International Journal of Gynecology and Obstetrics 124 (2014) 274–277
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
EDUCATION AND TRAINING
Implementing an obstetric ultrasound training program in rural Africa Natalie Greenwold a,b, Sarah Wallace b, Anne Prost b, Eric Jauniaux a,b,⁎ a b
Academic Department of Maternal and Fetal Medicine, UCL Elizabeth Garrett Anderson Institute for Women's Health, London, UK Medical Aid Films, London, UK
a r t i c l e
i n f o
Article history: Received 2 June 2013 Received in revised form 29 August 2013 Accepted 26 November 2013 Keywords: Africa Education Fetal Low-income countries Obstetrics Training Ultrasound
a b s t r a c t Objective: To evaluate the feasibility and sustainability of basic obstetric ultrasound training in rural Africa. Methods: An 8-week training course, led by UK-based sonographers, was supported by training videos and followed by 10 months of remotely supported scanning in Mandimba, Mozambique. Data were collected prospectively using an Android tablet and the EpiCollect web application. Results: The study group included 1744 pregnant women: 804 scanned by trainees under direct supervision and 940 scanned by trainees alone. Ultrasound identified 36 (2.1%) twin pregnancies, 230 (13.2%) breech presentations, 83 (4.8%) transverse presentations, and 22 (1.3%) cases of placenta previa. The detection rates for the above features were similar in the 2 groups. A subgroup of 230 (13.2%) women had a follow-up scan and 62 (3.6%) were referred to a doctor; 21 of these women required cesarean delivery. Conclusion: Ultrasound training in a rural setting supported remotely is feasible, efficient, and sustainable. It can help local healthcare workers to screen their prenatal populations for obstetric and neonatal risks, and therefore has the potential to improve outcomes at delivery and provide site-specific epidemiologic data that can be used to develop new healthcare provision strategies. © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction In high-resource countries, ultrasound was introduced into obstetric practice in the early 1970s, mainly to diagnose life-threatening maternal conditions such as placenta previa, ectopic pregnancy, multiple pregnancies, and complete hydatidiform mole. With the development of high-resolution ultrasound in the 1980s, screening for fetal malformations has been progressively incorporated into routine prenatal care but it has had very little impact on global perinatal mortality and, thus, has remained relatively controversial in terms of health economics in both high- and low-resource countries [1]. Maternal mortality in most low-income countries (LIC) remains high, mainly because of lack of infrastructure, qualified medical personnel, and access to care [2]. Further reduction in maternal and neonatal morbidity and mortality in LIC remains limited by the lack of trained staff at grassroots level and by the lack of prenatal screening for early identification of obstetric risk. The development of portable and robust ultrasound equipment offers the possibility of broader use of ultrasound, in particular in helping to triage emergencies in low-resource settings [3–5]. Ultrasound imaging can be used to identify a series of prenatal findings clearly associated with increased risk in labor such as placenta previa and twins. When these findings are made early, management of labor can be altered to achieve a reduction in maternal and neonatal morbidity and mortality. ⁎ Corresponding author at: Academic Department of Maternal and Fetal Medicine, UCL Elizabeth Garrett Anderson Institute for Women's Health, 86–96 Chenies Mews, London WC1E 6HX, UK. Tel.: +44 207 6796057; fax: +44 207 3837429. E-mail address: [email protected] (E. Jauniaux).
There are only a small number of published studies reporting on the use of portable ultrasound in low-resource settings. However, in combination with available anecdotal data, these studies support the view that the use of ultrasound in lower-resource regions is feasible and might result in a relatively low-cost improvement in healthcare, particularly obstetric care [6–15]. Within this context, training local staff in performing basic obstetric scans in a rural setting has never been evaluated prospectively. The aim of the current study was to explore the feasibility of training healthcare workers in performing basic obstetric ultrasound examination in a low-resource setting in rural Mozambique, in an area where there was previously no access to ultrasound imaging. 2. Materials and methods In a prospective cohort population study, women attending prenatal clinics at 4 health centers in Mandimba district, Niassa province, northwestern Mozambique, were recruited between August 1, 2011, and July 31, 2012. According to the 2003 Demographic and Health Survey, Mozambique had a population of 18.5 million inhabitants, 69.5% of whom were living in rural areas [16]. The total fertility rate was 5.5 and maternal mortality was estimated to be 408 (range, 327–492) per 100 000 live births. The study was organized as part of a basic obstetric ultrasound training program developed by Medical Aid Films, which is a UK-based charity that provides educational programs for healthcare training based in LIC. The basic obstetric ultrasound training program ran over 8 weeks and included 1 week of formal lectures with supporting films in Mandimba Health Clinic. Practical hands-on training followed for
0020-7292/$ – see front matter © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2013.09.018
N. Greenwold et al. / International Journal of Gynecology and Obstetrics 124 (2014) 274–277
