and regulation surrounding practice is lacking. We aimed to review published literature examining antenatal PoCUS training programs, comparing teaching approaches and study methodologies. METHODS A search of electronic databases EMBASE, MEDLINE and Google Scholar was conducted. Original research articles evaluating antenatal PoCUS training of healthcare professionals worldwide were identified for analysis. Articles with limited detail on the PoCUS training intervention and those describing comprehensive diagnostic training programs were excluded. Evaluations were compared against the Kirkpatrick Evaluation Framework (KEF). RESULTS Twenty-seven studies were included from an initial search result of 484 articles. There was considerable heterogeneity between the PoCUS training programs described. Course duration ranged from 3 hours to 2 years, with 11 of the 27 studies delivering obstetric-exclusive content. 44% trained multidisciplinary groups of health professionals. Long-term follow-up training and skills assessments were lacking in over half of the reviewed studies. Study quality and reporting detail varied, but overall beneficial outcomes were reported with 3/4s of the studies reaching upper KEF levels 3 and 4. CONCLUSION PoCUS performed by upskilled healthcare professionals offers an attractive solution to the problem of inequitable access to antenatal ultrasound. A review of available literature highlighted a paucity of comparable high-quality studies needed to establish a stronger evidence base for antenatal PoCUS, and a need to standardise training and competency assessment. This review may inform educators, researchers and policy-makers on existing training formats and methodologies to assist in establishing best practice antenatal PoCUS training methods for safe service delivery by remote healthcare professionals.
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Affiliation(s)
- Amber Bidner
- Department of Allied Health and Human Performance, The University of South Australia, Adelaide, South Australia, Australia
- CONTACT Amber Bidner Department of Allied Health and Human Performance, The University of South Australia, Adelaide, South Australia, Australia
| | - Eva Bezak
- Department of Allied Health and Human Performance, The University of South Australia, Adelaide, South Australia, Australia
- Department of Physics, The University of Adelaide, Adelaide, South Australia, Australia
| | - Nayana Parange
- Department of Allied Health and Human Performance, The University of South Australia, Adelaide, South Australia, Australia
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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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Gomes RG, Vwalika B, Lee C, Willis A, Sieniek M, Price JT, Chen C, Kasaro MP, Taylor JA, Stringer EM, McKinney SM, Sindano N, Dahl GE, Goodnight W, Gilmer J, Chi BH, Lau C, Spitz T, Saensuksopa T, Liu K, Tiyasirichokchai T, Wong J, Pilgrim R, Uddin A, Corrado G, Peng L, Chou K, Tse D, Stringer JSA, Shetty S. A mobile-optimized artificial intelligence system for gestational age and fetal malpresentation assessment. COMMUNICATIONS MEDICINE 2022; 2:128. [PMID: 36249461 PMCID: PMC9553916 DOI: 10.1038/s43856-022-00194-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 09/28/2022] [Indexed: 11/05/2022] Open
Abstract
Background Fetal ultrasound is an important component of antenatal care, but shortage of adequately trained healthcare workers has limited its adoption in low-to-middle-income countries. This study investigated the use of artificial intelligence for fetal ultrasound in under-resourced settings. Methods Blind sweep ultrasounds, consisting of six freehand ultrasound sweeps, were collected by sonographers in the USA and Zambia, and novice operators in Zambia. We developed artificial intelligence (AI) models that used blind sweeps to predict gestational age (GA) and fetal malpresentation. AI GA estimates and standard fetal biometry estimates were compared to a previously established ground truth, and evaluated for difference in absolute error. Fetal malpresentation (non-cephalic vs cephalic) was compared to sonographer assessment. On-device AI model run-times were benchmarked on Android mobile phones. Results Here we show that GA estimation accuracy of the AI model is non-inferior to standard fetal biometry estimates (error difference -1.4 ± 4.5 days, 95% CI -1.8, -0.9, n = 406). Non-inferiority is maintained when blind sweeps are acquired by novice operators performing only two of six sweep motion types. Fetal malpresentation AUC-ROC is 0.977 (95% CI, 0.949, 1.00, n = 613), sonographers and novices have similar AUC-ROC. Software run-times on mobile phones for both diagnostic models are less than 3 s after completion of a sweep. Conclusions The gestational age model is non-inferior to the clinical standard and the fetal malpresentation model has high AUC-ROCs across operators and devices. Our AI models are able to run on-device, without internet connectivity, and provide feedback scores to assist in upleveling the capabilities of lightly trained ultrasound operators in low resource settings.
