Evaluation of an Obstetric Ultrasound Curriculum for Midwives in Liberia

Insights into an innovative point of care ultrasound curriculum for Ontario primary maternity care providers

Point of care ultrasound (POCUS) has increasingly been used by midwives worldwide. In 2018, the scope of midwifery care in Ontario was expanded to include POCUS to allow practitioners to provide more comprehensive care. In response to the scope expansion, a new continuing POCUS education course was created in collaboration with faculty and clinicians from obstetrics, midwifery, and medical radiation sciences. The continuing education sonography course focused on fostering the knowledge, skills and judgment Ontario midwives required to safely perform these new POCUS skills. The course included online modules, a two-day hands-on bootcamp workshop, and a clinical practicum under the supervision of a sonographer to confirm competency across the three trimesters of pregnancy. This paper outlines the process for POCUS curriculum development and implementation in pregnancy care following course completion. The first cohort of 17 learners completed the course in 2019. The new curriculum was well received by learners for learning and applying bedside sonography in clinical care. The indications to use POCUS most frequently reported by learners after course completion included assessment of pregnancy viability and fetal presentation. Challenges identified by participants with the course included learning new content such as physics and struggling to complete the clinical practicum due to the coronavirus pandemic. The success of this course is indicated by the completion of the objective structured clinical exams for all learners and meeting the competencies for beginning their practicum. The POCUS continuing education course plays an important role in providing the knowledge, skills and ability to perform point of care pregnancy scans among midwives.

Pioneering point-of-care obstetric ultrasound integration in midwifery education - the MEPOCUS study

BACKGROUND

Ultrasound technology is indispensable in perinatal care due to its non-invasive and painless nature, offering vital insights into foetal development and childbirth. With the academisation of midwifery in Germany, there is a growing necessity to incorporate ultrasound training into midwifery education. This paper discusses the development and implementation of an introductory obstetric ultrasound curriculum tailored for midwifery students, focusing on fundamental ultrasound techniques in obstetrics.

MATERIALS AND METHODS

We used Kern's six-step approach of curricular development comprising [1] problem identification and general needs assessment [2], needs assessment of the targeted learners [3], goals and objectives [4], educational strategies [5], implementation, and [6] evaluation and feedback. The individual components of the curriculum were meticulously designed based on comprehensive literature reviews, thorough consultations with experienced ultrasound experts and evaluated needs of participants prior to the course instruction.

RESULTS

Twenty-seven ultrasound-naive midwifery students participated in the newly developed obstetric ultrasound course. Structured as a modular and integrated framework, the course aimed to provide theoretical and practical instruction in basic obstetric ultrasound, with intrapartum sonography and focused assessment with abdominal sonography for trauma (FAST) as key supplementary specialisations. The results demonstrated a significant increase in the students' overall knowledge and practical skills, as evidenced by the median post-course total score rising from 20 to 60 out of 75 (p < 0.001) in the objective structured clinical examination (OSCE) and from 9 to 19 out of 20 (p = 0.001) in the knowledge test. Additionally, students reported high satisfaction with the course and noted substantial personal benefits.

CONCLUSION

The integration of basic obstetric ultrasound training within the midwifery curriculum is feasible and effective to teach fundamental knowledge and skills of obstetric ultrasound examinations to midwifery students. Expansion, standardisation and regulatory structures are critical components for a continued improvement and realistic integration into midwifery educational frameworks and thus the further development of the midwifery profession.

Shaping ultrasound in midwifery: towards an evidence-based training framework for enhanced prenatal care

BACKGROUND

Academic advancement of the midwifery profession highlights the need to establish standardized qualifications in obstetric ultrasound diagnosis, being a central part of prenatal care. Thus, introduction of an evidence-based training program is warranted. We aimed to reviewed curriculum designs used in midwifery ultrasound education.