7 weeks using 2 M-Turbo (Sonosite, Bothell, WA, USA) portable ultrasound machines with integrated obstetric biometric charts. The training program was conducted by 8 UK-based and certified sonographer volunteers who went to Mandimba in pairs for 2 weeks at a time. The practical training included use of the ultrasound machine; firsttrimester ultrasound; estimation of gestational age; evaluation of fetal and placental position; and detection of multiple pregnancies and uterine fibroids. Mandimba district has 9 health centers: a main referral health center/ clinic in Mandimba town and 8 peripheral health centers/dispensaries serving a rural population of more than 113 000 people [16]. Major surgical procedures such as cesarean delivery are available at the district general hospital in Lichinga, which is a 2–3-hour drive from Mandimba. The practical sessions were organized in Mandimba Health Clinic and at rural health centers in Lissiete, Lussungasse, and Ntembo. Transportation of staff and equipment was arranged by a local non-governmental organization (MaMA Mozambique). The initial group of trainees included 9 nurses and clinical officers with no previous exposure to ultrasound imaging, and 1 doctor observing. At the end of the training program, 4 trainees (3 nurses and 1 clinical officer) showing a special interest and aptitude for ultrasound were chosen as the local ultrasound coordinators for a specific site. A follow-up evaluation of the quality of ultrasound examination provided by the trainees was organized 4 months after the beginning of the training by one of the trainers returning on site for an additional 2 weeks. All women were offered an obstetric scan at the time of a prenatal visit examination between 11 weeks and term. Gestational age was determined by either menstrual age or ultrasound measurement of the fetal crown–rump length up to 13 weeks, or by biparietal diameter after 13 weeks. All women were informed about the project and consented verbally. Ethics approval for the project was obtained from the Directorate of Health, Mandimba District Health Office. Interview questionnaires were completed at the time of the ultrasound examination and included last menstrual period (LMP), parity, age, and obstetric history. Ultrasound findings included number of fetuses, fetal position from 20 weeks, placental position from 20 weeks, presence of fibroids involving the lower segment, and basic fetal anomalies with possible obstetric impact. Data and immediate clinical outcomes were recorded using Android (Google, Mountain View, CA, USA) tablets and EpiCollect (Imperial College, London, UK) via Android operating system. The tablets also enabled image transfer via Wi-Fi (Wi-Fi Alliance, Austin, TX, USA) for qualitative evaluation of ultrasound data and pictures by the project team, at a cost of approximately US $24 per calendar month. A weekly report, including data transfer, was provided by the trainees. The data obtained by the trainees under supervision and without supervision were analyzed via Stata version 12 (StataCorp, College Station, TX, USA). Standard Kurtosis analysis indicated that some values were normally distributed; means and standard deviations were compared using the t test, and proportions using the χ2 test with Yates correction when required. P b 0.05 was considered to be statistically significant.
275
Table 1 Demographics of women who underwent ultrasound examination at the clinic compared with those scanned at health centers.a Variable
Health clinic (n = 803)
Rural health centers (n = 931)
P value
Maternal age, y Women with known LMP Parity Women with previous complicated obstetric outcomeb Women not pregnant at time of scan Gestational age, wkc
24.4 ± 6.4 136 (16.9) 3.2 ± 1.9 196 (24.4)
24.3 ± 7.3 609 (65.4) 3.0 ± 2.1 258 (27.7)
0.763 b0.001 0.309 0.125
69 (8.6) 28.9 ± 10.1
17 (1.8) 28.7 ± 7.3
b0.001 0.634
Abbreviation: LMP: last menstrual period. a Values are given as mean ± SD or number (percentage) unless otherwise indicated. b Including previous cesarean delivery for obstructed birth and stillbirth. c From LMP and/or ultrasound dating.
death; and 4 (0.2%) involving large fibroids in the lower segment and resulting in unstable fetal lie. Table 1 displays the demographic characteristics of the population studied and compares the data from the subgroup scanned in Mandimba Health Clinic with those from women scanned in the rural health centers. Only 745 (43.0%) women knew the date of their LMP and 86 (5.0%) women with pregnancy symptoms were found not to be pregnant at the time of the ultrasound examination. The numbers of women with known LMP and those with no evidence of a pregnancy on ultrasound were significantly (P b 0.001) lower and higher, respectively, in the subgroup scanned in the clinic. There was no significant difference in mean maternal age, mean parity, mean gestational age from LMP and/or ultrasound dating at the first scan, or number of women with a history of previous obstetric complications, including stillbirth/intrapartum death and emergency cesarean. Table 2 compares the detection rates for the basic ultrasound findings taught during the training course for ultrasound examinations performed by trainees under the supervision of the trainer and those performed by trainees alone. The detection rates for the different ultrasound variables were similar in the 2 subgroups—except for the detection of fetal anomalies, which was significantly (P b 0.001) higher in the subgroup scanned by trainees under the supervision of the trainer. Following the initial ultrasound examination, 230 (13.3%) women were offered a second scan to evaluate the fetal or placental position later in the pregnancy. In total, 62 (3.6%) women were referred to Mandimba Health Clinic for delivery and further clinical evaluation; 21 of these women were referred on to the district general hospital in Lichinga for cesarean delivery.
