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

Use and misuse of ultrasound in obstetrics with reference to developing countries

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estimated in 1997 that 50% of developing countries had no access to ultrasound imaging, and available equipment was outdated or broken.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.

Age of first diagnosis and incidence rate of uterine fibroids in Ghana. A retrospective cohort study

BACKGROUND

Uterine fibroids are benign tumors that grow in or on the uterus of women. Globally, they occur in more than 80% of women of African ancestry and 70% in white women. Uterine fibroid requires much attention because of its high incidence rate among women of all races and ages. This study sought to document the age of first diagnosis and incidence rates of uterine fibroids in our urban setting.

METHODS

This study reviewed and analyzed the ages and year of diagnosis of all 2,469 patients with the first diagnosis of uterine fibroids from 1st January 2018 to 31st December 2021 in South-Central Ghana. The obtained data were analyzed using GNU PSPP, Python on Jupyter Notebook and Libre Office Calc with statistical significance level set at p≤0.05.

RESULTS

The overall average age was 36.29±8.08 years, with age range 17-61 years and the age groups with the highest frequencies were 35-39 years (n = 642, 26.00%), 30-34 years (n = 563, 22.80%) and 40-44 years (n = 381, 15.43%). The mean ages of the patients in 2018, 2019, 2020 and 2021 were 36.70±8.00 years (95%CI = 35.97-37.43), 37.07±7.66 years (95%CI = 36.45-37.70), 35.92±7.87 years (95%CI = 35.30-36.53) and 35.78±8.54 years (95%CI = 35.19-36.38) respectively. The incidence rate (per 100,000) of uterine fibroids in 2018, 2019, 2020 and 2021 were 66.77 (95% CI = 60.63-72.90), 81.86 (95%CI = 75.19-88.58), 85.60 (95%CI = 78.85-92.35) and 92.40 (95%CI = 85.88-98.92) respectively, with 35-39 age group recording the highest in all years.

CONCLUSION

The incidence rate of uterine fibroids increased as the years progressed and it is mostly high in 35-39 years age category, with a decreasing annual mean age trend indicative of early diagnosis.

Antenatal Doppler ultrasound implementation in a rural sub-Saharan African setting: exploring the perspectives of women and healthcare providers

Background

The World Health Organization recommends research to evaluate the effects of a single third trimester Doppler ultrasound examination on preventable deaths in unselected-risk pregnancies, particularly in low- and middle-income countries (LMICs) where the evidence base is scarce. While evaluating such technologies, researchers often ignore women and health care provider perspectives. This study explored the views and experiences of women and healthcare providers regarding the use of advanced ultrasound technology to optimize the health of mothers and their babies in a rural community in mid-western Uganda.

Methods

We enrolled 53 mothers and 10 healthcare providers, and captured data on their perceptions, barriers, and facilitators to the use of Doppler ultrasound technology using focus group discussions, semi-structured interviews and observations. Using qualitative content analysis, we inductively coded the transcripts in ATLAS.ti 8.0, detecting emerging themes.

Results

Women were afraid that ultrasound would harm them or their fetuses and many of them had never seen an ultrasound scan. The majority of the women found their partners supportive to attend antenatal care and use ultrasound services. Healthcare providers in Kagadi Hospital were unfamiliar with Doppler technology and using it to guide clinical decisions. Other barriers to the implementation of Doppler ultrasound included shortage of trained local staff, insufficient equipment, long distance to and from the hospital, and frequent power cuts.

Conclusions

We found limited exposure to Doppler ultrasound technology among women and healthcare providers in mid-western Uganda. Engaging male partners may potentially influence the likelihood of accepting and using it to improve the health of women and their fetuses while wide spread myths and misconceptions about it may be changed by community engagement. Healthcare workers experienced difficulties in offering follow-up care to mothers detected with complications and Doppler ultrasound required a high level of training. While introducing advanced ultrasound machines to weak health systems, it is important to adequately train healthcare providers to avoid inappropriate interventions based on misinterpretation of the findings, consider where it is likely to be most beneficial, and embed it with realistic clinical practice guidelines.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01233-5.

