Routine second-trimester ultrasound for low risk pregnancies in a South African community

Association between antenatal ultrasound findings and neonatal outcomes in rural Uganda: a secondary analysis

BACKGROUND

Although the use of prenatal ultrasound services has increased in low- income and lower middle-income countries, there has not been a concurrent improvement in perinatal mortality. It remains unknown whether individual ultrasound findings in this setting are associated with neonatal death or the need for resuscitation at delivery. If associations are identified by ultrasound, they could be used to inform the birth attendant and counsel the family regarding risk, potentially altering delivery preparedness in order to reduce neonatal mortality.

METHODS

This was a secondary analysis of data collected from a prospective cohort. Data was gathered at Nawanyago Health Centre III in Kamuli District, Uganda. Participants included pregnant women who received second and third trimester prenatal ultrasound scans and delivered at that center between July 2010 and August 2018. All ultrasounds were performed at Nawanyago and deliveries were attended solely by midwives or nurses. Predictor variables included the following ultrasound findings: fetal number, fetal presentation, and amniotic fluid volume. The primary outcome was bag-mask ventilation (BMV) of the neonate at delivery. The secondary outcome was stillbirth or neonatal death in the delivery room.

RESULTS

Primary outcome data was available for 1105 infants and secondary outcome data was available for 1098 infants. A total of 33 infants received BMV at delivery. The odds of receiving BMV at delivery was significantly increased if amniotic fluid volume was abnormal (OR 4.2, CI 1.2-14.9) and there were increased odds for multiple gestation (OR 1.9, CI 0.7-5.4) and for non-vertex fetal presentation (OR 1.4, CI 0.6-3.2) that were not statistically significant. Stillbirth or neonatal death in the delivery room was diagnosed for 20 infants. Multiple gestation (OR 4.7, CI 1.6-14.2) and abnormal amniotic fluid volume (OR 4.8, CI 1.0-22.1) increased the odds of stillbirth or neonatal death in the delivery room, though only multiple gestation was statistically significant.

CONCLUSION

Common findings that are easily identifiable on ultrasound in low- and lower middle-income countries are associated with adverse perinatal outcomes. Education could lead to improved delivery preparedness, with the potential to reduce perinatal mortality. This was a preliminary study; larger prospective studies are needed to confirm these findings.

Routine ultrasound for fetal assessment before 24 weeks' gestation

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.

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

OBJECTIVES

The potential benefits and challenges of achieving universal access to obstetric ultrasound services in resource constrained settings were reviewed, with a view to making some recommendations to address the huge burden of avoidable maternal and child morbidity and mortality.

KEY FINDINGS

In most resource-poor settings of the world, antenatal ultrasound is available only to a privileged few in urban centres, while the majority of the population living in rural areas have little or no access to diagnostic imaging services. There is also the extreme shortage of sonographers and doctors with specialist training in sonography. A comprehensive regulation must be put in place to achieve maximum benefits and to ensure quality assurance; appropriate use and application of ethics and training must be comprehensive.

CONCLUSION

Ultrasound service provision, in resource-scarce settings, has the potential to improve access and quality of health care services in areas like the point of care ultrasound service provision and in the fields of obstetrics and gynaecology. A comprehensive regulation must be put in place to achieve maximum benefits and to ensure quality assurance.

IMPLICATIONS FOR PRACTICE

Making ultrasound technology available and affordable in resource scare settings has the potential to improve access to diagnostic imaging services and reduce avoidable maternal and child death in resource constrained settings.

Implementing the INTERGROWTH-21st gestational dating and fetal and newborn growth standards in peri-urban Nairobi, Kenya: Provider experiences, uptake and clinical decision-making

Background

Perinatal and newborn complications are major risk factors for unfavorable fetal and neonatal outcomes. Gestational dating and growth monitoring can be instrumental in the identification and management of high-risk pregnancies and births. The INTERGROWTH-21^st Project developed the first global standards for gestational dating and fetal and newborn growth monitoring, supplying a toolkit for clinicians. This study aimed to assess the feasibility and acceptability of the first known implementation study of these standards in a low resource setting.

