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

18 Jan.,2023


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This study assessed the views and experiences of women, healthcare workers, and health system managers regarding the use of modern ultrasound equipment with Doppler and color flow capabilities in an obstetric department in a rural Ugandan hospital. Many women had never seen or undergone an ultrasound scan and the majority of them were afraid it would harm them or their fetuses. On a positive note, the majority of the women found their husbands supportive of antenatal care attendance including the use ultrasound services. Healthcare providers were unfamiliar with Doppler technology and using it to guide clinical decisions. Other barriers to its implementation were a shortage of trained local staff, insufficient equipment, long distance to and from the hospital, and frequent power cuts.

Mothers felt that an ultrasound exam would reduce their lifespan and/or harm their fetuses. Nearly every healthcare worker we interviewed had heard this. The literature reports mixed perceptions of women regarding ultrasound safety [14]. Women in selected health facilities in Uganda have previously reported fears and misconceptions about imaging [15]. Similarly, in Thailand, 5.1% of respondents reported that they believed ultrasound could be dangerous, while the majority viewed it as a safe and useful tool in pregnancy [11]. In Kenya, 30% (10/34) of the women interviewed before receiving an ultrasound were worried it could harm them or their fetus [10]. That proportion dropped to 8% (n = 2/25) at their second or subsequent ANC visit [10], demonstrating that with exposure and proper health education, perceptions can transform. In a high-income setting, women generally held positive views about getting a third trimester ultrasound [20]. Even though some women in this study were afraid that the procedure could cause harm, the service demand remained high probably due to the larger number of patients Kagadi hospital receives yet they had only a single machine donated by the EPID project.

Negative views may be attributable to lack of exposure and common myths. Such misconceptions regarding the safety of ultrasound in pregnancy could preclude future adoption and large-scale implementation of this technology in vulnerable, poor communities. However, it is also possible that widespread implementation and continued public engagement on the safety and role of obstetric ultrasound, stressing the importance of early initiation of antenatal care and adequate pregnancy dating can lead to its greater acceptance over time.

Pregnant women had challenges accessing screening and follow-up scans due to the unreliable electricity supply characterized by frequent blackouts, equipment breakdown attributed to power supply, insufficient equipment, shortage of trained local staff and long distance to and from Kagadi Hospital. Empowering community-level heath workers to support expectant mothers and engaging them with the health system could improve follow-up care. Uganda’s skilled birth attendance policy previously implemented by the Ministry of Health to improve access to obstetric care through training more health workers, expanding infrastructure, equipment, and distribution of supplies could be enhanced [21]. We recommend context-specific strategies to improve access to follow-up care in other LMICs.

In addition, the majority of the women had never seen or undergone an ultrasound examination. These findings are in line with the results of previous studies undertaken in similar low-resource settings [7, 8, 12,13,14], implying inequitable distribution of ultrasound services and its benefits to vulnerable poor women in rural communities. This is contrary to the WHO recommendations that every woman should receive at least one scan before 24 weeks gestation to estimate gestational age and improve detection and referral for the care of pregnancy complications [4]. Accurate gestational age estimation and early identification of complications guide the timing for delivery and appropriate management of a mother and fetus at risk [4]. Doppler ultrasound is indicated for close monitoring and management of high-risk pregnancies [4].

However, the healthcare staffs’ interpretation and application often limit the usefulness of a diagnostic tool such as Doppler ultrasound. Healthcare staff in Kagadi Hospital were unfamiliar with antenatal Doppler ultrasound technology and using it to manage high-risk pregnancies, but received training about it and a Doppler ultrasound machine from EPID project. There is a need for training activities beyond Kagadi Hospital. Our study highlights the need for continued education and targeted interventions on the interpretation of Doppler ultrasound findings as an important component of introducing modern ultrasound technology for clinical practice in Uganda and beyond. Likewise, two studies from Uganda and Tanzania observed that frequent training may be necessary when introducing new obstetric tools into ANC settings of LMICs to improve healthcare providers’ knowledge and ensure their acceptability and correct usage, despite differences in the technologies studied [22, 23]. Furthermore, local staff and stakeholders should be involved in developing realistic clinical practice guidelines (for example “bottom-up guidelines” in Suriname) so that the new interventions are well suited and accepted in the local setting (for example the Partoma project in Tanzania) [24, 25]. It is key to note that in many LMICs, babies still die due to poor transportation, lack of skilled health care workers, poor quality of care provided to pregnant and laboring women, and high rates of home deliveries among other reasons. Therefore, while introducing advanced ultrasound machines to weak health systems, we must carefully consider where it is likely to be beneficial. Its introduction into antenatal care requires a health system strong enough to manage an increase in the number of detected high-risk pregnancies including the surgical capacity to manage a potential increase in caesarean sections.

In the current study, the majority of the women reported that their husbands supported them to attend ANC and use ultrasound services. Male involvement in sexual and reproductive health has recently been recognized as a strategy for enhancing ANC attendance and utilization of antenatal care interventions [26, 27]. Engaging male partners and other stakeholders to support women and children to access care promote men’s positive involvement as husbands, fathers, and birth companions [26,27,28]. Men in Uganda have most of the access to economic resources and decision-making power, and their optimal involvement could facilitate the implementation and uptake of ultrasound. However, key actors such as international organizations and the Ministry of Health inadequately address male involvement strategies in Uganda, and gaps between policy and practice exist [29]. Strategies that accommodate men, such as making the obstetric services more father-friendly by improving ultrasound room spaces, and male recruitment into healthcare services are required.

Strengths of this study included the large number of interviews conducted with a heterogeneous sample including women, healthcare workers and health system managers, yielding broader understandings of Doppler ultrasound implementation issues in a low resource setting from the perspectives of major actors in maternal, newborn, and child health. Additionally, a multi-disciplinary and team approach in developing a working analytical framework, selecting emerging codes and themes, and data interpretation allowed multiple stakeholders to engage with the data and offer their perspectives during analysis. This systematic and rigorous data analysis approach in addition to triangulation of results from different methods and sources enhanced the credibility and trustworthiness of our findings.

The study had some limitations. We had one main coder (OK) though she was very experienced in qualitative research and the codes were continuously reviewed and discussed by a larger research team to ensure that no important perspectives were left out. Although interviews at different time points (first contact, follow-up Doppler exam, and after delivery) and multiple facilities, and sustained engagement with respondents to capture their views on our interpretations might have provided additional insights, this is one of the first studies of its kind. Further, we did not conduct any IDI of healthy women but many women of this category were included in FGDs. While practitioners should extrapolate the findings to other geographical regions with caution, we remain confident that they are representative of similar low resource settings. Important dimensions outside the scope of the current study such as views of men could be considered in future research.