Globally, nearly three million babies are stillborn every year, but most especially in low- and middle-income countries like Uganda. One of the factors contributing to a high number of stillbirths in low-income countries is the difficulty in identifying complications and accessing high quality care during pregnancy. Although antenatal Doppler scans are being widely used to diagnose complications in high-risk pregnancies in developed countries, studies evaluating it in LMICs are needed before it is implemented on a wide scale. We engaged 53 mothers, eight health workers from a hospital and two healthcare managers from a local government in Uganda to attain their opinions about Doppler ultrasound. We found that spousal involvement may promote acceptance and use of ultrasound services. However, the health workers did not have adequate knowledge about Doppler technology and using it for the benefit of mothers and the mothers feared that ultrasound procedures might harm them or their unborn babies. Making matters worse, the hospital faced frequent power cuts that affected the use of the equipment. Further, mothers must cover a long distance to access the hospital and its services. To reduce the number of babies dying during pregnancy or a few days after birth in Uganda and similar low-resource settings using Doppler technology, it is essential to strengthen the health systems. Starting with the training of healthcare providers to equipping and stabilizing power supply in health facilities, and educating the public about critical health procedures to break myths and misconceptions.

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

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

Health Pregnancy, Healthy Baby: testing the added benefits of pregnancy ultrasound scan for child development in a randomised control trial

BACKGROUND

The 2016 World Health Organization Antenatal Guidelines and the 2015 South African Maternal and Child Health Guidelines recommend one early antenatal ultrasound scan to establish gestational age and to detect multiple pregnancies and fetal abnormalities. Prior research indicates that ultrasound scan can also increase parental-fetal attachment. We aim to establish whether, compared to routine care, messages to promote parental attachment and healthy child development, conducted during one or two pregnancy ultrasound scans, improve early child development and growth, exclusive breastfeeding, parental-child interactions and prenatal and postnatal clinic attendance.

METHODS

The effect of messages to sensitise mothers and fathers to fetal development will be tested in a three-armed randomised trial with 100 mothers and their partners from Soweto, Johannesburg in each arm. The primary outcome is child development at 6 months postnatally. Secondary outcomes include infant feeding, parental attachment and interaction, parental mental health and infant growth, assessed at 6 weeks and 6 months. Parents in Arm 1 receive a fetal ultrasound scan < 25 weeks during routine antenatal care at tertiary hospitals, and a second standard ultrasound scan at the research site within 2 weeks. Arm 2 participants receive the routine antenatal ultrasound scan and an additional ultrasound scan < 25 weeks at the research site, together with messages to promote parental attachment and healthy child development. Arm 3 participants receive the routine ultrasound scan and two additional ultrasound scans at the research site, < 25 weeks and < 36 weeks, together with messages to promote parental attachment and healthy child development.

DISCUSSION

Evidence from high-income countries suggests that first-time prospective mothers and fathers enjoy seeing their fetus during ultrasound scan and that it is an emotional experience. A number of studies have found that ultrasound scan increases maternal attachment during pregnancy, a predictor of positive parent-infant interactions which, in turn, promotes healthy infant development. It is generally agreed that studies are needed which follow up parental-child behaviour and healthy child development postnatally, include fathers and examine the construct in a wider diversity of settings, especially in low and middle-income countries. Testing the added benefits of pregnancy ultrasound scan for child development is a gap that the proposed trial in South Africa seeks to address.

TRIAL REGISTRATION

Pan African Clinical Trials Registry, PACTR201808107241133. Registered on 15 August 2018.

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

OBJECTIVES

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

DESIGN

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

SETTING

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

PARTICIPANTS

Participants were 289 obstetricians/gynaecologists and 535 midwives.

RESULTS

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

CONCLUSIONS

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

Factors influencing referrals for ultrasound-diagnosed complications during prenatal care in five low and middle income countries

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.