Methods

The study was performed in two 12-month phases from March 2016 to March 2018 at Jacaranda Health, a private maternity hospital in peri-urban Nairobi, Kenya. In-depth interviews, focus group discussions and a provider survey were utilized to evaluate providers’ experiences during implementation. Client chart data, for pregnant women attending antenatal care and/or delivering at Jacaranda Health along with their newborns, were captured to assess uptake and effect of the standards on clinical decision-making.

Results

Facility-level support and provider buy-in proved to be critical factors driving the success of implementing the standards. However, additional support was needed to strengthen capacity to conduct and interpret ultrasounds and maintain motivation among providers. We observed a significant increase in the uptake of obstetric ultrasounds, particularly gestational dating, during the implementation of the standards. Although no significant changes were detected in the identification of high-risk pregnancies, referrals and deliveries by Cesarean section during implementation, we did observe a significant reduction in inductions for post-date. No significant barriers were reported regarding the use of the newborn standards. Over 80% of providers advocated for the standards to remain in place with some enhancements related mainly to training, advocacy and procurement.

Conclusions

The findings are timely with increasing global adoption of the standards and the challenging and multi-faceted nature of translating new, evidence-based guidelines into routine clinical practice.

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.

Routine antenatal ultrasound in low- and middle-income countries: first look - a cluster randomised trial

OBJECTIVE

Ultrasound is widely regarded as an important adjunct to antenatal care (ANC) to guide practice and reduce perinatal mortality. We assessed the impact of ANC ultrasound use at health centres in resource-limited countries.

DESIGN

Cluster randomised trial.

SETTING

Clusters within five countries (Democratic Republic of Congo, Guatemala, Kenya, Pakistan, and Zambia) METHODS: Clusters were randomised to standard ANC or standard care plus two ultrasounds and referral for complications. The study trained providers in intervention clusters to perform basic obstetric ultrasounds.

MAIN OUTCOME MEASURES

The primary outcome was a composite of maternal mortality, maternal near-miss mortality, stillbirth, and neonatal mortality.

RESULTS

During the 24-month trial, 28 intervention and 28 control clusters had 24 263 and 23 160 births, respectively; 78% in the intervention clusters received at least one study ultrasound; 60% received two. The prevalence of conditions noted including twins, placenta previa, and abnormal lie was within expected ranges. 9% were referred for an ultrasound-diagnosed condition, and 71% attended the referral. The ANC (RR 1.0 95% CI 1.00, 1.01) and hospital delivery rates for complicated pregnancies (RR 1.03 95% CI 0.89, 1.20) did not differ between intervention and control clusters nor did the composite outcome (RR 1.09 95% CI 0.97, 1.23) or its individual components.

CONCLUSIONS

Despite availability of ultrasound at ANC in the intervention clusters, neither ANC nor hospital delivery for complicated pregnancies increased. The composite outcome and the individual components were not reduced.

TWEETABLE ABSTRACT

Antenatal care ultrasound did not improve a composite outcome that included maternal, fetal, and neonatal mortality.

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.

'Essential but not always available when needed' - an interview study of physicians' experiences and views regarding use of obstetric ultrasound in Tanzania

Background

The value of obstetric ultrasound in high-income countries has been extensively explored but evidence is still lacking regarding the role of obstetric ultrasound in low-income countries.

Objective

We aimed to explore experiences and views among physicians working in obstetric care in Tanzania, on the role of obstetric ultrasound in relation to clinical management.

Design

A qualitative study design was applied. Data were collected in 2015, through 16 individual interviews with physicians practicing in obstetric care at hospitals in an urban setting in Tanzania. Data were analyzed using qualitative content analysis.

Results

Use of obstetric ultrasound in the management of complicated pregnancy was much appreciated by participating physicians, although they expressed considerable concern about the lack of ultrasound equipment and staff able to conduct the examinations. These limitations were recognized as restricting physicians’ ability to manage complications adequately during pregnancy and birth. Better availability of ultrasound was requested to improve obstetric management. Concerns were also raised regarding pregnant women's lack of knowledge and understanding of medical issues which could make counseling in relation to obstetric ultrasound difficult. Although the physicians perceived a positive attitude toward ultrasound among most pregnant women, occasionally they came across women who feared that ultrasound might harm the fetus.