4. Discussion The present results indicate that basic obstetric ultrasound can be used in rural areas in LIC and that local health carers can be trained to provide a service that is efficient and sustainable.
3. Results Over a 12-month period, including 2 months as part of the training program, a total of 1744 women received an ultrasound examination at one of the study sites. In total, 804 ultrasound examinations were performed by the trainees under direct supervision of the trainer and 940 were performed by the trainees alone. Ten scans performed by the trainees were incomplete or of poor quality and were not included in the final analysis. Of the 1734 cases included, ultrasound identified 407 (23.5%) with potential clinical impact: 230 (13.3%) breech presentations; 83 (4.8%) transverse presentations; 36 (2.1%) twin pregnancies; 23 (1.3%) involving various fetal structural defects; 22 (1.3%) involving placenta previa; 9 (0.5%) involving second-trimester pregnancy loss or intrauterine fetal
Table 2 Comparison of detection rates for basic ultrasound findings taught during the training course. Variable
Trainee under supervision (n = 804)
Trainee alone (n = 930)
P value
Pregnancy loss/intrauterine fetal death Twin pregnancies Fibroids Placenta previa Breech presentation Transverse presentation Fetal anomalies
6 (0.7) 21 (2.6) 1 (0.1) 6 (0.7) 118 (14.7) 35 (4.3) 21 (2.6)
3 (0.3) 15 (1.6) 3 (0.3) 16 (1.7) 112 (12.1) 48 (5.2) 2 (0.2)
0.374 0.198 0.722 0.111 0.123 0.501 b0.001
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N. Greenwold et al. / International Journal of Gynecology and Obstetrics 124 (2014) 274–277
Table 3 Literature review of studies evaluating the role of general and obstetric ultrasound imaging in low-income countries. Author
Location
Type of scan
Operator
No. of cases
Main finding
Doehring-Schwerdtfeger et al., 1992 [6] Steinmetz and Berger, 1999 [7] Adler et al., 2008 [8]
DGH, Sudan
General ultrasound
Local and German physicians
863
Rural clinic, Cameroon Refugee camp, Tanzania DGH, Rwanda
General ultrasound
French physicians
1119
General emergency ultrasound General ultrasound
US physicians and locally trained health workers US and locally trained physicians
460
Rijken et al., 2009 [13]
Refugee camp, Thailand
Obstetric ultrasound biometry
Dutch physician and locally trained health workers
349
Kimberly et al., 2010 [14] Rijken et al., 2012 [15]
Rural clinic, Zambia Refugee camp, Thailand
Obstetric ultrasound
US physician and locally trained midwives Dutch physician and locally trained health workers
441
Immediate therapeutic benefits in 25% of the patients examined Useful when treatment was decided upon in 62% of cases Pregnancy-related exams accounted for 24.1% of total usage Obstetric scanning was the most frequently used application Measurements by local health workers showed high levels of agreement with those of expatriate doctor Ultrasound findings led to a change in clinical decision making in 17% of cases Measurements by local health workers were associated with low SD values and within the normal limits of Asian and European charts
Shah et al., 2009 [12]
Obstetric ultrasound biometry
345
1090
Abbreviation: DGH, district general hospital.
Very few studies have been performed to evaluate the use of portable ultrasound for obstetric care. These machines offer the unique advantage of easy use for multiple sites, less complicated care, and robust features for rugged settings such as emergency rooms in lowresource countries [17]. Data from the present study indicate that fetal malpresentation, multiple pregnancies, and placenta previa can be reliably identified using portable ultrasound by healthcare workers with only 8 weeks of direct supervised training and follow-up support within 6 months. Because hospital access and funding of ensuing care have been identified as major causes for delay in receiving care in emergency situations [2], early detection of possible obstetric complications via ultrasound is of clear clinical benefit. The present study is the largest on the subject so far and, like other similar studies (Table 3), shows that healthcare workers in rural areas of Sub-Saharan Africa can be trained to perform basic obstetric ultrasound and that ultrasound skills can be retained over the training period and after. In most previous studies, ultrasound was used as part of the development of a general ultrasound service by expatriate specialist doctors trained in high-resource countries and, thus, the long-term impact and sustainability of ultrasound on obstetric care were difficult to evaluate. However, consistent with the present results, these studies showed that healthcare workers can be locally trained when working in a well-organized unit with ongoing quality control and can achieve more complex obstetric ultrasound examinations, including accurate fetal biometry measurements [15]. In the present study, the training was focused on basic ultrasound skills, and therefore—not surprisingly—the trainees had a lower detection rate for fetal anomalies when scanning alone (Table 2), as these did not form part of the core training program. Approximately 24% of the women examined in the study revealed a high risk factor, which we believe could be addressed with the current level of clinical provision in the Mandimba district. The study was limited by the absence of detailed follow-up information after referral to the district general hospital but this issue can be addressed in subsequent studies by the use of mobile phone-based data collection systems. Remote support of the trainees in their practice through use of the local mobile network to transfer data and internet evaluation of ultrasound pictures, as provided by the present project, is a novel approach that is easily scalable to ensure quality control, at least over the initial period of scanning after the trainers have left. The data collection software can be installed onto any tablet computer or smartphone [18]. Data input can be performed in rural areas and transferred through the local mobile network or by Wi-Fi at low costs. Continuous collection of accurate and unique epidemiologic data should enable international health organizations and local healthcare providers to adapt care distribution more accurately to the needs of their population. For example, before the start of the present project,