METHODS

A systematic literature research was conducted. Embase, PubMed and Google Scholar database was reviewed for publications using the terms "[midwife], [midwives], [midwifery students], [obstetric ultrasound], [midwife sonographer] and [education], [teaching], [program], [course], [curriculum] and [learning]". Papers with full description of curriculum designs or educational programs on obstetrical ultrasound for midwives were included and scrutinized against pre-defined criteria according to the PICO (Population, Intervention, Comparator, Outcomes) scheme.

RESULTS

29 publications were included. Studies demonstrated a significant disparity according to course concepts being used. Differing parameters included: Duration, structure, learning approaches, course content, examination concepts and target groups (practising midwives vs. midwives in education).

CONCLUSION

An evidence-based ultrasound educational program for midwives remains to be developed, including further educational guidelines. Clinical applications by midwives, as well as the distinctions from medical practise, particularly in terms of legal considerations, needs to be defined.

Canadian midwives' perspectives on the clinical impacts of point of care ultrasound in obstetrical care: A concurrent mixed-methods study

Introduction

Point of Care Ultrasound (POCUS) is used globally in obstetrics to conduct real time bedside ultrasound scans to answer a clinical question, and it may be conducted by a non-sonography healthcare practitioner. The College of Midwives of Ontario expanded the scope of practice in 2018 to allow registered midwives to perform POCUS during clinical assessments. In response, a POCUS training curriculum for practicing midwives was developed. This paper reports on the perceptions of learners about the impact of this training on their clinical practice.

Methods

We conducted a mixed-methods study to understand learner perceptions. Data collection included surveys at four time points over a year, and semi-structured interviews. Quantitative data were analyzed through descriptive statistics, and qualitative analyses used a constructivist approach to grounded theory.

Results

The frequency of POCUS use within antenatal care increased among learners, with common applications including assessment of fetal presentation and confirmation of viability. POCUS was seen to holistically aid practitioners care by providing additional skills and knowledge to improve care quality and access to care, particularly for remote areas where ultrasounds are not easily available. However, participants articulated a need for clearer regulatory guidelines outlining how this technology should be applied in midwifery. Equipment purchasing and maintaining costs were a barrier for many midwives.

Conclusions

Participants who had access to a device are continuing to use sonography within their clinics to provide comprehensive midwifery care informed by real-time ultrasound assessments. POCUS scans were seen to offer many benefits to improve patient care.

The training of midwives to perform obstetric ultrasound scan in Africa for task shifting and extension of scope of practice: a scoping review

INTRODUCTION

Ultrasound scan is one of the essential assessments that is crucial in the early identification of health risks during antenatal care. Its accessibility to women in low-and middle-income countries remains a serious challenge because ultrasound scans are not within the scope of practice for midwives. However, task shifting and extension of scope of practice aim to train midwives to assess pregnant women through an ultrasound scan. This paper aims to report the findings of a scoping review on the training of midwives to perform obstetric ultrasound scans in Africa.

METHODS

The 6-step iterative framework for scoping reviews by Arksey and O'Malley was used to determine the extent of qualitative and quantitative evidence available on the training of midwives on obstetric ultrasound scans, which includes specifying the research question, identifying relevant studies, selecting studies, extracting and charting data, collating, summarising, and synthesising and reporting findings.

RESULTS

A total of 12 articles from eight African countries were included in this scoping review. Three main themes and 13 sub-themes emerged and they are: obstetric ultrasound scan training, challenges experienced by midwives from task shifting and extension of scope of practice regarding obstetric ultrasound scan, and the value of task shifting and extension of scope of practice regarding obstetric ultrasound scan to midwives.

DISCUSSION

Despite the available evidence that the training of midwives on obstetric ultrasound scans is essential to ensure the accessibility of quality antenatal health services, the training of midwives on obstetric ultrasound scans in some African countries remains a serious challenge. It is evident from this scoping review results that there is a need for African countries to incorporate obstetric ultrasound scans as part of the scope of practice of midwives. Task shifting necessitates prioritising the training of midwives on the use of obstetric ultrasound scans as one of the steps towards the achievement of the United Nations Sustainable Development Goal number 3 targets by 2030.