Conclusions

There seems to be a need to provide more physicians in antenatal care in Tanzania with ultrasound training to enable them to conduct obstetric ultrasound examinations and interpret the results themselves. Physicians also need to acquire adequate counseling skills as counseling can be especially challenging in this setting where many expectant parents have low levels of education. Providers of obstetric care and policy makers in Tanzania will need to take measures to ensure appropriate use of the scarce resources in the Tanzanian health care system and prevent the potential risk of overuse of ultrasound in pregnancy.

Ultrasound for fetal assessment in early pregnancy

BACKGROUND

Diagnostic ultrasound is a sophisticated electronic technology, which utilises pulses of high-frequency sound to produce an image. Diagnostic ultrasound examination may be employed in a variety of specific circumstances during pregnancy such as after clinical complications, or where there are concerns about fetal growth. Because adverse outcomes may also occur in pregnancies without clear risk factors, assumptions have been made that routine ultrasound in all pregnancies will prove beneficial by enabling earlier detection and improved management of pregnancy complications. Routine screening may be planned for early pregnancy, late gestation, or both. The focus of this review is routine early pregnancy ultrasound.

OBJECTIVES

To assess whether routine early pregnancy ultrasound for fetal assessment (i.e. its use as a screening technique) influences the diagnosis of fetal malformations, multiple pregnancies, the rate of clinical interventions, and the incidence of adverse fetal outcome when compared with the selective use of early pregnancy ultrasound (for specific indications).

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 March 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

Published, unpublished, and ongoing randomised controlled trials that compared outcomes in women who experienced routine versus selective early pregnancy ultrasound (i.e. less than 24 weeks' gestation). We have included quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We used the Review Manager software to enter and analyse data.

MAIN RESULTS

Routine/revealed ultrasound versus selective ultrasound/concealed: 11 trials including 37,505 women. Ultrasound for fetal assessment in early pregnancy reduces the failure to detect multiple pregnancy by 24 weeks' gestation (risk ratio (RR) 0.07, 95% confidence interval (CI) 0.03 to 0.17; participants = 295; studies = 7), moderate quality of evidence). Routine scans improve the detection of major fetal abnormality before 24 weeks' gestation (RR 3.46, 95% CI 1.67 to 7.14; participants = 387; studies = 2,moderate quality of evidence). Routine scan is associated with a reduction in inductions of labour for 'post term' pregnancy (RR 0.59, 95% CI 0.42 to 0.83; participants = 25,516; studies = 8), but the evidence related to this outcome is of low quality, because most of the pooled effect was provided by studies with design limitation with presence of heterogeneity (I² = 68%). Ultrasound for fetal assessment in early pregnancy does not impact on perinatal death (defined as stillbirth after trial entry, or death of a liveborn infant up to 28 days of age) (RR 0.89, 95% CI 0.70 to 1.12; participants = 35,735; studies = 10, low quality evidence). Routine scans do not seem to be associated with reductions in adverse outcomes for babies or in health service use by mothers and babies. Long-term follow-up of children exposed to scan in utero does not indicate that scans have a detrimental effect on children's physical or cognitive development.The review includes several large, well-designed trials but lack of blinding was a problem common to all studies and this may have an effect on some outcomes. The quality of evidence was assessed for all review primary outcomes and was judged as moderate or low. Downgrading of evidence was based on including studies with design limitations, imprecision of results and presence of heterogeneity.

AUTHORS' CONCLUSIONS

Early ultrasound improves the early detection of multiple pregnancies and improved gestational dating may result in fewer inductions for post maturity. Caution needs to be exercised in interpreting the results of aspects of this review in view of the fact that there is considerable variability in both the timing and the number of scans women received.

Public foetal images and the regulation of middle-class pregnancy in the online media: a view from South Africa

Ultrasonography images and their derivatives have been taken up in a range of 'public' spaces, including medical textbooks, the media, anti-abortion material, advertising, the Internet and public health facilities. Feminists have critiqued the personification of the foetus, the bifurcation of the woman's body and the reduction of the pregnant woman to a disembodied womb. What has received less attention is how these images frequently intersect with race, class, gender and heteronormativity in the creation of idealised and normative understandings of pregnancy. This paper focuses on the discursive positioning of pregnant women as 'mothers' and foetuses as 'babies' in online media targeted at a South African audience, where race and class continue to intersect in complex ways. We show how the ontologically specific understandings of 'mummies' and 'babies' emerge through the use of foetal images to construct specific understandings of the 'ideal' pregnancy. In the process, pregnant women are made responsible for ensuring that their pregnancy conforms to these ideals, which includes the purchasing of the various goods advertised by the websites. Not only does this point to a commodification of pregnancy, but also serves to reinforce a cultural understanding of White, middle-class pregnancy as constituting the normative 'correct' form of pregnancy.

