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Rittenhouse KJ, Vwalika B, Sebastião YV, Pokaprakarn T, Sindano N, Shah H, Stringer EM, Kasaro MP, Cole SR, Stringer JSA, Price JT. Accuracy of portable ultrasound machines for obstetric biometry. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:772-780. [PMID: 38011589 PMCID: PMC11128480 DOI: 10.1002/uog.27541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 11/07/2023] [Accepted: 11/15/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVE To evaluate the accuracy of two portable ultrasound machines (PUM) in assessing fetal biometry and estimated gestational age (EGA). METHODS This was a secondary analysis of data from the Fetal Age Machine Learning Initiative, an observational study of pregnant women in the USA and Zambia. Each participant underwent ultrasound assessment by an experienced sonographer using both a high-specification ultrasound machine (HSUM) and a PUM (Butterfly iQ or Clarius C3) to measure fetal biometry and calculate EGA at each visit. By comparing paired PUM and HSUM scans, we estimated agreement between individual biometry measurements and aggregate gestational age estimates by reporting mean difference, intraclass correlation coefficient (ICC) and Bland-Altman plots, adjusting for trend. RESULTS Between April and December 2021, 818 participants contributed 1386 paired PUM-HSUM ultrasound investigations, of which 991 PUM scans were obtained using the Butterfly iQ device and 395 using the Clarius C3 device. Gestational age at scan ranged from 7 to 38 weeks. Compared with HSUM, the Butterfly iQ PUM had a mean difference of -0.20 (95% CI, -0.60 to 0.20) days in the first trimester and -0.68 (95% CI, -0.93 to -0.44) days in the second/third trimesters. Compared with HSUM, the Clarius C3 PUM had a mean difference of -0.47 (95% CI, -1.11 to 0.18) days in the first trimester and -1.67 (95% CI, -2.10 to -1.25) days in the second/third trimesters. ICCs were 0.989 or greater throughout. Increasing gestational age was associated with increasing error and absolute error in EGA and fetal biometry. Both PUM devices demonstrated a modest trend toward underestimation of EGA with advancing gestational age in second/third-trimester scans, compared with HSUM. CONCLUSION The Butterfly iQ and Clarius C3 PUM devices were highly accurate in performing fetal biometry in a diverse population from the USA and Zambia. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- K. J. Rittenhouse
- Department of Obstetrics and Gynecology, University of
North Carolina School of Medicine, Chapel Hill, NC, USA
| | - B. Vwalika
- Department of Obstetrics and Gynecology, University of
North Carolina School of Medicine, Chapel Hill, NC, USA
- Department of Obstetrics and Gynaecology, University of
Zambia School of Medicine, Lusaka, Zambia
| | - Y. V. Sebastião
- Department of Obstetrics and Gynecology, University of
North Carolina School of Medicine, Chapel Hill, NC, USA
| | - T. Pokaprakarn
- Department of Biostatistics, University of North Carolina
Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - N. Sindano
- UNC Global Projects – Zambia, LLC, Lusaka,
Zambia
| | - H. Shah
- Department of Psychiatry, University of North Carolina
School of Medicine, Chapel Hill, NC, USA
| | - E. M. Stringer
- Department of Obstetrics and Gynecology, University of
North Carolina School of Medicine, Chapel Hill, NC, USA
| | - M. P. Kasaro
- Department of Obstetrics and Gynaecology, University of
Zambia School of Medicine, Lusaka, Zambia
- UNC Global Projects – Zambia, LLC, Lusaka,
Zambia
| | - S. R. Cole
- Department of Epidemiology, University of North Carolina
Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - J. 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
| | - J. 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
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Elmi N, Sadri Y, Myslik F, Chenkin J, Cherniak W. Self-administered at-home lung ultrasound with remote guidance in patients without clinical training. Respir Res 2024; 25:111. [PMID: 38443957 PMCID: PMC10916118 DOI: 10.1186/s12931-024-02744-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 02/21/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Access to timely and accurate diagnostic imaging is essential for high-quality healthcare. Point-of-care ultrasound has been shown to be accessible and effective in many aspects of healthcare, including assessing changes in lung pathology. However, few studies have examined self-administered at-home lung ultrasound (SAAH-LUS), in particular performed by non-clinical patients (NCPs). RESEARCH QUESTION Are NCPs able to perform SAAH-LUS using remote teleguidance and produce interpretable images? STUDY DESIGN Patients were enrolled to the study in a mix of in-person and virtual recruitment, and shipped a smartphone as well as a point of care ultrasound device. Tele-guidance was provided by a remote physician using software integrated with the point of care ultrasound device, allowing real-time remote visualization and guidance of a patient scanning their own chest. A post-intervention survey was conducted to assess patient satisfaction, feasibility, and acceptability of SAAH-LUS. Two POCUS expert reviewers reviewed the scans for interpretability, and inter-rater agreement between the two reviewers was also computed. RESULTS Eighteen patients successfully underwent 7-14 days of daily telemedicine in parallel to daily SAAH-LUS. Across 1339 scans obtained from ten different lung zones, the average proportion of interpretability was 96% with a chance-corrected agreement, or Cohen's kappa, reported as κ = 0.67 (significant agreement). 100% of NCPs surveyed found SAAH-LUS to be a positive experience, particularly for its ease of operation and ability to increase access to healthcare services. INTERPRETATION This study demonstrates that NCPs can obtain interpretable LUS images at home, highlighting the potential for SAAH-LUS to increase diagnostic capacity, particularly for rural and remote regions where complex imaging and healthcare providers are difficult to obtain. Trial registration The clinical trials has been registered (clinicaltrials.gov). REGISTRATION NUMBER NCT04967729.