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Affiliation(s)
| | - Bellington Vwalika
- Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC USA
| | | | | | | | - Joan T. Price
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC USA
- UNC Global Projects—Zambia, LLC, Lusaka, Zambia
| | | | - Margaret P. Kasaro
- Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia
- UNC Global Projects—Zambia, LLC, Lusaka, Zambia
| | | | - Elizabeth M. Stringer
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC USA
| | | | | | | | - William Goodnight
- Department of Obstetrics and Gynaecology, University of Zambia School of Medicine, Lusaka, Zambia
| | | | - Benjamin H. Chi
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC USA
- UNC Global Projects—Zambia, LLC, Lusaka, Zambia
| | | | | | | | - Kris Liu
- Google Health, Palo Alto, CA USA
| | | | | | | | | | | | | | | | | | - Jeffrey S. A. Stringer
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC USA
- UNC Global Projects—Zambia, LLC, Lusaka, Zambia
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11
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Luntsi G, Ugwu AC, Ohagwu CC, Kalu O, Sidi M, Akpan E. Impact of ultrasound scanning on pregnant Women's compliance with attendance at antenatal care visits and supervised delivery at primary healthcare centres in northern Nigeria: Initial experiences. Radiography (Lond) 2022; 28:480-486. [PMID: 35123883 DOI: 10.1016/j.radi.2022.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 12/18/2021] [Accepted: 01/16/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The world health organisation (WHO) recommends at least one ultrasound scan amidst eight antenatal care visits, however, most pregnant women in low and middle-income countries do not achieve this. This study aims to assess the impact of limited obstetrics ultrasound (LOUS) within primary healthcare centres in northern Nigeria. METHODS A cross sectional study was conducted across selected primary healthcare centres in Bauchi and Kano States (northern Nigeria). The study protocol was approved by the Ministry of Health in each State. Within each State a total of nine primary healthcare centres were randomly selected. Information on all complete antenatal care (ANC) records of women who used the primary healthcare facility for 12 months prior to introduction of ultrasound (January 2016 to December 2016) and 12 months after (January 2018 to December 2018) were collected. Study data were analysed using descriptive (mean, standard deviations) and inferential statistics. Independent sample t-test were used to find out if there was a statistical difference between the pre and post-intervention data on women compliance to ANC visits, facility based delivery, maternal and child mortality. Data were analysed using the Statistical Package for Social Sciences and significance was set at p ≤ 0.05. RESULTS There was a significant increase in the number of ANC visits and supervised facility delivery after introduction of ultrasound services (LOUS) in the primary healthcare centres. The number of ANC visits in Kano State was 2637.6 ± 972.0 before and 3793.0 ± 517.5 after the introduction of ultrasound services. The number of ANC visits in Bauchi State was 1866.6 ± 488.3 before and 2854.0 ± 631.3 after the introduction of ultrasound services. The number of supervised facility deliveries in Kano state was 520.1 ± 128.7 before and 1021.1 ± 217.0 after the introduction of LOUS. The number of supervised facility deliveries for Bauchi state was 553.1 ± 309.9 before and 1056.3 ± 295.4 after introduction of LOUS. A total of 2486 (11.0%) women were referred for further imaging due to equivocal ultrasound findings. A total of 2185 (9.7%) pregnant women were referred for appropriate care due to multiple gestations. CONCLUSION This study found that LOUS, in resource scarce settings, has the potential of improving ANC visits, facility delivery rates and reduce maternal and child mortality. It also leads to change in patient management plans resulting in referrals for appropriate care. IMPLICATION FOR PRACTICE Technological interventions using ultrasound have the potential to motivate pregnant women to attend ANC, give birth in a healthcare facility and thus reduce maternal and child morbidity and mortality. This is in line with the global drive to reduce maternal and child death by 2030 to less than 70 maternal deaths in 100,000 live births and neonatal mortality reduction to 12 in 1000 live births and under 5 mortality reduction to 25 in 1000 live births.
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Affiliation(s)
- G Luntsi
- Department of Medical Radiography, Faculty of Allied Health Sciences, College of Medical Sciences, University of Maiduguri, Nigeria.
| | - A C Ugwu
- Department of Radiography and Radiological Sciences, Faculty of Health Sciences, Nnamdi Azikiwe University, Awka, Nigeria.
| | - C C Ohagwu
- Department of Radiography and Radiological Sciences, Faculty of Health Sciences, Nnamdi Azikiwe University, Awka, Nigeria.
| | - O Kalu
- Department of Radiography and Radiological Sciences, Faculty of Health Sciences, Evangel University Ebonyi State, Nigeria.
| | - M Sidi
- Department of Medical Radiography, Faculty of Allied Health Sciences, College of Medical Sciences, Bayero University Kano, Nigeria.
| | - E Akpan
- Grayscale International Ltd Lagos, Nigeria.
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12
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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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13
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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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14
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Saleem M, Liaqat N, Butt J, Hashim I, Iqbal A, Raza A, Urooj A. Jejunoileal atresia: a case-series of 63 neonates and risk factors to mortality. ANNALS OF PEDIATRIC SURGERY 2022. [DOI: 10.1186/s43159-021-00147-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Introduction
Jejunoileal atresia (JIA) among neonates is still a condition which has huge morbidity and mortality, particularly in the developing world. We share a case series of JIA in context of their presentation, management, and outcome.
Materials and methods
This study was conducted at Children’s Hospital and Institute of Child Health, Lahore, over 1 year. We included all patients presenting with JIA, and their demographic details, presentation, investigations, treatment strategies, and the outcome were noted at a pre-designed proforma. All data were analyzed using SPSS version 26.