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

INTRODUCTION

Although growing, evidence on the impact, access, utility, effectiveness, and cost-benefit of obstetric ultrasound in resource-constrained settings is still somewhat limited. Hence, questions around the purpose and the intended benefit as well as potential challenges across various domains must be carefully reviewed prior to implementation and scale-up of obstetric ultrasound technology in low-and middle-income countries (LMICs).

MAIN BODY

This narrative review discusses these issues for those trying to implement or scale-up ultrasound technology in LMICs. Issues addressed in this review include health personnel capacity, maintenance, cost, overuse and misuse of ultrasound, miscommunication between the providers and patients, patient diagnosis and care management, health outcomes, patient perceptions and concerns about fetal sex determination.

CONCLUSION

As cost of obstetric ultrasound becomes more affordable in LMICs, it is essential to assess the benefits, trade-offs and potential drawbacks of large-scale implementation. Additionally, there is a need to more clearly identify the capabilities and the limitations of ultrasound, particularly within the context of limited training of providers, to ensure that the purpose for which an ultrasound is intended is actually feasible. We found evidence of obstetric uses of ultrasound improving patient management. However, there was evidence that ultrasound use is not associated with reducing maternal, perinatal or neonatal mortality. Patients in various studies reported to have both positive and negative perceptions and experiences related to ultrasound and lastly, illegal use of ultrasound for determining fetal sex was raised as a concern.

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

The potential benefits of obstetric ultrasound have yet to be fully realized in sub-Saharan Africa (SSA), despite the region bearing the greatest burden of poor perinatal outcomes. We reviewed the literature for challenges and opportunities of universal access to obstetric ultrasound and explored what is needed to make such access an integral component of maternity care in order to address the massive burden of perinatal morbidity and mortality in SSA. Original peer-reviewed literature was searched in various electronic databases using a 'realist' approach. While the available data were inconclusive, they identify many opportunities for potential future research on the subject within the region that can help build a strong case to justify the provision of universal access to ultrasound as an integral component of comprehensive antenatal care.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Two sides of the same coin--an interview study of Swedish obstetricians' experiences using ultrasound in pregnancy management

BACKGROUND

The extended use of ultrasound that is seen in maternity care in most Western countries has not only affected obstetric care but also impacted on the conception of the fetus in relation to the pregnant woman. This situation has also raised concerns regarding the pregnant woman's reproductive freedom. The purpose of this study was to explore Swedish obstetricians' experiences and views on the role of obstetric ultrasound particularly in relation to clinical management of complicated pregnancy, and in relation to situations where the interests of maternal and fetal health conflict.

METHODS

A qualitative study design was applied, and data were collected in 2013 through interviews with 11 obstetricians recruited from five different obstetric clinics in Sweden. Data were analysed using qualitative content analysis.

RESULTS

The theme that emerged in the analysis 'Two sides of the same coin' depicts the view of obstetric ultrasound as a very important tool in obstetric care while it also was experienced as having given rise to new and challenging issues in the management of pregnancy. This theme was built on three categories: I. Ultrasound is essential and also demanding; II. A woman's health interest is prioritised in theory, but not always in practice; and III. Ultrasound is rewarding but may also cause unwarranted anxiety.

CONCLUSIONS

The widespread use of ultrasound in obstetric care has entailed new challenges for clinicians due to enhanced possibilities to diagnose and treat fetal conditions, which in turn might conflict with the health interests of the pregnant woman. There is a need for further ethical discussions regarding the obstetrician's position in management of situations where maternal and fetal health interests conflict. The continuing advances in the potential of ultrasound to impact on pregnancy management will also increase the need for adequate and appropriate information and counselling. Together with other health care professionals, obstetricians therefore need to develop improved ways of enabling pregnant women and their partners to make informed decisions regarding pregnancy management.

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

Objective

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

Design

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

Results

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

Conclusions

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