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Affiliation(s)
- Nika Elmi
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.
| | - Yasmin Sadri
- Dalhousie Medical School, Dalhousie University, Halifax, NS, Canada
| | - Frank Myslik
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Jordan Chenkin
- Department of Emergency Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
| | - William Cherniak
- Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- School of Professional Studies, Northwestern University, Chicago, IL, USA
- Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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Wanjiku GW, Bell G, Kapadia S, Wachira BW. Impact of point-of-care ultrasound use on patient referral decisions in rural Kenya: a mixed methods study. BMC Health Serv Res 2024; 24:212. [PMID: 38360660 PMCID: PMC10870490 DOI: 10.1186/s12913-024-10673-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 02/01/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Point-of-care ultrasound (POCUS) is recognized as a key imaging modality to bridge the diagnostic imaging gap in Low- and Middle-Income Countries (LMICs). POCUS use has been shown to impact patient management decisions including referral for specialist care. This study explored the impact of POCUS use on referral decisions among trained healthcare providers working in primary rural and peri-urban health facilities in Kenya. METHODS A concurrent mixed methods approach was used, including a locally developed survey (N = 38) and semi-structured interviews of POCUS trained healthcare providers (N = 12). Data from the survey was descriptively analyzed and interviews were evaluated through the framework matrix method. RESULTS Survey results of in-facility access to Xray, Ultrasonography, CT scan and MRI were 49%, 33%, 3% and 0% respectively. Only 54% of the facilities where trainees worked had the capacity to perform cesarean sections, and 38% could perform general surgery. Through a combined inductive and deductive evaluation of interview data, we found that the emerging themes could be organized through the framework of the six domains of healthcare quality as described by the Institute of Medicine: Providers reported that POCUS use allowed them to make referral decisions which were timely, safe, effective, efficient, equitable and patient-centered. Challenges included machine breakdown, poor image quality, practice isolation, lack of institutional support and insufficient feedback on the condition of patients after referral. CONCLUSION This study highlighted that in the setting of limited imaging and surgical capacity, POCUS use by trained providers in Kenyan primary health facilities has the potential to improve the patient referral process and to promote key dimensions of healthcare quality. Therefore, there is a need to expand POCUS training programs and to develop context specific POCUS referral algorithms.
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Affiliation(s)
- Grace W Wanjiku
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, 55 Claverick Street Suite 101, Providence, RI, 02903, USA.