Results
A total of 63 neonates with JIA were included. Most of them (79.4%) presented after 48 h of life, and the mean age at presentation was 5.68 ± 4.75 days. There were 37 male patients (58.7%), and 51 (81%) were full-term. The most common presenting complaint was not being able to pass meconium (88.9%). Type III atresia was the most common subtype (41.3%). Most of them underwent resection without tapering. The mean hospital stay was 12.81 ± 6.53, and it was significantly longer among those who underwent re-exploration (P = 0.034). Twenty-three patients (36.5%) expired within 6 months of follow-up. The only significant factor for mortality was the presence of short bowel syndrome (P = 0.030). All other demographic and management factors did not alter the mortality rate.
Conclusion
Management of surgical neonates is a difficult job in developing countries with limited resources. There is a high mortality rate of neonates following JIA surgeries, and surgeons in these countries must fight on many fronts to improve the outcome.
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15
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Kaelin Agten A, Xia J, Servante JA, Thornton JG, Jones NW. Routine ultrasound for fetal assessment before 24 weeks' gestation. Cochrane Database Syst Rev 2021; 8:CD014698. [PMID: 34438475 PMCID: PMC8407184 DOI: 10.1002/14651858.cd014698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Ultrasound examination of pregnancy before 24 weeks gestation may lead to more accurate dating and earlier diagnosis of pathology, but may also give false reassurance. It can be used to monitor development or diagnose conditions of an unborn baby. This review compares the effect of routine or universal, ultrasound examination, performed before 24 completed weeks' gestation, with selective or no ultrasound examination. OBJECTIVES: To assess the effect of routine pregnancy ultrasound before 24 weeks as part of a screening programme, compared to selective ultrasound or no ultrasound, on the early diagnosis of abnormal pregnancy location, termination for fetal congenital abnormality, multiple pregnancy, maternal outcomes and later fetal compromise. To assess the effect of first trimester (before 14 weeks) and second trimester (14 to 24 weeks) ultrasound, separately. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, and the World Health Organization's International Clinical Trials Registry Platform (ICTRP) on 11 August 2020. We also examined the reference lists of retrieved studies. SELECTION CRITERIA We included randomised controlled trials (RCTs), quasi-RCTs, cluster-RCTs and RCTs published in abstract form. We included all trials with pregnant women who had routine or revealed ultrasound versus selective ultrasound, no ultrasound, or concealed ultrasound, before 24 weeks' gestation. All eligible studies were screened for scientific integrity and trustworthiness. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for eligibility and risk of bias, extracted data and checked extracted data for accuracy. Two review authors independently used the GRADE approach to assess the certainty of evidence for each outcome MAIN RESULTS: Our review included data from 13 RCTs including 85,265 women. The review included four comparisons. Four trials were assessed to be at low risk of bias for both sequence generation and allocation concealment and two as high risk. The nature of the intervention made it impossible to blind women and staff providing care to treatment allocation. Sample attrition was low in the majority of trials and outcome data were available for most women. Many trials were conducted before it was customary for trials to be registered and protocols published. First trimester routine versus selective ultrasound: four studies, 1791 women, from Australia, Canada, the United Kingdom (UK) and the United States (US). First trimester scans probably reduce short-term maternal anxiety about pregnancy (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.65 to 0.99; moderate-certainty evidence). We do not have information on whether the reduction was sustained. The evidence is very uncertain about the effect of first trimester scans on perinatal loss (RR 0.97, 95% CI 0.55 to 1.73; 648 participants; one study; low-certainty evidence) or induction of labour for post-maturity (RR 0.83, 95% CI 0.50 to 1.37; 1474 participants; three studies; low-certainty evidence). The effect of routine first trimester ultrasound on birth before 34 weeks or termination of pregnancy for fetal abnormality was not reported. Second trimester routine versus selective ultrasound: seven studies, 36,053 women, from Finland, Norway, South Africa, Sweden and the US. Second trimester scans probably make little difference to perinatal loss (RR 0.98, 95% CI 0.81 to 1.20; 17,918 participants, three studies; moderate-certainty evidence) or intrauterine fetal death (RR 0.97, 95% CI 0.66 to 1.42; 29,584 participants, three studies; low-certainty evidence). Second trimester scans may reduce induction of labour for post-maturity (RR 0.48, 95% CI 0.31 to 0.73; 24,174 participants, six studies; low-certainty evidence), presumably by more accurate dating. Routine second trimester ultrasound may improve detection of multiple pregnancy (RR 0.05, 95% CI 0.02 to 0.16; 274 participants, five studies; low-certainty evidence). Routine second trimester ultrasound may increase detection of major fetal abnormality before 24 weeks (RR 3.45, 95% CI 1.67 to 7.12; 387 participants, two studies; low-certainty evidence) and probably increases the number of women terminating pregnancy for major anomaly (RR 2.36, 95% CI 1.13 to 4.93; 26,893 participants, four studies; moderate-certainty evidence). Long-term follow-up of children exposed to scans before birth did not indicate harm to children's physical or intellectual development (RR 0.77, 95% CI 0.44 to 1.34; 603 participants, one study; low-certainty evidence). The effect of routine second trimester ultrasound on birth before 34 weeks or maternal anxiety was not reported. Standard care