we had assumed that the incidence of multiple pregnancies was higher in the whole of Sub-Saharan Africa than in Europe or North America [19]. Because twin pregnancies are associated with a high incidence of preterm delivery, the early detection of a twin pregnancy could improve the neonatal outcome if the mother were transferred to a hospital with neonatal facilities or attended by a skilled health worker with basic equipment for neonatal resuscitation and support. The present data indicate that the incidence of spontaneous twins is approximately 2% in the district of Mandimba, which is similar to that reported for Europe and the USA but 3-fold lower than that found in Nigeria [19]. We found that ultrasound training empowers local health workers and motivates them to screen their prenatal populations more accurately for obstetric and neonatal risks. The 4 trainees who were selected at the end of the training phase have not only completed their task of scanning and collecting data to the end of the project but also continued to provide a similar ultrasound service to the local population of pregnant women after the end of the project. Furthermore, we found that the use of ultrasound imaging draws mothers to prenatal clinics. We hypothesized that this “magnet” effect could explain the higher number of women presenting with pregnancy symptoms but no pregnancy on ultrasound in the clinic (Table 1), as the clinic is located in a more urban area with better communication services compared with the health centers. A recent study has shown that local healthcare providers and patients recognized ultrasound as a technology that improves the safety of pregnancy and delivery [20]. Unintended consequences of overuse and gender-selective abortions in African populations are not common but have been reported in other low-resource areas. Other potential misuses of the method are the use of ultrasound that is not medically required and/or that is paid for by patients, and the risks associated with an incompetent examiner giving women a false feeling of safety. These issues are also a problem in some LIC and should be considered with caution. In conclusion, the present data indicate that ultrasound training can be applied to the rural health areas in which most Sub-Saharan African women live and give birth. The potential for ultrasound to identify causal problems such as placenta previa and malposition before labor starts is clear and can be achieved in the most remote rural health centers. In selecting a shortlist of targeted obstetric ultrasound parameters that may alter management and outcome, we found that the training of local health workers is achievable in a short period of time. The use of educational film translated into local languages provides a sustainable source of continuous education for the local healthcare workers and an opportunity for the trainees to become trainers. Ultrasound imaging combined with a low-cost data collection system such as the one used in the present study also delivers pivotal information for the development of new healthcare strategies backed by local/regional-specific prospective epidemiologic data, which are crucial for the expansion of healthcare systems in LIC.
N. Greenwold et al. / International Journal of Gynecology and Obstetrics 124 (2014) 274–277
Acknowledgments Medical Aid Films, MaMA Mozambique, and Sonosite provided financial support for the development and implementation of the project. Conflict of interest The authors have no conflicts of interest. References [1] Bucher HC, Schmidt JG. Does routine ultrasound scanning improve outcome in pregnancy? Meta-analysis of various outcome measures. BMJ 1993;307(6895):13–7. [2] Darmstadt GL, Lee AC, Cousens S, Sibley L, Bhutta ZA, Donnay F, et al. 60 Million nonfacility births: who can deliver in community settings to reduce intrapartum-related deaths? Int J Gynecol Obstet 2009;107(Suppl. 1):S89–S112. [3] Mets T. Clinical ultrasound in developing countries. Lancet 1991;337(8737):358. [4] Kiserud T. Global reproductive health: is diagnostic ultrasound appropriate technology? Ultrasound Obstet Gynecol 2012;40(2):123–5. [5] Hofmeyr GJ, Haws RA, Bergström S, Lee AC, Okong P, Darmstadt GL, et al. Obstetric care in low-resource settings: what, who, and how to overcome challenges to scale up? Int J Gynecol Obstet 2009;107(Suppl. 1):S21–44 S44–5. [6] Doehring-Schwerdtfeger E, Abdel-Rahim IM, Dittrich M, Mohamed-Ali Q, Franke D, Kardorff R, et al. Ultrasonography as a diagnostic aid for a district hospital in the tropics. Am J Trop Med Hyg 1992;46(6):727–31. [7] Steinmetz JP, Berger JP. Ultrasonography as an aid to diagnosis and treatment in a rural African hospital: a prospective study of 1,119 cases. Am J Trop Med Hyg 1999;60(1):119–23. [8] Adler D, Mgalula K, Price D, Taylor O. Introduction of a portable ultrasound unit into the health services of the Lugufu refugee camp, Kigoma District, Tanzania. Int J Emerg Med 2008;1(4):261–6.