| | - Gregory Bell
- Department of Emergency Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Sonja Kapadia
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Benjamin W Wachira
- Accident and Emergency Department, The Aga Khan University, Nairobi, Kenya
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Komuhangi A, Akello R, Izudi J. Determinants of a high prevalence of cesarean section among women in eastern Uganda. Pan Afr Med J 2023; 46:90. [PMID: 38314237 PMCID: PMC10837275 DOI: 10.11604/pamj.2023.46.90.38208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 10/30/2023] [Indexed: 02/06/2024] Open
Abstract
Introduction increasing proportion of Uganda women deliver by cesarean section (C-section) but limited studies have examined the determinants of C-section. We investigated the prevalence and determinants of C-section among women aged 15-49 years in eastern Uganda. Methods we retrieved data for women who attended postnatal care across four large healthcare facilities in Kamuli district. C-section (surgical operation to deliver a baby through the abdomen, whether planned or not) was the outcome. Binary logistic regression was done to determine factors independently associated with C-section, reported as adjusted odds ratio (aOR) and 95% confidence interval (Cl). Results of 727 participants, 126 (17.3%) had delivered by C-section, with the associated factors as self (aOR=1.92, 95% CI 1.04-3.52) and unemployment (aOR=1.81; 95% CI 1.01-3.21), birth order namely second (aOR=3.13, 95% CI 1.77- 5.65), third (aOR=3.60, 95% CI 1.97-6.78), fourth (aOR=2.88, 95% CI 1.46-5.93) and fifth or beyond birth (aOR=2.16, 95% CI, 1.17-4.09), and a rural health facility (aOR=2.04, 95% CI 1.31-3.22). Conclusion the C-section prevalence is slightly higher than recommended by the World Health Organization. There is a need to promote contraceptive use to limit fertility, increase access to contraceptives among rural women, raise awareness among women about the importance of early and regular antenatal visits through education campaigns, equip healthcare facilities with well-trained staff and infrastructure to ensure quality antenatal care to prevent complications that could lead to C-sections, and conduct ongoing research to identify barriers and challenges faced by women in seeking quality healthcare and knowledge about obstetric risk factors.
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Affiliation(s)
- Alimah Komuhangi
- Institute of Public Health, Clarke International University, Kampala, Uganda
- Afya na Haki, Gayaza, Nakwero, Uganda
| | - Racheal Akello
- Institute of Public Health, Clarke International University, Kampala, Uganda
| | - Jonathan Izudi
- Institute of Public Health, Clarke International University, Kampala, Uganda
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
- Data Science and Evaluations (DSE) Unit, African Population and Health Research Center (APHRC), Nairobi, Kenya
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Kim C, Wagle K, Shrestha B, Bhatta S, Maharjan S, Dhakal L, Rizal R, Kristensen S. Perceptions of service providers, service recipients and female community health volunteers on a rural obstetric ultrasound program in rural Nepal: a qualitative study. BMC Pregnancy Childbirth 2023; 23:574. [PMID: 37563558 PMCID: PMC10413490 DOI: 10.1186/s12884-023-05876-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/26/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND In rural Nepal, where women face financial and geographic barriers in accessing ultrasound scans, the government initiated a Rural Obstetric Ultrasound Program (ROUSG) to train skilled birth attendants (SBAs) in rural birthing centers and expand access to routine ultrasound scans for local pregnant women. This study explores the perceived benefits and limitations of the training and implementation of this program. METHODS A qualitative study was conducted in 15 primary care facilities in Bhojpur and Dhading, two rural districts of Nepal. The research team conducted in-depth interviews with 15 trained SBAs and focus group discussions with 48 service recipients and 30 FCHVs to gain insight into their perceptions. All interviews and focus group discussions were recorded, reviewed, and manually coded into MS Excel. RESULTS Overall, our findings indicated that the ROUSG program was very well received among all our study participants, though critical gaps were identified, mostly during the training of the SBAs. These included insufficient guidance or practice opportunities during training and the challenges of implementing the mobile obstetric ultrasound service. Most importantly, though, our results suggest that the implementation of the ROUSG program increased access to prenatal care, earlier identification and referrals for abnormal scans, as well as reduced pregnancy-related stress. There was also a notable anecdotal increase in antenatal care utilization and institutional deliveries, as well as high satisfaction in both service providers and recipients. CONCLUSION Our findings highlighted that while the training component could use some strengthening with increased opportunities for supervised practice sessions and periodic refresher training after the initial 21-days, the program itself had the potential to fill crucial gaps in maternal and newborn care in rural Nepal, by expanding access not only to ROUSG services but also to other MNH services such as ANC and institutional deliveries. Our findings also support the use of ultrasound in areas with limited resources as a solution to identify potential complications at earlier stages of pregnancy and improve timely referrals, indicating the potential for reducing maternal and neonatal morbidities. This initial study supports further research into the role ROUSG can play in expanding critical MNH services in underserved areas and improving broader health outcomes through earlier identification of potential obstetric complications.