Ancillary benefits of antenatal ultrasound: an association between the introduction of a low-cost ultrasound program and an increase in the numbers of women receiving recommended antenatal treatments

Background

In June of 2010, an antenatal ultrasound program was introduced to perform basic screening examinations at a health care clinic in rural Uganda. The impact of the program on the existing antenatal care infrastructure including the proportion and number of women receiving recommended antenatal care at clinic visits was unknown. The aim of this study was to investigate the relationship between the advent of the ultrasound program and the proportion of women receiving recommended antenatal interventions at their clinic visits. Change in the absolute numbers of antenatal services provided was also assessed.

Methods

Records at the Nawanyago clinic were reviewed to determine the total numbers of women receiving specific interventions before and after the advent of the ultrasound program including HIV testing, intermittent preventive therapy for malaria, presumptive anti-parasitic treatment, and provision of iron and folate for anemia. The rate at which these interventions were provided (number of interventions per clinic visit) was also assessed. The differences in absolute numbers of antenatal interventions before and after the introduction of the ultrasound program were assessed using the Wilcoxon rank-sum test. Differences in intervention rate were assessed using negative binomial regression modeling.

Results

The mean monthly numbers of women receiving each of these interventions increased significantly with the greatest increase seen in numbers of women receiving anemia and deworming treatments at +113% and +102% respectively (p < 0.001). The intervention rate increased for anemia treatment, deworming treatment, and 2nd dose of intermittent preventive therapy for malaria. A slight decrease in intervention rate was observed for 1st dose of malaria treatment with a rate ratio of 0.88 (0.79 - 0.98, 95% CI). Intervention rate for HIV testing was not significantly changed.

Conclusion

The introduction of a low-cost antenatal ultrasound program at a health care clinic in rural Uganda was associated with increases in the number of women receiving specific recommended antenatal care interventions. Effect on intervention rates was mixed but showed an overall increase. The use of ultrasound in this context may provide a benefit to the maternal and neonatal health of the community.

First look: a cluster-randomized trial of ultrasound to improve pregnancy outcomes in low income country settings

BACKGROUND

In high-resource settings, obstetric ultrasound is a standard component of prenatal care used to identify pregnancy complications and to establish an accurate gestational age in order to improve obstetric care. Whether or not ultrasound use will improve care and ultimately pregnancy outcomes in low-resource settings is unknown.

METHODS/DESIGN

This multi-country cluster randomized trial will assess the impact of antenatal ultrasound screening performed by health care staff on a composite outcome consisting of maternal mortality and maternal near-miss, stillbirth and neonatal mortality in low-resource community settings. The trial will utilize an existing research infrastructure, the Global Network for Women's and Children's Health Research with sites in Pakistan, Kenya, Zambia, Democratic Republic of Congo and Guatemala. A maternal and newborn health registry in defined geographic areas which documents all pregnancies and their outcomes to 6 weeks post-delivery will provide population-based rates of maternal mortality and morbidity, stillbirth, neonatal mortality and morbidity, and health care utilization for study clusters. A total of 58 study clusters each with a health center and about 500 births per year will be randomized (29 intervention and 29 control). The intervention includes training of health workers (e.g., nurses, midwives, clinical officers) to perform ultrasound examinations during antenatal care, generally at 18-22 and at 32-36 weeks for each subject. Women who are identified as having a complication of pregnancy will be referred to a hospital for appropriate care. Finally, the intervention includes community sensitization activities to inform women and their families of the availability of ultrasound at the antenatal care clinic and training in emergency obstetric and neonatal care at referral facilities.

DISCUSSION

In summary, our trial will evaluate whether introduction of ultrasound during antenatal care improves pregnancy outcomes in rural, low-resource settings. The intervention includes training for ultrasound-naïve providers in basic obstetric ultrasonography and then enabling these trainees to use ultrasound to screen for pregnancy complications in primary antenatal care clinics and to refer appropriately.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT # 01990625).