plus two ultrasounds and referral for complications versus standard care: one cluster-RCT, 47,431 women, from Democratic Republic of Congo, Guatemala, Kenya, Pakistan and Zambia. This trial included a co-intervention, training of healthcare workers and referral for complications and was, therefore, assessed separately. Standard pregnancy care plus two scans, and training and referral for complications, versus standard care probably makes little difference to whether women with complications give birth in a risk appropriate setting with facilities for caesarean section (RR 1.03, 95% CI 0.89 to 1.19; 11,680 participants; moderate-certainty evidence). The intervention also probably makes little to no difference to low birthweight (< 2500 g) (RR 1.01, 95% CI 0.90 to 1.13; 47,312 participants; moderate-certainty evidence). The evidence is very uncertain about whether the community intervention (including ultrasound) makes any difference to maternal mortality (RR 0.92, 95% CI 0.55 to 1.55; 46,768 participants; low-certainty evidence). Revealed ultrasound results (communicated to both patient and doctor) versus concealed ultrasound results (blinded to both patient and doctor at any time before 24 weeks): one study, 1095 women, from the UK. The evidence was very uncertain for all results relating to revealed versus concealed ultrasound scan (very low-certainty evidence). AUTHORS' CONCLUSIONS Early scans probably reduce short term maternal anxiety. Later scans may reduce labour induction for post-maturity. They may improve detection of major fetal abnormalities and increase the number of women who choose termination of pregnancy for this reason. They may also reduce the number of undetected twin pregnancies. All these findings accord with observational data. Neither type of scan appears to alter other important maternal or fetal outcomes, but our review may underestimate the effect in modern practice because trials were mostly from relatively early in the development of the technology, and many control participants also had scans. The trials were also underpowered to show an effect on other important maternal or fetal outcomes.
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Affiliation(s)
- Andrea Kaelin Agten
- Department of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jun Xia
- Nottingham China Health Institute, The University of Nottingham Ningbo, Ningbo, China
| | - Juliette A Servante
- Department of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jim G Thornton
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Nia W Jones
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
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16
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Bresnahan BW, Vodicka E, Babigumira JB, Malik AM, Yego F, Lokangaka A, Chitah BM, Bauer Z, Chavez H, Moore JL, Garrison LP, Swanson JO, Swanson D, McClure EM, Goldenberg RL, Esamai F, Garces AL, Chomba E, Saleem S, Tshefu A, Bose CL, Bauserman M, Carlo W, Bucher S, Liechty EA, Nathan RO. Cost estimation alongside a multi-regional, multi-country randomized trial of antenatal ultrasound in five low-and-middle-income countries. BMC Public Health 2021; 21:952. [PMID: 34016085 PMCID: PMC8135981 DOI: 10.1186/s12889-021-10750-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 04/04/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Improving maternal health has been a primary goal of international health agencies for many years, with the aim of reducing maternal and child deaths and improving access to antenatal care (ANC) services, particularly in low-and-middle-income countries (LMICs). Health interventions with these aims have received more attention from a clinical effectiveness perspective than for cost impact and economic efficiency. METHODS We collected data on resource use and costs as part of a large, multi-country study assessing the use of routine antenatal screening ultrasound (US) with the aim of considering the implications for economic efficiency. We assessed typical antenatal outpatient and hospital-based (facility) care for pregnant women, in general, with selective complication-related data collection in women participating in a large maternal health registry and clinical trial in five LMICs. We estimated average costs from a facility/health system perspective for outpatient and inpatient services. We converted all country-level currency cost estimates to 2015 United States dollars (USD). We compared average costs across countries for ANC visits, deliveries, higher-risk pregnancies, and complications, and conducted sensitivity analyses. RESULTS Our study included sites in five countries representing different regions. Overall, the relative cost of individual ANC and delivery-related healthcare use was consistent among countries, generally corresponding to country-specific income levels. ANC outpatient visit cost estimates per patient among countries ranged from 15 to 30 USD, based on average counts for visits with and without US. Estimates for antenatal screening US visits were more costly than non-US visits. Costs associated with higher-risk pregnancies were influenced by rates of hospital delivery by cesarean section (mean per person delivery cost estimate range: 25-65 USD). CONCLUSIONS Despite substantial differences among countries in infrastructures and health system capacity, there were similarities in resource allocation, delivery location, and country-level challenges. Overall, there was no clear suggestion that adding antenatal screening US would result in either major cost savings or major cost increases. However, antenatal screening US would have higher training and maintenance costs. Given the lack of clinical effectiveness evidence and greater resource constraints of LMICs, it is unlikely that introducing antenatal screening US would be economically efficient in these settings--on the demand side (i.e., patients) or supply side (i.e., healthcare providers). TRIAL REGISTRATION Trial number: NCT01990625 (First posted: November 21, 2013 on https://clinicaltrials.gov ).