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Affiliation(s)
| | | | | | | | | | | | - Rajiv Rizal
- AMDA-Nepal, AMDA Hospital, Damak, Jhapa, Nepal
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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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Eggleston AJ, Farrington E, McDonald S, Aziz S. Portable ultrasound technologies for estimating gestational age in pregnant women: a scoping review and analysis of commercially available models. BMJ Open 2022; 12:e065181. [PMID: 36450429 PMCID: PMC9717352 DOI: 10.1136/bmjopen-2022-065181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 10/03/2022] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVES To identify all available studies assessing the use of portable ultrasound devices for pregnant women, with the specific aim of finding evidence for devices used to determine gestational age and their validity when compared with conventional ultrasound machines. We also wanted to determine what portable ultrasound models are commercially available for obstetric use. DESIGN Systematic scoping review. PRIMARY AND SECONDARY OUTCOME MEASURES Extracted variables included study design, population, method of ultrasound measurement, devices used and whether studies formally validated accuracy against conventional ultrasound. RESULTS We searched four databases-Medline, Embase, CINAHL and Maternal and Infant Care. In total 56 studies from 34 countries were identified; most were observational studies. Across all studies, 27 different portable ultrasound models (from 17 manufacturers) were evaluated. Twenty-one studies assessed use of portable ultrasound for evaluating fetal characteristics or estimating gestational age, and 10 of these were formal validation studies. In total, six portable devices have been validated for gestational age estimation against a conventional ultrasound comparator. The web searches identified 102 portable devices (21 manufacturers). These were a mix of handheld devices that connected to a phone or computer, or laptop-style portable ultrasound devices. Prices ranged from US$1190 to US$30 000 and weight ranged from 0.9 kg to 13.0 kg. CONCLUSION While the number of commercially available portable ultrasound devices continues to grow, there remains a lack of peer-reviewed, quality evidence demonstrating their accuracy and validity when compared with conventional ultrasound machines. This review identified some models that may be useful in gestational age estimation in low-resource settings, but more research is required to help implement the technology at scale. TRIAL REGISTRATION NUMBER Registered via Open Science Framework (DOI: 10.17605/OSF.IO/U8KXP).
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Affiliation(s)
| | - Elise Farrington
- Medical Department, Western Health, Footscray, Victoria, Australia
| | - Steve McDonald
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Samia Aziz
- Department of Public Health, Independent University, Bangladesh, Dhaka, Dhaka District, Bangladesh
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Abawollo HS, Tsegaye ZT, Desta BF, Beshir IA, Mengesha BT, Guteta AA, Heyi AF, Mamo TT, Gebremedhin ZK, Damte HD, Zelealem M, Argaw MD. Contribution of portable obstetric ultrasound service innovation in averting maternal and neonatal morbidities and mortalities at semi-urban health centers of Ethiopia: a retrospective facility-based study. BMC Pregnancy Childbirth 2022; 22:368. [PMID: 35484533 PMCID: PMC9052561 DOI: 10.1186/s12884-022-04703-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 04/20/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The maternal and neonatal mortalities in Ethiopia are high. To achieve the Sustainable Development Goals, innovations in ultrasound scanning and surveillance activities have been implemented at health centers for over 2 years. This study aims to estimate the contribution of obstetric ultrasound services on averted maternal and neonatal morbidities and mortalities in Ethiopia. METHODS A retrospective facility-based cross-sectional study design was conducted in 25 selected health centers. Data were extracted from prenatal ultrasound registers. SPSS version 25 was used for analysis. To claim statistically significant relationship among sartorial variables, a chi-square test was analyzed and P < 0.05 was the cut-off point. RESULTS Over the 2 years, 12,975 pregnant women were scanned and 52.8% of them were residing in rural areas. Abnormal ultrasound was reported in 12.7% and 98.4% of them were referred for confirmation of diagnosis and treatment. The ultrasound service has contributed to the prevention of 1,970 maternal and 19.05 neonatal morbidities and mortalities per 100,000 and 1,000 live births respectively. The averted morbidities and mortalities showed a statistically significant difference among women residing in rural and semi-urban areas, X,2 df (10) = 24.07, P = 0. 007 and X,2 df (5) = 20.87. P = 0.00, 1 respectively. CONCLUSION After availing the appropriate ultrasound machines with essential supplies and capacitating mid-level providers, significant number of high-risk pregnant women were identified on time and managed or referred to health facilities with safe delivery services. Therefore, scaling-up limited obstetric ultrasound services in similar setups will contribute to achieving the Sustainable Development Goals by 2030. It is recommended to enhance community awareness for improved utilization of ultrasound services by pregnant women before the 24th week of gestational age.