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

Background

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

Methods and Findings

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

Conclusions

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The value of adding a universal booking scan to an existing protocol of routine mid-gestation ultrasound scan

OBJECTIVE

To compare 2 routine obstetric ultrasound protocols regarding number of clinically relevant events detected and total ultrasound workload.

METHODS

An interventional before-and-after study comparing 2 groups of 750 consecutive low-risk pregnant women was conducted. The 1st group was routinely offered mid-trimester ultrasound and selective ultrasound examinations for specific indications; the 2nd group was, in addition to this, offered a scan at 1st prenatal visit.

RESULTS

The groups were comparable at baseline, and 78% underwent booking scan. The expanded protocol showed no improvement in detection of most clinically relevant findings but did detect twins slightly earlier (P=0.3) and significantly reduced the number of presumed post-term deliveries (8.4% vs 13.1%; OR 0.61 [95% CI, 0.41-0.90]). Although more women were scanned at any point or <24 weeks (P<0.001), the increase in women receiving a properly timed fetal anomaly scan was small (60.7% vs 52.3%; P=0.003). Total ultrasound workload increased by 74%, mainly because of more follow-up scans (323 vs 122) and more women being scanned for the 1st time >24 weeks (146 vs 51; P<0.001).

CONCLUSION

The results do not support a policy of routine booking scans and revealed no significant benefit apart from a small reduction in presumed post-term pregnancies.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Ultrasound for fetal assessment in early pregnancy

BACKGROUND

Diagnostic ultrasound is a sophisticated electronic technology, which utilises pulses of high frequency sound to produce an image. Diagnostic ultrasound examination may be employed in a variety of specific circumstances during pregnancy such as after clinical complications, or where there are concerns about fetal growth. Because adverse outcomes may also occur in pregnancies without clear risk factors, assumptions have been made that routine ultrasound in all pregnancies will prove beneficial by enabling earlier detection and improved management of pregnancy complications. Routine screening may be planned for early pregnancy, late gestation, or both. The focus of this review is routine early pregnancy ultrasound.

OBJECTIVES

To assess whether routine early pregnancy ultrasound for fetal assessment (i.e. its use as a screening technique) influences the diagnosis of fetal malformations, multiple pregnancies, the rate of clinical interventions, and the incidence of adverse fetal outcome when compared with the selective use of early pregnancy ultrasound (for specific indications).

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2009).

SELECTION CRITERIA

Published, unpublished, and ongoing randomised controlled trials that compared outcomes in women who experienced routine versus selective early pregnancy ultrasound (i.e. less than 24 weeks' gestation). We have included quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data for each included study. We used the Review Manager software to enter and analyse data.

MAIN RESULTS

Routine/revealed ultrasound versus selective ultrasound/concealed: 11 trials including 37505 women. Ultrasound for fetal assessment in early pregnancy reduces the failure to detect multiple pregnancy by 24 weeks' gestation (risk ratio (RR) 0.07, 95% confidence interval (CI) 0.03 to 0.17). Routine scan is associated with a reduction in inductions of labour for 'post term' pregnancy (RR 0.59, 95% CI 0.42 to 0.83). Routine scans do not seem to be associated with reductions in adverse outcomes for babies or in health service use by mothers and babies. Long-term follow up of children exposed to scan in utero does not indicate that scans have a detrimental effect on children's physical or cognitive development.

AUTHORS' CONCLUSIONS

Early ultrasound improves the early detection of multiple pregnancies and improved gestational dating may result in fewer inductions for post maturity. Caution needs to be exercised in interpreting the results of aspects of this review in view of the fact that there is considerable variability in both the timing and the number of scans women received.

Obstetric ultrasound scanning by local health workers in a refugee camp on the Thai-Burmese border

OBJECTIVES

Ultrasound examination of the fetus is a powerful tool for assessing gestational age and detecting obstetric problems but is rarely available in developing countries. The aim of this study was to assess the intraobserver and interobserver agreement of fetal biometry by locally trained health workers in a refugee camp on the Thai-Burmese border.

METHODS

One expatriate doctor and four local health workers participated in the study, which included examinations performed on every fifth pregnant woman with a singleton pregnancy between 16 and 40 weeks' gestation, and who had undergone an early dating ultrasound scan, attending the antenatal clinic in Maela refugee camp. At each examination, two examiners independently measured biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC) and femur length (FL), with one of the examiners obtaining duplicate measurements of each parameter. Intraobserver measurement error was assessed using the intraclass correlation coefficient (ICC) and interobserver error was assessed by the Bland and Altman 95% limits of agreement method.