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[9] Spencer JK, Adler RS. Utility of portable ultrasound in a community in Ghana. J Ultrasound Med 2008;27(12):1735–43. [10] Stein W, Katunda I, Butoto C. A two-level ultrasonographic service in a maternity care unit of a rural district hospital in Tanzania. Trop Doct 2008;38(2):125–6. [11] Shah S, Noble VE, Umulisa I, Dushimiyimana JM, Bukhman G, Mukherjee J, et al. Development of an ultrasound training curriculum in a limited resource international setting: successes and challenges of ultrasound training in rural Rwanda. Int J Emerg Med 2008;1(3):193–6. [12] Shah SP, Epino H, Bukhman G, Umulisa I, Dushimiyimana JM, Reichman A, et al. Impact of the introduction of ultrasound services in a limited resource setting: rural Rwanda 2008. BMC Int Health Hum Rights 2009;9:4. [13] Rijken MJ, Lee SJ, Boel ME, Papageorghiou AT, Visser GH, Dwell SL, et al. Obstetric ultrasound scanning by local health workers in a refugee camp on the Thai-Burmese border. Ultrasound Obstet Gynecol 2009;34(4):395–403. [14] Kimberly HH, Murray A, Mennicke M, Liteplo A, Lew J, Bohan JS, et al. Focused maternal ultrasound by midwives in rural Zambia. Ultrasound Med Biol 2010;36(8): 1267–72. [15] Rijken MJ, Mulder EJ, Papageorghiou AT, Thiptharakun S, Wah N, Paw TK, et al. Quality of ultrasound biometry obtained by local health workers in a refugee camp on the Thai-Burmese border. Ultrasound Obstet Gynecol 2012;40(2):151–7. [16] Nhacolo AQ, Nhalungo DA, Sacoor CN, Aponte JJ, Thompson R, Alonso P. Levels and trends of demographic indices in southern rural Mozambique: evidence from demographic surveillance in Manhiça district. BMC Public Health 2006;6:291. [17] Kim CH, Shin SD, Song KJ, Park CB. Diagnostic accuracy of focused assessment with sonography for trauma (FAST) examinations performed by emergency medical technicians. Prehosp Emerg Care 2012;16(3):400–6. [18] Aanensen DM, Huntley DM, Feil EJ, al-Own F, Spratt BG. EpiCollect: linking smartphones to web applications for epidemiology, ecology and community data collection. PLoS One 2009;4(9):e6968. [19] Smits J, Monden C. Twinning across the Developing World. PLoS One 2011;6(9): e25239. [20] Rijken MJ, Gilder ME, Thwin MM, Ladda Kajeechewa HM, Wiladphaingern J, Lwin KM, et al. Refugee and migrant women’s views of antenatal ultrasound on the Thai Burmese border: a mixed methods study. PLoS One 2012;7(4):e34018.
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
EDUCATION AND TRAINING
Implementing an obstetric ultrasound training program in rural Africa Natalie Greenwold a,b, Sarah Wallace b, Anne Prost b, Eric Jauniaux a,b,⁎ a b
Academic Department of Maternal and Fetal Medicine, UCL Elizabeth Garrett Anderson Institute for Women's Health, London, UK Medical Aid Films, London, UK
a r t i c l e
i n f o
Article history: Received 2 June 2013 Received in revised form 29 August 2013 Accepted 26 November 2013 Keywords: Africa Education Fetal Low-income countries Obstetrics Training Ultrasound
a b s t r a c t Objective: To evaluate the feasibility and sustainability of basic obstetric ultrasound training in rural Africa. Methods: An 8-week training course, led by UK-based sonographers, was supported by training videos and followed by 10 months of remotely supported scanning in Mandimba, Mozambique. Data were collected prospectively using an Android tablet and the EpiCollect web application. Results: The study group included 1744 pregnant women: 804 scanned by trainees under direct supervision and 940 scanned by trainees alone. Ultrasound identified 36 (2.1%) twin pregnancies, 230 (13.2%) breech presentations, 83 (4.8%) transverse presentations, and 22 (1.3%) cases of placenta previa. The detection rates for the above features were similar in the 2 groups. A subgroup of 230 (13.2%) women had a follow-up scan and 62 (3.6%) were referred to a doctor; 21 of these women required cesarean delivery. Conclusion: Ultrasound training in a rural setting supported remotely is feasible, efficient, and sustainable. It can help local healthcare workers to screen their prenatal populations for obstetric and neonatal risks, and therefore has the potential to improve outcomes at delivery and provide site-specific epidemiologic data that can be used to develop new healthcare provision strategies. © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction In high-resource countries, ultrasound was introduced into obstetric practice in the early 1970s, mainly to diagnose life-threatening maternal conditions such as placenta previa, ectopic pregnancy, multiple pregnancies, and complete hydatidiform mole. With the development of high-resolution ultrasound in the 1980s, screening for fetal malformations has been progressively incorporated into routine prenatal care but it has had very little impact on global perinatal mortality and, thus, has remained relatively controversial in terms of health economics in both high- and low-resource countries [1]. Maternal mortality in most low-income countries (LIC) remains high, mainly because of lack of infrastructure, qualified medical personnel, and access to care [2]. Further reduction in maternal and neonatal morbidity and mortality in LIC remains limited by the lack of trained staff at grassroots level and by the lack of prenatal screening for early identification of obstetric risk. The development of portable and robust ultrasound equipment offers the possibility of broader use of ultrasound, in particular in helping to triage emergencies in low-resource settings [3–5]. Ultrasound imaging can be used to identify a series of prenatal findings clearly associated with increased risk in labor such as placenta previa and twins. When these findings are made early, management of labor can be altered to achieve a reduction in maternal and neonatal morbidity and mortality. ⁎ Corresponding author at: Academic Department of Maternal and Fetal Medicine, UCL Elizabeth Garrett Anderson Institute for Women's Health, 86–96 Chenies Mews, London WC1E 6HX, UK. Tel.: +44 207 6796057; fax: +44 207 3837429. E-mail address: [email protected] (E. Jauniaux).