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Affiliation(s)
- Hailemariam Segni Abawollo
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute Inc, Addis Ababa, Ethiopia.
| | - Zergu Tafesse Tsegaye
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute Inc, Addis Ababa, Ethiopia
| | - Binyam Fekadu Desta
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute Inc, Addis Ababa, Ethiopia
| | - Ismael Ali Beshir
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute Inc, Addis Ababa, Ethiopia
| | - Birhan Tenaw Mengesha
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute Inc, Addis Ababa, Ethiopia
| | - Asfaw Adugna Guteta
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute Inc, Addis Ababa, Ethiopia
| | - Atrie Fekadu Heyi
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute Inc, Addis Ababa, Ethiopia
| | - Tsega Teferi Mamo
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute Inc, Addis Ababa, Ethiopia
| | - Zenawork Kassa Gebremedhin
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute Inc, Addis Ababa, Ethiopia
| | - Heran Demissie Damte
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute Inc, Addis Ababa, Ethiopia
| | - Meseret Zelealem
- Ministry of Health, Maternal and Child Health Directorate, Addis Ababa, Ethiopia
| | - Mesele Damte Argaw
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute Inc, Addis Ababa, Ethiopia
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11
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Shaddock L, Smith T. Potential for Use of Portable Ultrasound Devices in Rural and Remote Settings in Australia and Other Developed Countries: A Systematic Review. J Multidiscip Healthc 2022; 15:605-625. [PMID: 35378744 PMCID: PMC8976575 DOI: 10.2147/jmdh.s359084] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/17/2022] [Indexed: 02/02/2023] Open
Abstract
Introduction Objective Methods Results Conclusion
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Affiliation(s)
- Liam Shaddock
- Medical Radiation Science, School of Health Sciences, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Tony Smith
- The University of Newcastle Department of Rural Health & School of Health Sciences, The University of Newcastle, Newcastle, New South Wales, Australia
- Correspondence: Tony Smith, The University of Newcastle Department of Rural Health, C/- 69A High Street, Taree, Newcastle, NSW, Australia, Tel +61 466 440 037, Email
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12
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Abrokwa SK, Ruby LC, Heuvelings CC, Bélard S. Task shifting for point of care ultrasound in primary healthcare in low- and middle-income countries-a systematic review. EClinicalMedicine 2022; 45:101333. [PMID: 35284806 PMCID: PMC8904233 DOI: 10.1016/j.eclinm.2022.101333] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/03/2022] [Accepted: 02/16/2022] [Indexed: 12/17/2022] Open
Abstract
Low-and middle-income countries (LMIC) are faced with healthcare challenges including lack of specialized healthcare workforce and limited diagnostic infrastructure. Task shifting for point-of-care ultrasound (POCUS) can overcome both shortcomings. This review aimed at identifying benefits and challenges of task shifting for POCUS in primary healthcare settings in LMIC. Medline and Embase were searched up to November 22nd, 2021. Publications reporting original data on POCUS performed by local ultrasound naïve healthcare providers in any medical field at primary healthcare were included. Data were analyzed descriptively. PROSPERO registration number CRD42021223302. Overall, 36 publications were included, most (n = 35) were prospective observational studies. Medical fields of POCUS application included obstetrics, gynecology, emergency medicine, infectious diseases, and cardiac, abdominal, and pulmonary conditions. POCUS was performed by midwives, nurses, clinical officers, physicians, technicians, and community health workers following varying periods of short-term training and using different ultrasound devices. Benefits of POCUS were yields of diagnostic images with adequate interpretation impacting patient management and outcome. High cost of face-to-face training, poor internet connectivity hindering telemedicine components, and unstable electrici'ty were among reported drawbacks for successful implementation of task shifting POCUS. At the primary care level in resource-limited settings task shifting for POCUS has the potential to expand diagnostic imaging capacity and impact patient management leading to meaningful health outcomes.
