Abstract
Many high-risk conditions of pregnancy are undetected until the time of delivery in low-income countries. We developed a point-of-care ultrasound training protocol for providers in rural Uganda to detect fetal distress or demise, malpresentation, multiple gestation, placenta previa, oligohydramnios and preterm delivery. This was a mixed-methods study to evaluate the 2-week training curriculum and trainees' ability to perform a standard scanning protocol and interpret ultrasound images. Surveys to assess provider confidence were administered pre-training, immediately after, and at 3-month follow up. Following lecture and practical demonstrations, each trainee conducted 25 proctored scans and were required to pass an observed structured clinical exam (OSCE). All images produced 8 weeks post course underwent blinded review by two ultrasound experts to assess image quality and to identify common errors. Key informant interviews further assessed perceptions of the training program and utility of point-of-care ultrasound. All interviews were audio recorded, transcribed, and reviewed by multiple readers using a content analysis approach. Twenty-three nurse/nurse midwives and two physicians from one district hospital and three health centers participated in the training curriculum. Confidence levels increased from an average of 1 point pre-course to over 6 points post-course for all measures (maximum of 7 points). Of 25 participants, 22 passed the OSCE on the first attempt (average score 89.4%). Image quality improved over time; the final error rate at week 8 was less than 5%, with an overall kappa of 0.8-1 for all measures between the two reviewers. Among the 12 key informant interviews conducted, key themes included a desire for more hands-on training and longer duration of training and challenges in balancing clinical duties with ability to attend training sessions. This study demonstrates that providers without previous ultrasound experience can detect high-risk conditions during labor with a high rate of quality and accuracy after training.
Highlights
In low- and middle-income countries (LMIC), national standards of obstetric care do not routinely include antenatal ultrasound exams to identify high-risk conditions
This ultrasound training was conducted as part of a larger study assessing the impact of point-of care ultrasound (POCUS) on identification of 6 obstetric complications at one public district hospital (DH) and three health centers (HC) in Busoga Region, Eastern Uganda
Our study demonstrates that nurse midwives in a LMIC context were able to build confidence and skills after an ultrasound training course and accurately perform ultrasound during labor triage to detect high-risk conditions in pregnancy
Summary
In low- and middle-income countries (LMIC), national standards of obstetric care do not routinely include antenatal ultrasound exams to identify high-risk conditions. Physical exam for certain high-risk conditions such as fetal distress, oligohydramnios, placenta previa, and multiple gestation, as well as the determination of preterm labor provides limited certainty. Even during labor, of high-risk conditions of pregnancy may allow for better maternal and neonatal outcomes [1, 8]; lack of complete antenatal care and limited access to ultrasound underscore the need to develop other strategies to identify and manage these complications, including training midwives and others to perform obstetric ultrasound
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