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Affiliation(s)
- B W Bresnahan
- Department of Radiology, University of Washington, Seattle, WA, USA.
| | - E Vodicka
- Department of Pharmacy, University of Washington, Seattle, WA, USA
| | - J B Babigumira
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - A M Malik
- Aga Khan University, Karachi, Pakistan
| | - F Yego
- Moi University, Eldoret, Kenya
| | - A Lokangaka
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | | | - Z Bauer
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - H Chavez
- University of Francisco Marroquin, Guatemala City, Guatemala
| | | | - L P Garrison
- Department of Pharmacy, University of Washington, Seattle, WA, USA
| | - J O Swanson
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - D Swanson
- Department of Radiology, University of Washington, Seattle, WA, USA
| | | | | | | | | | - E Chomba
- University of Zambia, Lusaka, Zambia
| | - S Saleem
- Aga Khan University, Karachi, Pakistan
| | - A Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - C L Bose
- University of North Carolina, Chapel Hill, NC, USA
| | - M Bauserman
- University of North Carolina, Chapel Hill, NC, USA
| | - W Carlo
- University of Alabama Birmingham, Birmingham, AL, USA
| | - S Bucher
- Indiana University, Indianapolis, IN, USA
| | | | - R O Nathan
- Department of Radiology, University of Washington, Seattle, WA, USA
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17
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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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18
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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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19
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Perception of Ghanaian Primigravidas Undergoing Their First Antenatal Ultrasonography in Cape Coast. Radiol Res Pract 2020; 2020:4589120. [PMID: 33149949 PMCID: PMC7603634 DOI: 10.1155/2020/4589120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 10/12/2020] [Accepted: 10/14/2020] [Indexed: 11/22/2022] Open
Abstract
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.
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20
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Wong HY, Marcu LG, Bezak E, Parange NA. Review of Health Economics of Point-of-Care Testing Worldwide and Its Efficacy of Implementation in the Primary Health Care Setting in Remote Australia. Risk Manag Healthc Policy 2020; 13:379-386. [PMID: 32440241 PMCID: PMC7212773 DOI: 10.2147/rmhp.s247774] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/20/2020] [Indexed: 11/30/2022] Open
Abstract
There are important differences concerning health outcomes between the Australian population living in rural/remote regions and the urban population. Health care provision in remote areas, particularly in regions with a low number of inhabitants, is not without challenges. Aboriginal, rural and remote communities are therefore affected, as they face various obstacles in accessing health services, owing to geographical settings, difficulties in transportation to nearby hospitals, limited or inexistent local qualified personnel. The implementation of point-of-care testing could be a plausible solution to these challenges, as various point-of-care services that have been successfully put into action worldwide indicate towards positive clinical outcomes. Point-of-care units have a real potential in reducing morbidity and mortality in all population groups. This article aims to review the published literature on point-of-care testing around the world, with a focus on health economics and the feasibility of its implementation in Australian rural and remote regions.
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Affiliation(s)
- Hoi Yan Wong
- Division of Health Sciences, University of South Australia, Adelaide, SA 5000, Australia
| | - Loredana G Marcu
- Faculty of Informatics & Science, University of Oradea, Oradea 410087, Romania.,Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia
| | - Eva Bezak
- Division of Health Sciences, University of South Australia, Adelaide, SA 5000, Australia.,Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia.,Department of Physics, University of Adelaide, Adelaide, SA 5005, Australia
| | - Nayana Anupam Parange
- Division of Health Sciences, University of South Australia, Adelaide, SA 5000, Australia.,Cancer Research Institute and School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia
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21
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Dornhofer K, Farhat A, Guan K, Parker E, Kong C, Kim D, Nguyen T, Mogi J, Lahham S, Fox JC. Evaluation of a point-of-care ultrasound curriculum taught by medical students for physicians, nurses, and midwives in rural Indonesia. JOURNAL OF CLINICAL ULTRASOUND : JCU 2020; 48:145-151. [PMID: 31876301 DOI: 10.1002/jcu.22809] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 12/04/2019] [Accepted: 12/14/2019] [Indexed: 05/09/2023]
Abstract
PURPOSE In the Indonesian health-care system, nurses and midwives often serve as the primary health-care providers due to physician shortages. Seeking to address the need for medical care in resource-limited environments, some have advocated for portable equipment in the hands of health-care providers. We hypothesized that medical students are able to effectively teach point-of-care ultrasound (POCUS) to physicians, nurses, and midwives in rural Indonesia. METHODS We conducted a prospective, observational study using health-care practitioners from a clinic and accredited school for nursing and midwifery in Mojokerto, East Java, Indonesia. Enrolled practitioners took part in a 4-week POCUS course followed by postinstructional testing. RESULTS A total of 55 health-care practitioners completed the course. This included 19 physicians, 13 nurses, and 19 midwives. Of the 55 clinicians, 43 (72%) passed the course and 12 (28%) failed. CONCLUSIONS Physicians, nurses, and midwives in rural Indonesia showed significant acquisition of ultrasound (US) knowledge and skills following a 4-week US course. Following training, all three groups displayed skills in practical US use during a postcourse practical examination. This is one of the first studies to assess the efficacy of medical students teaching POCUS to midwives and nurses.