There are only a small number of published studies reporting on the use of portable ultrasound in low-resource settings. However, in combination with available anecdotal data, these studies support the view that the use of ultrasound in lower-resource regions is feasible and might result in a relatively low-cost improvement in healthcare, particularly obstetric care [6–15]. Within this context, training local staff in performing basic obstetric scans in a rural setting has never been evaluated prospectively. The aim of the current study was to explore the feasibility of training healthcare workers in performing basic obstetric ultrasound examination in a low-resource setting in rural Mozambique, in an area where there was previously no access to ultrasound imaging. 2. Materials and methods In a prospective cohort population study, women attending prenatal clinics at 4 health centers in Mandimba district, Niassa province, northwestern Mozambique, were recruited between August 1, 2011, and July 31, 2012. According to the 2003 Demographic and Health Survey, Mozambique had a population of 18.5 million inhabitants, 69.5% of whom were living in rural areas [16]. The total fertility rate was 5.5 and maternal mortality was estimated to be 408 (range, 327–492) per 100 000 live births. The study was organized as part of a basic obstetric ultrasound training program developed by Medical Aid Films, which is a UK-based charity that provides educational programs for healthcare training based in LIC. The basic obstetric ultrasound training program ran over 8 weeks and included 1 week of formal lectures with supporting films in Mandimba Health Clinic. Practical hands-on training followed for
0020-7292/$ – see front matter © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2013.09.018
N. Greenwold et al. / International Journal of Gynecology and Obstetrics 124 (2014) 274–277
7 weeks using 2 M-Turbo (Sonosite, Bothell, WA, USA) portable ultrasound machines with integrated obstetric biometric charts. The training program was conducted by 8 UK-based and certified sonographer volunteers who went to Mandimba in pairs for 2 weeks at a time. The practical training included use of the ultrasound machine; firsttrimester ultrasound; estimation of gestational age; evaluation of fetal and placental position; and detection of multiple pregnancies and uterine fibroids. Mandimba district has 9 health centers: a main referral health center/ clinic in Mandimba town and 8 peripheral health centers/dispensaries serving a rural population of more than 113 000 people [16]. Major surgical procedures such as cesarean delivery are available at the district general hospital in Lichinga, which is a 2–3-hour drive from Mandimba. The practical sessions were organized in Mandimba Health Clinic and at rural health centers in Lissiete, Lussungasse, and Ntembo. Transportation of staff and equipment was arranged by a local non-governmental organization (MaMA Mozambique). The initial group of trainees included 9 nurses and clinical officers with no previous exposure to ultrasound imaging, and 1 doctor observing. At the end of the training program, 4 trainees (3 nurses and 1 clinical officer) showing a special interest and aptitude for ultrasound were chosen as the local ultrasound coordinators for a specific site. A follow-up evaluation of the quality of ultrasound examination provided by the trainees was organized 4 months after the beginning of the training by one of the trainers returning on site for an additional 2 weeks. All women were offered an obstetric scan at the time of a prenatal visit examination between 11 weeks and term. Gestational age was determined by either menstrual age or ultrasound measurement of the fetal crown–rump length up to 13 weeks, or by biparietal diameter after 13 weeks. All women were informed about the project and consented verbally. Ethics approval for the project was obtained from the Directorate of Health, Mandimba District Health Office. Interview questionnaires were completed at the time of the ultrasound examination and included last menstrual period (LMP), parity, age, and obstetric history. Ultrasound findings included number of fetuses, fetal position from 20 weeks, placental position from 20 weeks, presence of fibroids involving the lower segment, and basic fetal anomalies with possible obstetric impact. Data and immediate clinical outcomes were recorded using Android (Google, Mountain View, CA, USA) tablets and EpiCollect (Imperial College, London, UK) via Android operating system. The tablets also enabled image transfer via Wi-Fi (Wi-Fi Alliance, Austin, TX, USA) for qualitative evaluation of ultrasound data and pictures by the project team, at a cost of approximately US $24 per calendar month. A weekly report, including data transfer, was provided by the trainees. The data obtained by the trainees under supervision and without supervision were analyzed via Stata version 12 (StataCorp, College Station, TX, USA). Standard Kurtosis analysis indicated that some values were normally distributed; means and standard deviations were compared using the t test, and proportions using the χ2 test with Yates correction when required. P b 0.05 was considered to be statistically significant.