Obstetric ultrasound training programmes for midwives: A scoping review

Background

Antenatal care is essential for all expectant mothers and assists in reducing maternal mortality rates thus addressing the Sustainable Development Goal 3. Obstetric ultrasound complements antenatal care and is used in pregnancy to identify and monitor high-risk pregnancies. However, disparities exist and in low- and middle-income countries, ultrasound services are not readily available. This contributes to maternal and neonatal morbidity and mortality within these populations. Short ultrasound training programmes for midwives can be beneficial in alleviating some of the challenges experienced.

Aim

The aim of this scoping review was to identify global ultrasound education programmes for midwives.

Method

Articles containing suitable keywords were retrieved from databases suitable to nursing, education and ultrasound. Themes were developed based on the articles included in the review.

Results

A total of 238 articles were identified, and after the duplicates and irrelevant studies were removed, 22 articles were included. Articles were analysed and discussed under the identified themes and categories.

Conclusion

It is essential that sufficient training is provided to medical professionals performing obstetric ultrasound so that adequate and safe care is offered to expectant mothers. With the introduction of ultrasound in low-resource settings, the knowledge of safety and competencies required to operate the equipment necessitate adequate training. Developed programmes have been found to meet the demands of the ever-changing workforce and allow for midwives to perform focused obstetric ultrasound examinations.

Contribution

This scoping review highlighted ultrasound training programmes for midwives and provided guidance on the development of future midwifery ultrasound training programmes.

Portable ultrasound technologies for estimating gestational age in pregnant women: a scoping review and analysis of commercially available models

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).

Training in Ultrasound to Determine Gestational Age (TUDA): Evaluation of a Novel Education Package to Teach Ultrasound-Naive Midwives Basic Obstetric Ultrasound in Malawi

Introduction

Although ultrasound to determine gestational age is fundamental to the optimum management of pregnancy and is recommended for all women by the World Health Organisation, it remains unavailable to many women in low-income countries where trained practitioners are scarce. This study aimed to evaluate a novel, context-specific education package to teach midwives basic obstetric ultrasound, including the determination of gestational age by measurement of fetal femur length.

Methods

The study was conducted across six sites in Malawi in January 2021. Following a virtual "training of the trainers", local teams delivered a 10-day programme encompassing both didactic and "hands on" components. Matched pre and post course tests assessed participants' knowledge of key concepts, with Objective Structured Clinical Examinations used to evaluate practical skills. To achieve a pass, trainees were required to establish the gestational age to within ±7 days of an experienced practitioner and achieve an overall score of >65% on five consecutive occasions. A matched pre and post course survey explored participants' attitudes and confidence in performing ultrasound examinations.

Results

Of the 29 midwives who participated, 28 finished the programme and met the criteria specified to pass. 22 midwives completed the matched knowledge tests, with the mean (SD) score increasing from 10.2 (3.3) to 18 (2.5) after training (P <0.0001). Mean difference 7.9, 95% CI 6.5-9.2. Midwives passed 87% of the Observed Structured Clinical Examinations, establishing the gestational age to within ±7 days of an experienced practitioner in 89% of assessments. Beliefs regarding the importance of antenatal ultrasound increased post course (p = 0.02), as did confidence in performing ultrasound examinations (p <0.0001).

Conclusion

This study demonstrates not only that ultrasound-naive practitioners can be taught to perform basic obstetric ultrasound dating scans, confidently and competently, after 10 days of training, but also that local teams can be orientated to successfully deliver the programme virtually. Previous ultrasound training initiatives, while often more comprehensive in their syllabus, have been of considerably longer duration and this is likely to be a barrier to upscaling opportunities. We propose that this focused training increases the potential for widescale and sustainable implementation.