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Affiliation(s)
- Kyle Dornhofer
- University of California, Irvine School of Medicine, California
| | - Ahmed Farhat
- University of California, Irvine School of Medicine, California
| | - Kevin Guan
- University of California, Irvine School of Medicine, California
| | - Erica Parker
- University of California, Irvine School of Medicine, California
| | - Christina Kong
- University of California, Irvine School of Medicine, California
| | - Daniel Kim
- University of California, Irvine School of Medicine, California
| | - Thalia Nguyen
- University of California, Irvine School of Medicine, California
| | - Jennifer Mogi
- University of California, Irvine School of Medicine, California
| | - Shadi Lahham
- Department of Emergency Medicine, University of California, Irvine, California
| | - John C Fox
- Department of Emergency Medicine, University of California, Irvine, California
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22
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Figueroa L, McClure EM, Swanson J, Nathan R, Garces AL, Moore JL, Krebs NF, Hambidge KM, Bauserman M, Lokangaka A, Tshefu A, Mirza W, Saleem S, Naqvi F, Carlo WA, Chomba E, Liechty EA, Esamai F, Swanson D, Bose CL, Goldenberg RL. Oligohydramnios: a prospective study of fetal, neonatal and maternal outcomes in low-middle income countries. Reprod Health 2020; 17:19. [PMID: 32000798 PMCID: PMC6993413 DOI: 10.1186/s12978-020-0854-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 01/06/2020] [Indexed: 11/25/2022] Open
Abstract
Background Oligohydramnios is a condition of abnormally low amniotic fluid volume that has been associated with poor pregnancy outcomes. To date, the prevalence of this condition and its outcomes has not been well described in low and low-middle income countries (LMIC) where ultrasound use to diagnose this condition in pregnancy is limited. As part of a prospective trial of ultrasound at antenatal care in LMICs, we sought to evaluate the incidence of and the adverse maternal, fetal and neonatal outcomes associated with oligohydramnios. Methods We included data in this report from all pregnant women in community settings in Guatemala, Pakistan, Zambia and the Democratic Republic of Congo (DRC) who received a third trimester ultrasound as part of the First Look Study, a randomized trial to assess the value of ultrasound at antenatal care. Using these data, we conducted a planned secondary analysis to compare pregnancy outcomes of women with to those without oligohydramnios. Oligohydramnios was defined as measurement of an Amniotic Fluid Index less than 5 cm in at least one ultrasound in the third trimester. The outcomes assessed included maternal morbidity and fetal and neonatal mortality, preterm birth and low-birthweight. We used pairwise site comparisons with Tukey-Kramer adjustment and multivariable logistic models using general estimating equations to account for the correlation of outcomes within cluster. Results Of 12,940 women enrolled in the clusters in Guatemala, Pakistan, Zambia and the DRC in the First Look Study who had a third trimester ultrasound examination, 87 women were diagnosed with oligohydramnios, equivalent to 0.7% of those studied. Prevalence of detected oligohydramnios varied among study sites; from the lowest of 0.2% in Zambia and the DRC to the highest of 1.5% in Pakistan. Women diagnosed with oligohydramnios had higher rates of hemorrhage, fetal malposition, and cesarean delivery than women without oligohydramnios. We also found unfavorable fetal and neonatal outcomes associated with oligohydramnios including stillbirths (OR 5.16, 95%CI 2.07, 12.85), neonatal deaths < 28 days (OR 3.18, 95% CI 1.18, 8.57), low birth weight (OR 2.10, 95% CI 1.44, 3.07) and preterm births (OR 2.73, 95%CI 1.76, 4.23). The mean birth weight was 162 g less (95% CI -288.6, − 35.9) with oligohydramnios. Conclusions Oligohydramnos was associated with worse neonatal, fetal and maternal outcomes in LMIC. Further research is needed to assess effective interventions to diagnose and ultimately to reduce poor outcomes in these settings. Trial registration NCT01990625.
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Affiliation(s)
- Lester Figueroa
- Instituto de Nutrición de Centro América y Panamá (INCAP), Guatemala City, Guatemala
| | - Elizabeth M McClure
- Social Statistical and Environmental Health Sciences, RTI International, Durham, NC, USA.