275
Table 1 Demographics of women who underwent ultrasound examination at the clinic compared with those scanned at health centers.a Variable
Health clinic (n = 803)
Rural health centers (n = 931)
P value
Maternal age, y Women with known LMP Parity Women with previous complicated obstetric outcomeb Women not pregnant at time of scan Gestational age, wkc
24.4 ± 6.4 136 (16.9) 3.2 ± 1.9 196 (24.4)
24.3 ± 7.3 609 (65.4) 3.0 ± 2.1 258 (27.7)
0.763 b0.001 0.309 0.125
69 (8.6) 28.9 ± 10.1
17 (1.8) 28.7 ± 7.3
b0.001 0.634
Abbreviation: LMP: last menstrual period. a Values are given as mean ± SD or number (percentage) unless otherwise indicated. b Including previous cesarean delivery for obstructed birth and stillbirth. c From LMP and/or ultrasound dating.
death; and 4 (0.2%) involving large fibroids in the lower segment and resulting in unstable fetal lie. Table 1 displays the demographic characteristics of the population studied and compares the data from the subgroup scanned in Mandimba Health Clinic with those from women scanned in the rural health centers. Only 745 (43.0%) women knew the date of their LMP and 86 (5.0%) women with pregnancy symptoms were found not to be pregnant at the time of the ultrasound examination. The numbers of women with known LMP and those with no evidence of a pregnancy on ultrasound were significantly (P b 0.001) lower and higher, respectively, in the subgroup scanned in the clinic. There was no significant difference in mean maternal age, mean parity, mean gestational age from LMP and/or ultrasound dating at the first scan, or number of women with a history of previous obstetric complications, including stillbirth/intrapartum death and emergency cesarean. Table 2 compares the detection rates for the basic ultrasound findings taught during the training course for ultrasound examinations performed by trainees under the supervision of the trainer and those performed by trainees alone. The detection rates for the different ultrasound variables were similar in the 2 subgroups—except for the detection of fetal anomalies, which was significantly (P b 0.001) higher in the subgroup scanned by trainees under the supervision of the trainer. Following the initial ultrasound examination, 230 (13.3%) women were offered a second scan to evaluate the fetal or placental position later in the pregnancy. In total, 62 (3.6%) women were referred to Mandimba Health Clinic for delivery and further clinical evaluation; 21 of these women were referred on to the district general hospital in Lichinga for cesarean delivery.
4. Discussion The present results indicate that basic obstetric ultrasound can be used in rural areas in LIC and that local health carers can be trained to provide a service that is efficient and sustainable.
3. Results Over a 12-month period, including 2 months as part of the training program, a total of 1744 women received an ultrasound examination at one of the study sites. In total, 804 ultrasound examinations were performed by the trainees under direct supervision of the trainer and 940 were performed by the trainees alone. Ten scans performed by the trainees were incomplete or of poor quality and were not included in the final analysis. Of the 1734 cases included, ultrasound identified 407 (23.5%) with potential clinical impact: 230 (13.3%) breech presentations; 83 (4.8%) transverse presentations; 36 (2.1%) twin pregnancies; 23 (1.3%) involving various fetal structural defects; 22 (1.3%) involving placenta previa; 9 (0.5%) involving second-trimester pregnancy loss or intrauterine fetal
Table 2 Comparison of detection rates for basic ultrasound findings taught during the training course. Variable
Trainee under supervision (n = 804)
Trainee alone (n = 930)
P value
Pregnancy loss/intrauterine fetal death Twin pregnancies Fibroids Placenta previa Breech presentation Transverse presentation Fetal anomalies
6 (0.7) 21 (2.6) 1 (0.1) 6 (0.7) 118 (14.7) 35 (4.3) 21 (2.6)
3 (0.3) 15 (1.6) 3 (0.3) 16 (1.7) 112 (12.1) 48 (5.2) 2 (0.2)
0.374 0.198 0.722 0.111 0.123 0.501 b0.001
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Table 3 Literature review of studies evaluating the role of general and obstetric ultrasound imaging in low-income countries. Author
Location
Type of scan
Operator
No. of cases
Main finding
Doehring-Schwerdtfeger et al., 1992 [6] Steinmetz and Berger, 1999 [7] Adler et al., 2008 [8]
DGH, Sudan
General ultrasound
Local and German physicians
863
Rural clinic, Cameroon Refugee camp, Tanzania DGH, Rwanda
General ultrasound
French physicians
1119
General emergency ultrasound General ultrasound
US physicians and locally trained health workers US and locally trained physicians
460
Rijken et al., 2009 [13]
Refugee camp, Thailand
Obstetric ultrasound biometry
Dutch physician and locally trained health workers
349
Kimberly et al., 2010 [14] Rijken et al., 2012 [15]
Rural clinic, Zambia Refugee camp, Thailand
Obstetric ultrasound
US physician and locally trained midwives Dutch physician and locally trained health workers
441
Immediate therapeutic benefits in 25% of the patients examined Useful when treatment was decided upon in 62% of cases Pregnancy-related exams accounted for 24.1% of total usage Obstetric scanning was the most frequently used application Measurements by local health workers showed high levels of agreement with those of expatriate doctor Ultrasound findings led to a change in clinical decision making in 17% of cases Measurements by local health workers were associated with low SD values and within the normal limits of Asian and European charts
Shah et al., 2009 [12]
Obstetric ultrasound biometry
345
1090
Abbreviation: DGH, district general hospital.