Enablers and barriers to introduction of obstetrics ultrasound service at primary care facilities in a resource-limited setting: a qualitative study in four regions of Ethiopia

Background

The World Health Organization (WHO) recommends a minimum of eight ANC contacts during pregnancy, of which having one ultrasound examination before 24 weeks of gestation is indicated. Ultrasound plays a significant role in the surveillance and management of high-risk pregnancies. However, the obstetric ultrasound coverage in resource limited settings remains low. Evidence examining the barriers and facilitators to obstetrics ultrasound use in a resource-limited setting like Ethiopia is lacking. This qualitative study explored the facilitators and barriers to introducing obstetric Vscan Access ultrasound in primary health care facilities in Ethiopia.

Methods

The study employed a qualitative descriptive exploratory study design using in-depth interviews (IDIs) and focus group discussions (FGDs). The study participant were mothers who have had recent birth, community members, maternal and newborn service providers, and their managers. We employed an inductive thematic analysis to analyze the data.

Result

We conducted a total of ten FGDs, three with community members and seven with maternal and newborn service providers, and 52 IDIs with the service providers and health facility managers. Two major themes, health system related and client-related factors, emerged from the analysis. The health system related enablers include increased knowledge and skill of the providers, improved mothers and providers’ motivation, increased service utilization, and improved quality of maternal and newborn care (MNC), and enhanced referral system. The health system related barriers include service interruption, staff shortage/workload, and the providers’ limited capacity. Under the main theme of client-related factors, barriers include perceived limited knowledge and skills of providers and the small size of the ultrasound machine while the facilitators include mothers’ needs and interest in ultrasound scan, availability of free of charge ultrasound service, and increased demand for ultrasound scan service.

Conclusion

Our data suggest that the health system provides an enabling context to introduce limited obstetric ultrasound service and routinely provide the service through mid-level maternal care providers at primary health care level in resource limited settings. Overcoming the health system and client related barriers will maximize and sustain the use of the technology.

Training in Ultrasound to Determine Gestational Age in Low- and Middle- Income Countries: A Systematic Review

Introduction

Establishing an accurate gestational age is essential for the optimum management of pregnancy, delivery and neonatal care, with improved estimates of gestational age considered a public health priority by the World Health Organization (WHO). Although ultrasound is considered the most precise method to achieve this, it is unavailable to many women in low- and middle- income countries (LMICs), where the lack of trained practitioners is considered a major barrier. This systematic review explores what initiatives have previously been undertaken to train staff to date pregnancies using ultrasound, which were successful and what barriers and facilitators influenced training.

Methods

The systematic review was conducted according to PRISMA guidelines and the protocol registered (PROSPERO CRD42019154619). Searches were last performed in July 2021. Studies were screened independently by two assessors, with data extracted by one and verified by the other. Both reviewers graded the methodological quality using the Mixed Methods Assessment Tool. Results were collated within prespecified domains, generating a narrative synthesis.

Results

25/1,262 studies were eligible for inclusion, all of which were programme evaluations. Eighteen were undertaken in Africa, three in South-East Asia, one in South America, and three across multiple sites, including those in Africa, Asia, and South America. Five programs specified criteria to pass, and within these 96% of trainees did so. Trainee follow up was undertaken in 18 studies. Ten met recommendations for training outlined by the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) but only 1 met the current standards set by the WHO.

Discussion

This systematic review is the first to evaluate this topic and has uncovered major inconsistencies in the delivery and reporting of basic obstetric ultrasound training in LMICs, with the majority of programs not meeting minimum recommendations. By identifying these issues, we have highlighted key areas for improvement and made recommendations for reporting according to the RE-AIM framework. With an increasing focus on the importance of improving estimates of gestational age in LMICs, we believe these findings will be of significance to those seeking to develop and expand the provision of sustainable obstetric ultrasound in LMICs.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019154619, PROSPERO CRD42019154619.

Twelve tips for point-of-care ultrasound teaching in low-resource settings

Point-of-care ultrasound (POCUS) has become the standard of care for many emergency department evaluations. Low-resource settings are ideal for POCUS to help improve access to imaging for a number of indications that are obstetric, disease or trauma related. The following twelve specific tips are aimed toward organizations and individuals who aspire to initiate POCUS training in a low-resource setting.