| | - Jonathan Swanson
- Department of Radiology, University of Washington Medical Center, Seattle, WA, USA
| | - Robert Nathan
- Department of Radiology, University of Washington Medical Center, Seattle, WA, USA
| | - Ana L Garces
- Instituto de Nutrición de Centro América y Panamá (INCAP), Guatemala City, Guatemala
| | - Janet L Moore
- Social Statistical and Environmental Health Sciences, RTI International, Durham, NC, USA
| | - Nancy F Krebs
- Department of Pediatrics, University of Colorado, Denver, CO, USA
| | | | - Melissa Bauserman
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Adrien Lokangaka
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Antoinette Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Waseem Mirza
- Department of Radiology, Aga Khan University, Karachi, Pakistan
| | - Sarah Saleem
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Farnaz Naqvi
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Waldemar A Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Elwyn Chomba
- Department of Pediatrics, University of Zambia, Lusaka, Zambia
| | - Edward A Liechty
- Department of Pediatrics, Indiana University, Indianapolis, IN, USA
| | | | - David Swanson
- Department of Radiology, Harborview Medical Center, University of Washington Medical Center, Seattle, WA, USA
| | - Carl L Bose
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Holmlund S, Lan PT, Edvardsson K, Phuc HD, Ntaganira J, Small R, Kidanto H, Ngarina M, Mogren I. Health professionals' experiences and views on obstetric ultrasound in Vietnam: a regional, cross-sectional study. BMJ Open 2019; 9:e031761. [PMID: 31548354 PMCID: PMC6773349 DOI: 10.1136/bmjopen-2019-031761] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Sophia Holmlund
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden
| | - Pham Thi Lan
- Department of Dermatology and Venereology, Hanoi Medical University, Hanoi, Vietnam
| | - 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, Victoria, Australia
| | - Ho Dang Phuc
- Department of Probability and Mathematical Statistics, Institute of Mathematics, Vietnam Academy of Science and Technology, Hanoi, Vietnam
| | - Joseph Ntaganira
- School of Public Health, University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda
| | - Rhonda Small
- Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Melbourne, Victoria, Australia
- Department of Women's and Children's and Reproductive Health, Karolinska Institutet, Stockholm, Sweden
| | - Hussein Kidanto
- Department of Obstetrics and Gynecology, Aga Khan University - Tanzania, Dar es Salaam, Tanzania
| | - Matilda Ngarina
- Department of Obstetrics and Gynecology, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Ingrid Mogren
- Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Melbourne, Victoria, Australia
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Swanson DL, Franklin HL, Swanson JO, Goldenberg RL, McClure EM, Mirza W, Muyodi D, Figueroa L, Goldsmith N, Kanaiza N, Naqvi F, Pineda IS, López-Gomez W, Hamsumonde D, Bolamba VL, Newman JE, Fogleman EV, Saleem S, Esamai F, Bucher S, Liechty EA, Garces AL, Krebs NF, Hambidge KM, Chomba E, Bauserman M, Mwenechanya M, Carlo WA, Tshefu A, Lokangaka A, Bose CL, Nathan RO. Including ultrasound scans in antenatal care in low-resource settings: Considering the complementarity of obstetric ultrasound screening and maternity waiting homes in strengthening referral systems in low-resource, rural settings. Semin Perinatol 2019; 43:273-281. [PMID: 30979599 PMCID: PMC6597951 DOI: 10.1053/j.semperi.2019.03.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Recent World Health Organization (WHO) antenatal care recommendations include an ultrasound scan as a part of routine antenatal care. The First Look Study, referenced in the WHO recommendation, subsequently shows that the routine use of ultrasound during antenatal care in rural, low-income settings did not improve maternal, fetal or neonatal mortality, nor did it increase women's use of antenatal care or the rate of hospital births. This article reviews the First Look Study, reconsidering the assumptions upon which it was built in light of these results, a supplemental descriptive study of interviews with patients and sonographers that participated in the First Look study intervention, and a review of the literature. Two themes surface from this review. The first is that focused emphasis on building the pregnancy risk screening skills of rural primary health care personnel may not lead to adaptations in referral hospital processes that could benefit the patient accordingly. The second is that agency to improve the quality of patient reception at referral hospitals may need to be manufactured for obstetric ultrasound screening, or remote pregnancy risk screening more generally, to have the desired impact. Stemming from the literature, this article goes on to examine the potential for complementarity between obstetric ultrasound screening and another approach encouraged by the WHO, the maternity waiting home. Each approach may address existing shortcomings in how the other is currently understood. This paper concludes by proposing a path toward developing and testing such a hybrid approach.
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Affiliation(s)
- David L. Swanson
- University of Washington, Seattle, WA, United States,Corresponding author.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Jamie E. Newman
- RTI International, Research Triangle Park, NC, United States
| | | | | | | | - Sherri Bucher
- Indiana University, Indianapolis, IN, United States.
| | | | | | | | | | | | - Melissa Bauserman
- University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.