Very few studies have been performed to evaluate the use of portable ultrasound for obstetric care. These machines offer the unique advantage of easy use for multiple sites, less complicated care, and robust features for rugged settings such as emergency rooms in lowresource countries [17]. Data from the present study indicate that fetal malpresentation, multiple pregnancies, and placenta previa can be reliably identified using portable ultrasound by healthcare workers with only 8 weeks of direct supervised training and follow-up support within 6 months. Because hospital access and funding of ensuing care have been identified as major causes for delay in receiving care in emergency situations [2], early detection of possible obstetric complications via ultrasound is of clear clinical benefit. The present study is the largest on the subject so far and, like other similar studies (Table 3), shows that healthcare workers in rural areas of Sub-Saharan Africa can be trained to perform basic obstetric ultrasound and that ultrasound skills can be retained over the training period and after. In most previous studies, ultrasound was used as part of the development of a general ultrasound service by expatriate specialist doctors trained in high-resource countries and, thus, the long-term impact and sustainability of ultrasound on obstetric care were difficult to evaluate. However, consistent with the present results, these studies showed that healthcare workers can be locally trained when working in a well-organized unit with ongoing quality control and can achieve more complex obstetric ultrasound examinations, including accurate fetal biometry measurements [15]. In the present study, the training was focused on basic ultrasound skills, and therefore—not surprisingly—the trainees had a lower detection rate for fetal anomalies when scanning alone (Table 2), as these did not form part of the core training program. Approximately 24% of the women examined in the study revealed a high risk factor, which we believe could be addressed with the current level of clinical provision in the Mandimba district. The study was limited by the absence of detailed follow-up information after referral to the district general hospital but this issue can be addressed in subsequent studies by the use of mobile phone-based data collection systems. Remote support of the trainees in their practice through use of the local mobile network to transfer data and internet evaluation of ultrasound pictures, as provided by the present project, is a novel approach that is easily scalable to ensure quality control, at least over the initial period of scanning after the trainers have left. The data collection software can be installed onto any tablet computer or smartphone [18]. Data input can be performed in rural areas and transferred through the local mobile network or by Wi-Fi at low costs. Continuous collection of accurate and unique epidemiologic data should enable international health organizations and local healthcare providers to adapt care distribution more accurately to the needs of their population. For example, before the start of the present project,
we had assumed that the incidence of multiple pregnancies was higher in the whole of Sub-Saharan Africa than in Europe or North America [19]. Because twin pregnancies are associated with a high incidence of preterm delivery, the early detection of a twin pregnancy could improve the neonatal outcome if the mother were transferred to a hospital with neonatal facilities or attended by a skilled health worker with basic equipment for neonatal resuscitation and support. The present data indicate that the incidence of spontaneous twins is approximately 2% in the district of Mandimba, which is similar to that reported for Europe and the USA but 3-fold lower than that found in Nigeria [19]. We found that ultrasound training empowers local health workers and motivates them to screen their prenatal populations more accurately for obstetric and neonatal risks. The 4 trainees who were selected at the end of the training phase have not only completed their task of scanning and collecting data to the end of the project but also continued to provide a similar ultrasound service to the local population of pregnant women after the end of the project. Furthermore, we found that the use of ultrasound imaging draws mothers to prenatal clinics. We hypothesized that this “magnet” effect could explain the higher number of women presenting with pregnancy symptoms but no pregnancy on ultrasound in the clinic (Table 1), as the clinic is located in a more urban area with better communication services compared with the health centers. A recent study has shown that local healthcare providers and patients recognized ultrasound as a technology that improves the safety of pregnancy and delivery [20]. Unintended consequences of overuse and gender-selective abortions in African populations are not common but have been reported in other low-resource areas. Other potential misuses of the method are the use of ultrasound that is not medically required and/or that is paid for by patients, and the risks associated with an incompetent examiner giving women a false feeling of safety. These issues are also a problem in some LIC and should be considered with caution. In conclusion, the present data indicate that ultrasound training can be applied to the rural health areas in which most Sub-Saharan African women live and give birth. The potential for ultrasound to identify causal problems such as placenta previa and malposition before labor starts is clear and can be achieved in the most remote rural health centers. In selecting a shortlist of targeted obstetric ultrasound parameters that may alter management and outcome, we found that the training of local health workers is achievable in a short period of time. The use of educational film translated into local languages provides a sustainable source of continuous education for the local healthcare workers and an opportunity for the trainees to become trainers. Ultrasound imaging combined with a low-cost data collection system such as the one used in the present study also delivers pivotal information for the development of new healthcare strategies backed by local/regional-specific prospective epidemiologic data, which are crucial for the expansion of healthcare systems in LIC.
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