An evaluation of obstetric ultrasound education program in Nepal using the RE-AIM framework

BACKGROUND

Nepal has a high prevalence of congenital anomaly contributing to high infant mortality. Ultrasound, an important tool to detect congenital anomalies and manage maternity-related risk factors, is not properly used in Nepal because Nepali doctors have limited opportunities for learning ultrasound techniques. Hence, we developed and implemented an ultrasound education program from 2016 to 2018. The objective of this study is to evaluate the education program using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework.

METHODS

We conducted a mixed-method study to evaluate each component of RE-AIM. The team collected quantitative data from administrative records, tests, surveys, and an online follow-up survey. Qualitative data were collected from individual in-depth interviews at least a year after the program. The proportions, means, and t-tests were used for quantitative data, and thematic coding for qualitative data.

RESULTS

A total of 228 healthcare workers representing 27.3% of the districts of Nepal were reached from 2016 to 2018. The program improved participants' knowledge (29.3, 8.7, and 23.8 increases out of 100, each year, p< 0.001, n=85) and self-confidence (0.6, 0.3, 1.3 increases out of 4.0, p< 0.01, n=111). The participants were highly satisfied with the program (4.2, 4.1, and 4.0 out of 5.0, n=162). Among the respondents of the online follow-up survey (n=28), 60.7% had used ultrasound in their daily practice after the education program, and a medical institution established an ultrasound training center. The absence of clear accreditation and practical guidelines in ultrasound use were presented as barriers for adoption and maintenance.

CONCLUSION

The program was successful in improving participant's knowledge and self-confidence in ultrasound techniques and showed great potential for the adoption and maintenance of the techniques in their practice. Continuous implementation of the program and institutional policy changes to facilitate ultrasound use may increase the ultrasound use and improve ultrasound service quality in Nepal.

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.

Exploring the availability and impact of antenatal point-of-care ultrasound services in rural and remote communities: A scoping review

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.

Comparing the effectiveness of training course formats for point-of-care ultrasound in the third trimester of pregnancy

INTRODUCTION

The availability of obstetric point-of-care ultrasound (PoCUS) services has been shown to improve pregnancy outcomes in regional and remote areas both in Australia and around the world. There is an increasing demand for efficient, cost-effective PoCUS courses for monitoring the fetus in the third trimester of pregnancy.

AIM

To compare the effectiveness of targeted PoCUS courses provided for health professionals that assess the fetus during the third trimester of pregnancy.

METHOD

The skill-teaching curriculum and competency outcomes of six obstetric PoCUS courses were compared. There were 55 learners with no prior ultrasound experience including 23 with English as a second language. Course duration ranged from 4 to 18 h, didactic lecture time up to 6 h and practical scanning sessions of 3-12 h. Learner/tutor ratio varied from 1:1 to 6:1. All courses included the teaching of knobology, image optimisation and probe manipulation. Practical sessions included supervised scanning of ultrasound phantoms and scanning women in the third trimester of pregnancy. The teaching outcomes that were assessed included image optimisation, determination of fetal lie, fetal heart rate, measuring the single deepest pocket of amniotic fluid, identifying the placental position and basic fetal biometry. The same pre- and post-course multiple choice test and course evaluation forms were used for every programme.

RESULTS

All participants achieved the limited course objectives, regardless of the differences in the course formats.

CONCLUSION

This study confirms that obstetric PoCUS courses can provide the initial basic knowledge and scanning skills required to perform limited scope third-trimester scanning.

Point-of-care ultrasound in obstetrics

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.

Global competencies for midwives: external cephalic version; ultrasonography, and tobacco cessation intervention

PROBLEM AND BACKGROUND

The International Confederation of Midwives (ICM) conducts regular updates to the Essential Competencies for Basic Midwifery Practice to determine the introduction or retention of items in the global scope of midwifery practice guidance document.

AIM

This article presents the review process that underpinned the deliberation about three specific clinical practices: external cephalic version, prenatal ultrasonography, and tobacco cessation interventions that occurred during the 2016-2017 global update study.