RESULTS

A total of 4188 ultrasound measurements (12 per woman) were obtained in 349 pregnancies at a median gestational age of 27 (range, 16-40) weeks in 2008. The ICC for BPD, HC, AC and FL was greater than 0.99 for all four trainees and the doctor (range, 0.996-0.998). For gestational ages between 18 and 24 weeks, interobserver 95% limits of agreement corresponding to differences in estimated gestational age of less than +/- 1 week were calculated for BPD, HC, AC and FL. Measurements by local health workers showed high levels of agreement with those of the expatriate doctor.

CONCLUSIONS

Locally trained health workers working in a well organized unit with ongoing quality control can obtain accurate fetal biometry measurements for gestational age estimation. This experience suggests that training of local health workers in developing countries is possible and could allow effective use of obstetric ultrasound imaging.

Obstetric ultrasonography in low-income countries

The major issues in obstetric practice in developing countries are the high rates of maternal and perinatal mortality. In most low-income countries health financing systems are not well established so most people pay for health services at the service delivery points. This causes cost-related issues to be of major concern. The main questions that therefore need to be addressed about obstetric ultrasonography in low-income countries is whether the practice improves maternal and neonatal outcomes and whether the service is within the means of most people in these countries. The indications for obstetric ultrasound, guidelines for the use of obstetric ultrasound and the benefits of obstetric ultrasound in low-income countries are discussed and the future of obstetric ultrasound in developing countries is also briefly considered.

Reducing stillbirths: screening and monitoring during pregnancy and labour

BACKGROUND

Screening and monitoring in pregnancy are strategies used by healthcare providers to identify high-risk pregnancies so that they can provide more targeted and appropriate treatment and follow-up care, and to monitor fetal well-being in both low- and high-risk pregnancies. The use of many of these techniques is controversial and their ability to detect fetal compromise often unknown. Theoretically, appropriate management of maternal and fetal risk factors and complications that are detected in pregnancy and labour could prevent a large proportion of the world's 3.2 million estimated annual stillbirths, as well as minimise maternal and neonatal morbidity and mortality.

METHODS

The fourth in a series of papers assessing the evidence base for prevention of stillbirths, this paper reviews available published evidence for the impact of 14 screening and monitoring interventions in pregnancy on stillbirth, including identification and management of high-risk pregnancies, advanced monitoring techniques, and monitoring of labour. Using broad and specific strategies to search PubMed and the Cochrane Library, we identified 221 relevant reviews and studies testing screening and monitoring interventions during the antenatal and intrapartum periods and reporting stillbirth or perinatal mortality as an outcome.

RESULTS

We found a dearth of rigorous evidence of direct impact of any of these screening procedures and interventions on stillbirth incidence. Observational studies testing some interventions, including fetal movement monitoring and Doppler monitoring, showed some evidence of impact on stillbirths in selected high-risk populations, but require larger rigourous trials to confirm impact. Other interventions, such as amniotic fluid assessment for oligohydramnios, appear predictive of stillbirth risk, but studies are lacking which assess the impact on perinatal mortality of subsequent intervention based on test findings. Few rigorous studies of cardiotocography have reported stillbirth outcomes, but steep declines in stillbirth rates have been observed in high-income settings such as the U.S., where cardiotocography is used in conjunction with Caesarean section for fetal distress.

CONCLUSION

There are numerous research gaps and large, adequately controlled trials are still needed for most of the interventions we considered. The impact of monitoring interventions on stillbirth relies on use of effective and timely intervention should problems be detected. Numerous studies indicated that positive tests were associated with increased perinatal mortality, but while some tests had good sensitivity in detecting distress, false-positive rates were high for most tests, and questions remain about optimal timing, frequency, and implications of testing. Few studies included assessments of impact of subsequent intervention needed before recommending particular monitoring strategies as a means to decrease stillbirth incidence. In high-income countries such as the US, observational evidence suggests that widespread use of cardiotocography with Caesarean section for fetal distress has led to significant declines in stillbirth rates. Efforts to increase availability of Caesarean section in low-/middle-income countries should be coupled with intrapartum monitoring technologies where resources and provider skills permit.