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Affiliation(s)
- Seth Kofi Abrokwa
- Institute of Tropical Medicine and International Health, Charité-Universitätsmedizin Berlin, Germany
- Corresponding author.
| | - Lisa C. Ruby
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | | | - Sabine Bélard
- Institute of Tropical Medicine and International Health, Charité-Universitätsmedizin Berlin, Germany
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
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13
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Hall EA, Matilsky D, Zang R, Hase N, Habibu Ali A, Henwood PC, Dean AJ. Analysis of an obstetrics point-of-care ultrasound training program for healthcare practitioners in Zanzibar, Tanzania. Ultrasound J 2021; 13:18. [PMID: 33829362 PMCID: PMC8026796 DOI: 10.1186/s13089-021-00220-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 03/20/2021] [Indexed: 11/10/2022] Open
Abstract
Background A point-of-care ultrasound education program in obstetrics was developed to train antenatal healthcare practitioners in rural Zanzibar. The study group consisted of 13 practitioners with different training backgrounds: physicians, clinical officers, and nurse/midwives. Trainees received an intensive 2-week antenatal ultrasound course consisting of lectures and hands-on practice followed by 6 months of direct supervision of hands-on scanning and bedside education in their clinical practice environments. Trainees were given a pre-course written exam, a final exam at course completion, and practical exams at 19 and 27 weeks. Trainees were expected to complete written documentation and record ultrasound images of at least 75 proctored ultrasounds. The objective of this study was prospectively to analyze the success of a longitudinal point-of-care ultrasound training program for antepartum obstetrical care providers in Zanzibar. Results During the 6-month course, trainees completed 1338 ultrasound exams (average 99 exams per trainee with a range of 42–128 and median of 109). Written exam scores improved from a mean of 33.7% (95% CI 28.6–38.8%) at pre-course assessment to 77.5% (95% CI 71–84%) at course completion (P < 0.0001). Practical exam mean scores improved from 71.2% at course midpoint (95% CI 62.3–80.1%) to 84.7% at course completion (95% Cl 78.5–90.8%) (P < 0.0005). Eight of the 13 trainees completed all training requirements including 75 proctored ultrasound exams. Conclusion Trainees improved significantly on all measures after the training program. 62% of the participants completed all requirements. This relatively low completion rate reflects the challenges of establishing ultrasound capacity in this type of setting. Further study is needed to determine trainees’ long-term retention of ultrasound skills and the impact of the program on clinical practice and health outcomes.
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Affiliation(s)
- Elizabeth A Hall
- Department of Emergency Medicine, Providence St. John's Health Center, 2121 Santa Monica Blvd, Santa Monica, CA, 90404, USA. .,Point-of-Care Ultrasound in Resource-Limited Environments (PURE), Malvern, PA, USA.
| | - Danielle Matilsky
- Point-of-Care Ultrasound in Resource-Limited Environments (PURE), Malvern, PA, USA.,Department of Emergency Medicine, Howard County General Hospital, John Hopkins University, Baltimore, MD, USA
| | - Rachel Zang
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Naomasa Hase
- Obstetrics & Gynecology, Wayne State University, Detroit, MI, USA
| | | | - Patricia C Henwood
- Point-of-Care Ultrasound in Resource-Limited Environments (PURE), Malvern, PA, USA.,Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Anthony J Dean
- Point-of-Care Ultrasound in Resource-Limited Environments (PURE), Malvern, PA, USA.,Emergency Medicine and Emergency Medicine in Radiology, University of Pennsylvania, Philadelphia, PA, USA.,World Interactive Network for Focused Ultrasound (WINFOCUS), Philadelphia, PA, USA
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14
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Weigelt MA, Hilerowicz Y, Leichter JA, Lev-Tov H. Sonographic Evaluation of Hidradenitis Suppurativa with Smartphone-Linked Portable Ultrasound. Dermatology 2021; 237:378-382. [PMID: 33684921 DOI: 10.1159/000513920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 12/12/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Clinical staging systems for hidradenitis suppurativa (HS) have poor interrater reliability and may underestimate disease activity. Sonographic staging systems may overcome these challenges, but conventional ultrasound (US) machines are expensive and bulky. Portable (p)US may facilitate the integration of sonography into routine practice. OBJECTIVES To assess the ability of a novel smartphone-linked pUS device to identify key sonographic lesions of HS. METHODS The charts of 16 patients with HS who were assessed with pUS at the outpatient Dermatology and Wound Care Clinics of a university hospital center were retrospectively reviewed. Clinical and sonographic images of the affected areas were examined. The main outcome measures were the number of patients with identifiable sonographic lesions and the number of patients with subclinical lesions detected by pUS. RESULTS All 3 key sonographic lesions of HS were identifiable with pUS. Sonographic lesions were identified in 10 patients (62.5%). Subclinical lesions were identified in 2 patients (12.5%); in both cases, this affected management decisions. CONCLUSIONS We demonstrate the ability of pUS to identify the key sonographic lesions of HS. pUS is a simple and affordable way to integrate HSUS into clinical and research settings, with clear potential benefits to patients.