| | | | | | - Antoinette Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Adrien Lokangaka
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Carl L. Bose
- University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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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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26
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Franklin HL, Mirza W, Swanson DL, Newman JE, Goldenberg RL, Muyodi D, Figueroa L, Nathan RO, Swanson JO, Goldsmith N, Kanaiza N, Naqvi F, Pineda IS, López-Gomez W, Hamsumonde D, Bolamba VL, Fogleman EV, Saleem S, Esamai F, Liechty EA, Garces AL, Krebs NF, Michael Hambidge K, Chomba E, Mwenechanya M, Carlo WA, Tshefu A, Lokangaka A, Bose CL, Koso-Thomas M, Miodovnik M, McClure EM. Factors influencing referrals for ultrasound-diagnosed complications during prenatal care in five low and middle income countries. Reprod Health 2018; 15:204. [PMID: 30541560 PMCID: PMC6291965 DOI: 10.1186/s12978-018-0647-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 11/23/2018] [Indexed: 11/16/2022] Open
Abstract
Background Ultrasound during antenatal care (ANC) is proposed as a strategy for increasing hospital deliveries for complicated pregnancies and improving maternal, fetal, and neonatal outcomes. The First Look study was a cluster-randomized trial conducted in the Democratic Republic of Congo, Guatemala, Kenya, Pakistan and Zambia to evaluate the impact of ANC-ultrasound on these outcomes. An additional survey was conducted to identify factors influencing women with complicated pregnancies to attend referrals for additional care. Methods Women who received referral due to ANC ultrasound findings participated in structured interviews to characterize their experiences. Cochran-Mantel-Haenszel statistics were used to examine differences between women who attended the referral and women who did not. Sonographers’ exam findings were compared to referred women’s recall. Results Among 700 referred women, 510 (71%) attended the referral. Among referred women, 97% received a referral card to present at the hospital, 91% were told where to go in the hospital, and 64% were told that the hospital was expecting them. The referred women who were told who to see at the hospital (88% vs 66%), where to go (94% vs 82%), or what should happen, were more likely to attend their referral (68% vs 56%). Barriers to attending referrals were cost, transportation, and distance. Barriers after reaching the hospital were substantial. These included not connecting with an appropriate provider, not knowing where to go, and being told to return later. These barriers at the hospital often led to an unsuccessful referral. Conclusions Our study found that ultrasound screening at ANC alone does not adequately address barriers to referrals. Better communication between the sonographer and the patient increases the likelihood of a completed referral. These types of communication include describing the ultrasound findings, including the reason for the referral, to the mother and staff; providing a referral card; describing where to go in the hospital; and explaining the procedures at the hospital. Thus, there are three levels of communication that need to be addressed to increase completion of appropriate referrals-communication between the sonographer and the woman, the sonographer and the clinic staff, and the sonographer and the hospital. Trial registration NCT01990625.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Antoinette Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Adrien Lokangaka
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Carl L Bose
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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27
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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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Vinayak S, Sande J, Nisenbaum H, Nolsøe CP. Training Midwives to Perform Basic Obstetric Point-of-Care Ultrasound in Rural Areas Using a Tablet Platform and Mobile Phone Transmission Technology-A WFUMB COE Project. ULTRASOUND IN MEDICINE & BIOLOGY 2017; 43:2125-2132. [PMID: 28716434 DOI: 10.1016/j.ultrasmedbio.2017.05.024] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 05/22/2017] [Accepted: 05/27/2017] [Indexed: 05/09/2023]
Abstract
Point-of-care ultrasound (POCUS) has become a topical subject and can be applied in a variety of ways with differing outcomes. The cost of all diagnostic procedures including obstetric ultrasound examinations is a major factor in the developing world and POCUS is only useful if it can be equated to good outcomes at a lower cost than a routine obstetric examination. The aim of this study was to assess a number of processes including accuracy of images and reports generated by midwives, performance of a tablet-sized ultrasound scanner, training of midwives to complete ultrasounds, teleradiology solution transmissions of images via internet, review of images by a radiologist, communication between midwife and radiologist, use of this technique to identify high-risk patients and improvement of the education and teleradiology model components. The midwives had no previous experience in ultrasound. They were stationed in rural locations where POCUS was available for the first time. After scanning the patients, an interim report was generated by the midwives and sent electronically together with all images to the main hospital for validation. Unique software was used to send lossless images by mobile phone using a modem. Transmission times were short and quality of images transmitted was excellent. All reports were validated by two experienced radiologists in our department and returned to the centers using the same transmission software. The transmission times, quality of scans, quality of reports and other parameters were recorded and monitored. Analysis showed excellent correlation between provisional and validated reports. Reporting accuracy of scans performed by the midwives was 99.63%. Overall flow turnaround time (from patient presentation to validated report) was initially 35 min but reduced to 25 min. The unique mobile phone transmission was faultless and there was no degradation of image quality. We found excellent correlation between final outcomes of the pregnancies and diagnoses on the basis of reports generated by the midwives. Only 1 discrepancy was found in the midwives' reports. Scan results versus actual outcomes revealed 2 discrepancies in the 20 patients identified as high risk. In conclusion, we found that it is valuable to train midwives in POCUS to use an ultrasound tablet device and transmit images and reports via the internet to radiologists for review of accuracy. This focus on the identification of high-risk patients can be valuable in a remote healthcare facility.
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Affiliation(s)
- Sudhir Vinayak
- Department of Imaging and Diagnostic Radiology, Aga Khan University Hospital, Nairobi, Kenya.
| | - Joyce Sande
- Department of Imaging and Diagnostic Radiology, Aga Khan University Hospital, Nairobi, Kenya
| | - Harvey Nisenbaum
- Department of Medical Imaging, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - Christian Pállson Nolsøe
- Department of Abdominal Surgery and Gastroenterology, Ultrasound Section, Herlev Hospital, University of Copenhagen, Herlev, Denmark
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