METHODS

A brief outline of the research methodology used in the 2016-2017 study is provided. Literature summaries about safety and effectiveness of three clinical skills are offered. Data addressing global and regional variations in support of each practice and final disposition of the items are documented.

FINDINGS

External cephalic version did not receive sufficient document support for inclusion in the initial list of items to be tested in the study. Prenatal ultrasonography was supported as an advanced (76.6%) or country-specific (18.8%) skill that midwives could acquire, to promote wider global access for pregnant women. Midwives' participation in tobacco cessation counselling was supported (≥85%) in each of ICM's regions. Knowledge about World Health Organization recommendations for nicotine replacement therapy was endorsed as an additional (62.4%) or country-specific (29.3%) skill.

DISCUSSION AND CONCLUSION

The current evidence of safety of midwives performing external cephalic version led to the recommendation that it be considered in the next document update. Conflicting views of midwives' role in acquiring skills to conduct prenatal ultrasound were evident. There was strong support for participation in smoking cessation counselling, but knowledge of World Health Organization recommendations was not highly endorsed.

Teaching obstetric ultrasound at Mulago Hospital - Kampala, Uganda

Background

Mulago Hospital is a high volume referral hospital under the Makerere University School of Medicine and Health Sciences. Basic obstetric ultrasound is a useful skill that can aid patient care.

Objectives

The purpose of the study was to assess the effectiveness of an intervention implemented to teach basic ultrasound skills to medical students and house officers at Mulago Hosptial, Kampala, Uganda.

Methods

Forty participants, including medical students, junior house officers (JHOs), and senior house officers (SHOs) were enrolled in the study. A didactic and practical hands-on teaching session was evaluated using a pre- and post-test that was administered to all participants.

Results

Participants included 12 medical students, 23 JHOs, and 5 SHOs. A significant difference in pre- and post-test scores was demonstrated in the medical students and JHOs (34% to 76%, p <0.0001) and this was retained when the results were stratified into the basic definitions and practical sections of the survey (33% to 71%, p<0.0001). The scores for the senior house officers had a mean increase of 2.3 points.

Conclusion

This original teaching intervention is an effective method to improve knowledge and skills for medical students and house officers at Mulago Hospital in the area of basic obstetric ultrasound.

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

BACKGROUND

Obstetric ultrasound has become an indispensable part of antenatal care worldwide. Although the use of ultrasound has shown benefits in the reduction of maternal and foetal morbidity and mortality, it has also raised many ethical challenges. Because of insufficient numbers of midwives in Rwanda, uncomplicated pregnancy care is usually provided by nurses in local health centres. Obstetric ultrasound is generally performed by physicians at higher levels of healthcare, where midwives are also more likely to be employed.

OBJECTIVES

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

METHODS

A qualitative study design was employed. Six focus group discussions were held in 2015 with 23 midwives working in maternity care in rural and urban areas of Rwanda, as part of the CROss Country Ultrasound Study (CROCUS).

RESULTS

Obstetric ultrasound was experienced as playing a very important role in clinical management of pregnant women, but participants emphasised that it should not overshadow other clinical examinations. The unequal distribution of ultrasound services throughout Rwanda was considered a challenge, and access was described as low, especially in rural areas. To increase the quality of maternity care, some advocated strongly for midwives to be trained in ultrasound and for physicians to receive additional training. In general, pregnant women were perceived both as requesting more ultrasound examinations than they received, and as not being satisfied with an antenatal consultation if ultrasound was not performed.

CONCLUSIONS

Obstetric ultrasound plays a significant role in maternity care in Rwanda. Increasing demand for ultrasound examinations from pregnant women needs to be balanced with medical indication and health benefits. Training of midwives to perform obstetric ultrasound and further training for physicians would help to address access to ultrasound for greater numbers of women across Rwanda. RESPONSIBLE EDITOR Virgilio Mariano Salazar Torres, Karolinska Institute, Sweden.