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Affiliation(s)
- Maximillian A Weigelt
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami, Miller School of Medicine, Miami, Florida, USA,
| | - Yuval Hilerowicz
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Jeffrey A Leichter
- UHealth Interventional Radiology, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Hadar Lev-Tov
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami, Miller School of Medicine, Miami, Florida, USA
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15
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Ultrasound in the Limited-Resource Setting: A Systematic Qualitative Review. CURRENT RADIOLOGY REPORTS 2019. [DOI: 10.1007/s40134-019-0331-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Doig M, Dizon J, Guerrero K, Parange N. Exploring the availability and impact of antenatal point-of-care ultrasound services in rural and remote communities: A scoping review. Australas J Ultrasound Med 2019; 22:174-185. [PMID: 34760554 DOI: 10.1002/ajum.12138] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background There are global disparities in the provision of maternal health care, with women from rural communities and under-resourced countries expecting poorer access to healthcare services. This potentially compounds the existing higher burden of maternal and neonatal morbidity within these populations. In this setting, point-of-care ultrasound (PoCUS) has the potential to improve outcomes while mitigating challenges and barriers associated with the introduction of new medical technology. Objectives To explore the availability and impact of PoCUS use for antenatal care (ANC) in under-resourced settings. Methods Medline, Embase and Scopus were searched with no year limit. Studies were included if the participants were pregnant women undergoing ANC in a rural setting or developing country and if the intervention was PoCUS use or training. Results A total of 3863 unique articles were identified, with 17 meeting the inclusion criteria. Studies originated from Africa, Asia, Central America and Australia. All studies reported that POCUS use for ANC produced positive outcomes. PoCUS introduction into routine ANC resulted in higher antenatal attendance and reduced maternal and neonatal mortality rates. It was demonstrated that it was feasible to provide local healthcare workers with limited training to perform quality scanning and reporting in their clinics. Methods and measures of these three primary outcomes varied between studies. Conclusion Integration of PoCUS into ANC in the settings examined improved outcomes in under-resourced areas. Further research should investigate the availability of PoCUS services at a country level, the clinical impact and economic feasibility.
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Affiliation(s)
- Mikaela Doig
- University of South Australia City East Campus, 108 North Terrace Adelaide South Australia 5001 Australia
| | - Janine Dizon
- University of South Australia City East Campus, 108 North Terrace Adelaide South Australia 5001 Australia
| | - Katherine Guerrero
- University of South Australia City East Campus, 108 North Terrace Adelaide South Australia 5001 Australia
| | - Nayana Parange
- University of South Australia City East Campus, 108 North Terrace Adelaide South Australia 5001 Australia
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Collins K, Collins C, Kothari A. Point-of-care ultrasound in obstetrics. Australas J Ultrasound Med 2019; 22:32-39. [PMID: 34760534 PMCID: PMC8411729 DOI: 10.1002/ajum.12133] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Point-of-care ultrasound, or PoCUS, where imaging is undertaken at the bedside, clinic or emergency department (ED) by the clinician overseeing treatment, is a rapid form of assessment that may be undertaken alongside or as an alternative to traditional, formal ultrasound performed by a radiology service. PoCUS reduces the time to diagnosis, thus allowing lifesaving treatment to be initiated. This is particularly relevant in Obstetrics and Gynaecology (OBGYN), where delayed diagnosis of pregnancy complications is often fatal or highly debilitating to the mother or fetus. The literature suggests that PoCUS is particularly useful in areas that are inadequately resourced, as it is relatively cheap and accessible. High-quality training is essential to ensure that the staff performing the scans are adequately qualified to deliver the service. Clinicians who perform PoCUS in their practice should be aware of the appropriate indications, as well as when to refer for formal imaging.
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Affiliation(s)
- Kelly Collins
- Northwest Private Hospital137 Flockton streetEverton ParkQueensland4053Australia
| | - Craig Collins
- Redcliffe HospitalAnzac AvenueRedcliffeQueensland4020Australia
| | - Alka Kothari
- Redcliffe HospitalAnzac AvenueRedcliffeQueensland4020Australia
- University of QueenslandSt LuciaQueensland4072Australia
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18
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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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